Oral Malodor
Marc Ouirynen, Sandra Van den Ve/de, Betty Vandekerckhove, and Jesica Dadamio
CHAPTER OUTLINE
SEMANTICS
Epidemiology
CLASSIFICATION
ETIOLOGY
lntraoral Causes
Extraoral Causes
PHYSIOLOGY OF MALODOR DETECTION
DIAGNOSIS OF MALODOR
Medical History
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~ text, figures, references, and tables may be out of numeric order in this printed chapter.
SEMANTICS
Breath odor can be defined as the subjective perception after smell-
ing someone's breath. It can be pleasant, unpleasant or even dis-
turbing, if not repulsive. If unpleasant, the terms breath ma/odor,
halitosis, bad breath, or Jetor ex ore can be applied. These terms,
however, are not synonymous with oral ma/odor, which has its origin
in the oral cavity. Th.is is not always the case for all breath malodors.
The term "oral malodor" is thus too restrictive.
Breath malodor should not be confused with the momentarily
disturbing odor caused by food intake (e.g., garlic, onions, and
certain spices}, smoking, or medication (e.g., metronidazole)
because these odors do not reveal a health problem. The same is
true for "morning" bad breath, as habitually experienced on awak-
ening. This malodor is caused by a decreased salivary flow and
increased putrefaction during the night and spontaneously disap-
pears after breakfast or oral hygiene measures. A persistent breath
malodor, by definition, does reflect some pathology.
Epidemiology
Breath malodor is a common complaint among the general popula-
tion. It has a significant socioeconomic impact but was neglected
until recently by scientists and clinicians and is hardly covered in
the medical curricula. Halitosis can lead to personal discomfort and
Clinical and Laboratory Examination
TREATMENT OF ORAL MALODOR
Mechanical Reduction of lntraoral Nutrients
and Microorganisms
Chemical Reduction of Oral Microbial
Load
Conversion of Volatile Sulfur Compounds
Masking the Malodor
SUMMARY
_J
social embarrassment and is still one of the biggest taboos in
society. Almost S1 billion a year is spent in the United States on
deodorant-type mouth (oral) rinses, mints, and related over-the-
counter products to manage bad breath.56 lt would be preferable to
spend this money on a proper diagnosis and etiologic care instead
of short-term and even inefficient masking attempts.
For more information on t he epidemiology of oral malodoj •
please visit the companion Expert CON1ULT website ot
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CLASSIFICATION
There are three main categories of halitosis: genuine halitosis,
pseudo-halitosis, and halitophobia. Genuine halitosis is the term
that is used when the breath malodor really exists and can be
diagnosed organoleptically or by measurement of the responsible
compounds. When an obvious breath malodor cannot be perceived,
but the patient is convinced that he or she suffers from it, this is
called pseudo-halitosis. If the patient still believes that there is bad
breath after treatment of genuine halitosis or diagnosis of pseudo-
halitosis, one considers halitophobia, which is a recognized psychi-
atric condition. 130
331
 ETIOLOGY L-cysteine
SH CH,
In the vast majority, breath malodor originates from the oral cavity. I I
Gingivitis, periodontitis, and especially tongue coating are the pre- fH2 cystolno dosullhydraso
CO + NH, + H2S
dominant causative factors. 20 •78·79·131·132 fH-NH2
I
COOH
COOH
Pyru\/ate
L•methlonlne
For more information on the etiology of oral malodor, CH,
please visit the companion Expert CO-.JSUl.f website at I CH,
www.expertconsult.com.
s I
I fH2
cH2 methionine y -lyase
I CO + NH, + CH3 SH
CH2 I
In general, one can identify two pathways for bad breath. The I COOH
first one involves an increase of certain metabolites in the blood fH•NH2
c,, kelobulyrate
circulation (e.g., due to a systemic disease), which will escape via COOH

the alveoli of the lungs during breathing (blood-gas exchange). The

second pathway involves an increase of either the bacterial load or Tryptophan to lndole
the amount of substrates for these bacteria at one of the lining
(Jo
OJ
CH2 -CHNH2 -COOH
surfaces of the oropharyngeal cavity, the respiratory tract, or the
esophagus. All types of infections, ulcerations, or tumors at one of ~ ----:::,..
