Seminar Halitosis

ORAL MALODOR by DR.SUHANI GOEL

1. ORAL MALODOR
Presented By – Dr. Suhani Goel

2. CONTENTS
Introduction
Classification
Etiology
Association between halitosis and periodontal disease
Diagnosis of malodor
•Direct method
•Indirect method
Management of oral malodor
Conclusion
References

3. INTRODUCTI
ON
BREATH ODOR can be defined as subjective perception after
smelling someone’s breath.
1
Restrictive term
Intraoral origin

4. HALITOSIS is a general term used to define an unpleasant or
offensive odor emanating from the breath regardless of whether the
odor originates from oral or non-oral sources.
2
The term is derived from :
 Latin 'halitus' (breath) and
 Greek suffix 'osis', indicating primarily an
increase in volume,
either physiologic or pathologic.
[1]

5. CLASSIFICATION
3
According to Scully C, Greenman J (2008)
I.Genuine halitosis
I.Physiologic halitosis
II.Pathologic halitosis
II.Pseudo halitosis
III.Halitophobia
Adapted from : Scully C, Greenman J. Halitosis: Periodontol 2000, 2008;48:66–75

6. • Transient halitosis,
• Origin: dorsum of tongue,
•Self limiting, and
• Does not prevent the patient
from carrying out a normal
life. Examples
1.Morning breath odor,
2.Tobacco smoking &
3.Certain foods & medications
•Permanent,
•Does not resolve by usual oral
hygiene methods, and
• Prevent the patient from
carrying out a normal life.
–Intra oral , OR
– Extra oral origin
–90% of patients → oral cavity
Physiological halitosis Pathological halitosis
I.GENUINE HALITOSIS

7. II. PSEUDO HALITOSIS
Apparently healthy individuals
 Many patients develop faulty perceptions about having bad breath
that affect their entire lives,
III. HALTOPHOBIA
Exaggerated fear of having halitosis
Attributed to a form of delusion or monosymptomatic
hypochondriasis (self-halitosis, halitophobia)..
Also referred as DELUSIONAL HALITOSIS
•Others who have halitosis are unaware of their condition: this is
called the ―Bad breath Paradox.

8. ETIOLOGY
1
Unpleasent smell of breath mainly originates from :
VOLATILE SULPHUR COMPOUNDS (VSCs) →
1.Hydrogensulphide [H
2
S, rotten egg smell],
2.Dimethyl sulphide [(CH
3
)
2
S, rotten cabbage smell]
3.Methyl mercaptan [CH
3
SH, fecal smell].
NON - SULPHUR CONTAINING SUBSTANCES →
1.Diamines
Cadaverine (cadaver smell) and
Putrescine (rotten meat smell),
2.Acetone and Acetaldehyde
3. Indoles
Indole
methy indole(skatole)
4. Short chain fatty acids
Butyric acid
propionic acid

9.  VSC'S: ORIGIN AND RELATION TO
PERIODONTITIS
3,5
Production of volatile sulfur compounds
Adapted from : Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci
2012;3:251-7.
5

10.  VSC'S: ORIGIN AND RELATION TO
PERIODONTITIS
VSC's are highly toxic to tissues even at extremely low
concentrations and, therefore, may play a role in the
pathogenesis of inflammatory conditions affecting the
periodontium.
6-8
1.Different in vitro studies have demonstrated that VSC's alter
the permeability of oral and junctional epithelium.,
therefore expose underlying connective tissues of periodontium to
bacterial metabolites
2.Methymercaptan increases interstitial collagenase production,
IL-1production by mononuclear cells and cathepsin B production,
thus further mediating connective tissue breakdown.

11. 3.They are toxic to fibroblasts, altering their morphology
and function.
9
4.Alter the metabolism of fibronectin , and interfere in
the enzymatic and immunological reactions leading to
tissue destruction while showing an increase in the release
of interleukin-1 and prostaglandin E
2
.
5.VSCs impede wound healing .

