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Halitosis: Current concepts
on etiology, diagnosis
and management
E U R J D E N T 2 0 1 6 ; 1 0 : 2 9 2 - 3 0 0 .
Journal ...
PROLOGUE
An unpleasant or
offensive odour
emanating from the
breath regardless of
whether the odour
originates from oral
o...
AIM
Succinctly focuses on the
development of a systematic
flow of events to come to the
best management of the
halitosis f...
INTRODUCTION
It was described as a clinical entity
by HOWE (1874).
Halitosis should not be confused
with the generally tem...
SYNONYM
S
Bad or foul
breath
Breath
malodour
Oral
malodour
Foetor ex-
ore
Foetor oris
Stomato
dysodia
van den Broek AM, Fe...
DEFINITIONS
Halitosis is the general
term used to describe a
foul odor emanating
from the oral cavity, in
which proteolysi...
DEFINITION
S
Breath malodor, defined as foul or offensive odor of expired air, may be
caused by a number of factors, both ...
HISTORY
The problem of halitosis has been
reported for many years.
References were found in papyrus
manuscripts dating bac...
A treaty in Islamic
literature from the year
850 talked about
dentistry, referring to
the treatment of fetid
breath & reco...
HISTORY
The Hindus consider the mouth as
the body's entry door and, therefore,
insist that it be kept clean, mainly
before...
EPIDEMIOLOGY
Miyazaki concluded that
there was increased
correlation between older
age and malodour with
aging resulting i...
Japan study 2,672
Individuals 6-23% of
subjects had oral
malodour (VSC) as in
expired air at some period
during the day (M...
C
L
A
S
S
I
F
I
C
A
T
I
O
N
CLASSIFICATIO
N
Genuine
halitosis
Physiologic
halitosis
Pathologic
halitosis
Intraoral Extraoral
CLASSIFICATIO
N
PHYSIOLOGIC
HALITOSIS
Morning
breath
odour
Decrease
in
frequent
liquid
intake
Stagnation of saliva
and putrefaction of
ent...
Genuine
halitosis
Physiologic
halitosis
Pathologic
halitosis
Intraoral Extraoral
CLASSIFICATIO
N
Pathologic halitosis
poor oral hygiene,
dental caries,
periodontal
diseases in
particular NUG,
NUP,
periodontitis,
pericoronitis,dry socket
ton...
OTHER ORIGINS OF
HALITOSIS
The resulting breath takes on a different odor that may last
several hours
Transient oral malod...
• 10-20%
• gastro intestinal diseases
• infections or malignancy in respiratory tract
• Chronic sinusitis and tonsillitis
...
Maximally 10% of the oral malodor cases originate from the ears, nose and throat (ENT)
region, from which 3% finds its ori...
Examples of
systemic
pathological
conditions
that cause
halitosis
Pathologic halitosis
CLASSIFICATIO
N
Delusional
halitosis
Pseudo
halitosis
Halitophobia.
Condition in which a subject believes that their breath odor is
offensive and is a cause of social nuisance, however, neit...
IMAGINARY OR
DELUSIONAL HALITOSIS
•Pseudo halitosis
– Apparently healthy individuals
•Haltophobia
– exaggerated fear of ha...
Pseudo-halitosis patients complain of
having oral malodor without actually
suffering from the problem and
eventually gets ...
Halitophobia is fear of having bad breath seen in at least 0.5–1% of adult
population
Such patients need psychological
cou...
OLFACTORY REFERENCE
SYNDROME
 Psychological disorder in which there
is a preconceived notion about one
having foul mouth ...
Halitosis generally arises as a result of the bacterial
decomposition of food particles, cells, blood and
some chemical co...
Volatile sulphur compounds → hydrogensulphide [H2S,
rotten egg smell], dimethyl sulphide [(CH3)2S, rotten
cabbage smell, a...
ROLE OF VOLATILE SULPHUR COMPOUNDS
IN THE PATHOGENESIS OF HALITOSIS
MAJOR COMPOUNDS IMPLICATED IN HALITOSIS
VSC’s - Methyl...
It increases the permeability of oral mucosa and crevicular epithelium. It
impairs oxygen utilization by host cells, and r...
Pathogenesis of oral malodor
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 201...
The role of tongue coatings in the
aetiology of oral malodour has been
extensively documented.
Tongue coatings include des...
The purulent discharge from the paranasal sinuses, seen in regurgitation
esophagitis, gets collected at the dorsum of the ...
