Dr. Hakan ÇolakDDS, PhDIshık University School of DentistryDepartment of Conservative Dentistry

Halitosis: A frequently ignored serious social problem 

Introduction• Halitosis is a crippling social problem with a common

complaint of up to one-third of the general population.• Lyrical term derived from the Latin word "halitus"

(breath) and the Greek suffix "osis" (condition, action or pathological process).

• In simple words, it means "Bad Breath". It is also called as fetor ex ore or fetor oris

Introduction• Halitosis frequently causes embrassment, may affect interpersonal social communication and also become

an important market for the pharmacological and cosmetic industries

Terminology

Scully C, Greenman J. Halitosis (breath odor). Periodontol 2000. 2008;48:66-75

Epidemiology• Swedish study

• clinical assessment• 840 men • Halitosis detected in around 2% of the population

• Large Japanese study • more than 2600 subjects assessed by VSC monitor • found the prevalence of malodour above 20%

• China• a study of 2500 subjects • reported an overall prevalence of malodour of 27.5%,• which was particularly associated with the presence of tongue

coating

Introduction• A wide range of conditions have been reported to

beable to cause halitosis• Extra-oral causes• Intra-oral causes

• Studies of affected subjects at dedicated malodour clinics have shown that nearly 90% of all cases of malodour are the result of oral causes

• Psychogenic causes• Transient causes

Hughes FJ, McNab R. Oral malodour--a review. Arch Oral Biol. 2008 Apr;53 Suppl

Aetiology and classification

•Periodontal disease

•Deep pocket formation

•Increased levels of VSCs

Aetiology and classification

Tongue coatings

Table 1. Characteristic smells of compounds that can berecovered from the mouth odour

PathogenesisOral malodour arises from the production of volatile malodourous compounds by the action of bacteria

in breaking down components of epithelial cells, salivary and serum proteins, and food debris

Pathogenesis• Volatile sulphur compounds (VSCs),

• primary cause of halitosisis• believed to be produced by gram-negative proteolytic

anaerobesThese microbes are located in the stagnant areas of the mouth, such

as theperiodontal pockets, tongue surface, and interproximalareas between the teeth.

• Include; hydrogen sulphide dimethyl sulphide methylmercaptan

believed to be the most malodourous component

Examination for Halitosis• The three main methods of analyzing oral malodour

are• organoleptic measurement• gas chromatography (GC) • sulphide monitoring

Hughes FJ, McNab R. Oral malodour--a review. Arch Oral Biol. 2008 Apr;53 Suppl

Organoleptic Measurement• a sensory test scored on the basis of the examiner’s

perception of a subject’s oral malodour. • carried out simply by sniffing the patient’s breath and

scoring the level of oral malodour

Organoleptic Measurement• Pre-procedural requirements

The patient is instructed to avoid taking antibiotics 3 weeks before procedure.

They should also be instructed to refrain from ingesting garlic, onion and spicy foods for 48 hours before the assessment.

Certain other requirements include avoiding use of perfumes, deodorants for 24 hours before the assessment and smoking and alcohol 12 hours before the procedure.

They should also be discouraged from using breath fresheners and oral rinses 12 hours before assessment

Organoleptic Measurement• Pre-procedural requirements

Examiner• The examiner conducting the test should have a normal sense of

smell. • He or she should avoid drinking coffee, tea or alcohol and abstain

from smoking. • Use of perfumes and scented cosmetics should be strictly avoided.

Organoleptic Measurement• Whole mouth breath test

• The patient and the examiner are seated on either side of a privacy screen.

• This screen will make the patient believe that he/she is undergoing a scientific test.

• A 50 - 70 cms long, 2.5cms diameter transparent tube is inserted through the privacy screen.

• The patient is asked to place one end of the tube into his mouth and exhale slowly as the examiner seated across the privacy screen will sniff the exhaled air on the other end and grade the halitosis.

Organoleptic Measurement

Organoleptic scoring scale (Miyazaki H et

al.)

