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aa BDS M6 - Periodontology > Halitosis > Flashcards

Halitosis Flashcards

1
Q

What is the definition of halitosis?

A

any noticeable unpleasant/disagreeable odour of expired air

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2
Q

Is halitosis a symptom or a diagnosis?

A

halitosis is a symptom and not a diagnosis in itself:
- it can be caused by a wide range of intra- and extra-oral conditions

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3
Q

What was halitosis first scientifically examined using?

A

an osmoscope (instrument that measured the intensity of odours) in the 1930s

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4
Q

What is the epidemiology of halitosis?

A
  • currently, there is a lack of reliable data although it is considered to be a common complaint
  • halitosis has been reported throughout the world in all cultures and age groups
  • prevalence data typically ranges from 15% to 50%
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5
Q

Why is the prevalence of halitosis difficult to study?

A
  • difficult to classify and quantify
  • variation of study methodology
  • data often based on subjective self-reporting
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6
Q

What epidemiological trends seem to be apparent for halitosis?

A
  • increase in prevalence with age
  • more prevalent in males
  • associated with fasting
  • associated with high protein diets
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7
Q

What are the 2 broad classifications of halitosis?

A
  • genuine halitosis
  • psychogenic halitosis
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8
Q

What are the types of genuine halitosis?

A

verified objectively
- physiological halitosis (transient halitosis)
- e.g. morning breath or food-induced
- pathologic halitosis
- oral malodour/intra-oral (foetar oris)
- extra oral

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9
Q

What are the types of psychogenic halitosis?

A
  • pseudo-halitosis - no objective evidence of malodour, but the patient thinks they have it
  • halitophobia - the patient persists in believing they have halitosis despite firm evidence for the absence of halitosis
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10
Q

Where does the majority of halitosis originate from?

A

90% from the mouth (hence the importance of the dentist’s role in its diagnosis and management)

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11
Q

What is morning breath (physiological halitosis)?

A

common and transient - typically resolves after eating breakfast and carrying out routine oral hygiene

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12
Q

What are the causes of morning breath?

A
  • increased microbial activity during sleep
  • reduced saliva flow during sleep
  • reduced saliva flow during sleep (circadian rhythm) - exacerbated by mouth breathing
  • fasting and starvation can also cause halitosis
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13
Q

What is the management for morning breath?

A

simple advice:
- eating
- routine oral hygiene regime
- rinsing with fresh water
- tongue brushing/scraping may be helpful

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14
Q

What are some foods and drinks associated with halitosis?

A
  • garlic
  • onion
  • cabbage
  • cauliflower
  • radish
  • spicy foods
  • coffee
  • alcohol
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15
Q

What are some of the intra-oral causes of pathological halitosis associated with oral sepsis/disease?

A
  • periodontal disease/poor oral hygiene/food packing
    • gingivitis
    • periodontitis
    • NG
  • pericoronitis
  • oral ulceration
  • acute herpetic gingivostomatitis
  • dry sockets/acute alveolar osteitis
  • post extraction/surgery - oral blood clots
  • xerostomia
  • infected tonsils/tonsilloliths
  • oral malignancy
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16
Q

What are some of the intra-oral causes of pathological halitosis not associated with oral sepsis/disease?

A
  • poor oral appliance hygiene (dentures, removable ortho etc)
  • mouth breathing
  • tongue coating
    • chronic bacterial growth and putrefaction
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17
Q

What is the pathogensis of intra-oral halitosis?

A

primary cause of halitosis is the production of volatile compounds by oral bacteria
- excessive bacterial reservoir on the tongue
- periodontal bacterial deposits etc

bacteria produce these compounds as the result of the breakdown of:
- epithelial cells
- salivary proteins
- serum proteins via the GCF
- food debris

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18
Q

What are some of the bacteria associated with intra-oral halitosis?

A

mainly gram-negative proteolytic anaerobes, and likely a complex interaction of several bacterial species responsible:
- Porphvromonas gingivalis
- Prevotella intermedia
- Tannerella forsvthia
- Treponema denticola
- Fusobacterium nucleatum
- Selenomonas species
- Solobacterium species
- Eubacterium species

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19
Q

What volatile compounds result from the bacterial breakdown of amino acids in the mouth?

