pdf file concern about halitosis that occur due to periodontal problems and their classification beside their treatment paln

2. Definition
Breath odor can be defined as the subjective
perception after smelling someone’s breath. It can
be pleasant, unpleasant or even disturbing, if not
repulsive. If unpleasant, the terms breath
malodor, halitosis, bad breath, or fetor ex ore can
be applied.

3. The term “oral malodor” is thus too restrictive.
Breath malodor should not be confused with the
momentarily disturbing odor caused by food
intake (e.g., garlic, onions, and certain spices),
smoking, or medication (e.g., metronidazole)
because these odors do not reveal a health
problem. The same is true for “morning” bad
breath, as habitually experienced on awakening.
This malodor is caused by a decreased salivary
flow and increased putrefaction during the night
and spontaneously disappears after breakfast or
oral hygiene measures.

4. Epidemiology
 Breath malodor is a common complaint among the
general population. It has a significant
socioeconomic impact .
 Almost $1 billion a year is spent in the United States
on deodorant-type mouth (oral) rinses, mints, and
related over-thecounter products to manage bad
breath. It would be preferable to spend this money
on a proper diagnosis and etiologic care instead of
short-term and even inefficient masking attempts.
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5. CLASSIFICATION
 Genuine halitosis : when the breath malodor really
exists and can be diagnosed or organoleptically or
by measurement of the responsible compounds.
 Pseudo-halitosis :When an obvious breath malodor
cannot be perceived, but the patient is convinced
that he or she suffers from it .
 Halitophobia : If the patient still believes that there
is bad breath after treatment of genuine halitosis or
diagnosis of pseudo halitosis .

6. ETIOLOGY
 In the vast majority, breath malodor originates
from the oral cavity. Gingivitis, periodontitis, and
especially tongue coating are the predominant
causative factors .

7.  In general, one can identify two pathways for bad breath.
1- The first one involves an increase of certain
metabolites in the blood circulation (e.g., due to a
systemic disease), which will escape via the alveoli of the
lungs during breathing (blood-gas exchange).
 2-The second pathway involves an increase of either the
bacterial load or the amount of substrates for these
bacteria at one of the lining surfaces of the oropharyngeal
cavity, the respiratory tract, or the esophagus. All types of
infections, ulcerations, or tumors at one of the previously
mentioned areas can thus lead to bad breath.

8. Bacteria involved in Halitosis
 Porphyromonas gingivalis,
 Prevotella intermedia/nigrescens,
 Aggregatibacter actinomycetemcomitans (previously
Actinobacillus actinomycetemcomitans),
 Campylobacter rectus,
 Fusobacterium nucleatum,
 Peptostreptococcus micros,
 Tannerella forsythia, Eubacterium spp,, and
spirochetes.
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9. a-Intraoral Causes
1-Tongue and Tongue Coating
 The dorsal tongue mucosa, with an area of 25 cm2,
shows a very irregular surface topography . The
posterior part exhibits a number of oval
cryptolymphatic units, which roughen the surface
of this area. The anterior part is even rougher
because of the high number of papillae .
 The accumulation of food remnants intermingled
with exfoliated cells and bacteria causes a coating
on the tongue dorsum. The latter cannot be easily
removed because of the retention offered by the
irregular surface of the tongue dorsum .
 High correlations have been reported between
tongue coating and odor formation .

10. Different clinical pictures of heavily coated
tongues.

11. 2-Periodontal Infections
 Several studies have shown a relationship between
periodontitis and oral malodor. However, not all
patients with gingivitis and/or periodontitis complain
about bad breath, and there is some disagreement in
the literature as to what extent oral malodor and
periodontal disease are related.
 Bacteria associated with gingivitis and periodontitis
such as ANAG or ANAS in are indeed able to produce
VSCs (A main cause of malodor) .