Kinberg et al. published a review in 2010, in which they examined 94 patients having
halitosis out of which 54 had gastroi...
Metabolic disorders like Trimethylaminuria (fish odor syndrome) is characterized by the
presence of trimethylamine (TMA), ...
MICROBIOLOGY AND BREATH
MALODOR
Fusobacterium
nucleatum,
Treponema
denticola,
Prevotella
intermedia,
Porphyromonas
gingiva...
DRUGS ASSOCIATED WITH
HALITOSIS
DIAGNOSIS
Complaint,
Medical, dental and
halitosis history,
Information about
diet and habits,
Confirming an
objective bas...
Discretely and intermittently recorded.
Questions such as frequency, duration, time of appearance within a day,
Whether ot...
DIRECT
1. By directly sniffing the bad breath
2. Determination of odoriferous sulfur
containing substances by gas
chromato...
1. Self-assessment,
2. Whole mouth
breath test,
3. Spoon test,
4. Dental floss odor
test,
5. Saliva odor test.
Direct test...
ORGANOLEPTIC MEASUREMENT
(SNIFF TEST)
Organoleptic measurement is a sensory test scored on the
basis of the examiner’s per...
Organoleptic Scores
(0- 5)
0 - No appreciable odor
1 - Barely noticeable odor
2 - Slight but noticeable odor
3 - Moderate ...
Yaegaki & coil 2000
DIAGNOSIS
The subjects are instructed to smell the
odor emanating from their entire mouth
by cupping their hands over thei...
Subjects are asked to
extend their tongue
and lick their wrist
in a perpendicular
fashion.
The presence of odor
is judged ...
Plastic spoon is used to
scrape and scoop material
from the back region of
the tongue.
The odor is judged by smelling
the ...
Unwaxed floss is passed through interproximal contacts.
Dental floss test
Involves having the subject
expectorate approx. 1-2 ml of
saliva into a petridish.
The dish is covered immediately,
incuba...
BANA TEST
If any of the these species are present, they hydrolyze the BANA
enzyme-producing B-naphthylamide which in turn ...
VOLATILE SULFIDE MONITOR
This electronic (Haiimeter,
InterScan, Chatsworth, Calif)
analyzes concentration of hydrogen
sulf...
GAS CHROMATOGRAPHY (GC):
GC, performed
with apparatus
equipped with a
flame photometric
detector, is specific
for detectin...
DIAMOND PROBE
 The Probe is placed directly into the
periodontal pocket or tongue.
 The sulfide-sensing element
generate...
NINHYDRIN METHOD OF
DETECTING AMINE
COMPOUNDS
Iwanicka et al (2005)
showed that amine levels
were higher in the saliva of
...
HALITOX SYSTEM
Quick and simple
Detects VSCs and poly
amines
TOPAS
It detects both VSC and
polyamines in the
sample.
The absorbent point
given with the kit is
inserted into the pocket...
PREVENTIVE MEASURES
Visit dentist regularly
Periodical tooth cleaning by dental
professional.
Brushing of teeth twice dail...
Flossing after brushing to remove food particles
stuck in between the tooth surfaces.
Limit intake of strong odour species...
MANAGEMENT AND
TREATMENT
1. Confirm the diagnosis,
2. Identify and eliminate the predisposing and modifying factors,
3. Id...
MANAGEMENT
Treatment needs (TN) for halitosis have been categorized into 5 classes in order to provide guidelines
for clin...
Mechanical
reduction of
intraoral
nutrients and
micro-organisms
Chemical
reduction of oral
microbial load
Conversions of
V...
Mechanical reduction of intraoral nutrients and micro-organisms
- Tongue cleaning
- Tooth brush
- Inter-dental cleaning
- ...
2. Chemical reduction of oral microbial load
- Chlorhexidine
- Essential oils
- Chlorine dioxide
- Two-phase oil- water ri...
CHLORHEXIDINE (CHX)
Mouth rinses containing antibacterial agents such as CHX and cetylpyridinium chloride (CPC) may
play a...
TWO-PHASE
OILWATER
RINSE: The
efficacy of
oilwater CPC
formulation is
thought to result
from the
adhesion of a
high propor...
3.Conversion of volatile sulfide compounds
- Metal salt solutions
- Toothpastes
- Chewing gum
MANAGEMENT
Metal salt solutions: Metal ions with affinity for sulfur are rather efficient
in capturing the sulfur-containing gases. Z...