A

when bacterial species degrade various sulphur containing amino acids they produce malodorous Volatile Sulphur Compounds (VSC)

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20
Q

What are VSCs?

A

chemicals produced by the bacteria in the mouth that cause bad breath

VSCs are highly volatile and are thought the be the major compounds responsible for intra-oral halitosis

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21
Q

What are the 3 main VSCs?

A
  • methyl mercaptan (CH3SH)
  • hydrogen sulphide (H2S)
  • dimethyl sulphide (CH3SCH3)
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22
Q

What does methyl mercaptan smell like?

A

pungent and smells of rotten cabbage

(evidence suggests this is the primary compound responsible for intra-oral halitosis)

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23
Q

What does hydrogen sulphide smell like?

A

rotten eggs

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24
Q

What does dimethyl sulphide smell like?

A

unpleasantly sweet smell

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25
Q

Do compounds dissolved in saliva cause halitosis?

A

if compounds are completely dissolved in the saliva then they are unlikely to cause halitosis, only the volatile ones cause halitosis

26
Q

What VSCs are responsible for the malodours associated with garlic?

A
  • allyl mercaptan
  • allyl methyl sulphide
27
Q

What VSCs are responsible for the malodours associated with onion?

A

methyl propyl sulphide

28
Q

Other than VSC, what other volatile compounds may be implicated in halitosis?

A
  • diamines
    • putrescine
    • cadaverine
    • butyric acid
  • phenyl compounds
    • indole
    • skatole
29
Q

How is intra-oral halitosis managed?

A

ensure oral health - oral hygiene
- standard OH and denture hygiene instruction
- reduced bacterial deposits/disturbance of biofilms
- removal of food debris

30
Q

What toothpastes may have some minor beneficial effects in treating halitosis?

A

some evidence that triclosan + copolymer containing toothpastes and baking soda-containing toothpastes may have some minor beneficial effects

31
Q

What is the benefit of tongue cleaning/scraping?

A

mechanically disrupts tongue coating
- especially on posterior third of tongue
- statistically small short-term reduction in VSC levels

32
Q

What can tongue brushing/scraping be carried out with?

A
  • toothbrush
  • toothbrush with a specific tongue cleaning section
  • tongue scraper

(reduced material for putrefaction on the tongue rather than reducing bacterial load)

33
Q

How is tongue scraping carried out (with a loop scrapper)?

A

part of daily routine
- extend tongue
- breathe calmly through nose
- apply tongue scrapper as far posteriorly on the tongue as possible
- apply light pressure to flatten the tongue
- pull scrapper forward over the tongue
- repeat several times in order to cover the dorsum and sides of the tongue

34
Q

What mouthwashes may be useful for managing intra-oral halitosis?

A

some evidence that mouthwashes may be helpful
- chlorhexidine and cetylpuridinium chloride
- chlorine dioxine (ultraDEX) and zinc containing mouthwashes can be effective in neutralisation of VSCs
- for halitosis, best to gargle mouthwash in order to reach back of mouth

35
Q

Other than oral hygiene etc, what advice can be given for the management of intra-oral halitosis?

A
  • dietary advice
    • removal of food and drink related causes
    • increased fluid intake (2L per day although this is now contested)
  • smoking cessation advice
  • alcohol reduction advice
36
Q

What dental treatment can be done for the management of intra-oral halitosis?

A
  • periodontal treatment
    • gingivitis/periodontitis/NG
  • restorative treatment
    • treatment of caries
    • removal of plaque traps/food packing
  • oral surgery
    • extraction of roots/treatment of periocoronitis
37
Q

What general advice can be given during the management of intra-oral halitosis?

A
  • regular dental appointments
  • regular meals
  • adequate hydration
  • proprietary breath freshening products may be helpful
    • sugar free mints and chewing gum
    • flavoured sprays
    • very short-term value
    • mask problem not treat it
38
Q

How is an extra-oral cause of halitosis sometimes made apparent?

A

by malodour affecting both oral and nasal exhaled breath

39
Q

What % of halitosis cases are due to extra-oral causes?

A

approx. 10%

40
Q

What are the 3 general aetiological factors of extra-oral halitosis?

