1. Dr. Ali Tahir

2.  Extremely common
 Majority of adult population has had it at some
point of time
 Most of the patients seek help from GPs rather
than a dentist
Dr. Ali Tahir

3.  Bacterial putrifaction of food debris, cells, saliva &
blood
Proteolysis of proteins  peptides  amino acids
 free thiol groups and volatile sulphides
 Can result from any form of sepsis: increased
anaerobic activity of pathogens (Traponema
denticola, P. Gingivalis and Bacteroides)
Dr. Ali Tahir

4. Importance
 Bad breath can be a sign of undiagnosed disease
 Unpleasant condition, can cause huge
embarrassment
 Its a big business
 Mouthwashes, mints, drops, gums, toothpastes
Dr. Ali Tahir

5. Compounds commonly produced by mouth bacteria
 Volatile sulphur compounds
 Hydrogen Sulphide – rotten egg
 Methyl mecaptan (CH3SH) – Natural gas
 Skatole
 Cadaverine
 Di-amino acid – spoiled meat
 Putrescine
 Oragnic acids
 Isovaleric acid, acetic acid, propionic acid, butyric acid
Dr. Ali Tahir

6.  Sleep.  Poor dental hygiene;
gingivitis, periodontitis, dentu
 Food res.
(onions, garlic, Broccoli, Caulifl
ower).  PN drip, sinusitis, nasal
polyps, adenoids, foreign
 Drugs: ISDN, disulfaram. bodies, tonsillitis & tonsilliths.
 Xerostomia  Ketones (acetone)
(anxiety, pyrexia, anticholiner  Trimethylamine (fishy odor)
gics, antihistamines, TCA’s, Sjö
gren’s Syndrome)

7.  Association with H.Pylori
 Pharyngeal pouch
 Gastric outlet probs  Delusional halitosis
 Severe Reflux
 Hallucinatory feature of
 DKA psychotic illness
 Renal dysfunction
 Hepatic dysfunction  Temporal Lobe Epilepsy
 Respiratory disease  Trimethylaminuria

8.  About 90% of halitosis originates in the mouth
 The other 10%
 Systemic disease
 Diabetes - ketoacidosis - acetone smell
 Cirrhosis, liver failure - "mousy", "musty" smells
 Renal failure - fishy smell
 Leukemia - "decaying blood" smell
 Carcinoma
Dr. Ali Tahir

9.  Respiratory system
 Exhalation of volatile food compounds
 Volatile medications - amyl nitrate
 Nasal/sinus/lung infections
 Tonsils and tonsiloliths (may not contribute to
mouth odor)
Dr. Ali Tahir

10.  Gastrointestinal system (considered rare)
 Reflux
 Carcinoma
 Helicobacter pylori infection (gastric ulcers)
 Genetic disorders (enzyme deficiencies)
 Trimethylaminuria (fishy odor) - autosomal recessive
 Cystinuria, cystathionuria heterozygotes
 Recessive defects in cysteine metabolism
 Very high VSC levels (gut bacteria)
Dr. Ali Tahir

11.  Frustrating to diagnose and treat - expensive
 Iatrogenic odors
 Gauze pad left behind after cleft palate surgery
 Foreign objects
 Inserted up the nose
 Young children and developmentally disabled
 If undetected, may lead to odor in adults
 Idiopathic odors
 Detectable by others, no apparent oral or non-oral cause
 Cause presumed rare, not yet defined
Dr. Ali Tahir

12.  Detectable only by patient - no apparent cause
 Patients often refuse to accept objective findings
 Associated with anxiety or depression
 Can be confused with genetic disorders
 Patients may show abnormalities by gas chromatography
 Trimethylaminuria heterozygotes
 May be more common than once thought
 Saliva TMA detectable by patient, but not others
Dr. Ali Tahir

13.  Posterior dorsum of tongue
 Depends on tongue coating, deep fissures, worsens with dry
mouth
 Periodontal pockets in periodontal diseases
 VSC can be measured in fluid from deep pockets
 Mouth odor/VSC proposed as early sign of periodontitis
 Not all periodontal patients have mouth odor
 Other oral lesions
 Abcesses, impactions
 Oral candidiasis
 Sweet fruity smell
Dr. Ali Tahir

14. Dr. Ali Tahir

15.  Tongue bacteria
 Streptococcus salivarius - a sign of “health”?
 May be dominant in persons w/o halitosis (n = 5)
 Gram-negative, proteolytic anaerobes
 May predispose towards halitosis
 Many novel species (n = 6)
 Digest nasal discharges, food debris,
saliva components, sloughed cells
 Produce VSC, cadaverine
 BANA hydrolysis test (Perioscan®) used for
detection
 Periodontal pathogens
Dr. Ali Tahir

16.  History
 Onset, duration?
 Constant or intermittent, morning, how long
after meals?
 Self-report, or reported by others?
 Dietary factors, smoking and alcohol use?
 Systemic disease and medication
 Neurological problems - taste and smell
function?
 Currently under stress?
 Comprehensive oral examination
Dr. Ali Tahir

17. Instruments for odor detection
 Gas chromatography of breath samples
 Most informative
 Extremely sensitive and precise
 Expensive and cumbersome
 Limited to research centers
 Portable sulfide meter (the Halimeter®)
 Can be used in a dental office
 Detects only VSC
 Must be calibrated regularly to maintain accuracy
Dr. Ali Tahir

18.  Strongest odor with lips closed - suggests
nose, sinuses
 Strongest odor with nostrils closed - oral or gastric
source
 Tongue sample to confirm oral origin
 Odor equally strong from nose or mouth - systemic
 No discernible odor - verify with others
(spouse, friend)
Dr. Ali Tahir

19.  Non-oral etiologies - appropriate referral
 Oral etiologies
 Treat all existing conditions
 Attempt to improve hygiene, flossing
 Encourage posterior tongue hygiene
 Commercial tongue scrapers
 Many designs on the market
 The gag reflex is a barrier to compliance
Dr. Ali Tahir

20. Dr. Ali Tahir

21.  Masking fragrances
 Mouth rinses, drops, gums, mints, etc.
 Chemicals that interact with VSC
 Oxidizing agents - products based on chlorine dioxide
 Only two published studies - short-term
 Zinc reacts with VSC
 Safe when not used in excess
 More published evidence
 Reduces VSC levels short-term
Dr. Ali Tahir

22.  Antibacterial products
 Should reduce bacterial odors, depending on efficacy
 Chlorhexidine is considered the gold standard
 High substantivity - remains on oral tissues for a long time
 Problems with taste and staining
 Others with published evidence for odor reduction
 Two-phase oil-water mouthrinse (cetylpyridinium chloride)
 Sulfides lower after 6 weeks of use
 More effective than Listerine (essential oils)
 Currently available in Israel and Great Britain
 Toothpaste with substantive triclosan copolymers - short term
Dr. Ali Tahir

23.  The probiotic concept
 Replace “bad” bacteria with “good” bacteria
 Lots of ongoing research
 FDA approves human trial of probiotic S. mutans
 Genetically engineered to be non-cariogenic
 Lots of safeguards required
 Probiotic treatment of bad breath in New Zealand
and Australia
 S. salivarius strain K12
 Indigenous strain that produces antibacterial peptides (BLIS)
 Step 1: Use chlorhexidine to knock down tongue flora
 Step 2: Replace tongue flora with K12
Dr. Ali Tahir