Oral malodour, types , reasons, detection methods,

1. ORAL MALODOR
PRESENTED BY:
PRABLEEN ARORA
MDS STUDENT

2. DEFINITIONS
• Breath odor can be defined as the subjective perception after
smelling someone’s breath.
• It can be pleasant, unpleasant or even disturbing, if not repulsive.
• If unpleasant, Synonyms:
• breath malodor
• halitosis
• bad breath,
• fetor ex ore
Carranza (11th edition)
• Breath malodor means an unpleasant odor of the expired air,
whatever the origin may be.
Jan Lindhe (4TH edition)

3. • Halitosis is derived from:
• The Latin word "Halitasia“ --bad breath
• The Greek word "Osis“ -- disease or condition.
• Halitosis, also termed fetor ex ore, fetor oris, and
oral malodor, is foul or offensive odor emanating
from the oral cavity. Carranza (9th edition)
• 3rd most frequent reason for seeking dental aid,
following tooth decay and periodontal disease.
(Loesche WJ et al 2002)

4. EPIDEMIOLOGY
• There are few studies that document the prevalence of oral
malodor.
• A large scale japanese study of more than 2500 subjects
reported that 1 in 4 subjects exhibited VSC values higher than
75 parts per billion.
(Miyazaki H et al 1995).
• Rosenberg M et al indicated higher prevalence of bad breadth
among women than men.
• Delanghe G et al : No association was found between
increased age and oral malodor. Age may range from 5-80
years.

5. CLASSIFICATION
ADA classification based on the etiological
pathways involved :
• Extrinsic pathways - Tobacco, alcohol and foods like
onions, garlic and certain spices.
• Intrinsic pathways – Oral origin (90 %)
– Systemic origin (10 %)

6. Classification based on the origin of
halitosis:
1. Due to local factors of Pathological origin.
2. Due to local factors of Non-pathological origin
3. Due to systemic factors of Pathological origin
4. Due to systemic factors of Non-pathological origin
5. Due to systemic administration of Drugs
6. Due to xerostomia.
(Dominic 1982)

7. Yaegaki K, Coil J (2000) classified
halitosis into three main categories :
Genuine
halitosis
When the breath
malodor really exists
and can be diagnosed
organoleptically or by
measurement of the
responsible
compounds.
Pseudo-halitosis
When an obvious
breath malodor
cannot be perceived,
but the patient is
convinced that he or
she suffers from it,
Halitophobia
If the patient still
believes that there is
bad breath after
treatment of genuine
halitosis or diagnosis
of pseudohalitosis.
It is a recognized
psychiatric condition.

9. ETIOLOGY
• In the vast majority, breath malodor originates from the
oral cavity.
• Gingivitis
• Periodontitis
• Tongue coating
Quirynen M et al (2009)
• Conducted a large scale study with 2000 halitosis
patients.
• Concluded: 76% oral cause: 43% tongue coating.
11% gingivitis/periodontitis
18% combination
: 4% extra-oral
Predominant
causative factors

10. Two pathways for bad breath.
• The first one involves an increase of certain
metabolites in the blood circulation (e.g., due to a
systemic disease), which will escape via the alveoli
of the lungs during breathing (blood-gas exchange).
• The second pathway involves an increase of either
the bacterial load or the amount of substrates for
these bacteria at one of the lining surfaces of the
oropharyngeal cavity, the respiratory tract, or the
esophagus.

11. Odiferous Compounds
Volatile Sulfur Compounds Methyl Mercaptan, Hydrogen
Sulfide Dimethyl Sulfide
Diamines Cadaverine,Putrescine
Short-Chain Fatty Acids Butyric Acid ,Valericacid,Propionic
Acid
Indoles Indole, Methyl-Indole (Skatole)

12. • For oral malodor, the unpleasant smell of the breath mainly
originates from VSCs.
• Tonzetich first discovered the volatile sulfur compounds
(VSC).
• hydrogen sulfide (H2S)
• methyl- mercaptan (CH3SH)
• less important dimethyl sulfide [(CH3)2S].
• However, in certain conditions (e.g., when the saliva dries out
on the mucosal surfaces), other compounds in mouth air may
also play a role such as:
• diamines (e.g., putrescine, cadaverine)
• indole
• skatole
• volatile organic acids like butyric or propionic acid.

