BDS class on halitosis, antiplaque, antigingivitis.pptx

bds class

1. HALITOSIS

2. INTRODUCTION Bad breath can be detrimental to one's self-image and confidence causing social, emotional, and psychological anxiety. Breath malodour may be an important factor in social communication and, therefore, may be the origin of concern not only for a possible health condition but also for frequent psychological alterations leading to social and personal isolation.

3. Breath odor can be defined as the subjective perception after smelling someone’s breath.It can be pleasant ,unpleasant or even disturbing. Breath malodor,halitosis or bad breath are terms used to describe an unpleasant or offensive odor emanating from the oral cavity. The term halitosis was introduced by Listerine company in 1921.

4. Halitosis is actually a combination of the Latin ‘halitus’, meaning "breath" and the Greek ending ‘osis’ often used to describe a medical condition; such as, cirrhosis of the liver. The recognition of oral malodor often begins with the complaint of the subject who either believes that he or she has bad breath or has been told as much by another individual.

5. CLASSIFICATION OF HALITOSIS Genuine halitosis Pseudo- halitosis " Genuine halitosis " is where the breath malodour is a real problem that can be easily diagnosed either by organoleptic or by physic-chemical means.

6. “ Pseudo-halitosis ” is where the oral malodour does not exist, but the patient believes that he or she has it.  If after successful treatment for either genuine halitosis or pseudo-halitosis the patient still believes that he or she has halitosis, then the diagnosis is termed "halitophobia." ,[Oxtoby & Field 1994].

7. Genuine halitosis physiologic halitosis pathologic halitosis Physiologic halitosis ( transient halitosis ) Has its origin in the dorsum of the tongue, is self-limited, does not prevent the patient from carrying out a normal life, and usually does not need any therapy.  This situation, also termed "morning breath ," is more a cosmetic problem than a health-related condition.

8. Pathologic halitosis This is permanent, does not resolve by usual oral hygiene methods, and prevents the patient from carrying out a "normal" life.  Pathologic halitosis should be treated and its therapeutic approach will depend on the source of the malodour. 

9. Depending on its origin, this pathologic halitosis has been sub classified as follows: Oral:   the origin of the pathologic condition is in the oral cavity and/or in the posterior dorsum of the tongue Extra oral:   the origin of the pathologic condition is outside of the mouth (upper/lower respiratory tract, digestive system, systemic disorders, etc.)

10. FACTORS INVOLVED IN THE ETIOLOGY OF HALITOSIS : The unpleasant smell of breath mainly originates from volatile sulfide compounds (VSCs),especially hydrogen sulfide ,methylmercaptan and dimethyl sulfide[1st discovered by Tonzetich,1976]. Other compounds in mouth air may also be offensive such as diamines (eg.,putrescine, cadaverine),indole,skatole and butyric or propionic acid.

11. List of volatile organic compounds produced by saliva or tongue coatings in vitro,[Goldberg et al.1995].

12. The volatile sulphur compounds result from the proteolytic degradation by oral microorganisms of peptides present in saliva,shed epithelium,food debris, gingival crevicular fluid,interdental plaque, postnasal drip and blood. Most malodorous compounds express themselves only when they are volatile.

13. INTRAORAL CAUSES: 1.DENTITION: Deep carious lesions with food impaction and putrefaction, extraction wounds filled with blood clot,purulent discharge,interdental food impaction ,acrylic dentures kept in the mouth at night or not regularly cleaned etc . 2.PERIODONTAL INFECTIONS: The gram –ve bacteria associated with gingivitis and periodontitis [Porphyromonas gingivalis,

14. Actinobacillus actinomycetemcomitans,Prevotella etc produce VSC. The amount of VSCs in breath increases with the number,depth and bleeding tendency of the periodontal pockets . VSCs aggravate the periodontitis process; they increase the permeability of the pocket and mucosal epithelium and therefore expose the underlying connective tissues of the periodontium to bacterial metabolites.

15. 3.DRY MOUTH: Patients with xerostomia present large amounts of plaque on teeth,prostheses and tongue dorsum.The increased microbial load and the escape of VSCs as gases when the saliva is drying up leads to halitosis. 4.TONGUE AND TONGUE COATING: Many studies implicate that the tongue is the primary source of oral malodor. The large surface area of the tongue can harbor high numbers of bacteria .