Tryptophanase I I
• NH3
the previously mentioned areas can thus lead to bad breath. The H H + pyruvate
most commonly involved bacteria are Porphyromonas gingivalis,
Prevotella intermedialnigrescens, Aggregatibacter actinomycetemcomi- L-lysine to cadaverine
tans (previously Actinobaci{lus actinomycetemcomitans), Campylo-
bacter rectus, Fusobacterium nucleatum, Peptostreptococcus micros, ~H• Lyslno decarboxylase 1H•
Tannerella forsythia, Eubacterium spp,, and spirochetes. fH2 9H2
In a special patient category, subjects imagine they have breath [fH2l, lfH2J, +CO2

malodor; this is called imaginary breath odor or halitophobia. 75 The fH•NH2

fH2
latter has been associated with obsessive-compulsive disorders and COOH NH2
hypochondria.
Figure 29-1 Proteolytic degradation by oral microorganisms of four
amino acids (two containing sulfur and two not containing sulfur) to mal-
For more information on the etiology of oral molodor, odorous compounds.
please visit the companion Expert CONSULT website at
www.expertconsult.com. kidney failure can be characterized by a fishy odor because of the
presence of dimethylamine and trimethylamine, 83

For oral malodor, the unpleasant smell of the breath mainly
originates from VSCs, especially hydrogen sulfide (H 2S), methyl-
mercaptan (CH3SH), and less important dimethyl sulfide
[(CH3)iS] , as first discovered by Tonzetich. 117 However, in certain
conditions (e.g., when the saliva dries out on the mucosa! surfaces),
other compounds in mouth air may also play a role such as diamines
(e.g., putrescine, cadaverine), indole, skatole, and volatile organic
acids like butyric or propionic acid. 33 Most of these compounds
result from the proteolytic degradation by oral microorganisms of
peptides present in saliva (sulfur-containing or non-sulfur-contain-
ing amino acids (Figure 29-1), shed epithelium, food debris, gin-
gival crevicular fluid (GCF), interdental plaque, postnasal drip, and
blood. In particular, gram-negative, anaerobic bacteria possess such
proteolytic activity.
For the extraoral causes of halitosis, other compounds besides
the VSCs may be involved, which have not all been identified yet. 50
Bad smelling metabolites can be formed/absorbed at any place in
the body (e.g., the liver, the gut) and be transported by the blood-
stream to the lungs. Exhalation of these volatiles in the alveolar air
then causes halitosis, at least when the concentrations of the bad
smelling metabolites are sufficiently high. The crevicular fluid
reflects the circulating molecules in the blood and can thus also
play a relevant role but due to the small amount probably not a
very dominant one. The extraoral causes are much more difficult to
detect, although they can sometimes be recognized by a typical
odor. Uncontrolled diabetes mellitus can be associated with a sweet
odor of ketones, liver disease can be revealed by a sulfur odor, and
lntraoral Causes
Tongue and Tongue Coating. The dorsal tongue mucosa,
with an area of 25 cm2, shows a very irregular surface topogra-
phy.16·108 The posterior part exhibits a number of oval cryptolym-
phatic units, which roughen the surface of this area. The anterior
part is even rougher because of the high number of papillae: the
filiform papillae with a core of 0.5 mm in length, a central crater
and uplifted borders; the fungiform papillae, 0.5 to 0.8 mm in
length; the foliate papillae, located at the edge of the tongue,
separated by deep folds; and rhe vallare papillae, 1 mm in height
and 2 to 3 mm in diameter. These innumerable depressions in the
tongue surface are ideal niches for bacterial adhesion and growth,
sheltered from cleaning actions. is,m Moreover, desquamated ceUs
and food remnants also remain trapped in these retention sites and
consequently can be putrefied by the bacteria.5 A fissurated tongue
(deep fissures on dorsum, also called scrotal tongue or lingua plicata)
and a hairy tongue (lingua villosa) have an even rougher surface
(Figure 29-2).
