Halitosis DR SINDHURA.pptx

Halitosis

1. Halitosis DR SINDHURA READER, DEPT. OF PERIODONTICS NAVODAYA DENTAL COLLEGE AND HOSPITAL

2. Definition Oral malodour or Halitosis is a general term denoting unpleasant breath arising from physiological & pathological causes from oral & systemic sources …to describe any disagreeable odour in the exhaled air of an individual, regardless of whether the odour originates in the oral cavity or elsewhere from within the body

3. Fair & Wells 1934

4. Murata et al, 2000

5. Pseudo-halitosis Genuine halitosis

6. Real halitosis…subdivided - Yaegaki & Coil, 2000

7. Odoriferous components that can give rise to oral malodor Volatile sulfur compounds Methyl mercaptan Hydrogen sulfide Dimethyl sulfide Diamines Putrescine Cadaverine Short-chain fatty acids Butyric acid Valeric acid Propionic acid Indoles Indole Methyl- indole ( skatole )

8. Physiologic halitosis Putrefactive process within the oral cavity Not specific to any disease Self-limiting Best example is “Morning breath”

9. Pathologic halitosis: Oral Halitosis: Halitosis caused by disease, pathological condition or malfunction of oral tissues. Halitosis derived from tongue coating, modified by pathological condition, e.g. periodontal disease, xerostomia .

10. The primary cause of halitosis - the release of odoriferous volatile sulphur compounds (VSC). VSC – putrefactive activity of anaerobic bacteria

11. Extra-oral halitosis: The VSC - absorbed by the blood stream from a remote part of the body,

12. Three factors are involved in the etiology of halitosis

13. Volatile Sulphur Compounds Malodour causing compounds Formed by microbial fermentation of Proteins Peptides M ucins found in saliva, blood, postnasal drip, GCF, lysed neutrophils D esquamated epithelial cells.

14. Many studies have demonstrated that hydrogen sulphide , methyl mercaptan & to a lesser extent, dimethyl sulphide accounts 90% of the total volatile sulphur compounds VSCs found in the mouth air, suggesting that these volatile sulphur compounds are the chemicals responsible for halitosis

15. Halitosis in 80-90% of the cases originates within the oral cavity, where anaerobic bacteria degrade sulphur containing amino acids to foul smelling VSC’s namely, hydrogen sulphide and methyl mercaptan . 10-20% of halitosis has non-oral causes.

16. Micro-organisms generally responsible… Periodontal pathogens identified, with BANA hydrolysis, on the posterior tongue, contributing to oral malodor include Treponema denticola Porphyromonas gingivalis Bacteroides forsythus . Additional periodontal pathogens, identified as VSC formers includes Fusobacterium nucleatum Bacteroides melanogenicus

17. Oral cause of halitosis

18. Temporary halitosis

19. ‘Morning breath’

20. Tongue coating

21. Classification of severity & extent of tongue coating degree 0 No visible coating degree 1 < 1/3 covered by easily removable coating degree 2 < 2/3 covered by easily removable coating & < 1/3 covered by not easily removable coating degree 3 > 2/3 covered by easily removable coating degree 4 > 2/3 covered by not easily removable plaque van Steenberghe , 2004

22. Pathological causes: Periodontal Infections The pathogens strongly associated with the etiology of periodontal disease are also associated in the production of VSC… In gingivitis, the bacteria-resistant epithelial seal around the teeth is lost due to the increased permeability of the gingival sulcus. VSC produces a similar effect on the gingiva.

23. The gingival fibroblasts developed an affected cytoskeleton when exposed to methyl mercaptan, the same gas altered cell proliferation & migration. VSCs are also known to impede wound healing.

