oral malodor -DR Anjhana ,dept of periodontics.pptx

oral malodor

1. ORAL MALODOR DR ANJHANA DEPT OF PERIODONTICS

2. Definition Breath odor can be defined as the subjective percep tio n after smelling someones breath. breath malodor,halitosis,bad breath,or fetor ex ore can be applied

3. Classification of halitosis Genuine halitosis :When breath malodor really exists,and can be diagnosed organoleptically or by measurement of responsible compounds Pseudohalitosis: When an obvious breath malodor cannot be perceived ,but the patient is convinced that he or she suffers from it Halitophobia: If the patient still believes that there is bad breath after treatment of genuine halitosis

4. ETIOLOGY Predominant causative factors: Gingivitis Periodontitis Tongue coating 2 pathways of bad breath: 1.Increase of certain metabolites in blood circulation(due to systemic disease), which escape via alveoli of lung during breathing 2.Increase of either the bacterial load or amount of substrate for these bacteria at one of the lining surfaces of the oral cavity ,respiratory tract or esophagus

5. Most commonly involved bacteria;Porphyromonas gingivalis,Prevotella intermedia,Aggregatibacter actinomycetemcomitans,Campylobacter Rectus,Fusobacterium Nucleatum,Peptostreptococcus micros,Tannerella forsythia,eubacterium species and spirochetes For oral malodour, the unpleasant smell of breath mainly originates from : H2S, Hydrogen sulfide Methyl Mercaptan Dimethyl sulfide

6. Bad smelling metabolites can be formed or absorbed at any place in the body and transported by blood stream to the lungs Exhalation of these volatiles in the alveolar air causes halitosis Uncontrolled Diabetes Mellitus – Sweet odour of ketones Liver disease- Sulfur odour Kidney failure-Fishy odour

7. Intraoral causes Tongue and tongue coating Irregular dorsal tongue surface Posterior part exhibits no of oval cryptolymphatic units Rough anterior part due to high no of papillae; filiform papillae with core of 0.5mm in length,foliate papillae located at the tongue edge,fungiform papillae 0.5 to 0.8 mm ,Vallate papillae

8. The innumerable depressions in the tongue ideal nitches for bacterial adhesion and growth Desquamated cells and food remnants remain trapped in the retention sites Scrotal tongue and hairy tongue have an even rough surface Accumulation of food remnants intemingled with exfoliated cells and bacteria forms a coating on tongue investigators have identified the dorsal posterior surface of the tongue as the primary source.

9. Periodontal Infections Not all patients with gingivitis and periodontitis complain of breath malodor Bacteria associated with gingivitis and periodontitis are indeed able to produce volatile sulfur compounds Amount of VSCs in breath increases with the number,depth and beedng tendencyof the periodontal pockets Methylmercaptan enhances interstitial collagenase production,Interleukin 1and cathepsin B -mediate connective tissue breakdown.

10. Prevalence of tongue coating is 6 times higher in patients with periodontitis Other malodorous manifestations of periodontium: Pericoronitis major recurrent oral ulcerations herpetic gingivitis necrotising gingivitis or periodontitis

11. Dental Pathologies Deep carious lesions with food impaction and putrefaction Extraction wounds filled with blood clot Purulent discharge leading to important putrefaction Interdental food impaction in large interdental areas Crowding of teeth Acrylic dentures when continuously kept or not regularly cleaned Denture surface facing gingiva is porous

12. Dry mouth Saliva has important cleansing action Xerostomia patients present with large amounts of plaque and extensive tongue coating Other causes of xerostomia: medication alcohol abuse sjogren syndrome diabetes

13. EXTRAORAL CAUSES EAR,NOSE,THROAT During chronic/purulent tonsillitis deep crypts of tonsils accumulate debris and bacteria,especially peri o pathogens resulting in putrefaction Other examples include acute pharyngitis and postnasal drip Foreign body in a nasal or sinus cavity can cause local irritation, ulceration and putrefaction

14. Bronchi and lung Chronic bronchitis Bronchiectasis Pneumonia Pulmonary abscess Bronchial carcinoma Carcinoma of lung

15. Gatrointestinal tract A zenker diverticulum( a hernia in esophageal wall) A gastric diaphragmatic hernia can cause reflux of gastric contents to oropharynx Regurgitation esophagitis Intestinal gas production: some gases are absorbed but not metabolised by intestinal endothelium and transported by blood, these can be exhaled through lungs

16. Liver Hepatocellular failure Portosysteic shunting of blood may acquire a sweet ,musty or even fecal aroma of breath termed fetor hepaticus, has been mainly attributed to the accumulation of dimethyl sulfide

17. Kidney Kidney insufficiency, primarily caused by chronic glomerulo nephritis ,will lead to an increase of the amines dimethylamine and trimethylamine which causes a typical fishy odor of breath

18. Systemic metabolic disorders Uncontrolled diabetes mellitus -accumulation of ketones, sweet smell Insulin resistance leads to an increase of triglycerides and free fatty acids and ketones and formed during lipolysis

19. Trimethylaminuria Hereditary metabolic disorder-typical fishy odor of breath,urine,sweat,and other body secretions Prevents transformation of trimethylamine to trimethylaminoxide , resulting in abnormal amounts of this molecule

20. Hormonal causes At certain moments during the menstrual cycle,typical breath odor can develop;partners are often well aware of this odor .

