1. Oral malodor
Presented by: Group B
Shekhar kumar mandal(26), Sangeet pant(28),Rusha
pote(31),Dipti poudel(32),Manisha poudel(33)
Presented to: Department of periodontics
COLLEGE OF MEDICAL SCIENCES BHARATPUR
NEPAL
2. Breath odor can be defined as a subjective perception after
smelling someone’s breath.
Oral malodor is the term specially used to describe the odor
emanating from the oral cavity.
It should not be confused with momentarily disturbing odor
caused by food intake( eg garlic, onion n certain spices), smoking
or medication ( eg metronidazole) because these odors donot
reveal a health problem. The same is true for morning bad
breath, as habitually experienced on awakening.
3. Classification
Based on etiology
1) local factors of pathologic origin, eg. Poor oral hygiene, extensive caries,
periodontal diseases, cysts and tumours of oral n pharyngeal cavities.
2) Local factors of non pathologic origin, eg stagnation of saliva associated with
food debris, dentures and excessive smoking.
3) Systemic factors of pathologic origin.eg diabetes mellitus, liver failure, lung
abscess, tuberculosis.
4) Systemic factors of non-pathologic origin , eg diet like garlic, onion, meat and
meat products, excessive alcohol consumption.
5) Xerostomia
4. Based on patients criteria
1)Genuine halitosis
2) Pseudohalitosis
3) Halitophobia
Geniune halitosis
Term used when the breath malodor really exits and can be diagnosed
organoleptically or by measurement of the responsible compounds.
Pseudohalitosis
When an obvious breath mal odor cannot be perceived, but the patient is convinced
that he or she suffers from it, this is called pseudohalitosis.
Halitophobia
If the patient still believes that there is bad breath after treatment of genuine
halitosis a diagnosis of pseudohalitosis, one considers halitophobia , which is
recognized psychiatric condition.
5. Etiology
90% of breath malodor originates from the oral cavity. Gingivitis , periodontitis and
special tongue coating are the predominant causative factors. The remaining 10% has
systemic or local causes.
In general one can identify two pathways for bad breath, the first one involves an
increase of certain metabolites in the blood circulation(due to the systemic disease),
which will escape via the alveoli of the lungs during breathing.
And the second pathways involves an increase of either the bacterial load ot the
amount of substrates fot these bacteria at one of the lining surfaces of the
oropharyngeal cavity, the respiratory tract,or the esophagus.
6. For oral malodor, the unpleasant smellof the breath mainly
originates from VSCs,(volatile sulphur compounds) especially
hydrogen sulfide, methyl mercaptan and less important dimethyl
sulfide.-however in certain condition,indole,skatole and volatile
organic acids like butyric or propionic acid.
Most of these compunds results from the proteolytic degradation
by oral microorganusms of peptides present in saliva, interdental
plaque, postnatal drip, and blood.
For the extra oral cases other than vscs may be involved, which
has not been identified yet.
12. Fundamentals/Physiology of malodor
detection
Breath of a person contains up to 150 different molecules.
Perception of the molecules depends on the following
factors:
1. Olfactory response (odor of molecule)
2. Threshold concentration (conc at which it can be
detected)
3. Odor power (conc to increase it score by one limit)
4. Volatility(express when they become volatile)
5. Substantivity (capacity to stay present)
13. 1. Skatole and methylmercaptan are detected at
the lowest concentrations
2. Odor power is the strongest for hydrogen sulfide
and methylmercaptan
3. The three sulfur molecules have the lowest
volatility
14. Diagnosis of Malodor
History taking and medical questionare
Clinical and Laboratory Examination
Self-Examination
Oropharyngeal Examination
Organoleptic Rating
Portable Volatile Sulfur Monitor
Gas Chromatography
Dark-Field or Phase-Contrast Microscopy
Saliva Incubation Test
Electronic Nose
Chair-Side Test
15. MEDICAL HISTORY
Proper diagnostic approach should starts with
a thorough questioning about the medical
history and about all the relevant pathologies
for breath malodor
patient history should be discretely and
intermittently noted.
16. Clinician should ask about the:
• frequency(eg.every month)
•time of appearance during the day(eg.after meal indicate
the stomach hernia)
•Time when the problem first appeared
•whether others(nonconfidants)have identified the
problems(to exclude imaginary breath odor)
•Which medications are taken and whether there are
possible contributing factors such as mouth breathing, dry
mouth ,allergies and nasal problems.
17. CLINICAL EXAMINATION
SELF EXAMINATION
It is done when intraoral cause has been
determined.This can motivate the patient to continue
the oral hygiene instructions.
Following self testing can be used:
•Smelling a metallic or non odorous 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.
•Licking the wrist and allowing it to dry.
18. OROPHARNGEAL EXAMINATION
•Inspection of deep carious lesion
•Interdental food impaction
•Wounds
•Bleeding of gums
•Periodontal pockets
•Tongue coating
•Dry mouth
•Tonsils and pharynx for tonsilities and pharyngitis
19. .