The accumulation of food remnants intermingled with exfoli-
ated cells and bacteria causes a coating on the tongue dorsum. The
latter cannot be easily removed because of the retention offered by
the irregular surface of the tongue dorsum (see Figure 29-2). As
such, the two factors essential for putrefaction are united. Several
investigators have identified the dorsal posterior surface of the
tongue as the primary source of breath malodor.5·15·18·99 Indeed, high
correlations have been reported between tongue coating and odor
formation.5•18·63·1.1 1
 Figure 29-2 Different clinical pictures of heavily coated tongues.
Studies also suggest that oral malodor is associated with the
total bacterial load of anaerobic bacteria in both saliva and tongue
coat.ing.89
Periodontal Infections. Several studies have shown a rela-
tionship between periodontitis and oral malodor. However, not all
patients with gingivitis and/or periodontitis complain about bad
breath, and there is some disagreement in the literature as to what
extent oral malodor and periodontal disease are related.5 •98·110 Bac-
teria associated with gingivitis and periodontitis are indeed able to
produce VSCs.•
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Several studies have shown that the VSC levels in the mouth
correlate positively with the depth of periodontal pockets (the
deeper the pocket, the more bacteria, particularly anaerobic species)
and that the amount ofVSCs in breath increases with the number,
depth, and bleeding tendency of the periodontal pockets. 15•77•132
VSCs aggravate the periodontitis process by increasing the perme-
ability of the pocket and mucosal epithelium and therefore expos-
ing the underlying connective tissues of the periodontium to
bacterial metabolites. Moreover, methylmercaptan enhances inter-
stitial collagenase production, interleukin-I (IL-1) production by
mononuclear cells, and cathepsin B production, thus further medi-
ating connective tissue breakdown.54•91 It was also shown that
human gingival fibroblasts developed an affected cytoskeleton
when exposed to methyl mercaptan.8•9 1 The same gas-altered cell
proliferation and migration. VSCs are also known to impede
wound healing. Thus, when periodontal surgery is planned, espe-
cially the insertion of implants, clinicians should recognize this
pathologic role of VSCs.
Some studies, however, have shown that when the presence of
tongue coating is taken into account, the correlation between peri-
odontitis and oral malodor is much lower, indicating that tongue
coating remains a key factor for halitosis. The prevalence of tongue
coating is six times higher in patients with periodontitis, and the
same bacterial species associated with periodontal disease can also
be found in large numbers on the dorsum of the tongue, particularly
when tongue coating is present. 13 1 The reported association between
periodontitis and oral malodor may thus primarily be due to the
effects of periodontal disease on tongue coating. This theory is
•References 46, 68, 70, 78, 79, and 117.
supported by a number of studies that have not found evidence for
a strong direct association between periodontitis and risk of oral
malodor.5 •110
Other relevant malodorous pathologic manifestations of the
periodontium are pericoronitis (the soft tissue "cap" being retentive
for microorganisms and debris), major recurrent oral ulcerations,
herpetic gingivitis, and necrotizing gingivitis/periodontitis. Micro-
biologic observations indicate that ulcers infected with gram-
negative anaerobes (i.e., Prrootella and Porphyromonas species) are
significantly more malodorous than noninfected ulcers.6
Dental Pathologies. Possible causes within the dentition are
deep carious lesions with food impaction and putrefaction, extrac-
tion wounds filled with a blood clot, and purulent discharge leading
to important putrefaction. lnterdental food impaction in large
interdental areas and crowding of teeth favor food entrapment and
accumulation of debris. Acrylic dentures, especially when kept con-
tinuously in the mouth at night or not regularly cleaned, can also
produce a typical smell. The denture surface facing the gingiva is
porous and retentive for bacteria, yeasts, and debris, which are all
factors that cause putrefaction.