16. The innumerable depressions in the tongue surface area are ideal niches for bacterial adhesion and growth ,sheltered from cleaning actions . The desquamated cells,food remnants remain trapped in the retention sites,then putrefied by the bacteria and forms a coating on the dorsum of the tongue giving rise to oral malodour, [Bosy et al.1994].

17. EXTRAORAL CAUSES 1.EAR-NOSE-THROAT: The ENT causes include acute pharyngitis (viral or bacterial),purulent sinusitis,purulent tonsillitis, postnasal drip. Postnasal drip is associated with chronic sinusitis or regurgitation esophagitis,in which the acidic content of the stomach reaches the nasopharynx and causes mucositis This is perceived by patients as a liquid flow in the throat,originating in the nasal cavity causing a very strong breath malodor, [Rosenberg 1995].

18. 2.BRONCHI AND LUNGS: Pulmonary causes include chronic bronchitis,bronchiectasis,bronchial carcinoma. 3.GASTROINTESTINAL TRACT: The following pathologies might be rarely responsible for less than 1% of malodor: Zenker”s diverticulum (hernia in esophagal wall,allowing accumulation of food and debris and thus putrefaction),[Crescenzo et al.1998]. Gastric hernia can cause reflux of the gastric contents up to the oropharynx

19. Regurgitation esophagitis . 3.LIVER: Cirrhosis of liver,ammonium will accumulate in the blood and will be exhaled, [Chen et al.1970]. 4.KIDNEY: Chronic glomerulonephritis,leads to an increased uric acid level in the blood, which is expressed in the expired air with a typical ammonium like breath. Intestinal gas production,some gases ( e.g., dimethylsulfide) are absorbed but not metabolized by the intestinal endothelium and thus transported by the blood and these gases are exhaled through the lungs.

20. 5.SYSTEMIC METABOLIC DISORDERS: Type I (insulin-dependent ) and Type II (non-insulin-dependent),in particular Type I can result in accumulation of ketones. 6. TRIMETHYLAMINURIA : Trimethylaminuria is an enzymatic defect that prevents the transformation of trimethylamine to trimethylaminoxide,resulting in abnormal amounts of this molecule. This leads to a typical fishy odor of breath,urine,sweat,expired air,[Mitchell & Smith 2001].

21. 7.HORMONAL CAUSES: Increased progesterone levels during menstrual cycle also causes a typical breath odor. VSC levels in the expired air are increased twofold to fourfold about the day of ovulation and in the premenstrual period. The breath during ovulation and menstruation has been described as a “mousy” odor. 8.MEDICATIONS: Certain drugs like metronidazole can cause breath odor (metallic taste), eucalyptus – melon like,arsenic - rotten onions.

22. DIAGNOSIS OF MALODOR Medical History: Through questioning about medical history. Ask about all relevant pathologies “ Listen to the patient, and the patient will tell you the diagnosis” Ask about frequency, time of appearance, whether anyone mentioned, what medications taken, whether patient has dryness of mouth or other symptoms.

23. The proper diagnostic approach to a malodor patient starts with a thorough questioning about the medical history. Self-Examination: The following self-testing can be used: Smelling a metallic or nonodorous plastic spoon after scraping the back of the tongue. Smelling a toothpick after introducing it in an interdental area. Licking the wrist and allowing it to dry .

24. Smelling saliva spit in a small cup or spoon (especially when allowed to dry for a fewseconds so that putrefaction odors can escape from the liquid). ORGANOLEPTIC MEASUREMENT The examiner should test their capacity to smell and recognize different odors (qualitative assessment) as well as their capacity to detect odors at low concentrations (quantitative assessment). Organoleptic scores, or the use of one’s nose to smell and rank the intensity of the odors emanating from the mouth,is the gold standard for the measurement of oral malodor.

25. Organoleptic Scores [Rosenberg & Mcculloch J.P. 1992] 0= no appreciable odor 3= moderate odor 1= barely noticeable odor 4= strong offensive odor 2= slight but noticable odor 5= extremely foul odor Organoleptic Scale (0-5).