4. Masking the malodor
-Rinses
-Mouth sprays
-Lozenges containing volatiles
-Chewing gum
MANAGEMENT
Herbs and essential
oils can be made into very
effective mouthwash
remedies to sweeten
breath and help
keep gums and teeth...
Thymol, one of the
constituents of thyme, is
contained in antiseptic
mouthwashes.
Neem leaf powder can be used
as an effec...
CONCLUSION
It’s a common complaint that may periodically affect most of the
adult population.
Oral maldor, which is common...
REASON FOR
CHOOSING THIS
ARTICLE?
REFERENC
ES1. Newman ,Takei, Carranza. Clinical periodontology ; 10th and 11th edition
2. J lindhe. Clinical periodontolog...
15. Roldán S, Herrera D, Santa-Cruz I, O’Connor A, González I, Sanz M. Comparative effects of different chlorhexidine
mout...
29. Study on the organoleptic intensity scale for measuring oral malodor. J Dent Res 2004;83:81-5.
30. Rosenberg M, McCull...
Thank
you
Halitosis - Dr Sanjana Ravindra
Halitosis - Dr Sanjana Ravindra
Halitosis - Dr Sanjana Ravindra
Halitosis - Dr Sanjana Ravindra
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Halitosis - Dr Sanjana Ravindra

halitosis - introduction
histroy
epidemiology
classification
etiology
pathophysiology
microbiology
diagnosis
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Halitosis - Dr Sanjana Ravindra

  1. 1. Halitosis: Current concepts on etiology, diagnosis and management E U R J D E N T 2 0 1 6 ; 1 0 : 2 9 2 - 3 0 0 . Journal club : 12
  2. 2. PROLOGUE An unpleasant or offensive odour emanating from the breath regardless of whether the odour originates from oral or non-oral sources. G Campisi, A Musciotto. Halitosis: could it be more than mere bad breath?; Intern Emerg Med (2011) 6:315–319.
  3. 3. AIM Succinctly focuses on the development of a systematic flow of events to come to the best management of the halitosis from the primary care practitioner’s point of view.
  4. 4. INTRODUCTION It was described as a clinical entity by HOWE (1874). Halitosis should not be confused with the generally temporary oral odour caused by intake of certain foods, tobacco, or medications. Originates from two Latin words ◦ Halitus → breath ◦ Osis → disease Armstrong BL, Sensat ML, Stoltenberg JL. Halitosis: A review of current literature. J Dent Hyg 2010;84:65-74.
  5. 5. SYNONYM S Bad or foul breath Breath malodour Oral malodour Foetor ex- ore Foetor oris Stomato dysodia van den Broek AM, Feenstra L, de Baat C. A review of the current literature on aetiology and measurement methods of halitosis. J Dent 2007;35:627-35
  6. 6. DEFINITIONS Halitosis is the general term used to describe a foul odor emanating from the oral cavity, in which proteolysis, metabolic products of the desquamating cells and bacterial putrefaction are involved. • Marita et al., 2001 Halitosis is the general term used to describe any disagreeable odor in expired air, regardless of whether the odorous substances originate from oral or non-oral sources. • -Tangerman, 2002 Halitosis is also termed as fetor ex ore or fetor oris. It is a foul or offensive odor emanating from the oral cavity. • Carranza(2003) Unpleasant odor of the expired air whatever the origin may be. Oral malodor specifically refers to such odor originating from the oral cavity itself. • Jan Lindhe(2003) J lindhe. Clinical periodontology and implant dentistry; vol 1: 5th edition Newman ,Takei, Carranza. Clinical periodontology ; 10th and 11th edition
  7. 7. DEFINITION S Breath malodor, defined as foul or offensive odor of expired air, may be caused by a number of factors, both intra-oral & extra-oral (gingivitis/ periodontitis, nasal inflammation, chronic sinusitis, diabetes mellitus, liver insufficiency etc.,) & can be linked to more serious underlying medical problems including primary biliary cirrhosis, uremia, lung carcinoma, decompensated liver cirrhosis & trimethylaminuria. Quirynen, Zhao, Avontroodt et al., 2003
  8. 8. HISTORY The problem of halitosis has been reported for many years. References were found in papyrus manuscripts dating back to 1550 BC. During Christianity, the devil's supreme malignant odor smelled of sulfur & it was presumed that sins produced a more or less bad smell. Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6:2-7
  9. 9. A treaty in Islamic literature from the year 850 talked about dentistry, referring to the treatment of fetid breath & recommended the use of siwak when breath had changed or at any time when getting out of bed. Buddhist monks in Japan also recommended teeth brushing & tongue scraping before the first morning prayers. HISTORY Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6:2-7