Dry Mouth. Saliva has an important cleaning function in the
oral cavity. Patients with xerostomia often present with large
amounts of plaque on teeth and an extensive tongue coating. The
increased microbial load and the escape of VSCs as gases when
saliva is drying up explain the strong breath malodor.46 Several
studies link stress with VSC levels, but it is not clear whether this
can simply be explained by a reduction of salivary flow.52•84 O ther
causes of xerostomia are medication,64 alcohol abuse,28 Sjiigren's
syndrome (a common autoimmune rheumatic disease), 58 and
diabetes. 127
Extraoral Causes
Ear-Nose-Throat.
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PHYSIOLOGY OF MALODOR DETECTION
The breath of a person contains up to 150 different molecules.81•120 •121
The characteristics of the expired molecules determine whether we
can smell them or not. Some gases can cause a striking odor at very
low concentrations, whereas others need to be present in much
higher quantities. The perception of the molecules depends on the
following factors34:

For more information on gas chromotography and to viewr I
Figure 29-6, please visit the companion Expert CO"'IISUI T
website at www.expertconsult.com.
Dark-Field or Phase-Contrast Microscopy. Gingivitis
and periodontitis are typically associated with a higher incidence
of motile organisms and spirochetes, so shifts in these proportions
allow monitoring of therapeutic progress. Another advantage of
direct microscopy is that the patient becomes aware of bacteria
being present in plaque, tongue coating, and saliva. Too often,
patients confuse plaque with food remnants.
Saliva Incubation Test. The analysis of the headspace above
incubated saliva by gas chromatography reveals next to VSCs also
other compounds like indole, skatole, lactic acid, methylamine, diphe-
11ylamine, cadaveri11e, putrescine, urea, ammonia, dodecanol, and
tetradecanol. By adding some proteins, such as lysine or cysteine,
the production of respectively cadaverine or hydrogen sulfide is
dramatically increased. Organoleptic evaluation (or assessment of
the VSCs) of the saliva headspace offers promising perspectives for
monitoring treatment results. 85 It is a less invasive test, especially
for the patient, than smelling breath in front of the oral cavity.
Electronic Nose. Electronic noses identify the specific com-
ponents of an odor and analyze its chemical makeup. They consist
of a mechanism for chemical detection, such as an array of elec-
tronic sensors, and a mechanism for pattern recognition. They are
smaller, less expensive, and easier to use than for example gas
chromatography but can only be developed for specific applications
if the important metabolites are already known. An artificial nose
that has the same capacities as the human nose would be ideal.
Currently, although significant improvements still need to be made,
the first trials thus far have been promising. 115
TREATMENT OF ORAL MALODOR
The treatment of oral malodor (thus of intraoral origin) should
preferably be cause related. Because oral malodor is caused by the
metabolic degradation of available proteins to malodorous gases by
certain oral microorganisms, the following general treatment strat-
egies can be applied:
• Mechanical reduction of intraoral nutrients (substrates) and
microorganisms
:;-:: S C I EN C E TR A N S F E R
The most common cause of oral malodor is bacterial metabolism
in the oral cavity. Many of the foul-smelling molecules come
from the anaerobic metabolism of proteins with subsequent
increases in volatile sulfur-containing compounds (VSC) includ-
ing hydrogen sulfide. The bacteria present in the biofilm attached
to teeth, particularly those seen in the subgingival plaque of
patients, play a major role in VSC production. Bacterial coating
of the tongue are also important contributors to oral malodor.
Much of oral malodor can be controlled by periodontal
therapy aimed at plaque removal and pocket reduction, coupled
with an effective patient centered daily oral hygiene routine that
• Chemical reduction of oral microbial load
• Rendering malodorous gases nonvolatile
• Masking the malodor
Treatment should be centered on reducing the bacterial load/
micronutrients by effective mechanical oral hygiene procedures,
including tongue scraping. Periodontal disease should be treated
and controlled, and as an auxiliary aid, oral rinses containing
chlorhexidine and other ingredients may further reduce the oral
malodor. If breath malodor persists after these approaches, other
sources of the malodor, such as the tonsils, lung disease, gastroin-
testinal disease, and metabolic abnormalities (e.g., diabetes) should
be investigated.
