halitosis and management

1. HALITOSIS
Dr.Navya, MDS

2. INTRODUCTION
• Breath malodor, oral malodor, fetor ex ore,
fetor oris, bad or foul breath, and halitosis
• The Latin "halitus" meaning "breath" and
the Greek "osis" meaning "abnormal" or
"diseased“

3. • Over 90% of all bad breath odors originate
in the mouth (Delanghe et al. 1997; van
Steenberghe 1997).

4. Classification of Halitosis
Patients
• Genuine halitosis,
• Pseudo-halitosis and
• Halitophobia
• Temporary or transient halitosis(morning
bad breath)

6. Intraoral causes
• Dentition
• Periodontal infections
• Dry mouth
• Tongue and tongue coating

7. Pathogenesis of intraoral
halitosis
• the bacterial degradation of sulfur-
containing amino acids (methionine,
cystine, and cysteine) into volatile sulfur
compounds (VSCs)
• methyl mercaptan (CH3SH) and
• hydrogen sulfide (H2S)
• other volatile compounds such as
cadaverine, indole, skatole, and butyric
acid

8. Periodontal infections
• Porphyromonas gingivalis
• Aggregatibacter actinomycetemcomitans
• Bacteroides spp.
• Selenomonas spp.
• Fusobacterium spp.
• Peptostreptococcus spp.
• Prevotella intermedia
• Tannerella forsythensis are all known to
produce VSCs.

9. Periodontal infections
VSCs are potentially capable of altering the
permeability of the gingival tissues, including
inflammatory responses.
By modulating the functions of gingival fibroblasts ;
(Torresyap et al. 2003).
Increase permeability of the pocket and mucosal
epithelium
MM has also been shown to act synergistically with
both lipopolysaccharide (LPS) and interleukin 1-
beta (IL-lb) PG E2 and collagenase (Ratkay et al.
1995).
Impede wound healing

10. Other periodontal conditions
• Pericoronitis
• NUG/NUP
• Major recurrent oral ulcerations(infected)
• Herpetic gingivitis

11. Tongue
• The posterior dorsum of the tongue is the
principal site.
• a significantly higher bacterial load on the
dorsum of the tongue.
• an ideal habitat for anaerobic bacteria
forming tongue coating of food debris,
dead cells, and hundreds of thousands of
bacteria, both living and dead.

12. Dry mouth
• Saliva has an important cleansing action

13. Extraoral Blood-borne Halitosis
Causes
• Systemic diseases
• Hepatic failure/liver cirrhosis
Uremia/kidney failure
• Diabetic ketoacidosis, diabetes
mellitus
• Metabolic disorders
• Isolated persistent
hypermethioninemia ,
• Fish odor syndrome,
trimethylaminuria
• Medication
• Disulfiram
• Dimethylsulfoxide
• Cysteamine
• Food
• Garlic
• Onion
Odorant
10% of cases
Tanger-man & Winkel 2007)

14. • Upper respiratory tract causes-
chronic sinusitis,
nasal obstruction,
nasopharyngeal abscess, and
carcinoma of the larynx.
• Lower respiratory tract causes-
bronchitis,
bronchiectasis,
pneumonia,
pulmonary abscess, and
carcinoma of the lungs

15. Pathogenesis of extraoral
halitosis
• by dimethyl sulfide
• unknown metabolic disorder resulting in
elevated odorous levels of dimethyl sulfide
in blood and breath.

16. Diagnosis
• Medical history
• Clinical and lab examination

17. Medical history
• Through questioning about the medical
history
• Enquire about the frequency, time of
occurrence within the day
• Whether others have identified it
• Medications
• Dryness of mouth

18. Clinical and lab examination
• SELF-EXAMINATION
• ORGANOLEPTIC RATING
• PORTABLE VOLATILE SULPHIDE
MONITOR
• GAS CHROMATOGRAPHY
• DARK- FIELD OR PHASE-CONTRAST
MICROSCOPY
• SALIVA INCUBATION TEST
• ELECTRONIC NOSE

19. SELF-EXAMINATION
• Involve the patient
• Helps in motivation
• Smelling the scraping from the back of the
tongue
• Smelling a toothpick from interdental area
• Smelling saliva spit
• Smelling the wrist after licking it

20. ORGANOLEPTIC RATING

21. By Rosenberg and
McCulloch
• 0-Absence of halitosis
• 1-Questionable
halitosis
• 2-Slight halitosis
• 3-Moderate halitosis
• 4-Strong halitosis
• 5-Severe halitosis
0 – 5 scale
• Odor cannot be detected
• Odor is detectable, although
the examiner could not
recognize it as halitosis
• Odor is deemed to exceed the
threshold of halitosis
recognition
• Halitosis is definitely detected
• Strong halitosis is detected,
but can be tolerated by
examiner
• Overwhelming halitosis is
detected and cannot be
tolerated by examiner
(examiner instinctively averts
the nose)