12.  VSC levels in the mouth correlate positively with the
depth of periodontal pockets (the deeper the pocket,
the more bacteria, particularly anaerobic species) and
that the amount of VSCs in breath increases with the
number, depth, and bleeding tendency of the
periodontal pockets. VSCs aggravate the periodontitis
process by increasing the permeability of the pocket
and mucosal epithelium and therefore exposing the
underlying connective tissues of the periodontium to
bacterial metabolites.
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13.  Some studies, however, have shown that when the
presence of tongue coating is taken into account, the
correlation between periodontitis and oral malodor is
much lower, indicating that tongue coating remains a
key factor for halitosis. The prevalence of tongue coating
is six times higher in patients with periodontitis, and the
same bacterial species associated with periodontal
disease can also be found in large numbers on the
dorsum of the tongue .

14. 3-pericoronitis
 Other relevant malodorous pathologic manifestations of
the periodontium are pericoronitis (the soft tissue “cap”
being retentive for microorganisms and debris), major
recurrent oral ulcerations, herpetic gingivitis, and
necrotizing gingivitis/periodontitis. Microbiologic
observations indicate that ulcers infected with
gramnegative anaerobes (i.e., Prevotella and
Porphyromonas species) are significantly more
malodorous than noninfected ulcers

15. 4-Dental Pathologies
 deep carious lesions with food impaction and
putrefaction, extraction
 wounds filled with a blood clot, and purulent discharge
leading to important putrefaction.
 Interdental food impaction in large interdental areas
 crowding of teeth favor food entrapment and
accumulation of debris.
 Acrylic dentures, especially when kept continuously in
the mouth at night or not regularly cleaned, can also
produce a typical smell. The denture surface facing the
gingiva is porous and retentive for bacteria, yeasts, and
debris, which are all factors that cause putrefaction

16. 5-Dry Mouth
 Saliva has an important cleaning function in the oral
cavity. Patients with xerostomia often present with large
amounts of plaque on teeth and an extensive tongue
coating. The increased microbial load and the escape of
VSCs as gases when saliva is drying up explain the
strong breath malodor.
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17. b-Extraoral Causes
Systemic diseases like
 Diabetes Mellitus
 Liver disease
 Advanced kidney failure
 Uremia
 Ear, Nose, Throat problems

18. DIAGNOSIS OF MALODOR
1-Medical History
 The proper diagnostic approach to a malodor patient
starts with a thorough questioning about the medical
history. Asking about all the relevant pathologies for
breath malodor just discussed is not time-consuming; it
may save time and expenses to achieve a proper
differential diagnosis. As often repeated, “listen to the
patient and the patient will tell you the diagnosis.”

19. 2-Self-Examination
 Smelling a metallic or nonodorous plastic spoon after
scraping the back of the tongue.
 Smelling a toothpick after introducing it in an
interdental area.
 Smelling saliva spit in a small cup or spoon (especially
when allowed to dry for a few seconds so that
putrefaction odors can escape from the liquid).
 Licking the wrist and allowing it to dry (reflects the
salivacontribution to malodor).

20.  3-Oropharyngeal Examination.
 The oropharyngeal examination includes inspection
of deep carious lesions, interdental food impaction,
wounds, bleeding of the gums, periodontal pockets,
tongue coating, dry mouth, and the tonsils and pharynx
(for tonsillitis and pharyngitis).
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21. Tests used for diagnosis
1- Organoleptic Rating
 Even though devices are available, the organoleptic assessment
by a judge is still the “gold standard” in the examination of
breath malodor. It is the easiest and most often used method
because it gives a reflection of the everyday situation when
halitosis is noticed. Moreover, the human nose can smell 10,000
different odors.39 In an organoleptic evaluation, a trained and
preferably calibrated “judge” sniffs the expired air and assesses
whether it is unpleasant by using an intensity rating, normally
from 0 to 5, as proposed by It is thus solely based on the
olfactory organs of the clinician:
 0 = no odor present,
 1 = barely noticeable odor,
 2 = slight but clearly noticeable odor,
 3 = moderate odor,
 4 = strong offensive odor, and
 5 = extremely foul odor.

