3. • Introduction
• History
• Classification
• Source of Halitosis
• Etiology
• Intra oral causes
• Extra oral causes
• Pathophysiology
• Correlation between the
presence of a pathogenic
microflora in the
subgingival microbiota and
halitosis
• Diagnosis of malodor
• Preventive measures
• Treatment needs
• Management of oral malodour
• Conclusion
• References
3
4. 4
Halitosis is a general term used to define an unpleasant or offensive
odour emanating from the breath regardless of whether the odour
originates from oral or non-oral sources.
It was described as a clinical entity by HOWE (1874).
Halitosis should not be confused with the generally temporary oral odour
caused by intake of certain foods, tobacco, or medications
Originates from two Latin words
Halitus → breath
Osis → disease
5. 5
Bad or foul breath
Breath malodour
Oral malodour
Foetor ex-ore
Foetor oris
Stomato dysodia
6. 6
Halitosis is also termed as fetor ex ore or fetor oris. It is a foul or
offensive odor emanating from the oral cavity.
Carranza’s clinical periodontology 10th edition
Unpleasant odor of the expired air whatever the origin may be. Oral
malodor specifically refers to such odor originating from the oral cavity
itself.
Clinical periodontology and implant dentistry 5th edition
7. HALITOSIS: Oral odor that is unpleasant or offensive to others. Caused by
a variety of factors including periodontal disease, xerostomia, bacterial
or fungal coating of tongue or dental prostheses (dentures), systemic
disorders (e.g., diabetes, upper respiratory infections), different types of
food, and use of tobacco products. Also known as fetor ex ore, fetor oris,
and stomatodysodia, and commonly referred to as "bad breath".
-American academy of periodontology: Glossary
7
8. The problem of halitosis has been reported for many years.
References were found in papyrus manuscripts dating back to
1550 BC.
During Christianity, the devil's supreme malignant odor smelled
of sulfur & it was presumed that sins produced a more or less bad
smell. (Rayman S, Almas K. 2008)
A treaty in Islamic literature from the year 850 talked about
dentistry, referring to the treatment of fetid breath &
recommended the use of siwak when breath had changed or at
any time when getting out of bed.
9. Buddhist monks in Japan also recommended teeth brushing &
tongue scraping before the first morning prayers. (Rayman S,
Almas K. 2008)
The Hindus consider the mouth as the body's entry door and,
therefore, insist that it be kept clean, mainly before prayers.
The ritual is not limited to teeth brushing, but includes scraping
the tongue with a special instrument and using mouthwash.
(Rayman S, Almas K. 2008)
11. Physiological halitosis (foul morning breath, morning
halitosis) is caused by stagnation of saliva and putrefaction
of entrapped food particles and desquamated epithelial cells
by the accumulation of bacteria on the dorsum of the
tongue, recognized clinically as coated tongue and decrease
in frequent liquid intake. (Porter SR, Scully C. 2006)
Intraoral conditions are the cause of 80–85% of halitosis
cases. (Wilhelm D et al 2012) Periodontal infections are
characterized by a tremendous increase in Gram-negative
bacteria that produce volatile sulfur compounds (VSCs).
The association between anaerobic bacteria that produces
VSCs and halitosis has been well-documented. (Delanghe
G et al 1997)
Most important VSCs are hydrogen sulfide (HS), methyl
mercaptan and dimethyl sulfide. ( Bollen CM, Beikler
T. 2012)
SOURCE OF HALITOSIS
12. The dorsum of the tongue is the biggest reservoir of bacteria as
a source of malodorous gases. (Wilhelm D et al 2012)
Pericoronitis, oral ulcers, periodontal abscess, and herpetic
gingivitis are some of the pathologies that result in increased
VSCs.
Diamines such as putrescine and cadaverine are also responsible
for oral malodor as with the increase in periodontal pocket
depth; oxygen tension decreases which results in low pH
necessary for the activation of the decarboxylation of amino
acids to malodorous diamines. ( Bollen CM, Beikler T. 2012)
13. Odontogenic infections include retention of food debris in
deep carious lesions and large inter-dental areas, malaligned
teeth, faulty restorations, exposed necrotic pulp, over wearing
of acrylic dentures atnight, wound infection at the extraction
site and ill-fitting prosthesis.
