Halitosis

definition + etiology + epidemiology + pathophysiology + management of halitosis

1. HALITOSIS

2. DEFINITION   OF HALITOSIS Halitosis is a term used to describe noticeably unpleasant odors exhaled in breathing. It is estimated to be the third most frequent reason for seeking dental-aid, following tooth decay & periodontal diseases .

3. Epidemiol ogy Extremely common. Majority of adult population have had it at some point in time. Unpleasant condition which creates huge embarrassment with potentially grave consequences.

4. Formed by bacterial putrefaction of food debris, cells, saliva and blood. Proteolysis of proteins , peptides , amino acids , free thiol groups & volatile sulphides. Results from any form of sepsis : increased anaerobic activity of pathogens. Despite rigorous hygiene, good dentition, posterior dorsum of tongue is often a source . Pathophysiology

5. Anaerobic Sulphur Producing Bacteria which normally live BELOW the surface of the tongue and in the throat ( Fusobacterium , Actinomyces , and Bacteriods forsythus) They assist humans in digestion by breaking down proteins found in specific foods,mucus or blood, and in diseased or “ broken-down ” oral tissue. Under certain conditions, these bacteria start to break down proteins at a very high rate.

6. Proteins are made up of Amino Acids.Two of Amino Acids in the mouth (Cysteine & methionine) are dense with sulphur. When “ beneficial ” bacteria break down these compounds, the odorous and “ lousy-tasting ” Volatile sulphur compounds (VSCs) are released, Hydrogen sulphide, Dimethyl sulphide & methyl mercaptan) with other bad tasting compounds.

7.    Compounds commonly produced by mouth bacteria and their odours:   Hydrogen sulfide- Rotten eggs Methyl mercaptan- Faeces Skatole- Faeces Cadaverine- Corpses Putrescine- Decaying meat Isovaleric acid - S weaty feet   Pathophysiology of Halitosis

8. Etiology of Halitosis Oral & Throat Causes Nasal / Nasopharyngeal problems Systemic disease Physiologic considerations Drugs Food Psychologic disorders

9. Oral & Throat Causes   1 . Poor dental hygiene & food impaction 2 . Dental & Gum diseases 3 . Bacteria accumulation on the posterior dorsum of tongue & tonsils 4 . Post nasal drip 5 . Chronic tonsillitis & Tonsillolith s( T onsil Stones ) 6 . Dry mouth 7 . Oral sepsis 8 . Oral Ulcerative lesions 9 . Oral malignancy

10. Dental & Gum Disease Periodontal disease Dental caries Faulty restoration Denture Impacted or abscessed tooth Infected extraction sites Residual post-operative blood Debris under bridges or appliances kept in mouth at night or not cleaned properly. Oral & Throat Causes  

11. The real reason for the bad breath is bacteria that accumulate on back of tongue,in pockets of gum or in the throat. Anaerobic bacteria produce volatile sulphur compounds (VSC) such as methyl mercaptan & hydrogen sulphide . These VSC’s are source of malodor Oral & Throat Causes  

12. Tonsil Stones(tonsilloliths ) are caused by an accumulation of sulfur-producing bacteria, post nasal drip, and debris that become lodged in the tonsil crypts When this debris combines with the Volatile Sulfur Compounds produced by the anaerobic bacteria beneath the surface of the tongue, it can also create chronic Halitosis Oral & Throat Causes  

13. Tonsillolith Oral & Throat Causes  

14. Breaking open one of these white tonsilloliths, causes an absolutely terrible smell! which is actually a combination of volatile sulfur compounds , post nasal drip, and bacteria . Oral & Throat Causes  

15. Dry Mouth is a Leading Cause of Bad Breath Dry mouth is naturally occurring in elderly, most cases are caused by medications, adult beverages and mouthwashes with alcohol Saliva contains Oxygen, which helps oxygenate the mouth keep it healthy and fresh Dry mouth with less saliva and less oxygen, makes bad breath gets worse by creating an anaerobic environment, perfect for the bacteria to produce more of these odorous compounds. Oral & Throat Causes  

