1. HALITOSIS Babak Saedi.MD Assistant professor of Tehran university Imam Khomeini Hospital

2. Extremely common. Extremely common. Majority of adult population have had it at some point in time! Up to ¼ on a regular basis. [1] Majority of adult population have had it at some point in time! Up to ¼ on a regular basis. [1] Very subjective “ it’s a perception rather than a real thing, everybody’s breath smells to a certain extent”. Very subjective “ it’s a perception rather than a real thing, everybody’s breath smells to a certain extent”. Most seek help from GP initially, not the dentist! Most seek help from GP initially, not the dentist!

3. Why is it important? Mouth odor can be a sign of undiagnosed disease Mouth odor can be a sign of undiagnosed disease Mouth odor has negative connotations in many cultures Mouth odor has negative connotations in many cultures Affects patient's self-image Affects patient's self-image Affects others’ attitudes towards patient Affects others’ attitudes towards patient Bad breath is big business Bad breath is big business Mouthwashes, mints, drops, gums, toothpastes Mouthwashes, mints, drops, gums, toothpastes Commercials reinforce existing attitudes Commercials reinforce existing attitudes

4. WHERE DOES IT COME FROM ? 85-90% comes from the mouth itself. 85-90% comes from the mouth itself. Despite rigorous hygiene, good dentition, posterior dorsum of tongue is often a source (? Post nasal drip related). Despite rigorous hygiene, good dentition, posterior dorsum of tongue is often a source (? Post nasal drip related).

5. MOST WANTED LIST Compounds commonly produced by mouth bacteria and their odours. Compounds commonly produced by mouth bacteria and their odours. Hydrogen SulphideRotten Eggs Hydrogen SulphideRotten Eggs Methyl mecaptanFaeces Methyl mecaptanFaeces SkatoleFaeces SkatoleFaeces CadaverineCorpses CadaverineCorpses PutrescineDecaying meat PutrescineDecaying meat Isovaleric acidSweaty Feet Isovaleric acidSweaty Feet

6. CAUSES Sleep. Sleep. Food (onions, garlic). Food (onions, garlic). Drugs: ISDN, disulfaram. Drugs: ISDN, disulfaram. Xerostomia: anxiety, pyrexia, anticholinergics, antihistamines, TCA’s, Sjögren’s Syndrome. Xerostomia: anxiety, pyrexia, anticholinergics, antihistamines, TCA’s, Sjögren’s Syndrome. Poor dental hygiene; gingivitis, periodontitis, dentures. Poor dental hygiene; gingivitis, periodontitis, dentures. PN drip, sinusitis, nasal polyps, adenoids, foreign bodies, tonsillitis & tonsilliths. PN drip, sinusitis, nasal polyps, adenoids, foreign bodies, tonsillitis & tonsilliths. Naso-oropharyngeal mal. Naso-oropharyngeal mal.

7. What causes halitosis? - poor oral hygiene - cancer - odiferous decaying food particles - hepatic failure - cellular & nutritional debris - plaque coated tongue - caries - bleeding gums - periodontal disease - Xerostomia - postsurgical states - purulent infections - improperly cleaned dentures - pulmonary disease - renal failure Tobacco, smoked and smokeless, can cause halitosis.

8. Tongue coating http://www.dent.ohio-state.edu/oralpath2/Tongue/25_2.jpg

9. Association with H.Pylori Association with H.Pylori Pharyngeal pouch Pharyngeal pouch Gastric outlet probs Gastric outlet probs Severe Reflux Severe Reflux DKA DKA Renal dysfunction Renal dysfunction Hepatic dysfunction Hepatic dysfunction Respiratory disease Respiratory disease Delusional halitosis Delusional halitosis Hallucinatory feature of psychotic illness Hallucinatory feature of psychotic illness Temporal Lobe Epilepsy Temporal Lobe Epilepsy Trimethyl aminuria Trimethyl aminuria