ORGANOLEPTIC RATING
“Gold standard” in the examination of breath odor.
Easiest and most often used method assest by judge.
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 Rosenberg
and McCulloch.It is thus solely based on the olfactory
organs of the clinician
20.
21. The judge smells a series of different air samples as follows:
1) Oral cavity odor
2) Breath odor
3) Saliva
4) Tongue coating
5) Nasal breath odor
22. The specific chracter of odor can provide additional
information such as:
•The smell of sulfur can be indicated for an intraoral
origin of halitosis.
•The smell of sulfur can however also point out to liver
disease(accumulation of ketones)
•The smell of rotten apples has been associated with
unbalance insulin-dependent diabetes,which leads to
the accumulation of ketones.
•A “fish odor”can suggest kidney insuffiency
characterized by uremia and accumulation of
dimethylamine and trimethylamine.
23. Portable Volatile Sulfur Monitor
The portable volatile sulfur monitor (Halimeter) 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 2cm behind the lips, without touching any surfaces, 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.
Readings-
Absence of breath malodor: 150 ppb or less.
Elevated concentrations of VSCs: 300-400 ppb.
Using a recorder or specific software, a graphic presentation can be obtained, called a
haligram.
24. Advantages-
Easy to use as a chairside test.
Relatively inexpensive.
Patients are usually less embarrassed.
Absence of odor in case of halitophobia can be more convincingly proven.
Drawbacks-
It detects only sulfur compounds and thus is used only for intraoral causes of halitosis.
It has no specificity and thus cannot discriminate among the different sulfur compounds.
The sensitivity for methylmercapton is very low (5 times lower than for hydrogen sulfide) and
is almost insensitive to dimethyl sulfide.
Ethanol and other compounds can disturb the measurement.
25. Gas Chromatography
It can analyze air, saliva, or crevicular fluid for different chemical compounds present in
them.
Advantage-
It can detect virtually any compound when using adequate materials and conditions.
It has a very high sensitivity and specificity.
Useful for identifying nonoral causes of breath malodor.
Drawbacks-
Only available in specialized centers.
Expensive.
Needs trained personnel.
26. OralChroma (Portable “Gas Chromatograph”)-
It is a recently introduced device for periodontal clinics.
It has a capacity to measure the concentration of 3 key
sulfur compounds:-
Hydrogen sulfide.
Methylmercaptan.
Dimethyl sulfide.
This can be helpful in differential diagnosis:
High concentration of methylmercaptan compared to
hydrogen sulfide- periodontitis.
Only hydrogen sulfide is increased- oral hygiene problem.
Dimethyl sulfide- extraoral causes.
Drawback-
Cannot detect other than sulfur compounds and some
intraoral and extraoral causes can thus be overlooked.
27. Dark-Field or Phase-Contrast
Microscopy
Gingivitis and periodontitis are typically associated with a higher incidence of
motile organisms and spirochetes.
Shifts in these proportions allow monitoring of therapeutic progress and dark-
field microscopy can be used to detect the microorganisms, especially the
spirochetes.
Patient also becomes aware of bacteria present in the plaque, tongue
coating, and saliva.
28. Saliva Incubation Test
By adding some proteins, such as lysine or cysteine, the production of
respectively cadaverine or hydrogen sulfide is dramatically increased.
Organoleptic evaluation of saliva headspace can be carried out for monitoring
treatment results.
It is a less invasive test, especially for the patient, than smelling breath in
front of the oral cavity.
29. Electronic Nose
It identifies the specific components of an odor and analyzes its chemical
makeup.
They are smaller, less expensive, and easier to use than gas chromatography
but can only be developed for specific applications if the important
metabolites are already known.
30. Chair-Side Test
Currently several tests based on the detection of bacteria or metabolites involved in the process of
oral malodor, are commercially available.
BANA test-
It is based on the ability of some bacterial species to hydrolyze a synthetic trypsin substrate (N-
benzoyl-DL-arginine-2-naphthylamine). In this way the test can detect three specific bacteria: P.
gingivalis, Bacteroides forsythus, and Treponema denticola related to periodontal disease.
β-galactosidase tests-
They quantify, by means of chromogenic substrates, bacterial enzymes involved in the initial
degradation of oral mucin.
β-galactosidase is one of the main responsible enzymes for the removal of carbohydrate side-chains,
a limiting step of the proteolysis of glycoproteins.
It has been demonstrated that the presence of the enzyme accounts for the presence of oral
malodor independently of the VSC level.
31. Ninhydrin method-
It is a colorimetric test to determine amino acids and low molecular weight
amines. These compounds are, as VSC, final products of bacterial proteolysis.
32.