26. Before the organoleptic assessment, both patients and examiner must follow some instructions in order to obtain a more reliable result. The use of any fragrance, shampoo, or body lotion, smoking and consumption of alcohol , garlic are prohibited 12 hours before the organoleptic assessment ,this applies to both the patient and the judge . Patients abstain from using oral rinse and breath fresheners also.

27. The judge smells a series of different air samples : 1.Oral cavity odor - The subject opens the mouth and refrains from breathing while the judge places his or her nose close to the mouth opening and smells the air while the patient counts from 1 to 20. 2.Breath odor- The subject expires through the mouth while the judge smells both at the beginning and at the end of the expiration .

28. 3.Tongue coating - The judge smells a tongue scraping. 4.Nasal breath odor - The subject expires through the nose, keeping the mouth closed. When the nasal expiration is malodorous, whereas the air expired through the mouth is not, a nasal/paranasal cause can be suspected .

29. Specific Character of Breath Odor A "rotten eggs" smell is indicative of VSCs. A sweet odor , has been associated with liver insufficiency; The smell of "rotten apples" has been associated with unbalanced insulin-dependant diabetes, which leads to the accumulation of ketones. A ‘fish odor’ can suggest kidney insufficiency chacterized by uremia and accumulation of dimethylamine and trimethylamine.

30. HALIMETER ( portable volatile sulfide monitor) This is a portable electronic device which analyzes the concentration of hydrogen sulfide and methyl mercaptan,but without discriminating them. The examination should preferably be done after at least 4 hours of fasting and after keeping the mouth closed for 3 minutes. The mouth air is aspirated by inserting a drinking straw fixed on the flexible tube of the instrument.

31. Halimeter The straw is kept about 2 cm behind the lips, without touching any surface and while the subject keeps the mouth slightly open and breathes normally.

32. The sulfide meter uses a voltametric sensor that generates a signal when exposed to sulfur-containing gases, especially hydrogen sulfide. Absence of breath malodor leads to readings of 100 ppb or lower. Patients with elevated concentrations of VSCs readings are 300 to 400 ppb. This has high sensitivity for hydrogen sulphide but low sensitivity for methyl mercaptan which is a significant contributor to halitosis caused by periodontal disease,(Yaegaki K, Coil JM,2000 ).

33. GAS CHROMATOGRAPHY This device can analyze air, (incubated) saliva, or crevicular fluid for any volatile component, (Goldberg et al.1994). Elaborate gas chromatography is especially useful for identifying nonoral causes. Small,portable gas chromatograph can be used in periodontal clinics which has the capacity to measure the concentration of the three key sulfides separately.

34. Small amount of the breath sample, aspirated with a plastic syringe, is injected into the input port of the Gc. The computer displays the detection and amount of the three important VSCs (in ppb) within 8 minutes. Portable gas chromatograph

35. Dark-field or Phase contrast microscopy Gingivitis and periodontitis are associated with high incidence of motile organisms and spirochetes – shift in these proportions allow monitoring of therapeutic progress. Another advantage is that patient becomes aware of bact. present in plaque,tongue coating and saliva. High proportions of spirochetes in plaque causes specific acidic malodor.

36. SALIVA INCUBATION TEST 0.5 ml of unstimulated saliva is collected in a glasstube (diameter 1.5cm), and the tube flushed with carbon dioxide (C02) and sealed. The sealing prevents inflow from outside air, and the glass prevents the smell of the hardware. It is incubated at 37 deg C in an anaerobic chamber under an atmosphere of 80% nitrogen, 10% carbon dioxide, and 10% hydrogen over 3 hours.

37. The headspace air in the tubes above the incubated saliva is examined for VSC production and organoleptic measurements. The organoleptic ratings highly correlate with VSC and organoleptic rating of the patient's breath.[Quirynen et al.2002]. BANA TEST Three bacteria’s associated with periodontal disease,Treponema denticola, Porphyromonas gingivalis and Tanneralla forsythus produce both volatile sulfur compounds and volatile fatty acids such as butyrate and propionate .

