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 periodonticsCOLLEGE OF MEDICAL SCIENCES BHARATPUR NEPAL

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.

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

Based on patients criteria1)Genuine halitosis2) Pseudohalitosis3) HalitophobiaGeniune halitosisTerm 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.

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.

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.

CausesIntraoral causes-Physiologic - Diet- Beverages- Alcohol- Dairy products that contain protein- Dehydration,constipation,salivation,diarrheaPathologic- tongue coating- Gingivitis- Periodontitis- Periocoronitis- Xerostomia- Oral sepsis- Oral cancer

Extra oral causes:ENT- Postnasal drip- Sinusitis- rhinitis- Tonsilitis- Nasal polype, carbuncles- Nasal obstructionSystemic factors:Lung- chronic bronchitis, bronchetisis, lung abscessRenal- renal failure, uremiaHepatic- cirrhosis, gallbladder dysfunction

Carcinomas- bronchial carcinomasDiabetic ketoacidosis- acetone breath of uncontrolled diabetesTrimethylaminuria- fish odor syndromeGIT- eosophageal reflux, pyloric stenosis, hiatal hernia, enteric infectionOther systemic condition- sjogrens syndrome, leukemias etcMedications- antihistamines, anticholinergics, antipshycotics,etcidiopathic

Etiopathology

Bacteria associated with malodor

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)

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

Diagnosis of MalodorHistory taking and medical questionareClinical and Laboratory Examination

Self-ExaminationOropharyngeal ExaminationOrganoleptic RatingPortable Volatile Sulfur MonitorGas ChromatographyDark-Field or Phase-Contrast MicroscopySaliva Incubation Test Electronic NoseChair-Side Test

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.

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.

CLINICAL EXAMINATION

SELF EXAMINATIONIt 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.

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

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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

The judge smells a series of different air samples as follows:1) Oral cavity odor2) Breath odor3) Saliva4) Tongue coating5) Nasal breath odor

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

TREATMENT OFORAL

MALODOR

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.

General treatment strategies

I. Masking malodorII. Mechanical reduction of intraoral nutrients (substrates) and

microorganisms.III. Chemical reduction of oral microbial loadIV. Rendering malodorous gases non volatile

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

Another pathway is to increase the solubility of malodorous compounds in saliva by increasing secretion of saliva which can be achieved by chewing gum.

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.

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.

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%.

Chemical reduction of oral Microbial load1)Chlorhexidine

Most effectiveantiplaque 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.

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.

3)Chlorine dioxide

Is powerful oxidizing agentCan eliminate bad breath by oxidation of hydrogen sulphite,

methylmercaptan, and amino acids, methionine and cysteine.

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.

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.

6) Hydrogen peroxide

Rinsing with 3% Hydrogen peroxide produced impressive reduction (about 90%) in sulfur gases that persisted for 8 hrs.

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.

8)Baking soda Confer a significant odor reducing benefit for time period

upto 3 hrs.Mechanism Bactericidal effects

Conversion of volatile sulfur compoundMetal 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.

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.

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.)

References

Carranza’s clinical periodontology 11th & 12th edition

Lindhe clinical periodontologyTHANK YOU