Issues related to oral malodor emphasize the clinician's need for
good diagnostic skills and stipulate an appreciation of chemistry.
First, the etiology of breath malodor can be from a large variety of
intraoral and extraoral causes, and much can be gained from a
careful patient history before any oral or extraoral examination.
Second, knowledge of the potential volatile substances and gases
(e.g., VSCs) and their formation, sources, power, substantivity, and
dilution capacity allows for treatment options and rational thera-
peutic interventions. Furthermore, this knowledge allows the dental
clinician to help predict the outcome of therapeutic interventions,
such as the short-term effectiveness of masking oral malodor and
the longer-term effect of mechanically and chemically reducing the
oral microbial load.
Mechanical Reduction of lntraoral Nutrients
and Microorganisms
Because of the extensive accumulation of bacteria on the dorsum
of the tongue, tongue cleaning should be emphasized. 12·105•131Previ-
ous investigations demonstrated that tongue cleaning reduces both
the amount of coating (and thus bacterial nutrients), as well as the
number of bacteria and thereby improves oral rnalodor effec-
tively.18·31·32·37·90 Other reports indicated that the reduction of the
microbial load on the tongue after cleaning is negligible and that
the malodor reduction probably results from the reduction of the
bacterial nutrients.60·89
Cleaning of the tongue can be carried out with a normal tooth-
brush, but preferably with a tongue scraper if a coating is estab-
lished. 74·76 Tongue cleaning using a tongue scraper reduced the
halitosis levels with 75% after 1 week. 76 This should be gentle
cleaning to prevent soft tissue damage. It is best to clean as far
backward as possible; the posterior portion of the tongue has the
most coating. 100 Tongue cleaning should be repeated until almost
includes toothbrushing and tongue scraping. The use of antimi-
crobal mouthwashes, such as those containing chlorhexidine, is
also an important contributor to control of oral malodor.
Although electronic devices can detect some sulfur-contain-
ing compounds and gas chromotography can give an even wider
and accurate measurement of up to 150 compounds, the use of
the clinician's nose to rate oral malodor on a scale of O to 5 is
probably all that is needed to diagnose and treat oral malodor.
Patients are generally unreliable in detecting oral malodor in their
own mouths and so clinicans and friends and family can play a
role in giving feedback on the status of bad breath.
no coating material can be removed. 13 Gagging reflexes often are
elicited, especially when using brushes89; practice helps to prevent
this. 11 It can also be helpful to pull the tongue out with a gauze
pad. Tongue deaning has the additional benefit of improving taste
sensation.89·129
Interdental cleaning and toothbrushing are essential mechanical
means ofdental plaque control. Both remove residual food particles
and organisms that cause putrefaction. Clinical studies have shown
that exclusively brushing the teeth has no appreciable influence on
the concentration ofVSCs. 114 ln a short-term study, a combination
of tooth and tongue brushing or toothbrushing alone had a benefi-
cial effect on bad breath for up to 1 hour (73% and 30% reduction
in VS Cs, respectively).118
Because periodontitis can cause chronic oral malodor, profes-
sional periodontal therapy is needed.5·15·77•132 A one-stage, full-
mouth disinfection, combining scaling and root planing with the
application of chlorhexidine, reduced the organoleptic malodor
levels up to 90%.87 In a recent study of the same authors, initial
periodontal therapy had only a weak impact on the VSC levels,
except when combined with a mouthrinse containing
chlorhexidine. 85
Chewing gum may control bad breath temporarily because it
can stimulate salivary flow. 93 The salivary flow itself also has a
mechanical cleaning capability. Not surprisingly, therefore, subjects
with extremely low salivary flow rate have higher VSC ratings and
tongue coating scores than those with normal saliva production.49
Waler 128 showed that chewing of a gum without any active ingredi-
ent can reduce halitosis modestly.
