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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
Do compounds dissolved in saliva cause halitosis?
if compounds are completely dissolved in the saliva then they are unlikely to cause halitosis, only the volatile ones cause halitosis
26
What VSCs are responsible for the malodours associated with garlic?
- allyl mercaptan - allyl methyl sulphide
27
What VSCs are responsible for the malodours associated with onion?
methyl propyl sulphide
28
Other than VSC, what other volatile compounds may be implicated in halitosis?
- diamines - putrescine - cadaverine - butyric acid - phenyl compounds - indole - skatole
29
How is intra-oral halitosis managed?
ensure oral health - oral hygiene - standard OH and denture hygiene instruction - reduced bacterial deposits/disturbance of biofilms - removal of food debris
30
What toothpastes may have some minor beneficial effects in treating halitosis?
some evidence that triclosan + copolymer containing toothpastes and baking soda-containing toothpastes may have some minor beneficial effects
31
What is the benefit of tongue cleaning/scraping?
mechanically disrupts tongue coating - especially on posterior third of tongue - statistically small short-term reduction in VSC levels
32
What can tongue brushing/scraping be carried out with?
- toothbrush - toothbrush with a specific tongue cleaning section - tongue scraper (reduced material for putrefaction on the tongue rather than reducing bacterial load)
33
How is tongue scraping carried out (with a loop scrapper)?
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
What mouthwashes may be useful for managing intra-oral halitosis?
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
Other than oral hygiene etc, what advice can be given for the management of intra-oral halitosis?
- 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
What dental treatment can be done for the management of intra-oral halitosis?
- 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
What general advice can be given during the management of intra-oral halitosis?
- 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
How is an extra-oral cause of halitosis sometimes made apparent?
by malodour affecting both oral and nasal exhaled breath
39
What % of halitosis cases are due to extra-oral causes?
approx. 10%
40
What are the 3 general aetiological factors of extra-oral halitosis?
- drug-induced - systemic disease - habits (smoking, alcohol)
41
What drugs may induce extra-oral halitosis?
- alcohol - tobacco/smoking - betel - solvents - disulfiram - cytotoxics - phenothiazines - amphetamines - in addition, drugs which cause/predispose to xerostomia
42
What categories of systemic disease may be extra-oral causes of halitosis?
- nasal and pharyngeal infections - respiratory pathology - gastro-intestinal pathology - metabolic conditions
43
What nasal ad pharyngeal infections may cause extra-oral halitosis?
- chronic sinusitis/post nasal drip - tonsillitis - pharyngeal pouch - foreign bodies - malignancy
44
What respiratory pathology may cause extra-oral halitosis?
- respiratory tract infections/chronic bronchitis - bronchial carcinoma
45
What GI pathology may cause extra-oral halitosis?
- oesophageal reflux - pyloric stenosis
46
What metabolic conditions may cause extra-oral halitosis?
- diabetes (ketoacidosis - acetone-like smell associated with uncontrolled diabetes) - renal failure (uremic breath) - hepatic failure (foetar hepaticus associated with cirrhosis)
47
What will many patient be convinced their halitosis is related to?
GIT problems - but these are a rare cause of halitosis because the oesophagus is usually collapsed
48
What is pseudo-halitosis?
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
What is halitophobia?
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
What may halitophobia stem from?
- 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
What are the 2 principal methods of halitosis assessment?
- organoleptic assessment - laboratory methods - halimeter (portable sulphide monitor) - gas chromatography
52
What is organoleptic assessment?
- most common method - easy in practice - clinician smells the patient’s exhaled breath (mouth and nose) and subjectively assesses it for odour
53
How is organoleptic assessment carried out?
- 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
Ideally, what should be avoided before organoleptic assessment?
- 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
What may malodour from air exhaled from the nose indicate?
may indicate the source of the problem is from the nose, sinuses, respiratory or GI tracts
56
What is a halimeter?
portable gas monitor (electro-chemical sensor)
57
What does a halimeter do?
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
What is gas chromatography used for?
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
What is OralChroma?
portable gas chromatography machine
60
What is OralChroma very sensitive to?
very sensitive to levels of three major VSCs - hydrogen sulphide - methyl mercaptan - dimethyl sulphide
61
Summarise the primary role of the dentist in halitosis management.
62
Summarise the management of halitosis when referral made to GMP/Oral medicine.

aa BDS M6 - Periodontology (3 decks)

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