  10. 10. HISTORY The Hindus consider the mouth as the body's entry door and, therefore, insist that it be kept clean, mainly before prayers. The ritual is not limited to teeth brushing, but includes scraping the tongue with a special instrument and using mouthwash. Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6:2-7
  11. 11. EPIDEMIOLOGY Miyazaki concluded that there was increased correlation between older age and malodour with aging resulting in greater intensity the of odor. In above 60 years age group of the Turkish individuals, the incidence was around 28%. A recent study had revealed a prevalence of self-reported halitosis among Indian dental students ranging from 21.7% in males to 35.3% in females. In the general population, halitosis has a prevalence ranging from 50% in the USA to between 6% and 23% in china,
  12. 12. Japan study 2,672 Individuals 6-23% of subjects had oral malodour (VSC) as in expired air at some period during the day (Miyazaki 1996). Another study in the United States involving individuals older than 60 years found 24% had oral malodour (Rosenberg 1996). Epidemiology The prevalence of persistent oral malodor in a Brazilian study was reported to be 15%, was nearly three times higher in men than in women (regardless of age) and the risk was slightly more than three times higher in people over 20 years of age compared with those aged 20 years or under, controlling for gender .
  13. 13. C L A S S I F I C A T I O N
  14. 14. CLASSIFICATIO N
  15. 15. Genuine halitosis Physiologic halitosis Pathologic halitosis Intraoral Extraoral CLASSIFICATIO N
  16. 16. PHYSIOLOGIC HALITOSIS Morning breath odour Decrease in frequent liquid intake Stagnation of saliva and putrefaction of entrapped food particles and desquamated epithelial cells by the accumulation of bacteria on the dorsum of the tongue,
  17. 17. Genuine halitosis Physiologic halitosis Pathologic halitosis Intraoral Extraoral CLASSIFICATIO N
  18. 18. Pathologic halitosis
  19. 19. poor oral hygiene, dental caries, periodontal diseases in particular NUG, NUP, periodontitis, pericoronitis,dry socket tongue coating oral carcinoma. Intra oral origin Pathologic halitosis
  20. 20. OTHER ORIGINS OF HALITOSIS The resulting breath takes on a different odor that may last several hours Transient oral malodor Porter SR, Scully C. Oral malodour (halitosis). BMJ 2006;333:632-5.
  21. 21. • 10-20% • gastro intestinal diseases • infections or malignancy in respiratory tract • Chronic sinusitis and tonsillitis • stomach, intestine, liver or kidney affected by systemic diseases Extra oral origin Pathologic halitosis
  22. 22. Maximally 10% of the oral malodor cases originate from the ears, nose and throat (ENT) region, from which 3% finds its origin at the tonsils. The presence of acute/chronic tonsillitis and tonsilloliths represents a 10-fold increased risk of abnormal VSC levels due to deep tonsillar crypts formation. Foreign bodies in the nose can become a hub for bacterial degradation and hence produce a striking odor to the breath Pathologic halitosis
  23. 23. Examples of systemic pathological conditions that cause halitosis Pathologic halitosis
  24. 24. CLASSIFICATIO N Delusional halitosis Pseudo halitosis Halitophobia.
  25. 25. Condition in which a subject believes that their breath odor is offensive and is a cause of social nuisance, however, neither any clinician nor any other confidant can approve of its existence • Monosymptomatic • Hypochondriasis • Imaginary halitosis Interestingly, advertisements of oral hygiene products are responsible for the increase in a number of patients with delusional halitosis. IMAGINARY OR DELUSIONAL HALITOSIS
  26. 26. IMAGINARY OR DELUSIONAL HALITOSIS •Pseudo halitosis – Apparently healthy individuals •Haltophobia – exaggerated fear of having halitosis – also referred as delusional halitosis – considered variant of monosymptomatic hypochondrial psychosis. Yaegaki K, Coil JM. Genuine halitosis, pseudo-halitosis and halitophobia: classification, diagnosis, and treatment. Compend Cont Educ Dent 2000; 21(10A):880–886
  27. 27. Pseudo-halitosis patients complain of having oral malodor without actually suffering from the problem and eventually gets convinced of a disease free state during diagnosis and therapy 28% of patients complaining of bad breath did not show signs of bad breath IMAGINARY OR DELUSIONAL HALITOSIS
  28. 28. Halitophobia is fear of having bad breath seen in at least 0.5–1% of adult population Such patients need psychological counseling and should be given enough time during the consultation. IMAGINARY OR DELUSIONAL HALITOSIS
  29. 29. OLFACTORY REFERENCE SYNDROME  Psychological disorder in which there is a preconceived notion about one having foul mouth breath or emits offensive body odor.