The absence of saliva or hypofunction results in an increased
Gram-negative microbial load, which increases VSCs, a
known cause of malodor. Several mucosal lesions such as
syphilis, tuberculosis, stomatitis, intraoral neoplasia and peri-
implantitis allow colonization of microorganisms that releases
a large amount of malodors compounds. ( Bollen CM, Beikler
T. 2012, Wilhelm D et al 2012)
15. The role of tongue coatings in the
aetiology of oral malodour has been
extensively documented.
Tongue coatings include desquamated
epithelial cells, food debris, bacteria and
salivary proteins and provide an ideal
environment for the generation of VSCs
and other compounds that contribute to
malodour
15
16. Extra oral origin-10-20%
gastro intestinal diseases
infections or malignancy in respiratory tract
Chronic sinusitis and tonsillitis
stomach, intestine, liver or kidney affected by systemic diseases
16
22. Though the exact pathogenesis of oral malodor is not known, the
most accepted one is that the microbial putrefaction of food debris,
desquamated cells, saliva and blood causes oral malodor.
The bacterial interactions are mainly due to several proteolytic and
anaerobic, Gram-negative bacterial species and are not associated
with any specific bacterial infection.
The only Gram-positive bacteria so far proved to be associated with
halitosis is Stomatococcus mucilaginous. (Rosenberg M. 1996)
23.
24. Various agents such as volatile sulfur compounds (VSCs), diamines
and short chain fatty acids are produced due to this microbial
breakdown of amino acids by enzymes, resulting in oral malodor
(For e.g.: Breakdown of cystine, cysteine, and methionine produces
VSC) (Motta LJ et al 2011)
26. 26
In 1981, Pitts et al studied the correlations between odor scores and
microbiological findings in crevicular samples of periodontally healthy
subjects.
They found that odor scores were significantly correlated with the
concentration of overall bacterial populations and that higher levels of
crevicular bacteria were associated with greater odor scores.
27. 27
Recent studies indicate the presence of solobacterium moorei
associations with oral malodour
-Haraszthy VI, Gerber D, Clark B et al
30. 30
Self assessment tests(subjective tests)
Whole mouth malodor (Cupped breath)
The subjects are instructed to smell the odor emanating from their entire
mouth by cupping their hands over their mouth and breathing through
the nose. The presence or absence of malodor can be evaluated by the
patient himself/herself.
31. 31
Subjects are asked to extend their
tongue and lick their wrist in a
perpendicular fashion. The
presence of odor is judged by
smelling the wrist after 5 seconds
at a distance of about 3 cm.
32. Spoon test
Plastic spoon is used to scrape and
scoop material from the back
region of the tongue. The odor is
judged by smelling the spoon after
5 seconds at a distance of about5
cm organoleptically.
32
35. 35
In these instructions, subjects are asked not to:
1. take antibiotics for 8 weeks before assessment;
2. consume food containing onions, garlic or hot spices for 48 hours
before the baseline measurements;
3. drink alcohol or smoke in the previous 12 hours;
4. eat and drink in the previous 8 hours (drinking water up to 3 hours
before examinations is allowed);
36. 5. perform oral hygiene, including tooth brushing, interdental and
tongue cleaning, and not to use mouthrinses the morning of the
examination;
6. use scented cosmetics or after-shave lotions on the morning of
the examination.
36
37. 37
Organoleptic measurement is a sensory test scored on the basis of the
examiner’s perception of a subject’s oral malodor.
Organoleptic measurement can be carried out simply by sniffing the
patient’s breath and scoring the level of oral malodor.
38. 38
By inserting a translucent tube (2.5 cm diameter, 10 cm length) into
the patient’s mouth and having the person exhale slowly, the breath,
undiluted by room air, can be evaluated and assigned an organoleptic
score.
The tube is inserted through a privacy screen (50cm-70cm) that
separates the examiner and the patient. The use of a privacy screen
allows the patient to believe that they have undergone a specific
malodor examination rather than the direct-sniffing procedure.
41. This electronic meter (Haiimeter, InterScan, Chatsworth, Calif) analyzes
concentration of hydrogen sulfide and methyl-mercaptan , but without
discriminating between them.
38
42. 42
GC, performed with apparatus equipped with a flame photometric
detector, is specific for detecting sulphur in mouth air.
It measures directly the three VSC methyl mercaptan, hydrogen sulfide
and dimethyl sulfide.
GC is considered as the gold standard for measuring oral malodor.
This device can analyze air, saliva, crevicular fluid for a volatile
component.
44. 44
Quick and simple
It detects both VSC and polyamines in the sample.
