Halitosis

1

GOOD MORNING

2

HALITOSISGUIDED BY:-Dr. Anita PanchalDr. Hardik MehtaDr. Sachin K.Dr. Bhaumik NanavatiDr. Rahul Shah

PRESENTED BY:-Dr. Ganesh NairFirst Yr. PGDept. of Periodontology and Implantology

3

INDEX• Introduction • Classification• Etiology

• Intra oral causes• Extra oral causes

• Role of volatile sulphur compounds in the pathogenesis of halitosis• 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

4

INTRODUCTION 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

SYNONYMS Bad or foul breath

Breath malodour

Oral malodour

Foetor ex-ore

Foetor oris

Stomato dysodia

6

DEFINITIONS

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 fo tobacco products. Also known as fetor ex ore, fetor oris, and stomatodysodia, and commonly referred to as "bad breath".

-American academy of periodontology: Glossary

8

CLASSIFICATIONPseudo halitosis

Genuine halitosis

Physiological halitosis

Tongue coating

Pathological halitosis

Periodontium

ANUG

ANUP

Periodontitis

Others

Xerostomia

Caries

Temporary halitosis(morning bad breath)

Lu, D.P. (1982). Halitosis: an etiologic classification, a treatmentapproach, and prevention. Oral Surgery, Oral Medicine andOral Pathology 54, 521–526.

9

GENUINE HALITOSIS Physiological halitosis

Morning breath odour, tobacco smoking & certain foods &

medications.

Pathological halitosis

intra oral or extra oral origin

90% of patients → oral cavity

Bacteria, volatile sulphur compounds.

10

Pseudo halitosis

Apparently healthy individuals

Haltophobia

exaggerated fear of having halitosis

also referred as delusional halitosis

considered variant of monosymptomatic hypochondrial psychosis or

Ekbom syndrome.

11

ETIOLOGY:- Intra oral origin- 80-90%

poor oral hygiene, dental caries, periodontal diseases in particular

NUG, NUP, periodontitis, pericoronitis, dry socket, other oral

infections, tongue coating & oral carcinoma.

12

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

13

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

14

Common causes of halitosis

1) Local Causes

Oral diseases

Food impaction

ANUG

Acute gingivitis

Adult and aggressive

periodontitisPericoronitisDry socket

XerostomiaOral

ulcerationOral

malignancy

A.

15

RESPIRATORY DISEASES

SINUSITIS

TONSILLITIS

MALIGNANCY

BROCHIECTASIS

B.

16

VOLATILE FOOD STUFF

GARLIC ONIONS SPICES

C.

17

2) SYSTEMIC CAUSES Acute febrile illness

Leukemia

Respiratory tract infection

(usually upper)

Helicobacter pylori infection

Pharyngo-oesophageal

diverticulum Gastro-oesophageal reflux

disease

•Pyloric stenosis or duodenal

obstruction

•Hepatic failure (fetor

hepaticus)

•Renal failure (end stage)

•Diabetic ketoacidosis

•Trimethylaminuria

•Hypermethioninaemia

•Menstruation (menstrual

breath)

18

EXAMPLES OF SYSTEMIC PATHOLOGICAL CONDITIONS WITH THEIR CHARACTERISTIC ODOUR

Systemic diseases Characteristics odourDiabetes mellitus Acetone , sweet fruity.

Renal failure Urine or ammonia

Liver failure Fresh cadaver

Tuberculosis/ lung abscess Foul, putrefactive

Internal hemorrhage/ blood disorders Decomposed blood

Fever , dehydration Odour due to xerostomia and poor oral hygiene.

19

ROLE OF VOLATILE SULPHUR COMPOUNDS IN THE PATHOGENESIS OF HALITOSIS

Major compounds implicated in halitosis

VSC’s - Methylmercaptan, Hydrogen sulfide, dimethyl sulfide &

Dimethyl disulfide. Polyamides - Putrescein, Cadaverine, Skatole, Indole. Short chain Fatty Acids - Butyric, Propionic, Valeric & Isovaleric acid. Others - Acetone, Acetaldehyde, Ethanol diacyl.

20

It increases the permeability of oral mucosa and crevicular epithelium. It impairs oxygen utilization by host cells, and reacts with cellular proteins, and interferes with collagen maturation.

It increases the secretion of collagenases, prostaglandins from fibroblasts.

Which in turn increases the collagen solubility. VSC also reduce the intracellular pH; inhibit cell growth, and

periodontal cell migration. It decrease the DNA synthesis.

21

ODOUR QUALIFICATION OF SOME COMPOUNDS

Tangerman, A. (2002). Halitosis in medicine: a review. InternationalDental Journal 52 (Suppl 3), 201–206.

22

PATHOGENESIS OF ORAL MALODOR:

Diet +bacteri

a+ epithelial

cells

Peptides/ proteins

Amino acids

Putrefaction

products

Oral malodor

Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.