22. PORTABLE VOLATILE SULPHIDE
MONITOR
Halimeter™ (Rosen-berg et al. 1991)

23. Breathtron™ (Sopapornamorn 2006

24. Gas Chromatography

25. Portable Gas Chromatograph
OralChroma™

26. DARK- FIELD OR PHASE-
CONTRAST MICROSCOPY
• Detect motile organisms and spirochetes
• Monitoring of therapeutic progress
• Motivation of patients by direct microscopy

27. SALIVA INCUBATION TEST
• Analysis of incubated saliva by gas
chromatography
• Less invasive test
• Effect of oral rinses

28. ELECTRONIC NOSE
• The FF-1 odor discrimination analyzer
(electronic nose)
• composed of a pre-concentrator, an array
of 6 metal oxide semiconductor sensors
selected for their different sensitivities and
selectivities to fragrant substances, and
pattern recognition software.
Tanaka et al. J Dent Res 83(4) 2004

29. Oral inspection
• Periodontal condition
• Caries
• Tongue
• Oral hygiene

30. Index systems for tongue coating
• Miyazaki et al. (1995) divides the tongue into
three sections and the presence or absence
of tongue coating is registered as follows:
• Score
• 0 = none visible;
• 1 = less than one third of tongue dorsum is
covered;
• 2 = between one and two thirds;
• 3 = more than two thirds.

31. • Winkel et al. (2003) divides the tongue into six
sections, three in the posterior and three in the
anterior part of the tongue.
• Each sextant is categorized as:
score
• 0 = no coating present;
• 1 = presence of a light coating;
• 2 = presence of a distinct coating.
• The resulting Winkel tongue coating index (WTCI)
is obtained by adding all six scores (Winkel et al.
2003)

32. Therapy for halitosis

33. Treatment needs (TN) for halitosis(5 classes)
• TN-1- Explanation of halitosis and instructions for oral
hygiene (support and reinforcement of a patient’s
own self-care for further improvement of their oral
hygiene). Physiologic halitosis
• TN-2 -Oral prophylaxis, professional cleaning and
treatment for oral diseases, especially
periodontal diseases. Oral pathologic halitosis
• TN-3 -Referral to a physician or medical specialist.
Extraoral pathologic halitosis
• TN-4 -Explanation of examination data, further
professional instruction, education and reassurance.
Pseudo-halitosis
• TN-5 -Referral to a clinical psychologist, psychiatrist or
other psychological specialist. Halitophobia
TN-1 is applicable to all cases requiring TN-2 through TN-5

34. Treatment of oral malodor
• Mechanical reduction of intraoral nutrients
and microorganisms
• Chemical reduction of oral microbial load
• Rendering malodorous gases nonvolatile
• Masking the malodor

35. Mechanical reduction of intraoral
nutrients and microorganisms
• Tongue cleaning with tongue
scraper/normal toothbrush(Quirynen et al
2004)
• Interdental cleaning and toothbrushing for
plaque removal
• Combined effect- 70% reduction in VSCs
whereas only toothbrushing- 30%
reduction in VSCs
(Tonzetich et al 1976)

36. • Professional periodontal therapy- FMD-
90% reduction (Quirynen et al 1998)
• Chewing gum to stimulate salivary flow

37. Chemical reduction of oral
microbial load

38. Chlorhexidine
 0.12% CHX alone (CHX1NO),
 plus alcohol (CHX1ALC),
 plus 0.05% cetylpiridinium chloride (CHX1CPC),
 plus sodium fluoride (CHX1NaF),
 and 0.05% CHX plus 0.05% CPC, plus 0.14% zinc
lactate (CHX1Zn).
• Formulations that combine CHX and CPC
achieved the best results, and a formulation
combining CHX with NaF resulted in the
poorest.(Roldan et al 2004)

39. • Essential oils

40. • Chlorine dioxide

41. • Two-phase oil-water rinse

42. • Triclosan

43. • Aminefluoride/stannous fluoride

44. • Hydrogen peroxide

45. • Oxidizing lozenges

46. Rendering malodorous gases
nonvolatile

47. • Metal salt solutions

48. • Toothpastes

49. • Chewing gum

50. Masking the malodor
• Short term effects
• Rinses, sprays, lozenges
• Lowering the pH of saliva(orange juice)
• Increasing the flow of saliva(chewing gum)

52. Diagnosis

53. Conclusion
Halitosis can be a crippling social
problem and therefore needs to be
considered a serious problem.
Extraoral halitosis might be a
manifestation of a serious disease.
It is of paramount importance to
differentiate between extra- and
intraoral
halitosis.
The dental hygienist, dentist, and
Periodontist are the most
appropriate professionals to
diagnose and to treat this condition

54. Thank you