The absorbent point given with the kit is inserted into thepocket.
Left in place for 1 minute.
Submerge the absorbent point tip in the toxin reagent .
Wait for 5 minutes and see for yellow color in the specimen on the scale of
0-3, which is directly proportional to the level of toxins in thesample.
HALITOX - HALITOSIS LINKED TOXIN DETECTION ASSAY, BY
PENDERGRASS, JAMES, CURTIS
46. 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.
43
47. Used to determine the proteolytic activity of certain oral anaerobes that
contribute to oral malodor.
The test works on the principle that certain periopathogenic bateria have
the capability to reduce N-benzoyl DL-arginine β-napthylamide(BANA)
which can be detected using a chair side test.
48. 48
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.
Another advantage of direct microscopy is that the patient becomes
aware of bacteria being present in plaque, tongue coating, and saliva.
49. 49
0.5 ml of unstimulated saliva is collected in a glass tube (diameter 1.5
cm) and
the tube is flushed with carbon dioxide (CO2) and sealed.
It is incubated at 37° C in an anaerobic chamber under an atmosphere of
80% nitrogen, 10% carbon dioxide, and 10% hydrogen over 3 hours.
The organoleptic ratings highly correlate with VSC and organoleptic
rating of the patient's breath.
Applying the saliva incubation test instead of organoleptic ratings can
reduce the number of patients needed to reach statistical significance of
50%.
50. 50
Miyazaki et al. (1995) divides the tongue into three sections and the
presence or absence of tongue coating is registered as follows:
51. 51
Preventive measures rather than curative aspects are highly
recommended.
Visit dentist regularly
Periodical tooth cleaning by dental professional.
Brushing of teeth twice daily with appropriate brushing techniques
and for a duration of 2-3 mins.
Use of a tongue scraper to get rid of the lurking odour causing
bacteria in the tongue surface.
52. Flossing after brushing to remove food particles stuck in between the
tooth surfaces.
Limit intake of strong odour spicies.
Limit sugar and caffeine intake.
Drink plenty of liquids.
Chew sugar free gum for a minute when mouth feels dry.
Eat fresh fibrous vegetables such as carrots.
52
54. 55
(i) Mechanical reduction of intraoral nutrients and micro-organisms
(ii) Chemical reduction of oral microbial load
(iii) Rendering malodorous gases nonvolatile
(iv) Masking the malodor.
(v) Use of a confidant
55. 1. Mechanical reduction of intraoral nutrients and micro-organisms
- Tongue cleaning
- Tooth brush
- Inter-dental cleaning
- Professional periodontal therapy
- Chewing gum
Image courtesy- Google im5a2ge
57. - Metal salt solutions (eg of metal salts
HgCl2=CuCl2=CdCl2>ZnCl2>SnF2>SnCl2>PbCl2
- Toothpastes
- Chewing gum
Image courtesy-
Google images
54
YoungA, Jonski G, Rolla G, et al:Effects of metal salts on the oral production
of volatile sulfur containing compounds(VSCS). J Periodontal 28:776,2001
59. 5. Use of a Confidant
Research shows that the patients are generally unable to rate the
intensity of their own halitosis.
-Rosenberg et al 1995
Therefore, the patient cannot reliably assess the effectiveness of the
prescribed therapy.
The recommended course of action is to ask them to use another person
as a confidant.
A confidant could be a spouse, a family member or a close friend, who
is willing to smell the patient’s breath and provide straightforward
feedback.
60
60. 61
It’s a common complaint that may periodically affect most of the adult
population. Oral maldor, which is commonly noticed by patients, is an
important clinical sign and symptom that has many etiologies which
include local and systemic factors. It is often difficult for the clinician to
find the underlying pathologies.
Although consultation and treatment may result in dramatic reduction in
bad breathe, patients may find it difficult to sense the improvement
themselves
61. 62
Newman ,Takei, Carranza. Clinical periodontology ; 10th and 11th edition
J lindhe. Clinical periodontology and implant dentistry; vol 1: 5th edition
British Dental Association, Bad Breath FactFile. April2008.
Yaegaki K, Coil JM. Genuine halitosis, pseudo-halitosis and halitophobia: classification,
diagnosis, and treatment. Compend Cont Educ Dent 2000; 21(10A):880–886.