23

CORRELATION BETWEEN THE PRESENCE OF A PATHOGENIC MICROFLORA IN THE SUBGINGIVAL MICROBIOTA AND HALITOSIS:

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.

24

Sato and colleagues found that the number of leukocytes increased in the saliva of patients with periodontitis and that the level of methyl mercaptan produced correlated with bleeding on probing, pocket depth and gingival exudate

Recent studies indicate the presence of solobacterium moorei associations with oral malodour

-Haraszthy VI, Gerber D, Clark B et al

25

MICROORGANISMS AND THEIR CAUSATIVE ODOUR

26

SOME DRUGS THAT CAUSE HALITOSIS Tobacco

Alcohol

Chloral hydrate

Nitrites and nitrates

Dimethyl sulfoxide

Disulfiram

Cytotoxic agents

Phenothiazines

Amphetamines

27

DIAGNOSIS 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.

28

Wrist lick test

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.

Image courtesy- taken from Carranza’s Clinical Periodontology, 10th Edition

29

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.

30

Dental floss test

Unwaxed floss is passed through interproximal contacts.

31

OBJECTIVE TESTS

Organoleptic measurement

Gas chromatography (GC)

Sulphide monitoring

Electronic nose

BANA test

Tongue costing index

Dark Field or Phase Contrast Microscopy

Saliva Incubation Test

32

INSTRUCTIONS BEFORE FIRST VISITIn 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);

33

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. If the patient has any condition like diabetes, which will be

aggravated by fasting for the period of time indicated, please contact the dentist about alternative methods of preparation.

34

ORGANOLEPTIC MEASUREMENT (SNIFF TEST)

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.

35

METHODOLOGY

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.

36

Image courtesy- Clinical periodontology and implant dentistry 5th edition and google images

37

ORGANOLEPTIC SCORES (0- 5) BY ROSENBERG , MULLOCH ET AL 1991

Yaegaki, K. & Coil, J.M. (2000). Examination, classification, andtreatment of halitosis; clinical perspectives. Journal of theCanadian Dental Association 66, 257–261.

38

VOLATILE SULFIDE MONITOR:

This electronic (Haiimeter, InterScan, Chatsworth, Calif) analyzes concentration of hydrogen sulfide and methyl-mercaptan , but without discriminating between them.


39

GAS CHROMATOGRAPHY (GC):

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 the gold standard for measuring oral malodor.

This device can analyze air, saliva, crevicular fluid for a volatile

component.

40


41

HALITOXTM SYSTEM:

Quick and simple

It detects both VSC and polyamines in the sample.

The absorbent point given with the kit is inserted into the pocket.

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 the sample.

HALITOX - HALITOSIS LINKED TOXIN DETECTION ASSAY, BY PENDERGRASS, JAMES, CURTIS

42Image courtesy- Google images

43

ELECTRONIC NOSE:

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.

Image courtesy- Google images

44

BANA TEST:

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.


45

DARK FIELD OR PHASE CONTRASTMICROSCOPY

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.

46

SALIVA INCUBATION TEST 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%.

47

TONGUE COATING INDEXMiyazaki et al. (1995) divides the tongue into threesections and the presence or absence of tonguecoating is registered as follows:

0 = none visible; 1 = less than one third of tongue dorsum is covered; 2 = between one and two thirds; 3 = more than two thirds.

(Miyazaki et al. 1995; Gomez et al. 2001; Winkel et al. 2003; Lundgren et al. 2007).

48

PREVENTIVE MEASURES:

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.

49

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.

50

51

MANAGEMENT OF ORAL MALODOUR:-(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

52

1. Mechanical reduction of intraoral nutrients and micro-organisms- Tongue cleaning- Tooth brush- Inter-dental cleaning- Professional periodontal therapy- Chewing gum


53

2. Chemical reduction of oral microbial load- Chlorhexidine- Essential oils- Chlorine dioxide- Two-phase oil- water rinse- Triclosan- Aminefluoride/ Stannous fluoride- Hydrogen peroxide- Oxidising lozenges


54

3.Conversion of volatile sulfide compounds- Metal salt solutions (eg of metal salts

HgCl2=CuCl2=CdCl2>ZnCl2>SnF2>SnCl2>PbCl2

- Toothpastes- Chewing gum


Young A, 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

55

4. Masking the malodor-Rinses-Mouth sprays-Lozenges containing volatiles-Chewing gum


56

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.

57

CONCLUSION:

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

58

REFERENCES: 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. April 2008. 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, Sachin Kanagotagi, Tushar Pathak, Himani Gupta 10.5005/jp-journals-10031-1018; review article; Diagnosis and treatment of Halitosis: An Overview

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

Young A, 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

`THANK YOU

Health & Medicine

Halitosis