13. Production
and origin of
oral malodor
•Most of these compounds result from the proteolytic degradation by
oral microorganisms of peptides present in saliva (sulfur-containing or
non–sulfur-containing amino acids) shed epithelium, food debris,
gingival crevicular fluid (GCF), interdental plaque, postnasal drip, and
blood.
•In particular, gram-negative, anaerobic bacteria possess such
proteolytic activity.

14. • For the extraoral causes of halitosis, other compounds
besides the VSCs may be involved, which have not all
been identified yet.
• Bad smelling metabolites can be formed/absorbed at
any place in the body (e.g., the liver, the gut) and be
transported by the bloodstream to the lungs.
• Exhalation of these volatiles in the alveolar air then
causes halitosis, at least when the concentrations of
the bad smelling metabolites are sufficiently high.
• The extraoral causes are much more difficult to detect,
although they can sometimes be recognized by a
typical odor.

15. INTRAORAL CAUSES
Tongue and Tongue Coating.
The dorsal tongue mucosa shows a very irregular surface topography.
• The posterior part exhibits a number of oval cryptolymphatic units.
• The anterior part exhibits high number of papillae: the filiform papillae ,the
fungiform papillae, the foliate papillae, the vallate papillae.
• A fissurated tongue and a hairy tongue
• These innumerable depressions (irregular surface) in the tongue surface are ideal
niches for bacterial adhesion and growth, sheltered from cleaning actions.
• Desquamated cells and food remnants also remain trapped in these retention sites
and consequently can be putrefied by the bacteria.

16. • The accumulation of food remnants
intermingled with exfoliated cells and
bacteria causes a coating on the tongue
dorsum.
• Coil J et al (1992), Rosenberg M et al(1996) identified the
dorsal posterior surface of the tongue as the primary source
of breath malodor.
• High correlations have been reported between tongue
coating and odor formation.
Yaegaki K et al (1992), miyazaki H et al (1995).
• Quirynen M et al suggested that oral malodor is associated
with the total bacterial load of anaerobic bacteria in both
saliva and tongue coating.

17. PERIODONTAL INFECTIONS
• Niles and Gaffer (1995)- Gram negative bacteria can cause
unpleasent smell by production of sulfur compounds.
• Rosenberg M et al (2005) – Gram positive Streptococcus
salivarius also contributes to oral malodor.
• VSC levels in the mouth correlate positively with the depth of
periodontal pockets (the deeper the pocket, the more
bacteria, particularly anaerobic species)
• Amount of VSCs in breath increases with the number, depth,
and bleeding tendency of the periodontal pockets.
(Persson S et al, Yaegaki K et al, Coil J et al)

18. .
Exposing the underlying connective
tissues of the periodontium to
bacterial metabolites
enhances interstitial collagenase production,
interleukin-1 (IL-1) production by mononuclear
cells, and cathepsin B production, thus further
mediating connective tissue breakdown.

19. • The prevalence of tongue coating is 6 times higher
in patients with periodontitis.
• Other relevant malodorous pathologic
manifestations of the periodontium are:
1. Pericoronitis (the soft tissue “cap” being retentive
for microorganisms and debris)
2. Major recurrent oral ulcerations
3. Herpetic gingivitis
4. Necrotizing gingivitis/periodontitis.

20. Dental Pathologies
1. Deep carious lesions with food impaction and
putrefaction
2. Extraction wounds
3. Purulent discharge
4. Interdental food impaction
5. Acrylic dentures.
6. The denture surface facing the gingiva is porous
and retentive for bacteria, yeasts, and debris,
which are all factors that cause putrefaction.