A
  • drug-induced
  • systemic disease
  • habits (smoking, alcohol)
41
Q

What drugs may induce extra-oral halitosis?

A
  • alcohol
  • tobacco/smoking
  • betel
  • solvents
  • disulfiram
  • cytotoxics
  • phenothiazines
  • amphetamines
  • in addition, drugs which cause/predispose to xerostomia
42
Q

What categories of systemic disease may be extra-oral causes of halitosis?

A
  • nasal and pharyngeal infections
  • respiratory pathology
  • gastro-intestinal pathology
  • metabolic conditions
43
Q

What nasal ad pharyngeal infections may cause extra-oral halitosis?

A
  • chronic sinusitis/post nasal drip
  • tonsillitis
  • pharyngeal pouch
  • foreign bodies
  • malignancy
44
Q

What respiratory pathology may cause extra-oral halitosis?

A
  • respiratory tract infections/chronic bronchitis
  • bronchial carcinoma
45
Q

What GI pathology may cause extra-oral halitosis?

A
  • oesophageal reflux
  • pyloric stenosis
46
Q

What metabolic conditions may cause extra-oral halitosis?

A
  • diabetes (ketoacidosis - acetone-like smell associated with uncontrolled diabetes)
  • renal failure (uremic breath)
  • hepatic failure (foetar hepaticus associated with cirrhosis)
47
Q

What will many patient be convinced their halitosis is related to?

A

GIT problems - but these are a rare cause of halitosis because the oesophagus is usually collapsed

48
Q

What is pseudo-halitosis?

A

no objective evidence of malodour, but the patient is convinced they have it
- must first treat/rule out other causes of genuine halitosis (diagnosis by exclusion)

49
Q

What is halitophobia?

A

the patient persists in believing they have halitosis, even after successful treatment for genuine/pseudo-halitosis, despite firm evidence for the absence of halitosis

50
Q

What may halitophobia stem from?

A
  • may be an exaggerated fear of having halitosis
  • patient may show signs of OCD or hypochondria
  • may be related to an underlying psychological/psychiatric condition
51
Q

What are the 2 principal methods of halitosis assessment?

A
  • organoleptic assessment
  • laboratory methods
    • halimeter (portable sulphide monitor)
    • gas chromatography
52
Q

What is organoleptic assessment?

A
  • most common method - easy in practice
  • clinician smells the patient’s exhaled breath (mouth and nose) and subjectively assesses it for odour
53
Q

How is organoleptic assessment carried out?

A
  • patient closes their mouth for 1 minute
  • patient and dentist face eachother - the dentist’s nose approx. 10cm from pt mouth
  • patient then exhales slowly through their mouth
  • dentist assesses exhaled breath for odour
54
Q

Ideally, what should be avoided before organoleptic assessment?

A
  • ideally both the pt and the clinician should avoid smoking, drinking coffee/tea/juice and wearing perfumes/aftershaves prior to test
  • pt should avoid halitosis associated food e.g. garlic for 48 hours prior to test
55
Q

What may malodour from air exhaled from the nose indicate?

A

may indicate the source of the problem is from the nose, sinuses, respiratory or GI tracts

56
Q

What is a halimeter?

A

portable gas monitor (electro-chemical sensor)

57
Q

What does a halimeter do?

A

objectively detects VSC levels
- cannot differentiate between different VSCs
- more sensitive to hydrogen sulphide than the more important methyl mercaptan
- very sensitive to alcohol
- need to avoid drinking alcohol or using alcohol containing mouthwashes 12 hours prior to assessment
- expensive and rarely used in clinical practice

58
Q

What is gas chromatography used for?

A

useful for differentiating and quantifying specific compounds
- the gold standard assessment
- only available in specialist centres
- expensive and time consuming, special lab equipment and staff needed

59
Q

What is OralChroma?

A

portable gas chromatography machine

60
Q

What is OralChroma very sensitive to?

A

very sensitive to levels of three major VSCs
- hydrogen sulphide
- methyl mercaptan
- dimethyl sulphide

61
Q

Summarise the primary role of the dentist in halitosis management.

A
62
Q

Summarise the management of halitosis when referral made to GMP/Oral medicine.

A

aa BDS M6 - Periodontology (3 decks)

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