38. Their detection in plaque and/or tongue samples might provide additional information concerning factors contributing to the individual’s malodor. These organisms can be detected in plaques samples by the presence of an enzyme(s) that degrades benzoyl-DL-arginine-α- naphthylamide (BANA), a synthetic trypsin substrate ,forming a colored compound. A chair side enzyme assay (5-10 mins) can be done with the help of ( BANA Test,Oratec,Manassas,VA) that detects the presence of this enzyme(s) in plaque and tongue samples,[ Loesche et al.1992].

39. BANA Test Electronic nose. TREATMENT OF ORAL MALODOR The treatment of oral malodor should preferably be cause related. Treatment of extra-oral pathologic halitosis and halitophobia should be undertaken by a medical specialist,psychologist .

40. The best way to treat oral malodor is to motivate patients to practice good oral hygiene home care. Toothbrushing accompanied by tongue cleaning results in a substantial reduction in VSC levels, and in morning breath. Antimicrobial mouthrinses may also have a beneficial effect on periodontal pathogens producing oral malodor.

41. The following general treatment strategies can be applied: Mechanical reduction of intraoral nutrients and microorganisms Chemical reduction of oral microbial load Rendering malodorous gases nonvolatile Masking the malodor

42. Mechanical reduction of intraoral nutrients and microorganisms : Tongue cleaning reduces both the amount of coating (and thus bacterial nutrients) and the number of organisms and thereby reducing oral malodor effectively,[Gilmore et al.1972] . Interdental cleaning with both waxed and unwaxed dental floss and toothbrushing are essential mechanical means of dental plaque control. Cleaning of the tongue can be carried out with a normal toothbrush, a tongue scraper , clean as far as possible , the posterior portion of the tongue .

43. In periodontitis – periodontal therapy , one-stage full-mouth disinfection, combining scaling and root planing with the application of chlorhexidine, reduced the organoleptic malodor levels up to 90%. Dentures should be removed at bedtime and cleaned and soaked in a dental cleaning solution. Chemical Reduction of Oral Microbial Load: The active ingredients in oral rinses are usually antimicrobial agents such as chlorhexidine, cetylpyridinium chloride (CPC), essential oils, chlorine dioxide, hydrogen peroxide, and triclosan.

44. All the agents have only a temporary reducing effect on the total number of microorganisms in the oral cavity. Chlorhexidine rinses : Rinsing with 0.12 % chlorhexidine gluconate, in combination with tooth and tongue brushing, significantly reduced VSC levels,mouth odor, [DeBoever and Loesche 1995]. Because of its strong antibacterial effects ,superior substantivity in the oral cavity, chlorhexidne rinsing provides significant reduction in VSC levels and organoleptic ratings.

45. \ Halita, a new solution (0.05% chlorhexidine,0.05 % CPC, 0.14% zinc lactate, no alcohol) is more efficient than chlorhexidine alone. Essential Oils : Listerine is only relatively effective against oral malodor and caused a sustained reduction in the levels of odorigenic bacteria. Chlorine Dioxide Rinses : This is a powerful oxidizing agent that can eliminate bad breath by oxidation of hydrogen sulfide, methylmercaptan,and the amino acids methionine and cysteine.

46. `` Triclosan rinses : Triclosan, a broad-spectrum antibacterial agent is effective against most oral bacteria. Mouth rinse containing 15% triclosan and 0.84% zinc produced a more prolonged reduction in mouth odor . Two-Phase Oil-Water Rinse: A two-phase oil-water rinse containing CPC(designed by Rosenberg et al .1992) is shown to result in daylong reduction in oral malodor.

47. The efficacy of oil-water-CPC formulation results 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 rinse showed reductions in both VSC levels and organoleptic ratings. Aminefluoride/Stannous Fluoride rinses are also effective in reducing oral malodor.

48. Oxidizing Lozenges: Sucking a lozenge with oxidizing properties reduces the tongue dorsum malodor for 3 hours,[Greenstein et al.1997]. 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. Hydrogen peroxide 3% rinse produced reduction in sulphur gas that persisted for 8 hours.

