HALITOSIS BY Dr. Hossam A. Eid Assoc. Prof. of Periodontology Faculty of Dentistry, GMU

Halitosis and Oral malodor Definition: Halitosis is a term used to describe obvious unpleasant odor exhaled in breathing regardless of its source oral or non oral. Oral malodor – Is the term specially used to describe foul odor from oral cavity. 6/8/2016

Facts on Halitosis Halitosis affects a large proportion of population ( half of North American people). Halitosis causes a significant social or psychological handicap to those suffering from it. 20 % of the population views mouth odor as a serious concern. Causes – 90% of causes of halitosis due to oral causes – 10% due to systemic diseases. 6/8/2016

Why is it important? Mouth odor can be a sign of undiagnosed systemic and or oral disease Mouth odor has negative psychological effect in many cultures – Affects patient's self-image – Affects others’ attitudes towards patient Bad breath is big business – Mouthwashes, mints, drops, gums, toothpastes – Commercials reinforce existing attitudes 6/8/2016

Why is it important? 6/8/2016

Classification of Halitosis I- Genuine Halitosis: It is an obvious malodor, with intensity beyond socially acceptable level. It may be: A- Physiologic halitosis B- Pathologic halitosis: - Oral - Extra-oral 6/8/2016

I- Genuine Halitosis: A- Physiologic halitosis Causes: 1-Mouth breathing 2-Medications 3-Aging or poor dental hygiene (Unclean dentures) 4-Fasting/starvation 6/8/2016

I- Genuine Halitosis: A- Physiologic halitosis Causes: 5-Tobacco 6-Foods/drinks (Onion, garlic,……./ alcohol) 7- Hormonal changes: Ovulation Menstruation Pregnancy Postmenopausal 6/8/2016

I- Genuine Halitosis: B- Pathologic halitosis Causes: oral and other contributing factors 1-Periodontal infection: from subgingival plaque, specific diseases as ANUG 2-Tongue coating harbors bacteria 3-Stomatitis, xerostomia 4-Iatrogenic: faulty restorations retaining food & bacteria 6/8/2016

I- Genuine Halitosis: B- Pathologic halitosis Causes: oral and other contributing factors 5-Parotitis, cleft palate 6-Aphthous ulcer and dental abscesses 7-Oral cancers, candidal infection 6/8/2016

I- Genuine Halitosis: B- Pathologic halitosis Causes: Systemic & extra-oral factors 1-Nasal infection: rhinitis, sinusitis, tumors and foreign bodies 2-GIT diseases: Carcinomas, gastric ulcers, Gastroesophygeal reflux disorder. 3-Pulmonary infection: bronchitis, pneumonia, tuberculosis, carcinomas 6/8/2016

I- Genuine Halitosis: B- Pathologic halitosis Causes: Systemic & extra-oral factors 4-Systemic diseases like: Diabetes, Hepatic failure, liver cirrhosis, Renal failure, Uremia, fever, Dehydration. 6/8/2016

II- Pseudo-halitosis: In this condition obvious malodor is not perceived by others. Although patient insists on complaining of its existence. It can be improved by counseling and simple oral hygiene measures. 6/8/2016

III- Halitophobia: 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 6/8/2016

Biological Sources of Oral Malodor BLOOD NECROSIS PUS MUCOUS BACTERIA 6/8/2016

Etiology Oral Malodor Is commonly the result of microbial putrefaction of food debris, cells, saliva and blood within the oral cavity. The resultant substrates with free THIOL groups like cystein and reduced glutathionine, Rises to volatile sulfur compounds (VSCs), which are malodor substances. 6/8/2016

Measurement of Oral malodor Prior to measure oral malodor: Patients should be instructed NOT to: - Eat - Chew - Rinse -Smoke For at least two hours before examination. - Patients who are on antibiotics should be seen 2 weeks after discontinuation of medicines. 6/8/2016

Tests used to detect Halitosis A- Subjective Organoleptic ratings – The odor judge – Trained noses partly agree with sulfide meters – May be more relevant clinically – Requires extensive training, periodic calibration – Mainly for research, specialized clinics The jury of one's peers – Your spouse or your best friends – Your dentist (or your patient) 6/8/2016

Tests used to detect Halitosis A- Subjective Organoleptic ratings – Self-incrimination - least reliable – Many cannot detect odors apparent to others – Some perceive odors no one else can detect 6/8/2016

