oral malodour/ halitosis

This presentation describes halitosis, its etiology, diagnosis preventive measures and its treatment.

1. Oral malodour Dr Manisha Sinha II nd yr pg RAJARAJESWARI DENTAL COLLEGE AND HOSPITAL

2. CONTENTS Introduction Definitions Classification Microbiology Etiology Volatile Sulphur compounds Diagnosis Preventive Measures Treatment Association between Halitosis and Periodontal Disease Conclusion References

3. Halitosis is a medical term, first coined by the George Lambert in 1921, to describe oral malodor or bad breath.   Malodor is the scientific term for bad breath and has its origin from Latin (“ malus, ” bad, evil + “ odorem , odor, ” smell, scent) and defined as a distinctive smell that is offensively unpleasant. INTRODUCTION

4. definitions Halitosis is also termed as fetor ex ore or fetor oris . It is a foul or offensive odor emanating from the oral cavity. CARRANZA(2003) Unpleasant odor of the expired air whatever the origin may be. Oral malodour specifically refers to such odor originating from the oral cavity itself. JAN LINDHE(2003) Halitosis is the general term used to describe a foul odor emanating from the oral cavity, in which proteolysis, metabolic products of the desquamating cells and bacterial putrefaction are involved. MARITA ET AL., 2001

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

6. CLASSIFICATION

7. TEMPORARY PERMANENT

8. GENUINE:- Physiologic halitosis Pathologic halitosis

9. PSEUDO-HALITOSIS HALITOPHOBIA

10. OLFACTORY REFERENCE SYNDROME Olfactory reference syndrome (ORS) is defined as the psychiatric condition characterized by persistent preoccupation about body odour accompanied by shame, embarrassment, significant distress, avoidance behaviour and social isolation

11. When tricyclic antidepressant medication is used, xerostomia can appear, leading to an increase of halitosis awareness. Patients with symptoms of halitophobia or ORS, should not be treated by dental practitioners or by ENT specialists, but should be referred to psychologists or even to psychiatrists. Selective Serotonin Reuptake Inhibitor, which increases the concentration of serotonin in the brain, can help to treat this phenomenon.

12. MICROBIOLOGY OF ORAL HALITOSIS

13. AETIOPATHOGENESIS OF ORAL MALODOUR

14. In a recent study of 2000 patients who visited a multidisciplinary bad breath clinic in Leuven, Belgium, an oral cause was found in nearly 76% of the patients, especially tongue coating (43%), gingivitis/periodontitis (11%) or a combination of the two (18%). Pseudo-halitosis/ halitophobia was diagnosed in 16% of the cases; and ENT/extra-oral causes were found in 4% of the patients.

15. Physiologic Diet — vegetables such as onions, garlic, radishes, turnips Beverages such as tea and coffee Alcohol-based wine, brandy, whisky, liqueurs and beer Dairy products that contain protein Dehydration, starvation, constipation, diarrhea CAUSES

16. Pathologic Local oral Tongue coating (poor oral hygiene) Gingivitis-ANUG, acute herpetic gingivostomatitis Periodontitis Xerostomia (e.g. from drugs, Sjögren’s syndrome, radiotherapy, chemotherapy) Pericoronitis Candidiasis Oral sepsis Oral cancer Bone diseases — dry socket, osteomyelitis, osteonecrosis Debris under dental appliances (e.g., dentures, removable orthodontic appliances, bridges)

17. Extraoral ( nonoral systemic conditions) ENT Postnasal drip Tonsillitis, tonsilloliths Rhinitis, rhinoliths Sinusitis, antral malignancy Nasal polyps, carbuncle, carcinoma Nasal obstruction/foreign bodies

18. Other systemic factors Lung — chronic bronchitis, bronchiectasis, pulmonary abscess, tuberculosis, pneumonia, emphysema, secondary infection, bronchial carcinoma, pulmonary infarcts and its sequelae Renal — renal failure, uremia Hepatic — cirrhosis, gall bladder dysfunction, hepatic failure Carcinomas (various types) — bronchial carcinoma Diabetic ketoacidosis — acetone breath of uncontrolled diabetes Gastro-intestinal — esophageal refl ux , pyloric stenosis, hiatal hernia, malabsorption syndrome, enteric infection Other systemic conditions – dehydration, starvation, Sjögren’s syndrome, leukemias and other blood dyscrasias Medications — antihistamines/decongestants, antidepressants, anxiolytics, anticholinergics, antipsychotics etc