Vineet vaman kini, Richard pereira, Ashvini Padhve, SachinKanagotagi, Tushar Pathak,
Himani Gupta 10.5005/jp-journals-10031-1018; review article; Diagnosis and treatment of
Halitosis: AnOverview
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!.Chron
Young Sci 2012;3:251-7.
Halitox - halitosis linked toxin detection assay, by pendergrass, james, curtis,
2001
YoungA, Jonski G, Rolla G, et al:Effects of metal salts on the oral production of volatile sulfur
containing compounds(VSCS). J Periodontal 28:776,2001
Madhushankari, G S et al. “Halitosis - An overview: Part-I - Classification,
etiology, and pathophysiology of halitosis.” Journal of pharmacy & bioallied
sciences vol. 7,Suppl 2 (2015): S339-43. doi:10.4103/0975-7406.163441
64. • Introduction
• History
• Classification
• Source of Halitosis
• Etiology
• Intra oral causes
• Extra oral causes
• Pathophysiology
• Correlation between the
presence of a pathogenic
microflora in the
subgingival microbiota and
halitosis
• Diagnosis of malodor
• Preventive measures
• Treatment needs
• Treatment of oral
malodour
• Conclusion
• References
3
65. The treatment of oral malodor is based on a cause-
related strategy. Oral malodor is engendered by
microorganisms that cause metabolic degradation of
sulfur containing amino acids, present in available
proteins, into malodorous gases.
Treatment strategies can include:
I. masking the malodor;
II. mechanical reduction of intraoral nutrients,
substrates and microorganisms;
III. chemical reduction of the oral microbial load;
IV. rendering malodorous gases nonvolatile; and
V. chemical degradation of the malodorous gases.
66. Masking agents are frequently used to cover halitosis,
because of their instant relieving effect and commercial
accessibility.
Studies have shown, however, that the use of
mouthrinses, sprays and lozenges containing volatiles
with an agreeable odor only have a short-term effect
(Reingewirtz Y 1999, Replogle W, Beebe D. 1996).
Most common are mint containing lozenges or other
aromas present in rinses, which generally do not contain
any antibacterial agents (Dadamio J 2013).
67. Another pathway used to mask the malodor is to
increase the solubility of malodorous compounds in the
saliva by stimulating the secretion of saliva because of
the simple fact that larger saliva volumes allow
increased amounts of volatile sulfur compounds to
enter solution (Kleinberg I et al 2002).
This can be accomplished by ensuring a sufficient liquid
intake or by using chewing gum, as chewing triggers
the periodontal – parotid reflex.
68. The importance of tongue cleaning has already been
emphasized because of the extensive accumulation of
bacteria on the tongue dorsum (Cicek Y et al 2003,
Rowley E et al 1987, Yaegaki K, Sanada K. 1992).
Previous investigations demonstrated that tongue
cleaning reduces both the amount of coating (including
bacterial nutrients) and the number of bacteria, and
thereby effectively reduces oral malodor. (De Boever EH,
Loesche WJ. 1995, Gilmore E, Bhaskar S. 1972, Gilmore
E et al 1973, Gross A et al 1975, Ralph W. 1988)
69. Other reports indicate that the reduction of microbial
load on the tongue after cleaning is negligible and that
malodor reduction probably results partially from the
reduction of bacterial nutrients. (Menon M, Coykendall
A. 1994, Quirynen M 2004)
Cleaning of the tongue can be carried out with a regular
toothbrush, but in cases where a coating is established,
a tongue scraper is preferred. (Outhouse T, et al 2006,
Pedrazzi V et al 2006)
70. Tongue cleaning using a tongue scraper can reduce the
volatile sulfur compound levels by up to 75% after 1
week (Pedrazzi V et al 2006). To prevent soft-tissue
damage, scraping should be considered as gentle
cleaning.
As the posterior part of the tongue shows the greatest
accumulation of coating (Rosenberg M, Leib E. 1995), it
is recommended to clean as far backwards as possible
without injuring the circumvallate papillae.
Tongue cleaning should be repeated until no more
coating material can be removed (Clark G et al 1997).
71. Gagging reflexes can be provoked, especially when
using brushes (Quirynen M et al 2004), but practice will
help to prevent this (Christensen G. 1998).
It can also be helpful to pull out the tongue with a
gauze pad.
Tongue cleaning has the additional benefit of improving
taste sensation (Quirynen M et al 2004, Winkler S et al
1999).