Tests used to detect Halitosis B- Gas chromatography – This machine is designed to digitally measure molecular levels of the three major VSCs in a sample of mouth air which are: Hydrogen sulfide Methymercaptan Dimethyl sulfide - It is accurate - Produces visual results in graph via computer interface 6/8/2016

Halimeter C- Portable sulfide meter (the Halimeter®) – Can be used in a dental office – Detects only VSC (misrepresents mercaptan sulfide in test results which affects its accuracy) – Must be calibrated regularly to maintain accuracy – Sensitive to alcohol so one should stop drinking alcohol or using mouth wash containing alcohol for at least 12 hrs prior to test 6/8/2016

Tests used to detect Halitosis D- BANA test (Benzoyl-d, L-arginine-naphthyl amide) -Bacteria like P.gingivalis, T. denticola, B. forsthyus produce waste products contributing in causing bad breath. - These bacteria can produce an enzyme that degrades (Benzoyl-d, L-arginine-naphthyl amide) compound. - So when sample of saliva that contains these bacteria is placed within the BANA testing compound they cause its breakdown - Test compound changes its colour indicating a positive reaction 6/8/2016

Tests used to detect Halitosis D- Chemiluminescence: - Mixing a sample containing sulfur compounds (VSCs) with mercury compound. - The resultant reaction causes fluorescence - It is highly sensitive 6/8/2016

Treatment and management of Oral malodor 6/8/2016

Treatment and management of Oral malodor Non-oral etiologies - appropriate referral Oral etiologies – Treat all existing conditions – Attempt to improve hygiene, flossing – Encourage posterior tongue hygiene Commercial tongue scrapers 6/8/2016

Encourage posterior tongue hygiene 6/8/2016

Treatment and management of Oral malodor Oral etiologies Masking fragrances – Mouth rinses, drops, gums, mints, etc. Chemicals that interact with VSC – Oxidizing agents - products based on chlorine dioxide – Zinc reacts with VSC Safe when not used in excess More published evidence - small Ns Reduces VSC levels short-term 6/8/2016

Treatment and management of Oral malodor Oral etiologies Chlorhexidine is considered the gold standard – High substantivity - remains on oral tissues for a long time, but with problems with taste and staining – Toothpaste with substantive triclosan copolymers - short term – Mixtures including low dose chlorhexidine – Halita (containing Zinc) 6/8/2016

Treatment and management of Oral malodor Oral etiologies Ch 6/8/2016

Treatment and management of Oral malodor Oral etiologies The probiotic concept – Replace “bad” bacteria with “good” bacteria Probiotic treatment of bad breath in New Zealand and Australia – S. salivarius strain K12 Indigenous strain that produces antibacterial peptides (BLIS) 6/8/2016

Treatment and management of Oral malodor Oral etiologies The probiotic concept Patented, marketed as a dietary supplement (now in USA) Step 1: Use chlorhexidine to knock down tongue flora Step 2: Replace tongue flora with K12 6/8/2016

Oral Irrigation Medicinal Mouthwash Short-term for specific effect Associated risks Examples: Peridex (Chlorhexidine gluconate); Phenol Based with oils (Listerine); Cetyl- pyridinium Cl (Cepacol) Chlorine dioxide, herbal remedies, etc. Side effects: staining, taste changes, toxicity, overgrowth of bacteria, fungi etc. 6/8/2016

Saline Mouthwash & Gargle PREPARATION: NaCl common Table Salt Hypertonic solutions: stir one teaspoonful of salt in about 300ml water. Salt should remain at base of glass=Saturated solution  hypertonic Freshly prepared for each use. Not costly; available 6/8/2016

Saline Mouthwash & Gargle PREPARATION: NaCl common Table Salt Hypertonic solutions: stir one teaspoonful of salt in about 300ml water. Salt should remain at base of glass=Saturated solution  hypertonic Freshly prepared for each use. Not costly; available 6/8/2016

Hypertonicity dehydrates bacteria  bacteriostatic initial  then bacteriocidal Edema: Swollen Cells are reduced Saline debridement of tonsillar crypts Washes and irrigates mucous membranes; mucolytic Slows inflammation 6/8/2016 MODE OF ACTION

- Decrease the protein content in your meal - Follow up the oral hygiene instruction specially tooth brushing - Regular dental care visits - Use zinc containing mouth wash - Do not ignore the change in your breath, may be undiagnosed systemic disease behind 6/8/2016 THE MESSAGE Be optimistic Drink fluid as much as you can

Thank You Questions? 6/8/2016