19. Metabolic disorders Trimethylaminuria - fishy odour . According to Whittle et al., this genetic disease is the largest cause of undiagnosed body odour . is a disorder in which the volatile, fish-smelling compound, trimethylamine accumulates and is excreted in the urine, but it is also found in the sweat and breath. Because many patients have associated body odours or halitosis, trimethylaminuria sufferers can meet serious difficulties in their social context, leading to isolation and even depression.

20. Oesophagus . Only in specific cases, this is the origin of malodour . When a Zenker’s diverticulum is present, a chronic unpleasant odour appears. The incidence of this phenomenon is less than 0.1% and it is only diagnosed in patients over 65 years of age. Also bleeding of the oesophagus can cause a musty odour . When severe regurgitation is determined, halitosis will be present. Stomach. Infections with Helicobacter pylori can cause peptic ulcers. There is no 100% clear correlation found between these ulcers and halitosis. In vitro studies show significant VSC production by H. pylori. Intestines. In cases of intestinal obstruction, a faecal mouth odour may be detectable, as found in two siblings with extrinsic duodenal obstruction caused by congenital peritoneal bands.

21. Formation of volatile sulfur compounds: VSCs have also been implicated in the progression of periodontal disease. VSCs aggravate periodontitis by: Disrupting the oral mucosa (pocket epithelium), thereby increasing bacterial invasion. Impede wound-healing by altering metabolism of fibronectin. Increase the release of interleukin- 1 and PGE2. High VSC concentration might be a predictor of periodontal disease progression. Gram-negative, proteolytic bacteria are believed to play an essential role in the formation of VSCs, although Gram-positive bacteria such as Peptostreptococcus species have also shown ability to produce VSCs in vitro (McNamara et al. 1972; Persson 1989; Claesson 1990; Persson et al. 1990) VOLATILE SULPHUR COMPOUNDS

22. General medical questionnaire Specific halitosis questionnaire

23. At the 1 st Examination WRIST LICK TEST A. SELF ASSESSMENT

24. Organoleptic assessment considered as the “gold standard” to diagnose halitosis in a clinical setting. The trained judge or clinician smells a series of different air samples of the patient as follows: Oral cavity odor is examined on the subject as he is made to refrain from breathing while the examiner places his nose 10 cm from the oral cavity. The judge smells the expired air as the patient counts from 1 to 10 as this is done to promote drying up of the palate and tongue mucosa, expressing VSCs.

25. 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 malodour examination rather than the direct-sniffing procedure.

26. ORGANOLEPTIC SCORES 1. TONZETICH J ET AL (1976 ) 2. ORGANOLEPTIC SCORES (0- 5) BY ROSENBERG , MULLOCH ET AL 1991 1 0 – absence of odor 1 - detectable 2 – slightly objectionable 3 – slightly to moderately objectionable 4 – moderately objectionable 5 – moderately to strongly objectionable 6 – strongly objectionable

27. Portable Volatile Sulfide Monitor Halimeter analyzes the concentration of hydrogen sulfide and methylmercaptan , but without discriminating them. The examination should preferably be done after at least 4 hours of fasting and after keeping the mouth closed for 3 minutes. The mouth air is aspirated by inserting a drinking straw fixed on the flexible tube of the instrument. The straw is kept about 2 cm behind the lips, without touching any surface and while the subject keeps the mouth slightly open and breathes normally. The sulfide meter uses a voltametric sensor that generates a signal when exposed to sulfur-containing gases, especially hydrogen sulfide. Absence of breath malodor leads to readings of 100 ppb or lower.

