Halitosis

clinical assessment and treatment of oral malodour and halitosis.
includes microorganisms causing halitosis, volatile sulphur compounds and its relation to periodontal destruction.

1. Good morning 1

2. HALITOSIS GUIDED BY:- Dr. Anita Panchal Dr. Hardik Mehta Dr. Sachin K. Dr. Bhaumik Nanavati Dr. Rahul Shah PRESENTED BY:- Dr. Ganesh Nair First Yr. PG Dept. of Periodontology and Implantology 2

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 3

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 4

5. Synonyms Bad or foul breath Breath malodour Oral malodour Foetor ex-ore Foetor oris Stomato dysodia 5

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 10 th 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 5 th edition 6

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 7

8. CLASSIFICATION Lu, D.P. (1982). Halitosis: an etiologic classification, a treatment approach, and prevention. Oral Surgery, Oral Medicine and Oral Pathology 54, 521–526. 8

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. 9

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. 10

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. 11

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 12

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 13

14. Common causes of halitosis 1) Local Causes A. 14

15. B. 15

16. C. 16

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) 17

18. Examples of systemic pathological conditions with their characteristic odour Systemic diseases Characteristics odour Diabetes 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. 18

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 . 19

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. 20

21. Odour qualification of some compounds Tangerman , A. (2002). Halitosis in medicine: a review. International Dental Journal 52 ( Suppl 3), 201–206. 21

22. Pathogenesis of oral malodor: Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7. 22

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. 23

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 24

25. Microorganisms and their causative odour 25

26. Some drugs that cause halitosis Tobacco Alcohol Chloral hydrate Nitrites and nitrates Dimethyl sulfoxide Disulfiram Cytotoxic agents Phenothiazines Amphetamines 26

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. 27

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 , 10 th Edition 28

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 . 29

30. Dental floss test Unwaxed floss is passed through interproximal contacts. 30

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 31

32. Instructions before first visit 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); 32

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. 33

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. 34

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. 35

36. 36 Image courtesy- Clinical periodontology and implant dentistry 5 th edition and google images

37. Organoleptic Scores (0- 5) By Rosenberg , Mulloch Et Al 1991 Yaegaki , K. & Coil, J.M. (2000). Examination, classification, and treatment of halitosis; clinical perspectives. Journal of the Canadian Dental Association 66, 257–261. 37

38. VOLATILE SULFIDE MONITOR: This electronic ( Haiimeter , InterScan , Chatsworth, Calif ) analyzes concentration of hydrogen sulfide and methyl- mercaptan , but without discriminating between them. Image courtesy- taken from Carranza’s Clinical Periodontology , 10 th Edition 38

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. 39

40. Image courtesy- taken from Carranza’s Clinical Periodontology , 10 th Edition 40

41. Halitox TM 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 41

42. Image courtesy- Google images 42

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 43

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. Image courtesy- Google images 44

45. 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. Another advantage of direct microscopy is that the patient becomes aware of bacteria being present in plaque, tongue coating, and saliva. 45

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%. 46

47. Tongue coating index Miyazaki et al. (1995) divides the tongue into three sections and the presence or absence of tongue coating 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). 47

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. 48

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. 49

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51. MANAGEMENT of oral malodour:- Mechanical reduction of intraoral nutrients and micro-organisms Chemical reduction of oral microbial load Rendering malodorous gases nonvolatile Masking the malodor. Use of a confidant 51

52. Mechanical reduction of intraoral nutrients and micro-organisms Tongue cleaning Tooth brush Inter-dental cleaning Professional periodontal therapy Chewing gum Image courtesy- Google images 52

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 Image courtesy- Google images 53

54. 3.Conversion of volatile sulfide compounds Metal salt solutions ( eg of metal salts HgCl 2 =CuCl 2 =CdCl 2 >ZnCl 2 >SnF 2 >SnCl 2 >PbCl 2 Toothpastes Chewing gum Image courtesy- Google images 54 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 Image courtesy- Google images 55

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. 56

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 57

58. References: Newman ,Takei, Carranza. Clinical periodontology ; 10 th and 11 th edition J lindhe . Clinical periodontology and implant dentistry; vol 1: 5 th 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 58

59. ` THANK YOU 59