24. Halitosis

Question 1

What did the social study in Canada 1997 find?

Answer 1

• 1200 ps
• 16% worried a lot about halitosis
• 3% seen professional
• 3% said breath interferes with lives moderately or severely
  1% avoid social gatherings

Question 2

Prevalence of halitosis

Answer 2

• 50% of American adults suffer from oral malodour

Question 3

The USA spends … on mouthwash and sprays to combat it annually

Answer 3

500 million dollars

Question 4

Bad breath is the … worst smell in Britain

Answer 4

3rd

Question 5

Causes of halitosis

Answer 5

• 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

Question 6

Classification of halitosis

Answer 6

• genuine
• pseudo-halitosis
• halitophobia

Question 7

Types of genuine halitosis

Answer 7

• physiologic
• pathologic - includes intra and extra oral

Question 8

Sources of halitosis and percentages of commonness

Answer 8

• 85-90% oral
• 5-10% nose
• 3% tonsils
• 1% other

Question 9

How does the nose cause halitosis?

Answer 9

• sinusitis
• blockage of mucus flow (objects or disease)

Question 10

How are the tonsils a source of halitosis?

Answer 10

• putrefaction
• not tonsilloliths (calcified bacteria and debris)

Question 11

What comes under other sources of halitosis?

Answer 11

• bronchial and lung infections
• kidney failure
• various carcinomas
• metabolic and biochemical disorders e.g trimethylaminuria
• stomach origins very uncommon

Question 12

How does the oral env cause halitosis?

Answer 12

• 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

Question 13

Why does xerostomia cause halitosis?

Answer 13

• mouth breathing
• fasting
• prolonged talking
• stress
• salivary gland hypofunction
• medications

Question 14

How does smoking cause halitosis?

Answer 14

• dries mouth
• link to gingivitis and periodontal disease
• exacerbates post-nasal drip

Question 15

List intra-oral spaces where halitosis originates

Answer 15

• bacterial niches
• oral candidosis
• oral tumours
• tongue dorsum

Question 16

How do bacterial niches cause halitosis?

Answer 16

• 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

Question 17

List extra-oral sources of halitosis

Answer 17

• liver disorders
• respiratory tract infections
• GI disease
• endocrine disorders
• haematological disorders
• malignancy

Question 18

Give bacteria involved in halitosis

Answer 18

• gram negative anaerobes like treponema denticola, prophyromonas gingivalis, fusobacterium, veillonella, haemophilus
• gram positive stomatococcus mucilaginus

Question 19

Most active bacteria in halitosis are …

Answer 19

• porphyromonas gingivalis
• treponema denticola
• tannerella forsythia
  (anaerobic bacteria which are also associated with periodontal disease)

Question 20

Halitosis is primarily caused by …

Answer 20

• 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

Question 21

Lab studies show how volatile sulphur compounds production by …

Answer 21

• bacteriodes melaninogenicus
• T. denticola
• P. gingivalis
• P, intermedia
• T. forsythia
• fusobacterium peridonticum
  etc

Question 22

List volatile sulphur compounds or VSC associated with halitosis

Answer 22

• hydrogen sulfide
• dimethylsulphide
• diethylsulfide
• dimethyldisulfide
• diethyldisulfide
• methyl mercaptan

Question 23

Associated compounds in halitosis and their roles

Answer 23

• skatole for tryptophan metabolism
• cadaverine for protein breakdown
• putrescine for protein breakdown
• isovaleric acid for metabolite

Question 24

Arguments FOR the link between halitosis and periodontal disease

Answer 24

• 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

Question 25

Arguments AGAINST linking periodontal disease and halitosis

Answer 25

• 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%

Question 26

Diagnosis and measurements of halitosis

Answer 26

• self-reported halitosis
• organoleptic measure
• electrochemical meters
• gas chromatography
• saliva incubation

Question 27

Self assessment of halitosis is easy/hard
Why?

Answer 27

• hard
• need subjective organoleptic analysis by confidant
• assess smell of breath/air exhaled from nose and mouth
• floss
• tongue scrape

Question 28

How do electrochemical meters work for diagnosis?

Answer 28

• instrumental sniffers (portable sulphide monitors)
• very sensitive to H2S
• low sensitivity to mercaptan

Question 29

What is Benzoyl Arginine Naphthylamide/BANA?

Answer 29

• 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

Question 30

First step of halitosis treatment

Answer 30

• history from patient
• clinical exam
• medical history
• completion of appropriate dental treatment
• good record keeping essential

Question 31

Treatment strategies for halitosis

Answer 31

• 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

Question 32

How to improve oral hygeine?

Answer 32

• 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

Question 33

Aside from improving oral hygeine, how to treat halitosis?

Answer 33

• 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)

Question 34

A systematic review was done to see efficacy of mouthrinses in reducing halitosis. Evidence is lacking but what was found?

Answer 34

• 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

Question 35

How to manage patients with halitosis?

Answer 35

• 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