Gas Chromatography• highly sensitive technique • measure the most abundantly produced volatile

sulphur compounds in the mouth (CH3SH, H2S, and (CH3)2 S)

Gas Chromatography• The OralChroma

• portable gas chromatography device analyses individual concentrations of volatile sulphur compounds such as hydrogen sulfide, methyl mercaptan and himethyl sulfide and displays the concentrations on a display panel.

Sulphide Monitors• Sulphide monitor is portable chair side equipment that can assess

oral malodor, these monitors are cost effective and commercially marketed as HalimeterR (Interscan, Chatsworth, California.)

• The monitor is equipped with an electrochemical sensor. • The patient is asked to exhale into a transparent tube that carries

the breath to a suction pump which in turn carries the air to the monitor.

• These monitors analyze the total sulphur content of the individuals breath but cannot differentiate between various sulfides.

• The instrument measures parts per billion levels of hydrogen sulfide and, to a lesser extent, methyl mercaptan.

Sulphide Monitors

Management

The management of halitosis depends

largely on the cause

Management • Mechanical Reduction of Intraoral Nutrients and Microorganisms

• Chemical Reduction of Oral Microbial Load• Two-Phase Oil : Water Mouthrinse• Rendering Malodorous Gases Non-Vital

    Masking the Malodor

Mechanical Reduction of Intraoral Nutrients and Microorganisms

• The dorsal surface of most tongues usually has significant observable debris. Greasy foods rich in fat contribute significantly to accumulation of tongue debris.  

• Brushing studies indicate that the tongue was the main source of CH 3 SH and H 2 S.  

• Because of the extensive accumulation of bacteria on the tongue, tongue cleaning has been emphasized. 

• Tongue cleaning • reduce the amount of tongue coating and the bacterial load

on the tongue surface. • reduce the number of microorganisms and the plaque • The plaque forming potential of Streptococcus

salivarius percentage decreased• additional benefit of improving taste sensation.

• It was found that tongue brushing increased taste acuity in geriatric patients especially in denture wearers by removing the thick layer of plaque.

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Tongue Scraping

Chemical Reduction of Oral Microbial Load

• Mouthwashes are easily accessible, high ethanol products, marketed without-child resistant packaging.

• Mouthwashes, nowadays, have an alcohol content that varies from 6 to 26.9%. [20]

• The active ingredient in oral rinses is usually antimicrobial agents such as CHX, CPC, essential oils, chlorine dioxide, hydrogen peroxide and triclosan.

Chemical Reduction of Oral Microbial Load

• CHX• have pronounced antiseptic properties. • considered the most effective antiplaque and antigingivitis agent. • antibacterial action • can be explained by disruption of bacterial cell membrane by the CHX

molecules, increasing the permeability and resulting in cell lysis and death. 

• used to inhibit or reduce plaque-associated bacteria and as prophylaxis after periodontal surgery. 

• can be used alone CHX-Alc (0.2%) or in combination with other formulation like

• CHX-NaF (0.12% CHX + 0.05% NaF) • Halita/CHX-CPC-Zn (0.05% CHX + 0.05% CPC + 0.14% Zn lactate) • AmF/SnF  2 mouth rinse.

Two-Phase Oil : Water Mouthrinse

• These mouthrinses are highly effective in reducing bad breath parameters. 

• A twice daily rinse showed reductions in both VSC and organoleptic rating. 

• Two phase oil:water combinations have several possible advantages over single-phase mouthwash

• Their relative effectiveness in binding and desorbing oral microorganisms.• Since the bacteria and oral debris are stained blue by the food color, they can

be macroscopically and microscopically observe to adhere to the oil droplets following rinsing, affording direct observation and self-assessment.

• The two-phase mouthwash formulations do not contain alcohol, a substance which has potential side effects.

Rendering Malodorous Gases Non-Vital

• Metal salt solution • Zinc is an ion with two positive charges (Zn ++ )• which will bind to the twice negatively loaded sulfur radicals, • thus can reduce the expression of the VSCs.  • The non-toxic zinc and stannous ions had a great effect on

H 2 S and CH 3 SH. • Furthermost, mercury, cadmium and cuprous ions were

shown to have strong anti-VSC effect, whereas lead ions had little effect on VSC production in vitro