Toothbrushing and interdental cleaning are essential
mechanical agents of dental plaque control. Both
activities remove organisms and residual food particles
that cause putrefaction. However, clinical studies have
shown that the mechanical action of toothbrushing
alone has no appreciable influence on the concentration
of volatile sulfur compounds (Suarez F et al 2000).
72. Tonzetich & Ng (Tonzetich J, Ng S. 1975) showed a
short-term effect in bad breath reduction after brushing
with a sodium monofluorophosphate-containing
toothpaste. The effect was less than half of what was
observed when combined with tongue brushing (30%
and 73% reduction in volatile sulfur compounds,
respectively).
73. In cases where chronic oral malodor appears
with the presence of periodontitis,
additional periodontal therapy is required
(Bosy A et al 1994, Coil J, Tonzetich J. 1992,
Persson S. 1992, Yaegaki K, Sanada K. 1992)
A one stage full-mouth disinfection,
combining scaling and root planing with the
application of chlorhexidine, can reduce the
organoleptic malodor levels by up to 90%
(Quirynen M et al 1998).
In a more recent study by the same authors,
initial periodontal therapy alone had only a
weak impact on the volatile sulfur
compound levels, except when combined
with a mouthrinse containing chlorhexidine
(Quirynen M et al 2005).
74. Next to toothbrushing, mouth rinsing has become a
common oral-hygiene practice (Gagari E, Kabani S.
1995).
The active ingredients usually include antimicrobial
agents such as:
A. chlorhexidine,
B. cetylpyridinium chloride,
C. essential oils,
D. chlorine dioxide,
E. triclosan,
F. amine fluoride/stannous fluoride,
G. hydrogen peroxide and
H. baking soda.
75. It is considered the most effective
antiplaque and antigingivitis
agent. (Addy M et al 1994, Addy
M, Moran J. 1997, Addy M,
Renton-Harper P. 1997, Bollen C,
Quirynen M. 1996, Jones C. 1997)
Its antibacterial action can be
explained by disruption of the
bacterial cell membrane by the
chlorhexidine molecules,
increasing permeability and
resulting in cell lysis and death
(Jones C. 1997, Kuyyakanond T,
Quesnel L. 1992).
76. Because of its strong antibacterial
effects and superior substantivity in
the oral cavity, chlorhexidine rinsing
results in a significant reduction of
volatile sulfur compound levels and
organoleptic ratings (Carvalho M et al
2004, Rosenberg M et al 1992,
Rosenberg M et al 1991, Van
Steenberghe D et al 2001, Young A et
2003).
77. A study evaluating the short-term effect
(3 h) of a Listerine rinse (which contains
essential oils), found Listerine to be only
moderately effective against oral malodor
(25% reduction vs. 10% for placebo, of
volatile sulfur compounds at 30 min after
rinsing) and to cause a sustained
reduction in the levels of odorigenic
bacteria (Pitts G et al 1993). Similar
reductions in volatile sulfur compounds
were found after rinsing for 4 days
(Carvalho M et al 2004).
78. Rosenberg et al. (1992) designed a two-phase oil–water
rinse containing cetylpyridinium chloride.
The efficacy of oil–water–cetylpyridinium chloride
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
cetylpyridinium chloride.
A twice-daily rinse with this product showed reductions
in both volatile sulfur compound levels and organoleptic
ratings. These reductions were superior to Listerine and
significantly superior to a placebo (Kozlovsky A et al
1996, Rosenberg M et al 1992).
79. Triclosan, a broad-spectrum antibacterial agent, has
been found to be effective against most oral bacteria
and has a good compatibility with other compounds
used for oral home care.
A pilot study demonstrated that an experimental
mouthrinse containing 0.15% triclosan and 0.84% zinc
produced a stronger, and more prolonged, reduction in
bad breath than a Listerine rinse (Raven S et al 1996).
However, the anti-volatile sulfur compound effect of
triclosan seems to be strongly dependent on the
solubilizing agents (Young A et al 2002).
80. Flavoring oils or anionic detergents and copolymers are
added to increase the oral retention and decrease the
rate of release in toothpaste formulations containing
triclosan.
The effect of these toothpaste formulations in oral
malodor has been illustrated in several studies (Hu D et
al 2003, Niles H et al 2005, 1999, Sharma N et al 1999,
2007).
Significant reductions of the breath scores were
observed after a single use, as well as after 1 week (28%
and >50%, respectively), with similar effects on the
volatile sulfur compound levels (57% reduction after 1
week).