12. INTRA ORAL CAUSES
3
I. DENTITION
Deep carious lesions with food impaction and putrefaction
Extraction wounds filled with blood clot
Crowding of teeth and food impaction in large interdental areas
Acrylic dentures
Dry mouth

13. II. PERIODONTAL INFECTIONS
 Bacteria associated with gingivitis and periodontitis are almost
all Gram-negative and known to produce VSCs.
1.Porphyromonas gingivalis,
2.Prevotella intermedia,
3.Aggregatibacter actinomycetemcomitans
4.Camplyobacter rectus
5.Fusobacterium nucleatum
6.Peptostreptococcus micros,
7.Tannerella forsythensis,
8.Eubacterium species
9.Spirochetes.

14. III.TONGUE AND TONGUE COATINGS
The role of tongue coatings in the etiology 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 malodor.
Source – www.dentalpress.com (last accessed on 31/7/16)
10

15. EXTRAORAL CAUSES
Halitosis is less frequently associated with extra-oral
causes (i.e. conditions and diseases that do not affect
primarily the oral cavity).

16. I. RESPIRATORY SYSTEM(MICROBIAL
ETIOLOGY)
Sinusitis
Antral malignancy
Cleft palate
Foreign bodies in the nose
Nasal malignancy
Tonsilloliths
Tonsillitis
Pharyngeal malignancy
Lung infections
Bronchitis
Bronchiectasis
Lung malignancy

17. II. GASTROINTESTINAL TRACT
Esophageal diverticulum
Gastro-esophageal reflux disease
Malignancy
III. METABOLIC DISORDERS (BLOOD BORNE)
Acetone-like smell in uncontrolled diabetes
Uremic breath in renal failure
Foetor hepaticus in liver disease
Trimethylaminuria (fish odor syndrome)
Hypermethioninemia
Cystinosis
IV. DRUGS (BLOOD BORNE)
•Cytotoxic agents
• Nitrates and nitrites
• Solvent abuse
V. PSYCHOGENIC OR PSYCHOSOMATIC FACTORS
•May be at play in some patients.
•Interestingly, anxiety itself increases the levels of volatile sulfur compounds

18. EXAMPLES OF SYSTEMIC PATHOLOGICAL
CONDITIONS THAT CAUSE HALITOSIS
Diabetes mellitus
Renal failure
Liver failure
Tuberculosis/ lung abscess
Internal hemorrhage/ blood
disorders
Fever , dehydration
Acetone , sweet fruity
Urine or ammonia
Fresh cadaver
Foul, putrefactive
Decomposed blood

Odour due to xerostomia and
poor oral hygiene.
Systemic condition Characteristic odour

20. SELF ASSESSMENT TESTS
I. 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.
Source – www.ijdr.com (last accessed on 30/7/16)
11

21. II. 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 about 5 cm organoleptically.

22. III. Dental floss test/ tooth pick test
Unwaxed floss is passed through interproximal contacts.
Source – www.ijdr.com (last accessed on 30/7/16)

23. IV. Saliva odor test
Involves having the subject expectorate approx. 1-2 ml of
saliva into a petridish.
The dish is covered immediately, incubated at 37
0
C for five
minutes and then presented for odor evaluation at a distance of
4 cm from the examiner’s nose.

24. ORGANOLEPTIC MEASUREMENT
HEDONIC METHOD / SNIFF TEST
Even though instruments are available, organoleptic
assessment by judge is still the gold standard in
examination of oral malodor.
It involves a trained judge who sniffs and assess
whether or not it is unpleasant using an intensity
rating scale.
The human nose remains the “Gold Standard” as

the human nose is capable of smelling and defining as
pleasant/unpleasant not only the VSC, but also
other organic compounds that come from exhalation
and are identified as unpleasant.

25. For reliable diagnosis, the oral malodour assessment should
preferably be carried out on 2 or 3 different days, if
possible.
This is especially important when either pseudohalitosis or
halitophobia is suspected.
Patients are instructed to abstain from:
1. Taking antibiotics for 3 weeks before the assessment,
2.Eating garlic, onion and spicy foods for 48 hours before the
assessment and
3.Using scented cosmetics for 24 hours before the assessment.

26. On the day of examination Patients are instructed to
1.Abstain from ingesting any food or drink,
2. To omit their usual oral hygiene practices,
3.To abstain from using oral rinse and breath fresheners,
and
4. To abstain from smoking for 12 hours before the assessment
The oral malodour examiner, who
1. Should have a normal sense of smell,
2.Is required to refrain from drinking coffee/tea / juice,
3. And to refrain from smoking and
4.Using scented cosmetics before the assessment.