On the other hand, clinicians can use bacterial nutrients to
provoke malodor, to prove an intraoral origin of the bad breath for
example, or to test the efficacy of different oral rinses. Rinsing with
amino acids (e.g., cysteine challenge test) can result in a dramatic
increase in hydrogen sulfide47 (see Figure 29-1).
Chemical Reduction of Oral Microbial Load
Mouth rinsing has become a common practice in patients with oral
malodor. 29 The active ingredients in oral rinses are usually antimi-
crobial agents such as chlorhexidine, cetylpyridinium chloride
(CPC), essential oils, chlorine dioxide, hydrogen peroxide, and tri-
closan. All these agents have only a temporary reducing effect on
the total number of microorganisms in the oral cavity.
Chlorhexidine. Chlorhexidine is considered the most effective
antiplaque and antigingivitis agent. H.o Its antibacterial action can
be explained by disruption of the bacterial cell membrane by the
chlorhexidine molecules, increasing its permeability and resulting
in cell lysis and death. 43.53 Because of its strong antibacterial effects
and superior substantivity in the oral cavity, chlorhexidine rinsing
provides significant reduction in VSC levels and organoleptic
ratings. 9,102.103,126, 1J•
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Unfortunately, as mentioned in some trials, chlorhexidine at
concentrations ~.2% also has some disadvantages such as the
increased tooth and tongue staining, bad taste, and some temporary
reduction in taste sensation. 25
Essential Oils. Previous studies evaluated the short-term effect
(3 hours) of a Listerine rinse (which contains essential oils) com-
pared with a placebo rinse.82 Listerine was found to be only mod-
erately effective against oral malodor (±25% reduction versus 10%
for placebo of VSCs after 30 minutes) and caused a sustained
reduction in the levels of odorigenic bacteria. Similar VSC reduc-
tions were found after rinsing for 4 days. 9
Chlorine Dioxide. Chlorine dioxide (ClO2) is a powerful oxi-
dizing agent that can eliminate bad breath by oxidation of hydrogen
sulfide, methylmercaptan, and the amino acids, methionine and
cysteine. Studies demonstrated that single use of a ClOi-containing
oral rinse slightly reduces mouth odor.26.27
Two-Phase Oil-Water Rinse. Rosenberg et al 102 designed
a two-phase oil-water rinse containing CPC. The efficacy of oil-
water-CPC formulations is thought to result from the adhesion
of a high proportion of oral microorganisms to the oil droplets,
which is further enhanced by the CPC. A twice-daily rinse
with this product (before bedtime and in the morning) showed
reductions in both VSC levels and organoleptic ratings. These
reductions were superior to Listerine and significantly superior to
a placebo.51·102
Triclosan. Triclosan, a broad-spectrum antibacterial agent, has
been found to be effective against most oral bacteria and has a good
compatibility with other compounds used for oral home care. A
pilot study demonstrated that an experimental mouth rinse con-
taining 0.15% triclosan and 0.84% zinc produced a stronger and
more prolonged reduction in mouth odor than a Listerine rinse. 92
The anti-VSC effect of triclosan, however, seems strongly depen-
dent on the solubilizing agents. 133
Aminefluoride/ Stannous Fluoride. The association of
aminefluoride with stannous fluoride (AmF/SnF2) resulted in
encouraging reductions of morning breath odor, even when oral
hygiene is insufficient. 88
Hydrogen Peroxide. Suarez et al 114 reported that rinsing
with 3% hydrogen peroxide (H 2O 2) produced impressive reductions
(±90%) in sulfur gases that persisted for 8 hours.
Oxidizing Lozenges. Greenstein et al36 reported that sucking
a lozenge with oxidizing properties reduces tongue dorsum malodor
for 3 hours. This antimalodor effect may be caused by the activity
of dehydroascorbic acid, which is generated by peroxide-mediated
oxidation of ascorbate present in the lozenges.