21. Diagnosis of malodor M EDICAL HISTORY This can be done with a questionnaire that the patient fills out in the waiting room Patient should be asked about the frequency of halitosis When the problem first appeared? Whether others have identified the problem? Time of appearance during the day? Medical history should be recorded ENT HISTORY, Dental history

22. Clinical and laboratory examination Self examination smelling a metallic or nonodorous plastic spoon after scraping the back of the tongue smelling a toothpick after introducing it in interdental area smelling saliva spit in a small cup or spoon licking the wrist and allowing it to dry

23. Oropharyngeal examination Inspection of deep carious lesions Interdental food impaction Wounds Bleeding of the gums Periodontal pockets Tongue coating Dry mouth and tonsils and pharynx

24. Organoleptic rating Gold standard Easiest and most often used method Scoring done according to the intensity scale of Rosenberg and McCulloch score 0-Absence of odor score1-barely noticeable odor score2-slight but clearly noticeable odor score3-moderate malodor

25. score4-strong offensive odor score5- extremely foul odor

26. Portable volatile sulfur monitor (HALIMETER) Chairside diagnostic test Detect H2S and methyl mercaptan without diff them Lacks specificity Detect only sulfur compounds, used only for intraoral causes detection Inexpensive, less embarrassing

27. Gas chromatography A gas chromatographer can analyze air,saliva or crevicular fluids About 100 compounds have been isolated from head space of saliva and tongue coating Most important advantage; it can detect virtually any compound when using adequate materials and conditions Expensive and needs trained personnel

28. Recently a small portable ‘gas chromatograph’ has been introduced It has the capacity to measure the concentrtion of 3 key sulfur compounds- hydrogen sulfide,methyl mercaptan,dimethyl sulfide ) High concentration of methyl mercaptan-periodontitis increase in hydrogen sulfide -problem with oral hygiene dimethyl sulfide -extraoral causes Even identify non-oral causes

29. Dark field or phase contrast microscopy Gingivitis and periodontitis are typically associated with a higher incidence of motile organisms and spirochetes shifts in these proportion allow monitoring of therapeutic progress Patient becomes aware of bacteria being present in plaque ,tongue coating and saliva

30. Saliva incubation test Reveals volatile sulfur compounds and other compounds such as indole, skatole,lactic acid, methylamine, diphenylmine , urea, ammonia Less invasive test

31. Electronic nose Identify the specific components of an odor and analyse its chemical makeup. Chemical detection mechanism,like array of electronic sensors,and mechanism for pattern recognition Smaller,lesser expensive,easier to use

32. Chair side test Alternative tool for general practitioners BANA test is based on the ability of some bacteria to hydrolyze synthetic trypsin substrate Test can detect 3 species bacteria;P.gingivalis , bacteroides forsythus , treponema denticola B galactosidase test;quantify bacterial enzymes involved in the initial degradation of mucin Ninhydrin method is a colorimetric test to determine aminoacids and low molecular weight amines

33. Treatment of oral malodor Masking the malodor Mechanical reduction of intraoral microorganisms Chemical reduction of oral microbial load Rendering malodorous gases nonvolatile

34. Periodontal disease should be treated and controlled Auxiliary aid,oral rinses containing chlorhexidine Tonsils,lung disease,gastrointestinal disease and metabolic abnormalities should be investigated

35. Masking the malodor Treatment with rinses,mouth sprays and lozenges containing volatiles with a pleasant odor have only a short term effect Eg-mint containing lozenges and aroma present in rinses Increase the production of saliva by ensuring a proper liquid intake or by using a chewing gum

36. Mechanical Reduction Tongue cleaning reduces both the amount of coating as well as no of bacteria-improves oral malodor with a toothbrush but preferably with a tongue scraper Tongue cleaning using tongue scraper reduces halitosis levels 75% after 1week Interdental cleaning and toothbrushing professional periodontal therapy is needed one stage full mouth disinfection

37. Chemical reduction of oral microbial load Chlorhexidine Most effective antiplaque and antigingivitis agent Disruption of bacterial cell membrane Significant reduction in VSC levels and organoleptic ratings 0.2% or greater has some disadvantages like increased tooth and tongue staining,bad taste and temporary reduction in taste sensation

38. Essential oils Listerine rinse Moderately effective against oral malodor Sustained reduction in levels of odorigenic bacteria

39. Chlorine dioxide Powerful oxidising agent Oxidation of hydrogen sulfide,methylmercaptan and the amino acids,methionine and cysteine.

40. Two phase oil -water rinse Rosenberg et al designed a two -phase oil water rinse containing CPC A twice daily rinse with this product showed reductions in both VSC levels and organoleptic ratings

41. Triclosan Broad spectrum antibacterial agent. The Anti- vsc effect of triclosan seems strongly dependent on the solubilizing agents. Flavouring oils or anionic detergents and copolymers are added to increase the oral retention. Amine fluoride/stannous fluoride Association of amine fluoride with stannous fluoride resulted in encouraging reductions of morning breath odor Stannous fluoride in dentifrices has a role in reducing organoleptic scores and VSC levels

42. Hydrogen peroxide Rinsing with 3 percent hydrogen peroxide produced resulted in reduction of sulfer gases for 8 hrs Oxidizing lozenges Sucking a lozenge with oxidizing properties reduces tongue dorsum malodor Caused by the activity of dehydroascorbic acid Effective for time periods upto 3 hrs.

43. Conversion of volatile sulfur compounds Metal salt solutions Metal ions with affinity for sulfur are efficient in capturing sulfur containing gases Zinc ions with 2 positive charges bind to 2 negatively loaded sulfur radicals this can reduce expression of VSCs. Same applies for other metal ions like stannous, mercury and copper

44. Halita -rinse containing 0.05 percent chlorhexidine,0.05percent CPC and 0.14percent zinc lactate Special effect of Halita may result from VSC converting ability of zinc. Toothpastes. Baking soda dentifrices Chewing gums. With antibacterial agents like fluoride and chlorhexidine