27. AN ORGANOLEPTIC EXAMINATION INVOLVES THE DENTIST
ASSESSING THE ODOR AT A RANGE OF DISTANCES FROM
THE PATIENT [FIGURE).
5
Figure: A three stage scale at variable distance
‑

28. STRENGTH
1.Not only the VSC, but also other organic compounds
that come from exhalation and are identified as unpleasant.
2.Organoleptic measurement is highly recommended for
initial diagnosis.
LIMITATIONS
1.Subjective test based on examiner’s perception
2.Not quantitative
3.One potential risk of the organoleptic measurement is the
transmission of diseases via the expelled air
(particular concern following the severe acute respiratory
syndrome.)

29. Most widely used scoring system for ranking halitosis
It gives scoring on the scale of 0-5
0 - No appreciable odor
1 - Barely noticeable odor
2 - Slight but clearly noticeable odor
3 - Moderate odor
4 - Strong offensive odor
5 - Extremely foul odor
Rosenberg M, Mcculloch CA: Measurement of oral malodor :current methods & future prospects. J
Periodontol 1992;63:776.
Organoleptic Scores by Rosenberg and McCulloch(1992)
12

30. Yaegaki K, Coil JM. Examination, Classification, and Treatment of Halitosis;
Clinical Perspectives. Journal of the Canadian Dental Association 2000;66(5);257-61
Organoleptic Scores by Yaegaki and Coil(2000)
13

31. Yaegaki K, Coil JM(2000)
13
recommended that
Tanslucent tube (2.5 cm diameter, 10 cm length)
can be inserted into the patient’s mouth
Patient has to exhale slowly,
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.

32. GAS CHROMATOGRAPHY (GC)
14
This device can analyze
1.Air
2.Incubated(saliva)
3.Or, crevicular fluid
It is a preferred method if precise measurements of gases are required.
For any volatile
component

33. LIMITATIONS
Traditional laboratory gas chromatography are
1.Equipment is expensive, bulky
2.Require technicians or specialists with adequate training,
3.Need inert column carrier gas (gas cylinders of nitrogen or helium)
Thus, has been confined to research and not to clinical use.
14
Adapted from :www.abimedical.com.last accessed on 31/7/16
16

34. OralChroma
TM
(Abimedical , Abilit Corp., Osaka, Japan)
15
A newly developed portable gas chromatograph
Does not use a special carrier gas (using air instead)
Highly sensitive yet relatively low cost compared with a standard
gas chromatograph.
Device analyses individual concentrations of VSC's and displays the
concentrations on a display panel.
Adapted from :www.abimedical.com.last accessed on 31/7/16
16

35. ORALCHROMA SETUP GUIDE/ORALCHROMA OPERATION
GUIDE
16
Adapted from :www.abimedical.com.last accessed on 31/7/16
16

36. HALIMETER (Interscan Corp., Chatsworth, CA)
Portable sulphide monitor
Electronic device that aspirates the air of the mouth or expired
air through a straw and analyses the concentration of
HYDROGEN SULFIDE AND METHYL MERCAPTAN, without
discriminating between the two.
HALIMETRY

37. Tanita BreathAlert™
Innovative palm-size monitor
 Detects and measures the presence of VSC's and
hydrocarbon gases in mouth air.
Product Literature, Tokyo, Japan. Available from: http://www.tanita.co.uk Last accessed on 31 July 2016.
17

38. HALITOX
TM
SYSTEM
18
Halitosis Linked Toxins
 Quick, simple, colorimetric test
detects both VSC's and polyamines.
The kit consists of
•2 testing vials that contain specific
reagent chemicals.
•The only thing that comes in contact
with the patient is a sterile cotton tipped
swab used to obtain a tongue scraping
sample or pocket sample.
Morita M, Musinski DL, Wang HL. Assessment of newly developed tongue sulfide probe for detecting oral malodor. J Clin
Periodontal 2001;28:494-6. 
18