  30. 30. Halitosis generally arises as a result of the bacterial decomposition of food particles, cells, blood and some chemical compounds of the saliva. Moss, 1998 Etiology Yaegaki K, Sanada K. Volatile sulphur compounds in mouth air from clinically healthy subjects and patients with periodontal disease. J Periodontol Res 1992;27:233-8.
  31. 31. Volatile sulphur compounds → hydrogensulphide [H2S, rotten egg smell], dimethyl sulphide [(CH3)2S, rotten cabbage smell, and methyl mercaptan [CH3SH, fecal smell]. Non - sulphur containing substances → diamines [cadaverine (cadaver smell) and putrescine (rotten meat smell), acetone and acetaldehyde ETIOLOGY Yaegaki K, Sanada K. Volatile sulphur compounds in mouth air from clinically healthy subjects and patients with periodontal disease. J Periodontol Res 1992;27:233-8.
  32. 32. ROLE OF VOLATILE SULPHUR COMPOUNDS IN THE PATHOGENESIS OF HALITOSIS MAJOR COMPOUNDS IMPLICATED IN HALITOSIS VSC’s - Methylmercaptan, Hydrogen sulfide, dimethyl sulfide & Dimethyl disulfide. Polyamides - Putrescein, Cadaverine, Skatole, Indole. Short chain FA - Butyric, Propionic, Valeric & Isovaleric acid. Others - Acetone, Acetaldehyde, Ethanol diacyl. Miyazaki H, Sakao S, Katoh Y, Takehara T. Correlation between volatile sulphur compounds and certain oral health measurements in the general population. J Periodontol 1995;66:679-84
  33. 33. It increases the permeability of oral mucosa and crevicular epithelium. It impairs oxygen utilization by host cells, and reacts with cellular proteins, and interferes with collagen maturation. It also increases the collagen solubility. It decrease the DNA synthesis. It increases the secretion of collagenases, prostaglandins from fibroblasts. VSC reduce the intracellular pH; inhibit cell growth, and periodontal cell migration. Miyazaki H, Sakao S, Katoh Y, Takehara T. Correlation between volatile sulphur compounds and certain oral health measurements in the general population. J Periodontol 1995;66:679-84
  34. 34. Pathogenesis of oral malodor Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
  35. 35. The role of tongue coatings in the aetiology of oral malodour has been extensively documented. Tongue coatings include desquamated epithelial cells, food debris, bacteria and salivary proteins and provide an ideal environment for the generation of VSCs and other compounds that contribute to malodour
  36. 36. The purulent discharge from the paranasal sinuses, seen in regurgitation esophagitis, gets collected at the dorsum of the tongue resulting in halitosis. Atrophic rhinitis is caused by Klebsiella ozenae, which inhibits the self-cleaning property of nasal mucosa. Acute pharyngitis and sinusitis, caused by streptococcal species, are also responsible for producing halitosis. Carcinoma of the larynx, nasopharyngeal abscess, and lower respiratory tract infections such as bronchiectasis, chronic bronchitis, lung abscess, asthma, cystic fibrosis, bronchiectasis, interstitial lung diseases, and pneumonia have been known to cause halitosis Pathologic halitosis
  37. 37. Kinberg et al. published a review in 2010, in which they examined 94 patients having halitosis out of which 54 had gastrointestinal pathology suggesting that gastrointestinal is one of the common extra oral causes of halitosis. Gastrointestinal causes like Zenker’s diverticulum, Gastro-esophageal reflux disease (GERD),Gastric and peptic ulcers have been known to cause halitosis. Helicobacter pylori is known to cause a gastric and peptic ulcer and is recently associated with oral malodor. Congenital broncho esophageal fistula, gastric cancer, hiatus hernia, pyloric stenosis, enteric infections, dysgeusia, duodenal obstruction, and steatorrhea are some of the sources of pathological mouth odor Pathologic halitosis
  38. 38. Metabolic disorders like Trimethylaminuria (fish odor syndrome) is characterized by the presence of trimethylamine (TMA), whose odor resembles of rotting fish in the urine, sweat and expired air. Individuals with TMAuria have diminished the capacity to oxidize the dietary-derived amines TMA to its odorless metabolite TMA N-oxide resulting in an increased excretion of large amounts of TMA in body fluids. In hypermethioninemia the body produces a peculiar odor, which resembles that of, boiled cabbage and is emanated through sweat, breath and urine. If this condition is present, the extraoral origin should be determined, because the latter requires medical investigation and support in therapy. Pathologic halitosis