16. Excess Mucus (Post-Nasal Drip) is actually a Food Source For Anaerobic Bacteria When a person has post-nasal drip, mucus coats the back of the tongue and throat. Since mucus is made up of interlinked strands of protein, the bacteria, break down these proteins into odorous and sour tasting sulfur type compounds. Strong antihistamines don ’ t help, because the drying effect of the antihistamines also creates a problem (by reducing the amount of germ-controlling saliva ) Oral & Throat Causes  

17. Gingivitis A cute necrotizing ulcerative gingivitis (ANUG) or Trench mouth

18. Chronic Tonsillitis  

19. Black Hairy Tongue Oral & Throat Causes  

20. Patients with fissured tongue dorsum may have elongated filiform papillae along the fissure walls Black Hairy Tongue Oral & Throat Causes  

21. Low-magnification photo-micrograph,the elongation of filiform papillae is clearly evident. The debris between papillae consists of desquamated epithelial cells and microbial colonies Black Hairy Tongue Oral & Throat Causes  

22. Peritonsillar Abscess

23. Bilateral Recurrent Suppurative Parotitis  

24. Nasal/Nasopharyngeal problems   1 .   Sinusitis & Nasopharyngitis 2 . Chronic nasal airway obstruction 3 . Adenoid hypertrophy 4 . Rhinolithiasis & Nasopharyngeal lithiasis 5 . Nasal & Sinus granulomas 6 .   Nasal & Sinus tumors. 7 . Nasopharyngeal Carcinoma

25. Systemic diseases    Diabetes mellitus, Diabetic ketoacidosis, Renal failure, Bowel obstruction, etc. Liver failure Lung abscess, Bronchiectasis Severe GERD with H. Pylori Pharyngeal pouch Gastric & Esophageal carcinoma Carcinoma of the Larynx & Tracheobronchial Tree Granuloma of the Larynx & Tracheobronchial Tree Sj o gren syndrome & Post irradiation therapy Trimethylaminuria  

26. Physiologic considerations    1.   Reduction of salivation 2.   Dehydration 3.   Vitamin deficiency 4.   Hunger 5.   Morning breath 6.   Aging 7.   Gastroesophageal reflux 8.   Menstruation

27. Physiologic considerations     It must be kept in mind that bad breath under the following circumstances is normal: Morning breath because the function of salivary glands slows down over night and saliva thickens, which stops it from bathing mouth tissues properly, therefore mouth breathers face the problem more often, but it disappears when you eat or drink. Hunger breath accompanies morning breath and arises from putrefaction of pancreatic juice, which pours into the stomach when nothing is eaten or drunk. Hunger breath is more apparent even after brushing, if morning meals are omitted. Menstrual breath is caused because of hormonal disturbances, which trigger sloughing of the body ’ s lining tissues and oral tissues and creates more ridges for bacteria, leading to halitosis

28. Drugs     Antihistamines Anticholinergics Antihypertensives Anor ectics Antidepressants Antiparkinso n Diuretics Sulfa drugs L ong term use of antibiotics

29. Foods   1 .   Food eaten (onions, garlic , cabbage, etc ) 2 . High protein diet like Fish,red meat 3 . Dairy food 4 . Acidic food 5 . Sugars 6 .   Coffee 7 . Tobacco 8 . Alcohol  

30. Dense Protein Foods: A high protein diet is always ideal for anaerobic bacteria,e.g. Fish, eggs,red meat The end result is a buildup of amino acids, which are easily converted into volatile sulfur compounds by the anaerobic bacteria found within the surface of your tongue and throat.

31.   Sugars: Sugar , which are fuel for the bacteria to reproduce and create more sulfur compounds. In addition, other bacteria can take the sugars and produce glycan strands, which in turn end up causing thick layers of plaque on enamel and around gums. This leads to tooth decay and gum disease - and of course, worse breath

32.   Acidic Foods: Coffee - both decaf and regular contains high levels of acids. Tea is a much better alternative. Tomato Juice All Citrus Juices - Orange Juice, Pineapple Juice, Grapefruit Juice

33.   Acidic Foods: The reason why acidic foods are a concern has to do with the way the bacteria react to an acidic environment. The oral cavity has a normal pH o f 6.5 which is in the acid ic range. Acids make the bacteria reproduce much faster.