49. Conversion of Volatile Sulfide Compounds : Metal Salt Solutions: Zinc is an ion with two positive charges (Zn++),which binds to the twice-negatively loaded sulfur radicals,and thus can reduce the expression of the VSCs . Halita, a rinse containing 0.05 % chlorhexidine, 0.05% CPC, and 0.14% zinc lactate is more efficient than a 0.2% chlorhexidine formulation in reducing the VSC levels and organoleptic ratings which acts by the VSC conversion ability by zinc,[Young et al.2003].

50. Toothpastes: Baking soda dentifrices are effective with a 44% reduction of VSCs levels 3 hours after toothbrushing versus a 31%reduction for a fluoride dentifrice,[Niles & Gaffar 1995]. 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. Sodium fluoride containing paste , zinc citrate/triclosan toothpaste also show a reduction in VSC levels .

51. Chewing Gum: Chewing gum containing tea extracts Epigallocatchin (EGCg) reduces oral malodor to some extent. The chemical reaction between EGCg and CH3SH results in nonvolatile product. 2mg Zn++ acetate containing chewing gum also shows a reduction in VSC levels upto 45%. MASKING THE MALODOR Mouthrinses,mouth sprays ,lozenges with pleasant odor etc have only a short term effect.

52. Another way to mask malodor is to increase the solubility of malodorous compounds in the saliva by lowering the pH of saliva since low pH increases the solubility of VSCs,or increase the secretion of saliva because a larger volume allows the retention of larger volumes of soluble VSCs. Increase in salivary secretion can be achieved by proper liquid intake,chewing sugarless gum ,it also neutralize acids in the mouth. To lower the pH ,an orange juice is sufficient,but only a short term effect.

53. CONCLUSION Bad breath is a major concern for many people. Because it nearly always originates in the mouth it can and should be diagnosed and treated professionally. Recent developments in the understanding of the etiologies of breath malodor have spawned new techniques for its assessment and management.

54. REFERENCES Clinical Periodontology-Carranza -10th edition. Clinical Periodontology and Implantology -Jan Lindhe 4th edition. Periodontology 2000,Vol.28,2002, Microbiology and treatment of halitosis. Journal of CDP,vol 2,2005.

55. 55 ANTIPLAQUE AGENTS AND ANTIGINGIVITIS AGENTS

56. 56

57. 57 Streptococcus sanguis often appears first followed by Streptococcus mutans Both depend on a sheltered environment for growth and presence of extracellular carbohydrate (sucrose) Sucrose is used to synthesize intracellular polysaccharides that serve as an internal source of energy, as well as external polysaccharide coats

58. 58 ANTIPLAQUE AGENTS

59. 59

60. 60 Chlorhexidine gluconate is a cationic (positively charged) molecule After rinsing, chlorhexidine is attracted to and attaches to the negatively charged bacterial cell walls, causing lysis or breakage of the cell wall The contents of the cells leak out Chlorhexidine enters the cell through the opening, resulting in death of the bacteria

61. 61 By binding to the pellicle on the tooth surface, chlorhexidine inhibits plaque attachment Chlorhexidine exhibits substantivity, with approximately 30% of the drug binding to oral tissues and the plaque on the teeth, and showing antimicrobial activity for 8–12 hours afterward

62. 62 It is recommended to rinse twice a day for 30 seconds The positive charge of chlorhexidine causes it to bind to the negatively charged molecules in toothpastes such as fluorides and sodium lauryl sulfate (a detergent), and thus inactivates them Therefore, it is best to rinse either 30 minutes before or after toothbrushing or rinse very well with water after toothbrushing

63. 63 Because of this inactivation of anionic compounds, chlorhexidine is not available in toothpaste Chlorhexidine can be used as an irrigant , but it is usually diluted with water to reduce the incidence of staining

64. 64

65. 65

66. 66

67. 67 Listerine is a combination of phenolic compounds or essential oils, including thymol, eucalyptol, menthol, and methyl salicylate, in an alcohol vehicle MOA: cell wall disruption, resulting in leakage of intracellular components and lysis of the cell The original-formula Listerine contains 26.9% alcohol, whereas the Cool Mint, Fresh Burst Listerine, and Natural Citrus contain 21.6% alcohol

68. 68 Rinse for 30 seconds with 2/3 ounces, once in the morning and once at night Possible adverse side effects include a burning sensation and bitter taste