39. DIAMOND PROBE
®
/PERIO 2000® SYSTEM
19
Tongue Sulfide Probe
 Developed and manufactured by
Diamond General Development
Corp., Ann Arbor, MI, USA
Has been cleared by the Food and
Drug Administration for sale in the
United States.
 Until now, the system has been
available only in Europe.
Pavolotskaya A, McCombs G, Darby M, Marinak Kand, Dayanand N. Sulcular Sulfide Monitoring: An Indicator of
Early Dental Plaque-Induced Gingival Disease. Journal of Dental Hygiene.2006;80(1):1-12.
19

40. INTENDED FOR USE IN :
1.Measuring probing depths,
2.Evaluating the presence or absence of bleeding on probing, as
well as
3.Detecting the presence of sulfides in the periodontal pocket
LIMITATIONS
1.The probing pressure is not controlled.
2.Also, periodontal disease can be caused by bacteria that do not
produce volatile sulfur compounds, creating the potential for some
disease activity to be missed.

41. The thin, rounded probe tip has
incremental color-coded markings
at 3, 6, 8, and 11 mm for easy
measurement.
The tip diameter of the Diamond
Probe is 0.38 mm, which is the
same diameter as the "Michigan
O" probe.
The Probe is placed directly into
the periodontal pocket or tongue.
The sulfide-sensing element
generates an electrochemical
voltage proportional to the
concentration of sulfide ions
present.
Pavolotskaya A, McCombs G, Darby M, Marinak Kand, Dayanand N. Sulcular Sulfide Monitoring: An Indicator of
Early Dental Plaque-Induced Gingival Disease. Journal of Dental Hygiene.2006;80(1):1-12.

42. ELECTRONIC NOSE
20
..
•Electronic noses are chemical
sensors that have been used in recent
times for a quantitative assessment of
malodor associated with food and
beverages
•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.
Source – www.dentalpress.com(last accessed on 30/7/16)
Tanaka M, Anguri H, Nonaka A ,Kataoka K, Nagata H, Kita J, Shizukuishi S. Clinical Assessment of Oral Malodor by the Electronic Nose
System .J Dent Res.2004 83: 317.

43. INDIRECT TEST
1.BANA Test
2.PCR
•Other tests include the following:
1.Quantifying B-galactosidase activity
2.Ammonia monitoring
3.The ninhydrin method,
4.Zinc oxide thin film conductor (Ora test)
5.Cry-osmoscopy,
6.Ion trap transportable monitors.

44. BANA TEST-ENZYMATIC METHODS
21
Disadvantage:
1. May be positive at clinically healthy site
2. Cannot detect disease activity
3. Limited number of microorgaanisms organisms detected
4. Other pathogens may be present if it’s negative
Bacteria release specific enzymes. Certain group of species share common
enzymatic profile.
e.g. Tf , Pg, Td, and Capnocytophaga species release trypsin like enzyme

45.   MANAGEMENT AND TREATMENT
The management of halitosis entails 4 steps:
I.Confirm the diagnosis,
II.Identify and eliminate the predisposing and
modifying factors,
III.Identify any contributing medical conditions and
refer for management,
IV.Review and reassure.
After a positive diagnosis for oral halitosis has been
made, the treatment plan is implemented, which
comprises the elimination of causative agent and
improvement of oral health status.
This may be accomplished by mechanical or
chemical methods.

46. CLASSIFICATIONS WITH CORRESPONDING TREATMENT NEEDS WAS
REPORTED BY YAEGAKI K AND COIL JM IN 1999
12
WHICH IS WIDELY
USED BY THE PRACTITIONERS

47. Yaegaki K, Coil JM. Examination, Classification, and Treatment of Halitosis; Clinical Perspectives. Journal of the Canadian Dental
Association 2000;66(5);257-61.
13
Treatment needs (TN) for halitosis have been categorized into 5 classes in order
to provide guidelines for clinicians in treating halitosis patients:

49. TONGUE CLEANING
22
Aimed at :
dislodging trapped food, cells and bacteria from between the
filiform papillae, thus decreasing the concentration of VSCs.
Tongue cleaning should be carried out at night (because if done
early during the day may induce retching)
 Tongue scraper or a hard toothbrush and cold water, but no
toothpaste.
Outhouse TL, Al-Alawi R, Fedorowicz Z, Keenan JV. Tongue scraping for treating halitosis. Cochrane Database Syst Rev
2006: 19;(2):CD005519.