24. In periodontitis… inclusion of the PDL & alveolar bone PDL cells exposed to methyl mercaptan exhibit

25. Other pathologic manifestation of the periodontium Microbiologic observations … ulcers infected with G- ve anaerobes are significantly more malodourous than non-infected ulcers

26. Pathologic halitosis: Extraoral causes Nasal Paranasal Laryngeal regions Pulmonary tract Digestive tract Systemic diseases

27. Extra-oral causes of pathological halitosis: Only about 10% to 20% of halitosis is of extraoral origin ENT CAUSES: include Acute pharyngitis Purulent sinusitis Post nasal drip chronic sinusitis regurgitation esophagitis Ozena Chronic/purulent tonsillitis A foreign body in a nasal or sinus cavity…local irritation, ulceration & putrefaction.

28. Bronchi & Lungs: pulmonary causes Chronic bronchitis Bronchiectasis Bronchial carcinoma

29. GIT: rarely responsible for bad breath…less than 1% of malodor Zenkers diverticulum Gastric hernia Regurgitation esophagitis Intestinal gas production

30. Liver : Pts with liver insufficiency … cirrhosis, ammonium accumulates in blood … exhaled…fetor hepaticus Kidney : Insufficiency … chronic glomerulonephritis … increased uric acid level in blood … expressed in the expired air …

31. Systemic metabolic disorders Type 1 diabetes . Trimethylaminuria Hormonal causes

32. Medications Metronidazole Eucalyptus containing medications -melon like odor. Arsenic- rotten onions. amphetamines, chloral hydrate, cytotoxic agents, dimethyl sulphoxide , disulfiram, nitrates and nitrites, phenothiazines

33. Clinical & Lab Examinations Self examination Organoleptic rating Portable volatile sulphur monitor Gas chromatography Dark field microscopy Saliva incubation test Electronic nose

34. Organoleptic measurement … solely based on olfactory organs of clinician Most reliable practical procedure…in short referred to as “sniffing method”

35. Organoleptic Rating Rosenberg & McCulloch, 1992 Degree Description No odor 1 Barely noticeable odor 2 Slightly but clearly noticeable 3 Moderate odor 4 Strong offensive odor 5 Extremely foul odor

36. Classification of subjectively perceived halitosis ( Seemann , 2002) degree 0 From approximately 10cm distance, have the patient say “A”. No unpleasant smell is perceived. degree 1 From approximately 10cm distance, have the patient say “A”. An unpleasant smell is perceived. degree 2 From approximately 30cm distance an unpleasant smell is perceived during a conversation. degree 3 From approximately 1m distance, i.e. during the anamnesis talk, an obvious bad breath is perceived.

37. Management of oral malodor …is cause related …Strategies applied

38. Appropriate pdl management is the 1st step. NUG, gingivitis, chronic & aggressive periodontitis or periodontal pockets can increase the bacterial load so pdl health has significant importance in controlling the amount of halitosis caused by bacteria.

39. Mechanical reduction of intraoral nutrients (substrates) & micro-organisms A combination of tooth & tongue brushing or tooth brushing alone has a beneficial effect on bad breath for upto 1 hr (73% & 30% reduction in VSCs respectively) - Tonzetich 1976

40. For periodontitis…professional pdl therapy SRP+ chlorhexidine reduced organoleptic malodor levels upto 90% - Quirynen et al, 1998

41. Chemical reduction of oral microbial load Active ingredients in oral rinses are usually antimicrobial agents such as chlorhexidine , cetylpyridinium chloride, essential oils, chlorine dioxide, H 2 O 2, & triclosan ….temporary reducing effect on total no of micro-organisms in oral cavity.

42. Masking the malodor Treatment with rinses, mouth sprays, lozenges containing volatiles have only a short term effect…hence, for temporary halitosis Also, increasing the pathway of malodorous compound in the saliva by lowering the pH of saliva or by increasing the secretion of saliva…lowers malodor.

43. Conclusion It is crucial for dentists to have an understanding of all types of halitosis, especially those that arise from the oral cavity. The available evidence indicates that VSC are not just odoriferous, but that some of them are deleterious to periodontal health. Therefore treatment of halitosis can no longer be considered as just a cosmetic therapy.