  39. 39. MICROBIOLOGY AND BREATH MALODOR Fusobacterium nucleatum, Treponema denticola, Prevotella intermedia, Porphyromonas gingivalis, Bacteroides forsythus, Eubacterium. Some of the evidence in support of periodontal disease is indirect, as it is based on the in vitro ability of species indigenous to the sub-gingival plaque to produce VSC’s. produce large amounts of CH3 SH and H2 S from methionine, cysteine, or serum proteins Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
  40. 40. DRUGS ASSOCIATED WITH HALITOSIS
  41. 41. DIAGNOSIS Complaint, Medical, dental and halitosis history, Information about diet and habits, Confirming an objective basis to the complaint
  42. 42. Discretely and intermittently recorded. Questions such as frequency, duration, time of appearance within a day, Whether others have identified the problem (excludes pseudo-halitosis from genuine halitosis), List of medications taken, Habits (smoking, alcohol consumption) Other Symptoms (nasal discharge, anosmia, cough, pyrexia, and weight loss) should be carefully recorded DIAGNOSIS
  43. 43. DIRECT 1. By directly sniffing the bad breath 2. Determination of odoriferous sulfur containing substances by gas chromatography or halimetry and other methods INDIRECT These methods assess the products produced by microorganisms in vitro or identify odor producing microorganisms. Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
  44. 44. 1. Self-assessment, 2. Whole mouth breath test, 3. Spoon test, 4. Dental floss odor test, 5. Saliva odor test. Direct tests - Organoleptic Direct sniffing of the expired air (“organoleptic” and “hedonic” assessment) is the simplest, most common method to evaluate oral malodor. An organoleptic examination involves the dentist assessing the odor at a range of distances from the patient Organoleptic measurement is highly recommended for initial diagnosis. One potential risk of the organoleptic measurement is the transmission of diseases via the expelled air Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
  45. 45. ORGANOLEPTIC MEASUREMENT (SNIFF TEST) Organoleptic measurement is a sensory test scored on the basis of the examiner’s perception of a subject’s oral malodor. Organoleptic measurement can be carried out simply by sniffing the patient’s breath and scoring the level of oral malodor. By inserting a translucent tube (2.5 cm diameter, 10 cm length) into the patient’s mouth and having the person exhale slowly, the breath, undiluted by room air, can be evaluated and assigned an organoleptic score. The tube is inserted through a privacy screen (50cm-70cm) that separates the examiner and the patient. The use of a privacy screen allows the patient to believe that they have undergone a specific malodor examination rather than the direct-sniffing procedure.
  46. 46. Organoleptic Scores (0- 5) 0 - No appreciable odor 1 - Barely noticeable odor 2 - Slight but noticeable odor 3 - Moderate odor 4 - Strong odor 5- Extremely foul odor By Rosenberg , Mulloch Et Al 1991.
  47. 47. Yaegaki & coil 2000
  48. 48. DIAGNOSIS The subjects are instructed to smell the odor emanating from their entire mouth by cupping their hands over their mouth and breathing through the nose. The presence or absence of malodor can be evaluated by the patient himself/herself. SELF ASSESSMENT TESTS Whole mouth malodor (Cupped breath)
  49. 49. Subjects are asked to extend their tongue and lick their wrist in a perpendicular fashion. The presence of odor is judged by smelling the wrist after 5 seconds at a distance of about 3 cm. Wrist lick test
  50. 50. Plastic spoon is used to scrape and scoop material from the back region of the tongue. The odor is judged by smelling the spoon after 5 seconds at a distance of about 5 cm organoleptically. Spoon test
  51. 51. Unwaxed floss is passed through interproximal contacts. Dental floss test
  52. 52. Involves having the subject expectorate approx. 1-2 ml of saliva into a petridish. The dish is covered immediately, incubated at 370 C for five minutes and then presented for odor evaluation at a distance of 4 cm from the examiner’s nose. Saliva odor test
  53. 53. BANA TEST If any of the these species are present, they hydrolyze the BANA enzyme-producing B-naphthylamide which in turn reacts with imbedded diazo dye to produce a permanent blue color indicating a positive test It is a chair side, enzyme-based assay, which is used to determine the proteolytic activity of certain oral anaerobes that contribute to oral malodor and which are considered as active H2 SO4 producers. Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
  54. 54. VOLATILE SULFIDE MONITOR This electronic (Haiimeter, InterScan, Chatsworth, Calif) analyzes concentration of hydrogen sulfide and methyl-mercaptan , but without discriminating between them.
