24. Halitosis Flashcards
What did the social study in Canada 1997 find?
- 1200 ps
- 16% worried a lot about halitosis
- 3% seen professional
- 3% said breath interferes with lives moderately or severely
1% avoid social gatherings
Prevalence of halitosis
- 50% of American adults suffer from oral malodour
The USA spends … on mouthwash and sprays to combat it annually
500 million dollars
Bad breath is the … worst smell in Britain
3rd
Causes of halitosis
- intra-oral e.g accumulation of food debris, oral bacteria on teeth, soft tissues, tongue
- and extra-oral like microbial putrefaction of food debris, desquamated cells, saliva, blood
Classification of halitosis
- genuine
- pseudo-halitosis
- halitophobia
Types of genuine halitosis
- physiologic
- pathologic - includes intra and extra oral
Sources of halitosis and percentages of commonness
- 85-90% oral
- 5-10% nose
- 3% tonsils
- 1% other
How does the nose cause halitosis?
- sinusitis
- blockage of mucus flow (objects or disease)
How are the tonsils a source of halitosis?
- putrefaction
- not tonsilloliths (calcified bacteria and debris)
What comes under other sources of halitosis?
- bronchial and lung infections
- kidney failure
- various carcinomas
- metabolic and biochemical disorders e.g trimethylaminuria
- stomach origins very uncommon
How does the oral env cause halitosis?
- poor oral hygeine (increased microbe load/food trapped)
- gingivitis and periodontal disease
- oral infections
- tongue coating
- defective dental restorations
- dental abscesses
- exposed tooth pulp
- xerostomia
- recent dental extraction/dry socket
- oral malignancy
Why does xerostomia cause halitosis?
- mouth breathing
- fasting
- prolonged talking
- stress
- salivary gland hypofunction
- medications
How does smoking cause halitosis?
- dries mouth
- link to gingivitis and periodontal disease
- exacerbates post-nasal drip
List intra-oral spaces where halitosis originates
- bacterial niches
- oral candidosis
- oral tumours
- tongue dorsum
How do bacterial niches cause halitosis?
- posterior tongue dorsum
- periodontal tissue sites like gingival sulcus, pathological pockets, interdental spaces
- plaque at gingival margin
- localised plaque traps - over-hanging restorations, margins of crown
List extra-oral sources of halitosis
- liver disorders
- respiratory tract infections
- GI disease
- endocrine disorders
- haematological disorders
- malignancy
Give bacteria involved in halitosis
- gram negative anaerobes like treponema denticola, prophyromonas gingivalis, fusobacterium, veillonella, haemophilus
- gram positive stomatococcus mucilaginus
Most active bacteria in halitosis are …
- porphyromonas gingivalis
- treponema denticola
- tannerella forsythia
(anaerobic bacteria which are also associated with periodontal disease)
Halitosis is primarily caused by …
- microbial degradation of sulphur containing and non-sulphur containing amino acids
- derived from proteins in exfoliated human epithelial cells and white blood cell debris
- or present in plaque, saliva, blood, tongue coatings
Lab studies show how volatile sulphur compounds production by …
- bacteriodes melaninogenicus
- T. denticola
- P. gingivalis
- P, intermedia
- T. forsythia
- fusobacterium peridonticum
etc
List volatile sulphur compounds or VSC associated with halitosis
- hydrogen sulfide
- dimethylsulphide
- diethylsulfide
- dimethyldisulfide
- diethyldisulfide
- methyl mercaptan
Associated compounds in halitosis and their roles
- skatole for tryptophan metabolism
- cadaverine for protein breakdown
- putrescine for protein breakdown
- isovaleric acid for metabolite
Arguments FOR the link between halitosis and periodontal disease
- halitosis primarily caused by gram neg bacteria associated with periodontal disease
- halitosis commonly found in patients suffering from periodontitis
- elevated concs of VSCs in subjects with probing depth of over or equal to 4mm
- VSCs are toxic to gingival tissues
Arguments AGAINST linking periodontal disease and halitosis
- periodontally healthy patients can have halitosis
- tongue coatings are major cause of halitosis
- periodontal pockets are partially sealed and mass transfer of gases is low
- tongue cleaning reduces VSCs by more than 70%
Diagnosis and measurements of halitosis
- self-reported halitosis
- organoleptic measure
- electrochemical meters
- gas chromatography
- saliva incubation
Self assessment of halitosis is easy/hard
Why?
- hard
- need subjective organoleptic analysis by confidant
- assess smell of breath/air exhaled from nose and mouth
- floss
- tongue scrape
How do electrochemical meters work for diagnosis?
- instrumental sniffers (portable sulphide monitors)
- very sensitive to H2S
- low sensitivity to mercaptan
What is Benzoyl Arginine Naphthylamide/BANA?
- rapid and single diagnostic test for periodontal pathogens
- hydrolysis of BANA
- paper test-strip assays correlate highly with T. denticola, P. gingivalis and T. forsythia
- BANA test clinically useful for detecting activity and individuals who need periodontal treatment
- ability of subgingival plaque to hydrolyxe BANA was correlated with CPITN scores
First step of halitosis treatment
- history from patient
- clinical exam
- medical history
- completion of appropriate dental treatment
- good record keeping essential
Treatment strategies for halitosis
- masking malodor
- mechanicalc reduction of intraoral nutrients, substrates and microorganisms
- chemical reduction of oral microbial load
- rendering malodourous gases non-volatile
- chemical degradation of malodourous gases
How to improve oral hygeine?
- tongue brushing/scraping
- little difference between 2
- effect is short lived and can damage tongue
- effective tooth brushing with instructions
- interdental cleaning - floss and brushes
- management of gingivitis and periodontal disease
- address any defective restorations or carious lesions
Aside from improving oral hygeine, how to treat halitosis?
- avoidance of dry mouth - proper hydration
- gum chewing - limited to avoid TMJ problems
- oxidation of VSCs - commercial products e.g chlorine dioxide, mask the cause
- mouthrinses - most mask smell, evidence some are effective (chlorhexidine, Zn, Sr, phenol)
A systematic review was done to see efficacy of mouthrinses in reducing halitosis. Evidence is lacking but what was found?
- mouthrinses containing antibacterial agents (chlorhexidine or cetylpyridinium chloride) or those with chlorine dioxide or zinc will reduce halitosis to an extent
- extent is uncertain owing to incomplete reporting, study bias and variation in patient characteristics and assessment mode
How to manage patients with halitosis?
- ask patients if they’ve noticed altered/bad breath
- find out if patients notice associated factors (time of day, food/drink)
- take thorough medical and social history
- thorough dental history and home regime
- dental exam
- assess severity of halitosis
- discuss local measures - good oral hygeine practice and masking agents
- be aware of psych impact or true vs pseudo
- referral to physician if systemic cause suspected