21. Dry Mouth
• Saliva has an important cleaning function in the
oral cavity.
• Patients with xerostomia often present with large
amounts of plaque on teeth and an extensive
tongue coating.
• The increased microbial load and the escape of
VSCs as gases when saliva is drying up explain the
strong breath malodor.

22. EXTRORAL CAUSES
• Ear-nose-throat: During chronic and purulent tonsillitis, deep
crypts of the tonsils accumulates debris and
bacteria,especially periopathogens, resulting in putrefaction.
• Gastrointestinal tract: Helicobater pylori produces hydrogen
sulfide and methylmercaptan which results in halitosis. (Lee H
et al)
• Liver : hepatocellular failure
metabolizing function of the liver fails.
• Kidney: kidney insufficiency caused by chronic
glomerulonephritis which leads to increase of the amines
dimethylamine and trimethylamine, which causes a typical
fishy odor of the breadth.

23. • Systemic metabolic disorders- uncontrolled
diabetes mellitus- accumulation of ketones ehich
have a sweet smell like the odor of rotten apples.
• Trimethylaminuria – it is hereditary metabolic
disorder that leads to typical fishy odor of breadth ,
urine, sweat and other bodily secretion.
• Hormonal cause- during menstrual cycle- typical
breadth odor develops. VSC levels increases 2-4 fold
around the day od ovulation and in the
perimenstrual period.

24. PHYSIOLOGY OF MALODOR DETECTION
• Some gases can cause a striking odor at very low concentrations, whereas
others need to be present in much higher quantities.
• The perception of the molecules depends on the following factors:
1. The odor itself (olfactory response) can be pleasant, unpleasant, or even
repulsive.
2. Each particular molecule has its specific concentration before it can be
detected (threshold concentration).
3. The odor power is the extent of concentration that is necessary to increase
the odor score with one unit.
4. The volatility of the compound: malodorous molecules only express
themselves when they become volatile.
5. The substantivity: the capacity of the molecule to stay present and thus to
remain the cause of smell.

25. • The odor power is the strongest for hydrogen sulfide and methylmercaptan.
• If the concentration of these products increases fivefold to tenfold, the odor will
receive a higher organoleptic rating.
• For some other compounds, increases of 25 to 100 times are needed to reach a
similar effect.
• Skatole and methyl mercaptan are detected at the lowest concentrations.
• In a study of Kleinberg and Codipilly, aqueous solutions of oral odoriferous
volatiles were placed on the skin of the back of the hand.
• Afterward, odor scores were given (organoleptic score).
• All metabolites caused an explicit odor, which decreased in intensity over time.
• Some molecules disappeared very fast (e.g., hydrogen sulfide and
methylmercaptan).
• Whereas others produced a bad smell for a longer Period of time. (e.g., indole and
skatole, for 10 minutes and longer)

26. DIAGNOSIS OF MALODOR
MEDICAL HISTORY CLINICAL & LABORATORY
EXAMINATION
•Frequency (e.g., every month),
•Time of appearance during the day
•Time when the problem first appeared,
•Whether others (nonconfidants) have
identified the problem,
•Medications
•Factors such as mouth breathing, dry
mouth, allergies, and nasal problems.
•SELF EXAMINATION
•OROPHARYNGEAL EXAMINATION
•ORGANOLEPTIC RATING
•PORTABLE VOLATILE SULFUR MONITOR
•GAS CHROMATOGRAPHY
•DARK-FIELD OR PHASE-CONTRAST
MICROSCOPY

27. SELF EXAMINATION
• It can be worthwhile to involve the patient in monitoring the
results of therapy by self-examination.
• This can motivate the patient to continue the oral hygiene
instructions.
• The following self-testing can be used:
1. Smelling a metallic or nonodorous plastic spoon after
scraping the back of the tongue.
2. Smelling a toothpick after introducing it in an interdental
area.
3. Smelling saliva spit in a small cup or spoon (especially when
allowed to dry for a few seconds so that putrefaction odors
can escape from the liquid).
4. Licking the wrist and allowing it to dry.