69. 69 Alcohol-containing mouthrinses should not be used in a patient taking metronidazole A severe disulfiram-like reaction occurs with nausea, vomiting, flushing, and faintness

70. 70 Alcohol-free mouthrinses include: GUM® Chlorhexidine 0.12% alcohol-free rinse Crest Pro-Health Rinse Rembrandt Listerine Zero Oral B Plaque Rinse Listermint BreathRX

71. 71

72. 72 Since hydrogen peroxide liberates gaseous oxygen, it provides a cleansing action and gentle effervescence for oral wounds However, peroxide has minimal antimicrobial action against anaerobic microorganisms

73. 73

74. 74

75. 75

76. Disadvantages 76

77. Controlled-Release Antimicrobial Drugs Used in Dentistry • Microspheres of minocycline HCl • 10% doxycycline hyclate • 2.5 mg chlorhexidine gluconate perio chip

78. 78 Dyes used to facilitate clear visualization of dental plaque Dyes used as disclosing agent are: Erythrosine Fluorescein: Yellow dye which fluoresces under UV light Two-tone dye Newer plaque (< 3 days) stains red Older plaque (> 3 days) stains blue DISCLOSING AGENTS

79. 79 Tablets Mouth Rinses Pre Loaded Pellets Disclosing agents are available as

80. 80 Compatible in taste Good flavour Intensity of colour : Contrast between early and mature biofilm Should come out easily during procedure Not irritating to the gingiva, non-allergic Water soluble and biocompatible BASIC PROPERTIES

81. 81 Visualizing the dental biofilm The color guides the biofilm removal Calculus is easier to detect Faster, more efficient and minimally invasive For calculating Plaque indices Advantages of Disclosing agents

82. 82

83. 84

84. 85 Local Haemostatics (styptics) are substances used to stop bleeding from a local and approachable site Effective on oozing surfaces, e.g. tooth socket, abrasions STYPTICS

85. 86 Normally haemostasis occurs by Contraction of injured vessel wall (lasting few minutes) Adhesion and aggregation of platelets to form a plug Formation of a blood clot Dissolution of the clot by fibrinolysis

86. 87 Absorbable materials Fibrin (prepared from human plasma and dried as sheet or foam) Gelatin foam Oxidized cellulose (as strips which can be cut and placed in the socket) provide a meshwork  activates the clotting mechanism  checks bleeding  Left in situ  absorbed in 1–4 weeks  no foreign body reaction

87. 88 Thrombin obtained from bovine plasma may be applied as dry powder or freshly prepared solution to the bleeding surface in haemophiliacs Vasoconstrictors like 1% Adrenaline solution may be soaked in sterile cotton-gauze and packed in the bleeding socket (or nose in case of epistaxis) to check bleeding when vasoconstriction is inadequate

88. 89 Astringents such as tannic acid or metallic salts (e.g. alum, ferric chloride) are occasionally applied for bleeding gums, bleeding piles, etc.

89. 90 Many diseases and drugs can affect the vascular response to injury, platelet function or coagulation to create haemostatic problems

90. 91 Vitamin C deficiency impairs collagen synthesis and causes bleeding gums, excessive post extraction blood loss Long-term corticosteroid therapy can also compromise haemostasis by impairing vessel retraction as well as by reducing platelet count

91. 92 Platelet function may be deficient due to thrombocytopenia (count<100,000/mL) or use of drugs which inhibit platelet aggregation  Transfusion of platelet-rich plasma is indicated Aspirin and other NSAIDs are the most important drugs that inhibit platelet aggregation

92. 93 A large number of older individuals now receive long-term low dose aspirin prophylaxis for ischaemic heart disease or stroke Many others receive long term clopidogrel for a variety of thromboembolic disorders Several patients of arthritis regularly take NSAIDs

93. 94 Discontinuation of aspirin for 5 days before dental surgery should be considered Proper packing and use of local haemostatics is needed to prevent excess bleeding

94. 95 Monitoring of INR prior to dental surgery is essential INR > 3.5  stop the anticoagulant for 2–3 days or temporarily switch over to heparin In case of emergency dental bleed  give i.v. infusion of FFP (fresh frozen plasma : containing all coagulation factors) Vit. K may be injected Adequate packing and local measures