10. HISTORY Clinical Challenge ! Clinical Challenge ! Is c/o malodour justified; is the presenting odour originating in the mouth or elsewhere? Is c/o malodour justified; is the presenting odour originating in the mouth or elsewhere? Think about systemic causes. Think about systemic causes. Physiological halitosis, oral pathological halitosis Physiological halitosis, oral pathological halitosis

11. EXAMINATION Try to distinguish oral from non-oral. Try to distinguish oral from non-oral. Compare smell coming from mouth with that exiting the nose. Compare smell coming from mouth with that exiting the nose. Examination of nose, post nasal space & all mucosal surfaces of pharynx. Examination of nose, post nasal space & all mucosal surfaces of pharynx. Examine oral cavity, dentition, look for tonsilloliths, dentures etc. Examine oral cavity, dentition, look for tonsilloliths, dentures etc. Can take scraping from posterior dorsum of tongue. Can take scraping from posterior dorsum of tongue. “ Dangerous to assume dental, periodontal, dietary causes. Early oral & oropharyngeal carcinomas have few symptoms”. [4] “ Dangerous to assume dental, periodontal, dietary causes. Early oral & oropharyngeal carcinomas have few symptoms”. [4]

12. INVESTIGATIONS Instrumental analysis Instrumental analysis Level of intra oral Volatile Sulphur Compounds can be estimated using portable sulphide monitors. Concentration of VSC’s correlate well with level of malodour reported by observers. [2] Level of intra oral Volatile Sulphur Compounds can be estimated using portable sulphide monitors. Concentration of VSC’s correlate well with level of malodour reported by observers. [2] Gas Chromatography. Gas Chromatography.

13. Diagnosing smells History History Onset, duration? Onset, duration? Constant or intermittent, morning, how long after meals? Constant or intermittent, morning, how long after meals? Self-report, or reported by others? Self-report, or reported by others? Dietary factors, smoking and alcohol use? Dietary factors, smoking and alcohol use? Systemic disease and medication Systemic disease and medication Neurological problems - taste and smell function? Neurological problems - taste and smell function? Currently under stress? Currently under stress? Comprehensive oral examination Comprehensive oral examination

14. Diagnosis by smelling No commercial mouth rinses for 1 day previous No commercial mouth rinses for 1 day previous No eating, drinking, brushing, gum, mints, rinses for 2 h No eating, drinking, brushing, gum, mints, rinses for 2 h Avoid perfumes or scented products (patient; dentist) Avoid perfumes or scented products (patient; dentist) 2 min rest with lips closed - exhale through nostrils 2 min rest with lips closed - exhale through nostrils 2 min rest as before - close nostrils - exhale through lips 2 min rest as before - close nostrils - exhale through lips

15. 2 min rest as before - exhale with lips and nostrils open 2 min rest as before - exhale with lips and nostrils open Sample posterior tongue with plastic spoon Sample posterior tongue with plastic spoon Compare odor strength for each condition Compare odor strength for each condition

16. Interpretation Interpretation Strongest odor with lips closed - suggests nose, sinuses Strongest odor with lips closed - suggests nose, sinuses Strongest odor with nostrils closed - oral or gastric source Strongest odor with nostrils closed - oral or gastric source Tongue sample to confirm oral origin Tongue sample to confirm oral origin Odor equally strong from nose or mouth - systemic Odor equally strong from nose or mouth - systemic No discernible odor - verify with others (spouse, friend) No discernible odor - verify with others (spouse, friend)

17. ENT referral ENT referral ? Antral washout, adenoidectomy, tonsillectomy, biopsy etc. ? Antral washout, adenoidectomy, tonsillectomy, biopsy etc. Gastroenterology referral Gastroenterology referral Rare despite common belief ! Rare despite common belief ! Psychology/psychiatric referral Psychology/psychiatric referral ? Halitophobia. ? Halitophobia. Empirical treatment with metronidazole Empirical treatment with metronidazole

18. Thank you for listening ! Thank you for listening !