Clinical management of halitosis

Question 1

List the 6 topics you would ask a patient about when collecting medical histories to make a diagnosis for halitosis

Answer 1

· Frequency of the bad breathe
· Time of the day the bad breath is prominent
· Time when the issue first appeared
· Time when others identified the issue
· List of medications
· Breathing, dry mouth, allergies and nasal problems

Question 2

Explain the 6 steps involved the clinical management of halitosis

Answer 2

1. Review medical/ dental history: Medications and oral habits need to be evaluated as they can be causative agents. Moreover, the use of sugar-containing products need to be identified as they might be contributing to other dental disease processes
2. Examine oral tissues/ periodontal exam
3. Focus on removal of plaque biofilm/ tongue cleaning or deplaquing
4. Neutralise VSCs through post-procedural rinses
5. Recommend home care aids like chewing gums with the following ingredients: zinc citrate, sodium bicarbonate, eucalyptus and probiotics
6. Ongoing management through recalls/ referral

Question 3

List the 6 different types of diagnostic methods for halitosis

Answer 3

· Nose
· Organoleptic judges
· Gas chromatography
· Microbiological assay
· Sulphide-detection devices
· BANA-zyme

Question 4

Explain the “nose” as a detection method of halitosis by mentioning the associated disadvantages (3)

Answer 4

Issue is that is:

• Subjective
• Uncomfortable (for clinician and patient)
• Self-perception is not reliable

Question 5

Explain “organoleptic judges” as a detection method of halitosis

Answer 5

These are specialized individuals who can discern the difference and quality of odours.
Apparently, it provides consistent measurements and evaluation

Question 6

Explain “gas chromatography” as a detection method of halitosis and mention its disadvantage

Answer 6

This is a laboratory-based procedure that assesses presence of VSCs.

Issue is that it is very costly

Question 7

Explain “microbiological assays” as a detection method of halitosis

Answer 7

Evaluates specific sites for by-products of periodontal associated bacteria and VSCs

Question 8

Explain “sulphide-detection devices” as a detection method of halitosis and state what type of VSC it is most sensitive to

Answer 8

Explanation:
· Portable monitors that detect VSCs

Type of VSC it is most sensitive to:
· Hydrogen sulphide than other VSCs

Question 9

Explain “BANA-zyme” as a detection method of halitosis by stating how it works

Answer 9

Rapid chair side detection tool that uses samples of plaque from the dorsum of the tongue

Question 10

List the organoleptic scoring scale of halitosis (6)

Answer 10

0. Absence: No detectable odour
1. Questionable halitosis: Odour is detectable but examiner cannot recognise it as halitosis
2. Slight halitosis: Odour is deemed to exceed the threshold of halitosis recognition
3. Moderate halitosis: Halitosis is definitely detected
4. Strong halitosis: Strong halitosis is detected, but can but tolerated by examiner
5. Severe halitosis: Overwhelming halitosis is detected and cannot be tolerated by examiner

Question 11

List the 4 goals of clinical/ individual management of halitosis

Answer 11

• To educate the patient
• To increase salivary flow
• Eliminate sources of gram-negative bacteria or biofilms from key intraoral niches (posterior dorsum of the tongue, sulcus or periodontal pockets, tonsillar region)
• Neutralise VSCs

Question 12

Explain the goal of “patient education” in halitosis management by mentioning what occurs (4)

Answer 12

Discuss oral malodour with patients and:

• Assess the use of oral malodour-related products
• Correlate probing depths of more than 4mm with oral malodour
• Deplaque the tongue, and show patient the biofilm or tongue coating substance
• Use positive dialogue (maintain fresh breath versus eliminate bad breath)

Question 13

Explain the goal of “increasing salivary flow” in halitosis management by mentioning the different ways to achieve this (4)

Answer 13

• Saliva substitutes
• Increase intake of water
• Chew sugar-free gum or mints (preferably with xylitol)
• Use alcohol-free mouth rinses

Question 14

Explain the goal of “eliminating sources of gram negative bacteria” in halitosis management by mentioning the types of OH recommendations (4)

Answer 14

• Use of automated toothbrushes and interdental devices
• Use active agent-impregnated floss, tongue scrapers, etc
• Use of neutralizing agent-containing rinses, toothpastes, gums etc
• Maintain regular professional dental hygiene care/intervention

Question 15

Explain the goal of “neutralising VSCs” in halitosis management by stating what studies have shown to be the most effective method

Answer 15

• One trial showed reductions of VSC levels of 42% with the tongue cleaner, 40% with the tongue scraper and 33% with the toothbrush
• This has been withdrawn, the latest Cochrane review states that CHx and mechanical oral hygiene reduced bad breath for longer periods than tongue cleaning alone.

Question 16

Discuss the mechanical method for oral malodour treatment and prevention

Answer 16

Mechanical: tongue cleaning:
• Mechanical cleaning ensures that removal begins from the most posterior aspect of tongue
• A plastic spoon can be used or the regular toothbrush
• It should be carried out twice a day as part of the normal tooth brushing routine, there is no need to use toothpaste. Tongue cleaning is purely mechanical

Question 17

Discuss the use of chemotherapeutics in oral malodour treatment and prevention by stating

• The ingredients used (6)
• Which ingredient is the strongest and how it works

Answer 17

Ingredients used:
• Chlorhexidine
• Zinc
• Chloride dioxide
• Cetylpyridinium chloride = CPC (mild)
• Essential oils 
• Triclosan

How the strongest ingredient works:
• Zinc is especially effective because zinc ions have strong affinity for thiol groups present in VSCs. It converts VSCs to non-volatile sulfides

Question 18

Discuss the use of chemotherapeutics in oral malodour treatment and prevention by stating

• What studies have shown to be effective
• Negative side effects of ingredients

Answer 18

What studies have shown to be effective
• 0.05% chlorhexidine + 0.05% cetylpyridinium chloride + 0.14% zinc lactate mouthrinse significantly reduced the standard deviation of organoleptic scores from baseline and also caused a significant reduction in the standard deviation in peak levels of VSCs

Negative side effects of ingredients
• Chlorhexidine, cetylpyridinium chloride and zinc lactate mouth rinse showed significantly more tongue staining compared to placebo

Question 19

Discuss the use of chemotherapeutics in oral malodour treatment and prevention by stating
- The 2 ingredients used to mask odours

Answer 19

Odour masking constituents
• Essential oils
• Phenols

Question 20

Explain the “Ongoing management through recalls/ referrals” of halitosis

Answer 20

• The correct diagnosis is necessary - there may be underlying health issue causing halitosis and therefore, there may be a need for referral
• As with all treatments a review is necessary to track improvement
• If the review is not given then the patient should be aware of “markers” to gauge whether there has been a difference