28. OROPHARYNGEAL EXAMINATION
• Inspection of deep carious lesions
• Interdental food
• Impaction,
• Wounds,
• Bleeding of the gums,
• Periodontal pockets,
• Tongue coating,
• Dry mouth,
• Tonsils and pharynx (for tonsillitis and pharyngitis).

29. Organoleptic Rating
• “Gold standard” in the examination of breath malodor.
• In an organoleptic evaluation, a trained and preferably
calibrated “judge” sniffs the expired air and assesses
whether it is unpleasant by using an intensity rating,
normally from 0 to 5.
(Rosenberg and McCulloch)
• Based on the olfactory organs of the clinician
0 = no odor present,
1 = barely noticeable odor,
2 = slight but clearly noticeable odor,
3 = moderate odor,
4 = strong offensive odor,
5 = extremely foul odor.

30. • Judge smell series of different air samples:
1. Oral cavity odor: subjects opens the mouth and
refrains from breathing while the judge places his
or her nose close to the mouth opening.
2. Breadth odor: subject expires through the mouth
while the judge smells both the beginning and the
end of the expiration.
3. Saliva: patient lick his/her wrist. After drying judge
gives a score.
4. Tongue coating : judge smell the tongue scraping.
5. Nasal breadth odor: subjects expires through the
nose while mouth is closed. Nasal/paranasal cause
suspected.

31. • Specific character of the odor:
1. Smell of sulfur:- intraoral origin of halitosis.
2. Smell of sulfur:- also points to liver diseases.
sometimes combined with sweet odor
(accumulation of ketones.)
3. Smell of rotten apples:- unbalanced insulin
dependent diabetes which leads to accumulation
of ketones.
4. Fishy odor:- kidney insufficiency (characterized by
uremia and accumulation of dimethylamine and
trimethylamine).

33. Portable Volatile Sulfur Monitor.
• Halimeter is an electronic device that analyzes the
concentration of hydrogen sulfide and methyl
mercaptan but without discriminating them.
• The sulfur meter uses a voltametric sensor that
generates a signal when exposed to sulfur-containing
gases
ELEVATED CONCENTRATION:
300-400ppb.
Absence of mal odor: 150ppb
or lower.

34. Drawbacks:
• Detects only sulfur compounds therefore only used for
intraoral causes of halitosis.
• Absence of VSCs does not prove that there is no
breadth odor.
• Instrument has no specificity thus cannot discriminate
among different sulfur compounds.
• Sensitivity for methylmercaptan is five times lower than
hydrogen sufide .
• Insensitive to dimethyl sulfide.

35. Gas Chromatography
• A gas chromatography device can analyze air, saliva,
or crevicular fluid .
• About 100 compounds have been isolated from the
headspace of saliva and tongue coating, from
ketones to alkanes and sulfur-containing
compounds to phenyl compounds.

36. • The most important advantage of the technique (together
with mass spectrometry) is that it can detect virtually any
compound when using adequate materials and conditions.
• Moreover, it has a very high sensitivity and specificity
• Portable gas chromatograph- measures and differentiates :
1. hydrogen sulfide,
2. Methymercaptan,
3. Dimethyl sulfide
• Methymercaptan> hydrogen sulfide- periodontitis
• If only hydrogen sulfide increase- poor oral hygiene
• Dimethyl sulfide- extraoral causes

37. Dark-Field or Phase-Contrast
Microscopy.
• Gingivitis and periodontitis are typically associated
with a higher incidence of motile organisms and
spirochetes, so shifts in these proportions allow
monitoring of therapeutic progress.
• Patient becomes aware of bacteria being present in
plaque, tongue coating, and saliva.

38. Saliva Incubation Test.
• The analysis of the headspace above incubated saliva by gas
chromatography reveals next to VSCs also other compounds
like indole, skatole, lacticacid, methylamine, diphenylamine,
cadaverine, putrescine, urea, ammonia, dodecanol, and
tetradecanol.
• By adding some proteins, such as lysine or cysteine, the
production of respectively cadaverine or hydrogen sulfide is
dramatically increased.
• Organoleptic evaluation (or assessment of the VSCs) of the
saliva headspace offers promising perspectives for monitoring
treatment results.
• It is a less invasive test, especially for the patient, than
smelling breath in front of the oral cavity.