22. 2-Portable Volatile Sulfur Monitor
 The portable volatile sulfur monitor (Halimeter,
Interscan, Chatsworth, CA) is an electronic device that
analyzes the concentration of hydrogen sulfide and
methyl mercaptan but without discriminating them
The mouth air is aspirated by inserting a drinking straw
fixed on the flexible tube of the instrument. The straw
is kept about 2 cm behind the lips, without touching
any surface, while the subject keeps the mouth slightly
open and breathes through the nose. The sulfur meter
uses a voltametric sensor that generates a signal when
exposed to sulfur-containing gases.

23. Portable sulfide monitor (Halimeter)

24. 3-Gas Chromatography
 A gas chromatography device can analyze air, saliva, or
crevicular fluid About compounds have been isolated
from the headspace of saliva and tongue coating, from
ketones to alkanes and sulfur-containing compounds to
phenyl compounds. In the expired air of a person,
approximately 150 compounds can be found.
The most important advantage of the technique
(together with mass spectrometry) is that it can detect
virtually any compound when using adequate materials
and conditions. Moreover, it has a very high sensitivity
and specificity .
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25. Gas chromatography machinery, including thermal desorber (TD) to
release molecules trapped in special collectors); gas chromatograph
(GC) for separation of molecules; and mass spectrometer (MS) for
identification
of molecules.

26. TREATMENT OF ORAL MALODOR
1- Mechanical reduction of intraoral nutrients (substrates)
and microorganisms
2- Chemical reduction of oral microbial load
 Rendering malodorous gases nonvolatile
 Masking the malodor
 Treatment should be centered on reducing the bacterial
load/ micronutrients by effective mechanical oral hygiene
procedures, including tongue scraping. Periodontal disease
should be treated and controlled

27. Mechanical Reduction of Intraoral Nutrients and
Microorganisms

28.  Cleaning of the tongue can be carried out with a normal
toothbrush, but preferably with a tongue scraper if a
coating is established. Tongue cleaning using a tongue
scraper reduced the halitosis levels with 75% after 1 week.
This should be gentle cleaning to prevent soft tissue
damage. It is best to clean as far backward as possible; the
posterior portion of the tongue has the most coating.100
Tongue cleaning should be repeated until almost no
coating material can be removed .
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30.  Interdental cleaning and toothbrushing are essential
mechanical means of dental plaque control. Both
remove residual food particles and organisms that
cause putrefaction. Clinical studies have shown that
exclusively brushing the teeth has no appreciable
influence on the concentration of VSCs. In a short-term
study, a combination of tooth and tongue
brushing or toothbrushing alone had a beneficial
effect on bad breath for up to 1 hour (73% and 30%
reduction in VSCs, respectively).
 Because periodontitis can cause chronic oral malodor,
professional periodontal therapy is needed .

32.  Chewing gum may control bad breath temporarily
because it can stimulate salivary flow.
 The salivary flow itself also has a mechanical cleaning
capability. Not surprisingly, therefore, subjects with
extremely low salivary flow rate have higher VSC
ratings and tongue coating scores than those with
normal saliva production. It has been shown that
chewing of a gum without any active ingredient can
reduce halitosis modestly.
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33. Chemical Reduction of Oral Microbial Load
 Mouth rinsing has become a common practice in
patients with oral malodor. The active ingredients in
oral rinses are usually antimicrobial agents such as
chlorhexidine, cetylpyridinium chloride (CPC),
essential oils, chlorine dioxide, hydrogen peroxide, and
triclosan. All these agents have only a temporary
reducing effect on the total number of microorganisms
in the oral cavity .

34.  1-Chlorhexidine
 Chlorhexidine is considered the most effective
antiplaque and antigingivitis agent. Its antibacterial
action can be explained by disruption of the bacterial
cell membrane by the chlorhexidine molecules,
increasing its permeability and resulting in cell lysis and
death. Because of its strong antibacterial effects and
superior substantivity in the oral cavity, chlorhexidine
rinsing provides significant reduction in VSC levels and
organoleptic ratings.