28. Gas Chromatography . This device can analyze air, ( incubated) saliva, or crevicular fluid for any volatile component. About 100 compounds have been isolated from saliva and tongue coating, with most identified, from ketones to alkanes and sulfur-containing compounds to phenyl compounds. Elaborate gas chromatography is only available in specialized centers but is especially useful for identifying nonoral causes.

29. 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.

30. Saliva I n c u b a t i o n Test.

31. Electronic Nose. A new device that is being developed which has the capacity of the human nose is referred to as the electric nose. The electronic nose is an intelligent sensing device that uses an array of gas sensors which are overlapping selectively along with a pattern reorganization component.   Merits Can identify the specific components of an odor. Can analyze the chemical make-up of the compound. Smaller. Less expensive. Easier to use.

32. . BANA TEST It is a chair side, enzyme-based assay, which is used to determine the proteolytic activity of certain oral anaerobes that contribute to oral malodor and which are considered as active H2 S producers.

33. PREVENTIVE MEASURES

34. TREATMENT

35. A systemic review by van der Sleen et al., demonstrated that tongue brushing or tongue scraping have the potential to successfully reduce breath odour and tongue coating. Due to tongue cleaning, the taste seems to Improve again. A/c to a study by Rosenberg M et al, chlorhexidine (CHX): CHX is the most efficient molecule against plaque. Rosenberg showed that rinsing with 0.2% CHX causes a reduction of 43% in VSCs and of 50% in the organoleptical scores on a day-long basis.

36. Essential Oils Previous studies evaluated the short-term effect (3 hours) of a Listerine rinse (which contains essential oils) compared with a placebo rinse." '- Listerine was found to be only relatively effective against oral malodor (±25% reduction vs. 10% for placebo) and caused a sustained reduction in the levels of odorigenic bacteria. C h l o r i n e D i o x i d e Is a powerful oxidizing agent that can eliminate bad breath by oxidation of hydrogen sulfide, methylmercaptan , and the amino acids methionine and cysteine. A study by Frascella J et al, demonstrated that single use of a chlorine dioxide– containing oral rinse slightly reduces mouth odor by 29% after 4 hrs. .

37. Two-Phase Oil- Water Rinse Rosenberg et al designed a two-phase oil-water rinse containing CPC that was shown to result in daylong reduction in oral malodor. Triclosan A broad-spectrum antibacterial Agent, has been found to be effective against most oral bacteria and has a good compatibility with other compounds.   It has BACTERIOSTATIC action targets bacteria primarily by inhibiting fatty acid synthesis. Used for oral home care. An 84% reduction of VSCs after 3 h is proved in a study by Raven S et al.

38. Aniine fluoride / Stannous Fluoride. The association of aminefluoride with stannous fluoride ( AmF / Snl 2) resulted in encouraging reductions of morning breath odor, even when oral hygiene is insufficient. Hydrogen Peroxide. Suarez et aL reported that rinsing with 3'% hydrogen peroxide (H2O,) produced impressive reductions (±90%) in sulfur gas that persisted for 8 hours. O x i d i z i n g Lozenges Greenstein et al." reported that sucking a lozenge with oxidizing properties reduces tongue dorsum malodor for 3 hours. 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.

39. SUBSTANCES CAUSING CONVERSION OF VSCS 1. METAL SALT SOLUTIONS Young A. et al (2001) – special effect of Halita may result from the VSC conversion ability of Zinc. Commercially available Zn Salts: Toothpastes – Trioral , Viadent Advanced care, Aim TC, Close-up TC, Mentadent Gumcare . ----- Mouthwashes – Lavoris , Listermint 2. TOOTHPASTES : Brushing the dorso -posterior surface of the tongue with a dentifrice was more effective than brushing the teeth in reducing VSCs. ( Tonzetich (1976) Dentifrices with triclosan have shown to reduce OL scores significantly. ( Gerlach et al 1998, Niles 1999, Hu et al 2003 & Farrell in 2006) Dentifrices with Baking Soda (Brunette et al 1998), essential oils ( Olshan et al 2003 ) & stannous fluoride ( Gerlach et al 1998) seemed to be effective.