81. Stannous fluoride has been shown to be effective in the
management of oral malodor as a component of a
dentifrice for reducing both organoleptic scores and
volatile sulfur compound levels (Gerlach R et al 1998).
A superior short term and overnight benefit of a
stannous-containing dentifrice compared with a control
dentifrice on morning bad breath has been recently
demonstrated in a meta-analysis (Feng X et al 2010).
The association of amine fluoride with stannous fluoride
(amine fluoride/stannous fluoride) resulted in
encouraging reductions of morning breath odor, even
when oral hygiene was insufficient (Quirynen M et al
2002).
82. Recently, new evidence supporting the use of
this amine fluoride/stannous fluoride rinse
became available. The formulation showed
short and long-term effects on malodor
indicators in patients with obvious malodor
(Dadamio J et al 2013).
83. Suarez et al. (2000) demonstrated that rinsing
with 3% hydrogen peroxide produced
impressive reductions (90%) in sulfur gases,
which persisted for 8 h.
However, side effects (including oral
ulcerations) of the routine use of hydrogen
peroxide mouthrinses have been reported
(Rees T, Orth C. 1986).
In addition, there is some concern about the
potential carcinogenic effects of hydrogen
peroxide. (Lopez-Lazaro M. 2007, Murata M et
al 2003, Reiter M et al 2009, Weitzman S et al
1986)
84. Greenstein et al. (1997) reported
that sucking a lozenge with
oxidizing properties can reduce
tongue dorsum malodor for 3 h.
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.
85. Baking soda dentifrices have been shown to achieve a
significant odor-reducing benefit for time periods up to
3 h. (Brunette D et al 1998, Niles H, Gaffar A. 1995)
The mechanisms by which baking soda inhibits oral
malodor are related to its bactericidal effects (Putt M et
al 2008).
86. Metal salt solutions
Some metal ions are efficient in capturing sulfur
containing gases.
Zinc is an ion with two positive charges (Zn++),
which can bind to the twice-negatively loaded sulfur
radicals and thus reduce the expression of the
volatile sulfur compounds.
The same applies for other metal ions, such as
stannous, mercury and copper.
Clinically, the comparative volatile sulfur compound
inhibitory effect is CuCl2 > SnF2 > ZnCl2.
In vitro, the comparative inhibitory effect is HgCl2 =
CuCl2 = CdCl2 > ZnCl2 > SnF2 > SnCl2 > PbCl2
(Young A et al 2001).
87. Compared with other metal ions, zinc is relatively
nontoxic, noncumulative, gives no visible discoloration
and is one of the ingredients most commonly studied
for the control of oral malodor (Waler S. 1997, Young A
et al 2001).
Schmidt & Tarbet (1978) reported that a rinse
containing zinc chloride was remarkably more effective
than a saline rinse (or no treatment) in reducing the
levels of both volatile sulfur compounds (80% reduction)
and organoleptic scores (40% reduction) for 3 h.
Halita, a mouthrinse containing 0.05% chlorhexidine,
0.05% cetylpyridinium chloride and 0.14% zinc lactate,
has been demonstrated to be more effective than a 0.2%
chlorhexidine formulation in reducing the volatile sulfur
compound levels and organoleptic ratings. (Quirynen M
et al 2002, Van Steenberghe D et al 2001)
88. The effect of Halita may result from the
volatile sulfur compound conversion ability
of zinc, besides its antimicrobial action.
The combination of Zn++ and
chlorhexidine seems to act synergistically
(Young A et al 2003).
The addition of zinc ions to a basic
formulation containing amine fluoride and
stannous fluoride caused a short- and
long-term reduction of oral malodor
indicators in volunteers with morning bad
breath (Wigger-Alberti W et al 2010,
Wilhelm D et al 2010) as well as in
volunteers with obvious halitosis (Dadamio
J et al 2013).
89. In a study by Hoshi & van Steenberghe (1996), a zinc
citrate/triclosan toothpaste applied to the tongue
dorsum appeared to control morning breath malodor
for 4 h. However, if the flavor oil was removed, the
antimalodor efficacy of the active ingredients
decreased.
Another clinical study reported a reduction of up to 41%
in volatile sulfur compound levels after 7 days’ use of a
dentifrice containing triclosan and a copolymer, but the
benefit compared with a placebo was relatively small
(17% reduction) (Niles H et al 1999).
