Halitosis

Halitosis
Copyright (c) Department of Periodontology
University of Dental Medicine, Yangon
(Retyped version: Please check correct spelling)

1. 19 September 2018 Halitosis Department of Periodontology University of Dental Medicine, Yangon

2. Definition Halitosis is derived from Latin. It means breath and osis, an abnormal or diseased conditions. Unpleasant foul offensive odour; bad breath; malodour; fetor ex oris (ore)

3. Causes / Etiology The primary cause of halitosis is the uncontrolled growth of gram negative anaerobic bacteria.

4. Oral microbes are known to produce volatile sulphur compounds, namely methly mercaptan (CH3SH), hydrogen sulphide (H2S) and dimethyl sulfide (CH3)2S. The most commonly involved bacteria are Porphyromonas gingivalis, Prevotella intermedia / nigrescens, Aggregatibacter actinomycetemcomitans, Campylobacter rectus, Fusobacterium nucleatum, Peptostreptococcus micros, Tannerella forsythia, Eubacterium spp, and spirochetes.

5. These volatile sulphur compounds are the primary components of oral malodour. These are formed through the putrefactive action of oral microbes on sulphur containing amino acids, peptones or proteins found in the mouth.

6. Production of volatile sulfur compounds causing halitosis Proteins in diet Proteins in GCF Proteins in saliva Peptides Bacteria proteases Host proteases Sulfur containing amino acids Volatile sulfur compounds Halitosis Other amino acids Anaerobic gram negative bacteria

7. Many components besides sulfide components (e.g., diamines) in the GCF and saliva can be malodourous. First, pH has to be above the neutrality (i.e. basic) to cause halitosis. Conversely, an acidic pH is inhibitory to the proliferation of gram negative, anaerobic bacteria and consequently low pH leads to reduction of malodour.

8. Second, reduced flow of saliva allows colonization of bacteria on the teeth and soft tissue, thereby promoting the production of odorous gases. Other related important factors are age, genders, habits and diurnal variation.

9. A. Local causes (Oral Origins 90%) Poor oral hygiene Periodontal diseases are strongly associated with bad breath. The concentration of volatile sulphur compounds increases with severity of periodontal diseases. Carious lesions (especially with food particles) Tongue coating Food impaction Poor dental prothesis hygiene

10. Surgical or extraction sites Oral infections or abscess Soft tissue lesion with ulcerations, bleeding or necrosis Ingestion of highly flavored food and beverages Heavy smoking Xerostomia Allergic conditions Oral carcinoma

11. B. Systemic causes (Non-oral origins) Upper and lower respiratory tract diseases (e.g., bronchitis, bronchiectasis) Gastro-intestinal tract diseases (e.g., gastric hernia) Pathologic conditions of peri-oral structures (e.g., purulent sinusitis, chronic pharyngitis, post-nasal drip or discharges) Stress or nervous tension is a major enhance of bad breath. One major effect of stress is drying of the mouth.

12. Onset of menstruation Other systemic causes of breath malodour includes renal (uremia / fishy), pancreatic (acetone) and liver (ammonium)

13. C. Psychological or psychiatric causes

14. Classification There are three main categories of halitosis: Genuine halitosis Pseudo-halitosis Halitophobia

15. Genuine halitosis Genuine halitosis is the term that is used when the breath malodour really exists and can be diagnosed organoleptically or by measurement of the responsible compounds.

16. Psedo-halitosis When an obvious breath malodour cannot be perceived, but the patient is convinced that he is she suffers from it, this is called pseudo-halitosis.

17. Halitophobia If the patient still believes that there is bad breath after treatment of genuine halitosis or diagnosis of pseudo-halitosis, one considers halitophobia, which is a recognized psychiatric condition.

18. Management

19. A. Diagnosis i. Patient history There is a saying “Listening to the patient and he will tell you the diagnosis”

20. The common questions are about the frequency of odor, the time of appearance within the day, the time of appearance within the day, whether others have identified the problems, what kind of medications are taken and whether dryness of the mouth noticed.

21. ii. Clinical and Laboratory exmination Gas chromatography or combined with mass spectroscopy Sulphide monitor system (Helimeter) Organoleptic measurement

22. B. Treatment Local measures Systemic measures - specific treatment of systemic cause if present Psychotherapy (if needed)

23. Classification of halitosis on Treatment need (TN) No Classification Treatment Needs I Genuine halitosis A. Physiologic halitosis TN 1 B. Pathologic halitosis a. Oral Pathologic halitosis TN-1 and TN-2 b. Extra Oral Pathologic halitosis TN-1 and TN-3 II Pseudo halitosis TN-1 and TN-4 III Halitophobia TN-1 and TN-5

24. Treatment Needs (TN) for breath odor Category Description TN-1 Explanation of halitosis and instructions for oral hygiene
(Support and reinforcement of patient’s own self care for further improvement in their oral hygiene) TN-2 Oral prophylaxis, professional cleaning and treatments for oral diseases TN-3 Referral to a physician or medical specialist TN-4 Explanation of examination date, further professional instruction, education and reassurance TN-5 Referral to a clinical psychologist or other psychological specialists

25. Local measures An etiologic treatment is to be preferred. The treatment of oral malodour consists of the elimination of the local pathology / cause present. If underlying disease is suspected, the patient should be referred to the respective specialists. Thorough plaque control to remove plaque and food particle is a daily necessity. Regular check up to correct problems areas; common oral diseases, faulty restorations, leaking crowns, all of which causes food trap is a must.

26. Instructions on proper oral hygiene be reinforced and professional oral prophylaxis are essential. Inter-proximal cleaning is relatively more important because toothbrush bristles do not gain access to inter-proximal areas. Further, the tongue is probably some of the important reservoirs of bacteria involved in halitosis and tongue scraping should be an important component of the treatment.

27. Mouth rinses are valuable adjuncts but do not provide the best sole treatment. Chlorhexidine is the mouth rinse that demonstrates considerable reduction of malodour. It is well established that zinc containing mouth rinses have the property of the complex the divalent sulphur radicals, reducing the important cause of malodour. (Zinc can block the biologic effects of volatile sulphur compounds on protein synthesis) The use of hydrogen peroxide rinse also offers positive perspectives, mouth rinses are best used before bed time.

28. Any treatment that promotes increased level of saliva and tongue action will be of help to reduce malodour especially when oral dryness is at stage. This can mean a proper fluid intake or the use of sugarless chewing gum, candy or the fibrous vegetables. Vit C deficiency may be a cofactor on bad breath. Smokers especially should take regular supplements of Vit C since the nicotine in the cigarettes destroys Vit C.