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The oral biology of bad breath DENT 5301 Introduction to Oral Biology Dr. Joel Rudney.

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Presentation on theme: "The oral biology of bad breath DENT 5301 Introduction to Oral Biology Dr. Joel Rudney."— Presentation transcript:

1 The oral biology of bad breath DENT 5301 Introduction to Oral Biology Dr. Joel Rudney

2 Why is it important? zMouth odor can be a sign of undiagnosed disease zMouth odor has negative connotations in many cultures yAffects patient's self-image yAffects others’ attitudes towards patient zBad breath is big business yMouthwashes, mints, drops, gums, toothpastes yCommercials reinforce existing attitudes zDentists are consulted for advice, treatment yActive marketing of "breath treatment clinic" franchises

3 What smells? zProducts of bacterial activity yVolatile sulfur compounds (VSC) xHydrogen sulfide (H 2 S) - rotten eggs xMethyl mercaptan (CH 3 SH) - natural gas xMajor components of mouth odor in most persons yCadaverine - diamino acid - spoiled meat xAlso important xProduced independently of VSC yOrganic acids - goaty smells xAcetic, propionic, butyric, isovaleric

4 What smells too? zProducts of metabolic activity yVolatile food components xGarlic, onions, etc. xBroccoli, cauliflower (sulfur-rich) yKetones (acetone) xLow carb diets yTrimethylamine (fishy odor) zTobacco smoke zBeer, wine, and liquor

5 How much does it smell? zInstruments for odor detection zGas chromatography of breath samples yMost informative yExtremely sensitive and precise yExpensive and cumbersome yLimited to research centers zPortable sulfide meter (the Halimeter®) yCan be used in a dental office yDetects only VSC yMust be calibrated regularly to maintain accuracy

6 Who smells it? zOrganoleptic ratings - the odor judge yTrained noses partly agree with sulfide meters yMay be more relevant clinically yRequires extensive training, periodic calibration yMainly for research, specialized clinics zThe jury of one's peers yYour spouse or your best friends yYour dentist (or your patient) yRelevant to the social consequences of mouth odor zSelf-incrimination - least reliable yMany cannot detect odors apparent to others ySome perceive odors no one else can detect

7 Where does it smell? zPosterior tongue yOdor scores associated with degree of tongue coating yTongue anatomy may increase risk (deep fissures) yMay be primary source of odor in younger patients yWorse with dry mouth, after sleeping zPeriodontal pockets in periodontal disease yOdor scores associated with disease/severity yVSC can be measured in fluid from deep pockets yMouth odor/VSC proposed as early sign of periodontitis yNot all periodontal patients have mouth odor zOther oral lesions (e.g. abcesses, impactions) zOral candidiasis - "Sweet, fruity odor"

8 Tongue coating

9 Which bacteria are smelly? zTongue bacteria yStreptococcus salivarius - a sign of “health”? xMay be dominant in persons w/o halitosis (n = 5) yGram-negative, proteolytic anaerobes xMay predispose towards halitosis xMany novel species (n = 6) xDigest nasal discharges, food debris, saliva components, sloughed cells xProduce VSC, cadaverine xBANA hydrolysis test (Perioscan®) used for detection zPeriodontal pathogens

10 Systemic smells zAbout 90% of halitosis originates in the mouth zThe other 10% ySystemic disease xDiabetes - ketoacidosis - acetone smell xCirrhosis, liver failure - "mousy", "musty" smells xRenal failure - fishy smell xLeukemia - "decaying blood" smell yRespiratory system xExhalation of volatile food compounds xVolatile medications - DMSO, amyl nitrate xNasal/sinus/lung infections xTonsils and tonsiloliths (may not contribute to mouth odor) Treated by laser cryptolysis xCarcinoma

11 Other systemic smells zGastrointestinal system (considered rare) yReflux yCarcinoma yHelicobacter pylori infection (gastric ulcers) zGenetic disorders (enzyme deficiencies) yTrimethylaminuria (fishy odor) - autosomal recessive yCystinuria, cystathionuria heterozygotes xRecessive defects in cysteine metabolism xVery high VSC levels (gut bacteria)

12 Iatrogenic/idiopathic smells zFrustrating to diagnose and treat - expensive zIatrogenic odors yGauze pad left behind after cleft palate surgery zForeign objects yInserted up the nose yYoung children and developmentally disabled yIf undetected, may lead to odor in adults zIdiopathic odors yDetectable by others, no apparent oral or non-oral cause yCause presumed rare, not yet defined

