Halitosis

Halitosis

1. GOOD AFTERNOON

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3. Contents 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. INTRODUCTION 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. SYNONYMS 5  Bad or foul breath  Breath malodour  Oral malodour  Foetor ex-ore  Foetor oris  Stomato dysodia

6. DE F INITIONS 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 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

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. HISTORY

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)

10. CLASSIFICATION Pseudo halitosis Genuine halitosis Physiological halitosis Tongue coating Pathological halitosis Periodontium ANUG ANUP Periodontitis O thers Xerostomia Caries Temporary halitosis(morning bad breath) ( Lu , D.P . 1982) 8

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)

14. 14 ETIOLOGY:-  Intra oral origin - 80-90% poor oral hygiene , dental caries , periodontal diseases in particular NUG, NUP , periodontitis pericoronitis, dry socket , tongue coating & oral carcinoma.

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

17. 17  Common causes of halitosis  1) Local Causes Oral diseases Food impa ctio n A N U G Acute g in g i v itis Adult and aggressive p e r iodo n titis Pericoronitis Dry socket Xerostomia Oral ulceration Oral m al i g nan cy A.

18. B. 18

19. C.

20.  Acute febrile illness  Leukemia  Respiratory tract infection(usually upper)  Helicobacter pylori infection  P h ar y ngo -oesop h ageal diverticulum  Gastro-oesophageal reflux disease 2) SYSTEMIC CAUSES Pyloric stenosis or duodenal obstruction Hepatic failure (fetor hepaticus) Renal failure (end stage) Diabetic ketoacidosis Trimethylaminuria Hypermethioninaemia Menstruation (menstrual breath) 17

21. 21 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.

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) Pathophysiology

23. 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)

24. ODOUR QUALIFICATION OF SOME COMPOUNDS Tangerman, A. (2002 ) 21

25. 26 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.

26. 27  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

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28. 29 SOME DRUGS THAT CAUSE HALITOSIS  Tobacco  Alcohol  Chloral hydrate  Nitrites and nitrates  Dimethyl sulfoxide  Disulfiram  Cytotoxic agents  Phenothiazines  Amphetamines

29. 30 DI A GNOSIS  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.

30. 31 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.

31. 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

32. 33 Dental floss test Unwaxed floss is passed through interproximal contacts.

33. 34 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

34. 35 INSTRUCTIONS BEFORE FIRST VISIT In these instructions, subjects are asked not to : take antibiotics for 8 weeks before assessment; consume food containing onions, garlic or hot spices for 48 hours before the baseline measurements; drink alcohol or smoke in the previous 12 hours; eat and drink in the previous 8 hours (drinking water up to 3 hours before examinations is allowed);

35. perform oral hygiene, including tooth brushing, interdental and tongue cleaning, and not to use mouthrinses the morning of the examination; use scented cosmetics or after-shave lotions on the morning of the examination. 36

36. 37 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.

37. 38 METHO D O L O G Y  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.

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39. ORGANOLEPTI C SCORES (0- 5) (Rosenberg , Mulloch et al 1991) 37

40. VOLATILE SULFIDE MONITOR  This electronic meter ( Haiimeter , InterScan, Chatsworth, Calif) analyzes concentration of hydrogen sulfide and methyl-mercaptan , but without discriminating between them. 38

41. 42 GAS CHROMATOGRAPHY (GC)  GC , perf o r m e d with appar a tus eq u ipped with a fl a me p h oto m etr i c 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.  T h is de v ice ca n ana l y z e ai r , saliva, crevicular f luid for a volatile component.

42. Image courtesy- taken from Carranza’s Clinical Periodontology, 10 th Edition 43

43. 44 HALI T O X T M SYST E M:  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

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45. 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. 43

46. 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.

47. 48 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.

48. 49 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%.

49. 50 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:

50. 51 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.

51.  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

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53. To write in notes

54. 55 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

55. Mechanical reduction of intraoral nutrients and micro-organisms Tongue cleaning Tooth brush Inter-dental cleaning Professional periodontal therapy Chewing gum Image courtesy- Google im 5 a 2 ge

56. Chlorhexidine Essential oils Chlorine dioxide Two-phase oil- water rinse Triclosan Aminefluoride/ Stannous fluoride Hydrogen peroxide Oxidising lozenges 2. Chemical reduction of oral microbial load Image co u rtes y - 53

57. 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

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

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 CONCLU S IO N:  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 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 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

62. THANK YOU

63. PRESENTED BY:- Dr. Faheem Ahmed MDS 2 nd Year Dept. Of Periodontology & Implantology 2

64. Contents 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: masking the malodor; mechanical reduction of intraoral nutrients, substrates and microorganisms; chemical reduction of the oral microbial load; rendering malodorous gases nonvolatile; and chemical degradation of the malodorous gases. Treatment

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). I. Masking the malodor

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) II. Mechanical reduction of intraoral nutrients and microorganisms

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: chlorhexidine , cetylpyridinium chloride, essential oils, chlorine dioxide, triclosan , amine fluoride/stannous fluoride, hydrogen peroxide and baking soda. III. Chemical reduction of oral microbial load

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). A. Chlorhexidine

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). B. Essential oils

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). C. Two-phase oil–water rinse

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). D. Triclosan

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). E. Amine fluoride/Stannous fluoride

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) F. Hydrogen peroxide

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. G. Oxidizing 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). H. Baking soda

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). IV. Conversion of volatile sulfur compounds

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). . V. Chemical degradation of the malodorous gases

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. Conclusions

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.

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98. THANK YOU