  55. 55. GAS CHROMATOGRAPHY (GC): GC, performed with apparatus equipped with a flame photometric detector, is specific for detecting sulphur in mouth air. It measures directly the three VSC methyl mercaptan, hydrogen sulfide and dimethyl sulfide. GC is considered the GOLD STANDARD for measuring oral malodor. This device can analyze air, saliva, crevicular fluid for a volatile component.
  56. 56. DIAMOND PROBE  The Probe is placed directly into the periodontal pocket or tongue.  The sulfide-sensing element generates an electrochemical voltage proportional to the concentration of sulfide ions present.  The control unit reports the sulfide level at each site in a digital score from: 0.0 to 5.0
  57. 57. NINHYDRIN METHOD OF DETECTING AMINE COMPOUNDS Iwanicka et al (2005) showed that amine levels were higher in the saliva of subjects suffering from halitosis and lower in healthy controls. Tanaka M et al used these electronic noses to clinically assess oral malodor and examined the association between oral malodor strength and oral health status. ELECTRONIC NOSE
  58. 58. HALITOX SYSTEM Quick and simple Detects VSCs and poly amines
  59. 59. TOPAS It detects both VSC and polyamines in the sample. The absorbent point given with the kit is inserted into the pocket. Left in place for 1 minute. Submerge the absorbent point tip in the toxin reagent . Wait for 5 minutes and see for yellow color in the specimen on the scale of 0-5, which is directly proportional to the level of toxins in the sample.
  60. 60. PREVENTIVE MEASURES Visit dentist regularly Periodical tooth cleaning by dental professional. Brushing of teeth twice daily with appropriate brushing techniques and for a duration of 2-3 mins. Use of a tongue scraper to get rid of the lurking odour causing bacteria in the tongue surface. Preventive measures rather than curative aspects are highly recommended.
  61. 61. Flossing after brushing to remove food particles stuck in between the tooth surfaces. Limit intake of strong odour species. Limit sugar and caffeine intake. Drink plenty of liquids. Chew sugar free gum for a minute when mouth feels dry. Eat fresh fibrous vegetables such as carrots.
  62. 62. MANAGEMENT AND TREATMENT 1. Confirm the diagnosis, 2. Identify and eliminate the predisposing and modifying factors, 3. Identify any contributing medical conditions and refer for management, 4. Review and reassure. The management of halitosis entails four steps: Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
  63. 63. MANAGEMENT Treatment needs (TN) for halitosis have been categorized into 5 classes in order to provide guidelines for clinicians in treating halitosis patients: Rosenberg M, McCulloch CA. Measurement of oral malodor: Current methods and future prospects. J Periodontol 1992;63:776-82. Category Description TN- 1 Explanation of halitosis and instruction of oral hygiene TN- 2 Oral prophylaxis, Professional cleaning and treatment for oral diseases TN- 3 Referral to a physician or medical specialist TN- 4 Explanation of examination data, further professional instruction, education and reassurance TN- 5 Referral to a clinical psychologist , a psychiatrist or other psychology specialist
  64. 64. Mechanical reduction of intraoral nutrients and micro-organisms Chemical reduction of oral microbial load Conversions of VSCs Masking the malodor. MANAGEMENT
  65. 65. Mechanical reduction of intraoral nutrients and micro-organisms - Tongue cleaning - Tooth brush - Inter-dental cleaning - Professional periodontal therapy - Chewing gum MANAGEMENT
  66. 66. 2. Chemical reduction of oral microbial load - Chlorhexidine - Essential oils - Chlorine dioxide - Two-phase oil- water rinse - Triclosan - Aminefluoride/ Stannous fluoride - Hydrogen peroxide - Oxidising lozenges -Roldan S 2005,2004,2003 scully 2006 MANAGEMENT