13 “Psychosomatic” smells zDetectable only by patient - no apparent cause zPatients often refuse to accept objective findings zAssociated with anxiety or depression zCan be confused with genetic disorders yPatients may show abnormalities by gas chromatography yTrimethylaminuria heterozygotes xMay be more common than once thought xSaliva TMA detectable by patient, but not others

14 Diagnosing smells zHistory zOnset, duration? zConstant or intermittent, morning, how long after meals? zSelf-report, or reported by others? zDietary factors, smoking and alcohol use? zSystemic disease and medication zNeurological problems - taste and smell function? zCurrently under stress? zComprehensive oral examination

15 Diagnosis by smelling zNo commercial mouth rinses for 1 day previous zNo eating, drinking, brushing, gum, mints, rinses for 2 h zAvoid perfumes or scented products (patient; dentist) z2 min rest with lips closed - exhale through nostrils z2 min rest as before - close nostrils - exhale through lips z2 min rest as before - exhale with lips and nostrils open zSample posterior tongue with plastic spoon zCompare odor strength for each condition zInterpretation yStrongest odor with lips closed - suggests nose, sinuses yStrongest odor with nostrils closed - oral or gastric source yTongue sample to confirm oral origin yOdor equally strong from nose or mouth - systemic yNo discernible odor - verify with others (spouse, friend)

16 Treating smells - the basics zNon-oral etiologies - appropriate referral zOral etiologies yTreat all existing conditions yAttempt to improve hygiene, flossing yEncourage posterior tongue hygiene xCommercial tongue scrapers xMany designs on the market xThe gag reflex is a barrier to compliance

17 Tongue scraping One of many designs - no endorsement implied

18 Treating smells - short-term zMasking fragrances yMouth rinses, drops, gums, mints, etc. zChemicals that interact with VSC ySold online - by dentists offering halitosis clinics yOxidizing agents - products based on chlorine dioxide xDisinfectant - water treatment, pulp mills, cow udders xFDA approved for 2ndary food use (disinfecting chickens) xAppears to be safe at concentrations in breath products xOnly two published studies - short-term, small Ns yZinc reacts with VSC xSafe when not used in excess xMore published evidence - small Ns xReduces VSC levels short-term

19 Treating smells - long-term zAntibacterial products yShould reduce bacterial odors, depending on efficacy yVery few clinical studies document effects on odor long term zChlorhexidine is considered the gold standard yHigh substantivity - remains on oral tissues for a long time yOnly by Rx in USA, problems with taste and staining zOthers with published evidence for odor reduction yTwo-phase oil-water mouthrinse (cetylpyridinium chloride) xSulfides lower after 6 weeks of use xMore effective than Listerine (essential oils) - both worked xCurrently available in Israel and Great Britain yToothpaste with substantive triclosan copolymers - short term yMixtures including low dose chlorhexidine - Halita

20 Treating smells - probiotics? zThe probiotic concept yReplace “bad” bacteria with “good” bacteria yLots of ongoing research - NIH funded yFDA approves human trial of probiotic S. mutans xGenetically engineered to be non-cariogenic xLots of safeguards required zProbiotic treatment of bad breath in New Zealand and Australia yS. salivarius strain K12 xIndigenous strain that produces antibacterial peptides (BLIS) xPatented, marketed as a dietary supplement (now in USA) xStep 1: Use chlorhexidine to knock down tongue flora xStep 2: Replace tongue flora with K12 yLimited data - 2 wks., N = 13, only 3 controls, not yet published

21 ADA halitosis standards zMust be met to get ADA seal for any bad breath claims yApplies to products that already have ADA seal for other claims zTwo independent double-blind efficacy studies yMinimum 3-week trial period yPatients must have baseline organoleptic scores between 2-5 x“Slight” to “Very Strong” yGas chromatograph preferred to measure VSC xSulfide monitor OK if calibration data provided yMultiple malodor measurements yParallel evaluation of hard/soft tissue effects, microbiology xLong term safety data (six month follow up) xMust include patient-reported adverse effects (taste/staining) yToxicity data (cytotoxic, mutagenic, carcinogenic effects)

22 Why so few studies? zNo product currently has the ADA seal for halitosis ySome do have the ADA seal for other properties xPlaque control or caries prevention yWill the public make this distinction? xIs there a marketing benefit to getting the halitosis seal? zFDA approval yMay be sought under less stringent standards for cosmetics yIngredients already approved as safe for human use xChlorine dioxide products yMay fall under the much weaker rules for dietary supplements xProducts containing zinc xS. salivarius K12 zManufacturers lack incentives to do the studies

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