34.   Onions and garlic already contain powerful volatile sulphur compounds, called mercaptans -eating them simply adds more odor-which can sometimes enter the lungs and bloodstream . Milk and other dairy products may cause problems for most people (The fat content does not matter, so low fat milk is just as problematic as butter ) In lactose intolerance, the system cannot digest these dairy products properly,so they are available to the bacteria for an extended period of time.

35.   Trimethylaminuria-TMA “ Fish Odour Syndrome ” A rare problem occurs in people who have an inability to breakdown certain proteins found in beans.The odour produced is similar to decaying fish. The odor consists of sulfur compounds & nitrogen compounds ( amines ) People with this condition must abstain from beans and other dense protein foods.

36.   Smoking ( nicotine ) Smoking has a drying effect on oral tissues Destroys ascorbic acid (vitamin C) which is essential for immunity Odor associated with smoking depends on a number of factors, directly related to the tar, nicotine, and other foul smelling substances that accumulates on teeth and soft oral tissues (tongue, cheeks, gums)There is no effective way to totally eliminate smoker's breath, although oral hygiene can help to minimize it.

37. DIAGNOSIS Oral examination History taking Smelling Sampling by spoon, gauze, cotton Information from family, friend Self examination Use of the halimeter

38. EXAMINATION Some of the characteristic smells accompanied by various diseases include acetone ( a fruity smell ) caused by diabetic ketoacidosis. Sweaty smell caused by liver dysfunction and extremely foul smell caused by diphtheria.

39. INVESTIGATIONS Halimeter Level of intra oral Volatile Sulphur Compounds can be estimated using portable sulphide monitors.Concentration of VSC ’ s correlate well with level of malodour reported by observers.

40. Management Identify & eliminate obvious causes Dental & Oral hygiene Dietary advice Neti pot is an instrument used for irrigation of nasal passages   Laser Tonsillectomy or tonsillectomy Adenoidectomy Neti pot

41. Management Dental & Oral hygiene Regular Dental Consultation Regular proper tooth brushing Interdental flossing Tongue cleaning, brushing, scraping Tongue cleansing by tongue scrapper,      gauze, tooth brush without paste Mouth rinses Baking soda toothpaste or mouthwash. This changes the acidity of the mouth Denture care & soaking in antiseptic solution over night

42. Management   The only effective method of treating Halitosis is by attacking the bacteria ’ s ability to produce VSC ’ s and by converting the VSC ’ s into non-odorous and non-tasting organic salts. Nearly all cases of “ real ” bad breath and/or taste disorders (or Halitosis) involve good bacteria and should never be treated with antibiotics.

43.   Dietary advice Avoid odiferous foods:   Onion, Garlic, Spices Avoid habits:   Smoking, Alcohol, Coffee Take regular meals, fresh fruits Eat fresh, fibrous vegetables such as carrots Drink tea regularly:   Polyphenols in tea inhibit bacterial growth   Do not drink too much coffee

44. Management   Dietary advice Don't miss breakfast. Hunger lead to killing-breath. Drink plenty of liquids/ 8 glasses of water a day. Eat parsley or wintergreen with your main meals. These herbs release pleasant oils as they chew them which linger for hours. Avoid fats - cheese, butter, milk, fat meats - in your diet if indigestion is the source of your bad breath Avoid beans &high protein diet in Trimethylaminuria

45. Management   Dietary advice Stay away from candies, mints, and chewing gum if they contain sugar. Chew sugar-free gum for a minute or two at a time, especially if your mouth feels dry, chewing parsley, mint, cloves or fennel seeds may also help. In Xerostamia, increase your fluid intake (at least 18-20 glasses per day), suck on sugarless lozenges. Citrus fruits, Vitamin C makes you resistant to coughs and colds

46. THANK YOU Name – Amanjot Singh BDS Intern