  67. 67. CHLORHEXIDINE (CHX) Mouth rinses containing antibacterial agents such as CHX and cetylpyridinium chloride (CPC) may play an important role in reducing the levels of halitosis producing bacteria on the tongue. Chlorine dioxide and zinc containing mouth rinses can be effective in neutralization of odoriferous sulfur compounds. Roldan. S et al. evaluated five different commercial mouth rinses with respect to their anti-halitosis effect and anti-microbial activity on salivary bacterial counts. Formulations that combine CHX and CPC achieved the best results, and a formulation combining CHX with NaF resulted in the poorest. Essential oils: Listerine was found to be only relatively effective against oral malodor (±25% reduction vs. 10% of placebo) and caused a sustained reduction in level of odorigenic bacteria Chlorine dioxide: It is a powerful oxidizing agent that oxidizes the sulfides of the VSC’s to nonodorous sulfates and raises the oxidation/reduction ratio of the saliva toward the more oxidizing state. Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
  68. 68. TWO-PHASE OILWATER RINSE: The efficacy of oilwater CPC formulation is thought to result from the adhesion of a high proportion of microorganisms to the oil droplet which is further enhanced by the CPC. TRICLOSAN: A broad-spectrum antibacterial agent, has been found to be effective against most oral bacteria and has a good compatibility with other compounds used for oral home care AMINEFLUORID E/STANNOUS FLUORIDE (AMF/SNF2 ): The association of AmF/SnF2 resulted in encouraging reduction of morning breath odor, even when oral hygiene is insufficient HYDROGEN PEROXIDE: Suarez et al. reported that rinsing with 3% H2 O2 produced impressive reductions (±90%) in sulfur gas that persisted for 8 h. OXIDIZING LOZENGES: The anti-malodor effect of lozenges may be caused by the activity of dehydroascorbic acid which is generated by peroxide-mediated oxidation of ascorbate present in the lozenges. Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7. MANAGEMENT
  69. 69. 3.Conversion of volatile sulfide compounds - Metal salt solutions - Toothpastes - Chewing gum MANAGEMENT
  70. 70. Metal salt solutions: Metal ions with affinity for sulfur are rather efficient in capturing the sulfur-containing gases. Zinc is nontoxic, noncumulative, and gives no visible discoloration Tooth paste: Baking soda dentifrices have been shown to be effective, with a 44% reduction of VSCs level 3 h after tooth brushing versus a 31% reduction for fluoride dentifrices (Brunnet et al. 1998) Chewing gums: Tsunoda et al. (1996) investigated the beneficial effects of chewing gums containing tea extract for its deodorizing mechanism. MANAGEMENT
  71. 71. 4. Masking the malodor -Rinses -Mouth sprays -Lozenges containing volatiles -Chewing gum MANAGEMENT
  72. 72. Herbs and essential oils can be made into very effective mouthwash remedies to sweeten breath and help keep gums and teeth healthy fennel not only improves digestion, but also can reduce bad breath and body odor that originates in the intestines. Give raw carrots as a midday treat to help scour teeth of bacteria-laden plaque, a common cause of bad breath. Cardamom tea contains cineole, a potent antiseptic that kills bad-breath bacteria and sweetens breath. Herbal treatment: MANAGEMENT
  73. 73. Thymol, one of the constituents of thyme, is contained in antiseptic mouthwashes. Neem leaf powder can be used as an effective tooth powder to fight plaque and gingivitis when mixed with astringent herb powders and/or baking soda. A few drops of Tea tree oil , lemon or peppermint essential oils can be added to warm water for an effective mouth rinse to freshen breath Herbal treatment: MANAGEMENT
  74. 74. CONCLUSION It’s a common complaint that may periodically affect most of the adult population. Oral maldor, which is commonly noticed by patients, is an important clinical sign and symptom that has many etiologies which include local and systemic factors. It is often difficult for the clinician to find the underlying pathologies. Although consultation and treatment may result in dramatic reduction in bad breathe, patients may find it difficult to sense the improvement themselves The field of halitosis research would benefit from: • More reliable, portable instruments for measuring VSC’s, • A standard scale for assessing oral malodor, • Further studies with larger sections of the population, and • Development of site-specific measurements.
  75. 75. REASON FOR CHOOSING THIS ARTICLE?
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  79. 79. Thank you

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