33. Treatment of oral malodor is a step-by-step problem solving procedures.
Because of the complexity of its pathology, a malodor consultation is thus
preferably multidisciplinary,containing knowledge of periodontologist or
dentist an ENT specialist, an internist (if necessary) and psychologist or
psychiatrist.
Especially In one of its type i.e Halitophobia or imaginary breath malodor,
presence of psychologist or Psychiatrist at malodor consultation can be
helpful.
34. General treatment strategies
I. Masking malodor
II. Mechanical reduction of intraoral nutrients (substrates) and
microorganisms.
III. Chemical reduction of oral microbial load
IV. Rendering malodorous gases non volatile
35. Masking malodor
Treatment with rinses,mouth sprays and lozenges containing volatile with a
pleasant odor have only a short term effect.
Typical examples are:
Mint containing lozenges
Aroma present in rinses
36. Another pathway is to increase the solubility of malodorous compounds in
saliva by increasing secretion of saliva which can be achieved by chewing
gum.
37. Mechanical reduction of intraoral
nutrients and microorganism
Because of extensive accumulation of bacteria on the dorsum of tongue,
cleaning of tongue should be emphasized.
• Previous investigation demonstrated that tongue cleaning reduces both
amount of coating s well as number of bacteria and thereby improves oral
malodor effectively.
38. Cleaning of tongue can be carried out with normal toothbrush but
preferably with a tongue scraper if coating is established.
Tongue cleaning using tongue scraper reduces halitosis level 75% after1 week.
It is best to clean as backward as possible as posterior portion has most
coating.
39. Interdental cleaning are also essential mechanical means of plaque
control.
Full mouth disinfection , combining scaling and root planning with application
of chlorhexidine, reduced organoleptic malodor levels upto 90%.
40. Chemical reduction of oral Microbial load
1)Chlorhexidine
Most effective
antiplaque and antigingivitis agents.
MOA:
Disruption of bacterial cell membrane
Increase in permeability
Cell lysis and then death
Because of its strong antibacterial effect and superior sustantivity in oral
cavity, it provides significant reduction VSCs level and organoleptic rating.
But unfortuntely,it at cocentration greater than 0.2% causes increased tooth
and tongue staining,bad taste and temporary reduction on taste sensation.
41. 2)Essential oils
Listerine was found to be only moderately effective against oral malodor and
caused sustained reduction in levels of odorigenic bacteria.
VSC reduction were found after rinsing for 4 days.
42. 3)Chlorine dioxide
Is powerful oxidizing agent
Can eliminate bad breath by oxidation of hydrogen sulphite, methylmercaptan,
and amino acids, methionine and cysteine.
43. 4)Two-phase Oil- water rinse
Rosenberg et al designed two phase oil water rinse containing CPC.
A twice daily rinse with this product
( before bedtime and in morning) showed reduction in both VSC level and
organoleptic rating which was superior to LISTERINE.
44. 5)Aminefluoride/stannous fluoride
Reduction of morning breath odor, even when oral hygiene was insufficient.
The formulation showed not only short term but also long term effect on malodor
indicator in patients with obvious malodor.
45. 6) Hydrogen peroxide
Rinsing with 3% Hydrogen peroxide produced impressive reduction
(about 90%) in sulfur gases that persisted for 8 hrs.
46. 7) Oxidizing lozenges
Greenstein et al reported that sucking a lozenges with oxidizing properties
reduces tongue dorsum malodor for 3 hrs.
Antimalodor activity is caused by dehydroascorbic acid,generated by peroxide
mediated oxidation of ascorbate present in lozenges.
47. 8)Baking soda
Confer a significant odor reducing benefit for time period upto 3
hrs.
Mechanism
Bactericidal effects
48. Conversion of volatile sulfur compound
Metal salt solution
Metal ion with affinity for sulfur are efficient in capturing sulfur containing
gases
Zinc is an ion with two positive charges (zn++) which will bind to twice
negatively loaded sulfur radicals, thus can reduce expression of VSCs.
Same applies for other metal ion such as Stannous, Mercury & Copper.
Compared with other metal ion , Zn++ is relatively nontoxic and non
cumulative and gives no visible discoloration.
Thus Zn has been one of most studied ingrediant for control of oral malodor.
49. Halita, a rinse containing 0.05% chlorhexidine,
0.05% CPC, 0.14% zinc lactate has been even
more efficient than 0.2% chlorhexidine in
reducing VSC level and organoleptic rating.
50. Conclusion
Breath malodor has an important socioeconomic consequences and also can
reveal diseases.
A proper diagnosis and determination of etiology allow initiation of proper
etiologic treatment.
Although intraoral causes are common but clinician can’t overlook other,
more challenging extraoral causes.
Thus can be done by multidisciplinary consultation or if not fessible, a trial
therapy to deal quickly with intra oral causes (eg. Full mouth one stage
disinfection including use of proper mouthrinse, tongue scraper and
toothpaste.)