39. Electronic Nose
• Electronic noses identify the
specific components of an
odor and analyze its chemical
makeup.
• They consist of a mechanism
for chemical detection, such
as an array of electronic
sensors, and a mechanism
for pattern recognition.
• An artificial nose that has the
same capacities as the
human nose would be ideal.
Tanaka M et al used these
electronic noses to clinically assess
oral malodor and examined the
association between oral malodor
strength and oral health status.

40. DIAMOND PROBE
• Sensors are integrated
into the periodontal probe.
• Probe is placed directly
into the periodontal pocket or tongue.
• It has an electrical control unit and a disposable sensor
tip that combines a standard Michigan 0 styled dental
probe with a sulphide sensor which responds to the
sulfides present in the periodontal pocket.

41. BANA test
• The BANA test is practical for chair-side usage.
• It is a test strip which composed of benzoyl-DL-
arginine-a-naphthylamide and detects short-chain fatty
acids and proteolytic obligate gram-negative
anaerobes, which hydrolyze the synthetic trypsin
substrate and cause halitosis.
• It detects especially Treponema denticola, P. gingivalis,
and T. forsythensis that associated with periodontal
disease.
• By using the BANA test, we can detect not only
halitosis, but also periodontal risk assessment.

42. Treatment needs for breadth malodor
TN-1 : Explanation of halitosis for oral hygiene (support and
reinforcement of a patient’s own self care for further improvement
of their oral hygiene.
TN-2 : Oral prophylaxis, professional cleaning and treatment of oral
diseases, especially periodontal disease.
TN-3: Referral to physician.
TN-4: Explanation of examination data, further professional
instruction,education and reassurance.
TN-5: referral to clinical psychologist, psychiatrist or other psychology
specialist

43. TREATMENT OF ORAL MALODOR
• As oral malodor is caused by the metabolic degradation of
available proteins to malodorous gases by certain oral
microorganisms, the following general treatment strategies
can be applied:
• Mechanical reduction of intraoral nutrients (substrates) and
microorganisms.
• Chemical reduction of oral microbial load
• Rendering malodorous gases nonvolatile
• Masking the malodor

44. Mechanical Reduction of Intraoral Nutrients
and Microorganisms
• Tongue cleaning:
• Tongue cleaning using a tongue scraper reduced
the halitosis levels with 75% after 1 week. (Pedrazzi
V et al).
• It is best to clean as far backward as possible; the
posterior portion of the tongue has the most
coating.

45. • Interdental cleaning and toothbrushing are essential
mechanical means of dental plaque control.
• Periodontitis can cause chronic oral malodor,
professional periodontal therapy is needed.
• A one-stage, fullmouth disinfection, combining scaling
and root planing with the application of chlorhexidine,
reduced the organoleptic malodor levels up to 90%.
Quirynen M et al (1998)
• In a recent study by Quirynen M et al (2005), initial
periodontal therapy had only a weak impact on the VSC
levels,except when combined with a mouthrinse
containing chlorhexidine

46. • Chewing gum may control bad breath temporarily
because it can stimulate salivary flow.
• The salivary flow itself also has a mechanical
cleaning capability.
• Extremely low salivary flow rate have higher VSC
ratings and tongue coating scores than those with
normal saliva production.
• Waler showed that chewing of a gum without any
active ingredient can reduce halitosis modestly.