Similar reductions were also found in two other, more
recent, studies (Hu D et al 2003, Niles H et al 2005).
Chewing gum is often formulated with antibacterial
agents, such as fluoride or chlorhexidine, helping to
reduce oral malodor through both mechanical and
chemical approaches.
90. Tsunoda et al. (1996) investigated the mode
of action of chewing gum containing tea
extracts. The chemical reaction between
epigallocatechin, the main deodorizing
agent among the tea catechins, and methyl
mercaptan, resulted in a nonvolatile
product.
Waler (1997) compared different
concentrations of zinc in a chewing gum
and found that retention of chewing gum,
containing 2 mg of Zn++ acetate, in the
mouth for 5 min resulted in an immediate
reduction in the volatile sulfur compound
levels of up to 45%, but the long-term effect
was not mentioned.
91. Chlorine dioxide
Chlorine dioxide and chlorite anion are
powerful oxidizing agents that can
combat bad breath by the oxidation of
hydrogen sulfide and methyl mercaptan
to nonmalodorous compounds.
Through this oxidation, the precursor
amino acids methionine and cysteine are
consumed (Shinada K et al 2008). The
chlorite anion has a strong bactericidal
effect on odorigenic microorganisms
(Shinada K et al 2008). .
92. Studies have shown that the single use of a chlorine
dioxide-containing oral rinse only slightly reduces
mouth odor (Frascella J et al 2000, Shinada K et al
2008).
A recent study by Aung et al. (2015) showed that a
chlorine dioxide mouthwash reduced the levels of
volatile sulfur compounds significantly and kept these
volatile sulfur compound levels low during the study
period of 4 weeks. In addition, tongue coatings were
significantly reduced when using a chlorine dioxide
mouthwash without tongue cleaning (Aung et al. 2015).
93. Halitosis is a complex phenomenon that is mainly a
problem of oral origin.
The oral origin of halitosis is supported by the
observation that pathogenic oral bacteria are able to
putrefy a variety of substrates, including plaque, food
debris and epithelial cells, which are present in a variety
of oral niches, but mostly on the tongue dorsum.
The presence and amount of tongue coating is therefore
crucial in oral malodor.
On the other hand, the role of periodontal diseases has
not been fully ruled out.
94. Epidemiological data have shown that periodontal
diseases can be an additional, but less important, cause
of oral malodor as not all periodontally affected patients
will have oral malodor, and periodontally healthy
patients can present with malodor.
In a small number of patients, gingivitis or periodontitis
can be the single cause of halitosis. Several studies
suggest that it is more likely that inflamed periodontal
tissue (as measured by the bleeding index), rather than
the depth of pockets, is related to the formation of
volatile sulfur compounds.
As interdental spaces become larger in periodontally
affected patients, more food is impacted and
putrefaction becomes prevalent. Moreover, patients with
periodontitis harbor specific periodontal pathogens,
which have been associated with oral malodor.
95. It is a logical consequence that these organisms will
settle on other surfaces where they can grow and
multiply.
Therefore, the tongue dorsum is an ideal environment
for the generation of oral malodor.
In addition, studies in patients with periodontitis have
shown that with more tongue coating there is a greater
prevalence of P. gingivalis and levels of volatile sulfur
compounds.
Toxic volatile sulfur compounds are able to damage the
periodontal tissues, creating even more loss of
attachment. There is a mutual reinforcement of the loss
of periodontal attachment and production of volatile
sulfur compounds, resulting in a vicious cycle.
To break this cycle, an optimal oral hygiene regimen is
required.
96. The key message to patients is to clean the tongue
surface regularly because this approach reduces the
levels of volatile sulfur compounds by more than 70%.
Additional reductions of volatile sulfur compound levels
can be achieved by periodontal treatment and the use of
mouthwashes.
Chlorhexidine remains the most efficient anti-plaque
and anti-gingivitis agent.
Other antimicrobial products that contain
cetylpyridinium chloride, essential oils, chlorine dioxide,
triclosan, amine fluoride/ stannous fluoride, hydrogen
peroxide, baking soda and metal ions (Zn++) may also
be effective anti-plaque and anti-gingivitis agents.
Some of these agents only have a temporary effect on
the total number of microorganisms in the oral cavity.
Zn++ and chlorhexidine seem to act synergistically.
Chewing gum can reduce bad breath by increasing
salivary flow and enhancing the solubility of malodorous
compounds in the saliva. However, this effect is
transient.
97. 98
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