50. There is weak and unreliable evidence showing a small, but
statistically significant, difference in the reduction of
volatile sulfur compound levels when tongue scrapers or
cleaners, rather than toothbrushes, are used to reduce
halitosis in adults .
There is no high-level evidence comparing mechanical
cleaning with other forms of tongue cleaning.
The benefits of tongue scraping seem to be only short term .
Outhouse TL, Al-Alawi R, Fedorowicz Z, Keenan JV. Tongue scraping for treating halitosis. Cochrane Database
Syst Rev 2006: 19;(2):CD005519.
22

51. CONCLUSION:
Halitosis is a common complaint that may periodically affect most
of the adult population. It 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 breath.

52. REFERENCES:

1.Porter SR, Scully C. Oral malodour (halitosis). BMJ 2006: 333: 632–635.
2.Carranza, F., Newman, M., Takei, H. and Klokkevold, P. (2012). Carranza's
Clinical Periodontology. 11th ed. St. Louis, Mo.
3.Scully C, Greenman J. Halitosis: Periodontology 2000, 2008;48:66–75.
4.S R Porter, C Scully. Halitosis-clinical review ; BMJ 2006;333:632–635.
5.Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!.
Chron Young Sci 2012;3:251-7
6.Pitts G, Pianotti R, Feary TW, McGuiness J, Masurat T. The in vivo effects of
an antiseptic mouthwash on odor producing microorganisms. J Dent Res
‑
1981;60:1891 6.
‑
7.Reingewirtz Y. Halitose et parodontite; revue de littérature. Journal de
parodontologie & d’implantologie orale 1999;18:27 35
‑
8.Johnson PW, Ng W, Tonzetich J. Modulation of human gingival fibroblast
cell metabolism by methyl mercaptan. J Periodontal Res 1992; 27:476 83.
‑
9.Johnson PW, Yaegaki K, Tonzetich J. Methyl mercaptan modulates collagen
processing. J Dent Res 1996;75:324. Abstract
10. www.dentalpress.com (last accessed on 31/7/16
11.www. Ijdr.com. last accessed on 31/7/16.

53. 12.Rosenberg M, Mcculloch CA: Measurement of oral malodor :current methods & future prospects. J
Periodontol 1992;63:776.
13. Yaegaki K, Coil JM. Examination, Classification, and Treatment of Halitosis; Clinical Perspectives.
Journal of the Canadian Dental Association 2000;66(5);257-61
14.Whittle CL, Fakharzadeh S, Eades J, Preti G. Human breath odors and their use in diagnosis. Ann N
Y Acad Sci 2007:1098: 252–266.
15. Tanaka M, Anguri H, Nishida N, Ojima M, Nagata H, Shizukuishi S. Reliability of clinical
parameters for predicting the outcome of oral malodor treatment. J Dent Res 2003: 82: 518–522
16. www.abimedical.com.last accessed on 31/7/16
17. Product Literature, Tokyo, Japan. Available from: http://www.tanita.co.uk Last accessed on 31 July
2016.
18. Morita M, Musinski DL, Wang HL. Assessment of newly developed tongue sulfide probe for
detecting oral malodor. J Clin Periodontal 2001;28:494-6.
19. Pavolotskaya A, McCombs G, Darby M, Marinak Kand, Dayanand N. Sulcular Sulfide
Monitoring: An Indicator of Early Dental Plaque-Induced Gingival Disease. Journal of Dental
Hygiene.2006;80(1):1-12
20.Tanaka M, Anguri H, Nonaka A ,Kataoka K, Nagata H, Kita J, Shizukuishi S. Clinical Assessment
of Oral Malodor by the Electronic Nose System .J Dent Res.2004 83: 317.
21. Grisi MF, Salvador SL, Martins W Jr, Catandi N, Silva Neto CR. Correlation between
‑
the CPITN score and anaerobic periodontal infections assessed by BANA assay. Braz
Dent J 1999;10:93 7.
‑
22. Outhouse TL, Al-Alawi R, Fedorowicz Z, Keenan JV. Tongue scraping for
treating halitosis. Cochrane Database Syst Rev 2006: 19;(2):CD005519.

54. Thank you