47. Chemical Reduction of Oral Microbial Load
• All these agents have only a temporary reducing
effect on the total number of microorganisms in the
oral cavity.
• Chlorhexidine
• Essential oils
• Chlorine dioxide
• Two-phase oil-water rinse
• Triclosan
• Aminefluoride/stannous fluoride
• Hydrogen peroxide
• Oxidizing lozenges

48. • Chlorhexidine- its strong antibacterial effects and
superior substantivity in the oral cavity,
chlorhexidine rinsing provides significant reduction
in VSC levels and organoleptic ratings.
• Rosenberg et al – 0.2% chx regimen produced 43%
reduction in VSC values and greater than 50%
reduction in organoleptic mouth odor ratings.
• Loesche et al – 1 week rinsing with 0.12% chx on
combination with tooth and tongue brushing
reduces VSC level 73%, mouth odor 69% and
tongue odor 78%.

49. Essential oils:
• Listerine was found to be only moderately effective
against oral malodor (25% reduction versus 10% for
placebo of VSCs after 30 minutes) and caused a
sustained reduction in the levels of odorigenic
bacteria.
• Chlorine Dioxide.
• Chlorine dioxide (ClO2) is a powerful oxidizing agent
that can eliminate bad breath by oxidation of
hydrogen sulfide, methylmercaptan, and the amino
acids, methionine and cysteine.
• Studies demonstrated that single use of a ClO2–
containing oral rinse slightly reduces mouth odor

50. • Two-Phase Oil-Water Rinse.
• Rosenberg et al designed a two-phase oil-water
rinse containing CPC.
• The efficacy of oilwater- CPC formulations is
thought to result from the adhesion of a high
proportion of oral microorganisms to the oil
droplets, which is further enhanced by the CPC. A
twice-daily rinse with this product (before bedtime
and in the morning) showed reductions in both VSC
levels and organoleptic ratings.

51. • Triclosan- mouth rinse containing 0.15% triclosan
and 0.84% zinc produced a stronger and more
prolonged reduction in mouth odor than a Listerine
rinse.
• Aminefluoride/Stannous Fluoride-The association
of aminefluoride with stannous fluoride (AmF/SnF2)
resulted in encouraging reductions of morning
breath odor, even when oral hygiene is insufficient

52. • Hydrogen Peroxide- Suarez et al reported that
rinsing with 3% hydrogen peroxide (H2O2)
produced impressive reductions +90% in sulfur
gases that persisted for 8 hours.
• Oxidizing Lozenges.- Greenstein et al reported that
sucking a lozenge with oxidizing properties reduces
tongue dorsum malodor for 3 hours.
• This antimalodor effect may be caused by the
activity of dehydroascorbic acid, which is generated
by peroxide-mediated oxidation of ascorbate
present in the lozenges.

53. Conversion of Volatile Sulfur Compounds
Metal Salt Solutions
• Metal ions with affinity for sulfur are efficient in
capturing the sulfur-containing gases.
• Zinc is an ion with two positive charges (Zn++), which
will bind to the twice– negatively loaded sulfur radicals,
and thus can reduce the expression of the VSCs. The
same applies for other metal ions such as mercury and
copper.
• Schmidt and Tarbet already reported that a rinse
containing zinc chloride was remarkably more effective
than a saline rinse (or no treatment) in reducing the
levels of both VSCs (+80% reduction ) and organoleptic
scores (+40% reduction ) for 3 hours.

54. • Toothpastes
• Baking soda dentifrices have been shown to confer a significant
odor-reducing benefit for time periods up to 3 hours.
• The mechanisms by which baking soda produces its inhibition of
oral malodor might be related to its bactericidal effects and its
transformation of VSCs to a nonvolatile state.
• Chewing Gum.
• Chewing gum can be formulated with antibacterial agents, such as
fluoride or chlorhexidine, thus helping reduce oral malodor
through both mechanical and chemical approaches.
• Waler compared different concentrations of zinc in a chewing gum
and found that a 2-mg Zn++ acetate–containing chewing gum that
remained in the mouth for 5 minutes resulted in an immediate
reduction in the VSC levels of up to 45%, but the long-term effect
was not mentioned.

55. • Masking the Malodor
Treatments with rinses, mouth sprays, and
lozenges containing volatiles with a pleasant
odor have only a short-term effect.

57. THANK YOU