35. 2-Chlorine Dioxide.
 Chlorine dioxide (ClO2) is a powerful oxidizing
agent that can eliminate bad breath by oxidation of
hydrogen sulfide, methylmercaptan, and the amino
acids, methionine and cysteine. Studies demonstrated
that single use of a ClO2–containing oral rinse slightly
reduces mouth odor.

36. 3-Two-Phase Oil-Water Rinse
 Rosenberg et al designed a two-phase oil-water rinse
containing CPC. The efficacy of oilwater- CPC
formulations is thought to result from the adhesion of a
high proportion of oral microorganisms to the oil
droplets, which is further enhanced by the CPC. A twice-daily
rinse with this product (before bedtime and in the
morning) showed reductions in both VSC levels and
organoleptic ratings. These reductions were superior to
Listerine and significantly superior to a placebo .
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37. 4-Triclosan
 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. A pilot study demonstrated that an
experimental mouth rinse containing 0.15% triclosan and
0.84% zinc produced a stronger and more prolonged
reduction in mouth odor than a Listerine rinse. The anti-
VSC effect of triclosan, however, seems strongly
dependent on the solubilizing agents .

38.  5-Aminefluoride/Stannous Fluoride
 The association of aminefluoride with stannous fluoride
(AmF/SnF2) resulted in encouraging reductions of
morning breath odor, even when oral hygiene is
insufficient .

39. 6- Hydrogen Peroxide
Suarez et al reported that rinsing with 3% hydrogen
peroxide (H2O2) produced impressive reductions (±90%)
in sulfur gases that persisted for 8 hours.
7- Oxidizing Lozenges
Greenstein et al reported that sucking
a lozenge with oxidizing properties reduces tongue dorsum
malodor for 3 hours. This antimalodor effect may be
caused by the activity of dehydroascorbic acid, which is
generated by peroxide-mediated oxidation of ascorbate
present in the lozenges.

40. Toothpastes
 Baking soda dentifrices have been shown to confer a
significant odor-reducing benefit for time periods up
to 3 hours. The mechanisms by which baking soda
produces its inhibition of oral malodor might be
related to its bactericidal effects and its transformation
of VSCs to a nonvolatile state.
 Gerlach et al compared the antimalodor efficacy of
three different toothpastes and reported a slightly
better outcome, especially
for an SnF2-containing paste (±50% reduction),when
compared towater (±35% reduction).
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41. Chewing Gum
 Chewing gum can be formulated with antibacterial
agents, such as fluoride or chlorhexidine, thus
helping reduce oral malodor through both
mechanical and chemical Approaches
 Waler compared different concentrations of zinc in a
chewing gum and found that a 2-mg Zn++ acetate–
containing chewing gum that remained in the mouth
for 5 minutes resulted in an immediate reduction in
the VSC levels of up to 45%, but the long-term effect
was not mentioned.

42. Masking the Malodor
 Treatments with rinses, mouth sprays, and lozenges
containing volatiles with a pleasant odor have only a short-term
effect. Typical examples are the mint-containing
lozenges. Another pathway is to increase the solubility of
malodorous compounds in the saliva by increasing the
secretion of saliva; a larger volume allows the retention of
larger volumes of soluble VSCs. The latter can also be
achieved by ensuring a proper liquid intake or by using a
chewing gum; chewing triggers the periodontalparotid
reflex, at least when the lower (pre)molars are still present .

43. SUMMARY
 Breath malodor has important socioeconomic
consequences and can reveal important diseases .
 A proper diagnosis and determination of the etiology
allow initiation of the proper etiologic treatment .
 Although tongue coating and (less frequently)
periodontitis and gingivitis are by far the most
common causes of malodor, a clinician cannot take the
risk of overlooking other, more challenging diseases .