40. 3. CHEWING GUM : Tsunoda et al (1996) investigated the beneficial effects of chewing gum containing tea extracts. Epigallocatechin (EGCg) is the main deodorizing agent among tea catechins. The chemical reaction between EGC & CH3SH results in nonvolatile product. Waler S.M (1997) compared different concentration of zinc in a chewing gum and found that 2mg Zn acetate containing chewing gum remained in the mouth for 5min resulted in immediate reduction in VSC levels of upto 45% but long term effect was not mentioned.

41. Treatment with rinses, mouth sprays and lozenges containing volatiles with a pleasant odor have only a short term effect. ( Reingewirtz N. et al 1999 & Replogle W.H. in 1996) Eg - Mint – containing lozenges. Another pathway is to increase the solubility of malodorous compounds in the saliva by lowering the Ph of the saliva. (low ph increases the solubility of VSCs) MASKING THE ORAL MALODOR

42. VSCs aggravate the periodontitis process by: ASSOCIATION BETWEEN HALITOSIS AND PERIODONTAL DISEASE

43. 1981 , Pitts et al studied the correlations between odor scores and microbiological findings in crevicular samples of periodontally healthy subjects. They found that higher levels of crevicular bacteria were associated with greater odor scores. A porcine non-keratinized sublingual mucosa was exposed to hydrogen sulfide and methyl mercaptan , its permeability increases by 75% and 103%, respectively (Ng & Tonzetich 1984). Methyl mercaptan reduces collagen synthesis by 39%, while increases intracellular degradation of newly synthesized collagen by 62% (Johnson et al. 1996). When porcine epithelial tissues were treated with methyl mercaptan , the tissues demonstrated extensive impaired and dead cells (Johnson et al. 1992a). These findings suggest that VSC are directly toxic to epithelial tissues and can facilitate bacterial invasion into underlying connective tissue .

44. TREATMENT & MANAGEMENT OF HALITOSIS PATIENTS IN PERIODONTAL DISEASE

45. Individuals who flossed daily had significantly less odor level than those who did not (Rosenberg 1996). Hence, it is a good motivation tool to have patient smell the floss after each use. When the patients’ conventional hygiene is adequate but their oral malodor problem exist, tongue brushing is also an effective way (Rosenberg & Leib 1995). If the patients still suffer from oral malodor after maintaining good oral hygiene, rinsing or gargling with an effective mouthwash may be advised. Quirynen et al. (1998) monitored patients with oral malodor. Patients with srp + mouthrinse showed significant malodour reduction compared to group with srp alone

46. Miyazaki et al .(1999 ) established the recommended examination for halitosis and a classification of halitosis with corresponding treatment needs. Accordingly, different treatment needs (TN) have been described for the various diagnostic categories. The responsibility for the treatment of physiologic halitosis (TN-1), oral pathologic halitosis (TN-1 and TN-2), and pseudo-halitosis (TN-1 and TN-4) resides on dental practitioners. However, extra-oral pathologic halitosis (TN-3) and halitophobia (TN- 5) should be managed by a physician or medical specialist and a psychiatrist or psychological specialist.

47. Rosenberg M, McCulloch CA. Measurement of oral malodor : Current methods and future prospects. J Periodontol 1992;63:776-82.

48. RECALL THERAPY

49. CONCLUSION

50. REFERENCES Carranza, Newman-Clinical Periodontology. 11th & 12th edition. Halitosis: From diagnosis to management: J Nat Sci Biol Med. 2013 Jan­Jun; 4(1): 14–23. Association between oral malodor and adult periodontitis: a review: J Clin Periodontol 2001; 28: 813–819 Halitosis (breath odor):Periodontology 2000, Vol. 48, 2008, 66–75 Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7. Halitosis: A Review of Current Literature. Brenda L. Armstrong, RDH, MDH; Michelle L. Sensat , The Journal of Dental Hygiene Volume 84 Issue 2 Spring 2010. Halitosis: an overview of epidemiology,etiology and clinical management. Cassiano Kuchenbecker Rösing (a)Walter Loesche Braz Oral Res. 2011 Sep-Oct;25(5):466-71 Halitosis: Current concepts on etiology, diagnosis and management Uditi Kapoor

51. THANK YOU……