Conversion of Volatile Sulfur Compounds
Metal Salt Solutions. Metal ions with affinity for sulfur are
efficient in capturing the sulfur-containing gases. Zinc is an ion
with two positive charges (Zn.,.), which will bind to the twice-
negatively loaded sulfur radicals, and thus can reduce the expression
of the VS Cs. The same applies for other metal ions such as mercury
and copper. Clinically, the VSC inhibitory effect was CuC12 >
SnF2 > ZnCl2. In vitro, the inhibitory effect was HgC12 = CuC'2
= CdCl2 > ZnC!i > SnF2 > SnC12 > PbC12.135
Compared with other metal ions, Zn... is relatively nontoxic and
noncumulative and gives no visible discoloration. Thus, Zn++ has
been one of the most-studied ingredients for the control of oral
malodor. 128·135 Schmidt and Tarbet107 already reported that a rinse
containing zinc chloride was remarkably more effective than a
saline rinse (or no treatment) in reducing the levels of both VSCs
(±80% reduction) and organoleptic scores (±40% reduction) for
3 hours.
 As mentioned, Halita, a rinse containing 0.05% chlorhexidine,
0.05% CPC and 0.14% zinc lactate, has been even more efficient
than a 0.2% chlorhexidine formulation in reducing the VSC levels
and organoleptic ratings. 86•126 The special effect ofHalita may result
from the VSC conversion ability of zinc, besides its antimicrobial
action. The combination Zn•• and chlorhexidine seems to act
synergistically. 134
Toothpastes. Baking soda dentifrices have been shown to
confer a significant odor-reducing benefit for time periods up to 3
hours. 7•70 The mechanisms by which baking soda produces its inhi-
bition of oral malodor might be related to its bactericidal effects
and its transformation of VSCs to a nonvolatile state.
Gerlach et al30 compared the antimalodor efficacy of three dif-
ferent toothpastes and reported a slightly better outcome, especially
for an SnF2-containing paste (±50% reduction), when compared to
water (±35% reduction). In a study by Hoshi and van Steenber-
ghe, 40 a zinc citrate/triclosan toothpaste applied to the tongue
dorsum appeared to control morning breath malodor for 4 hours.
If the flavor oil was removed, however, the antimalodor efficacy of
the active ingredients decreased. Another clinical study reported an
up to 41% reduction in VSC levels after 7 days' use of a dentifrice
containing triclosan and a copolymer, but the benefit compared
with a placebo was relatively small (17% reduction). 71 Similar
reductions were also found in two other more recent studies.41 •72
Chewing Gum. Chewing gum can be formulated with anti-
bacterial agents, such as fluoride or chlorhexidine, thus helping
reduce oral malodor through both mechanical and chemical
approaches. Tsunoda et al119 investigated the beneficial effect of
chewing gum containing tea extracts for its deodorizing mecha-
nism. J:,'pigal/ocatechin (EGCg) is the main deodorizing agent
among the tea catechins. The chemical reaction between EGCg
and CH3SH results in a nonvolatile product. Waler128 compared
different concentrations of zinc in a chewing gum and found that
a 2-mg Zn•• acetate-containing chewing gum that remained in the
mouth for 5 minutes resulted in an immediate reduction in the
VSC levels of up to 45%, but the long-term effect was not
mentioned.
Masking the Malodor
Treatments with rinses, mouth sprays, and lozenges contammg
volatiles with a pleasant odor have only a short-term effect.93•94
Typical examples are the mint-containing lozenges.
Another pathway is to increase the solubility of malodorous
compounds in the saliva by increasing the secretion of saliva; a
larger volume allows the retention of larger volumes of soluble
VSCs.48 The latter can also be achieved by ensuring a proper liquid
intake or by using a chewing gum; chewing triggers the periodontal-
parotid reflex, at least when the lower (pre)molars are still present.
SUMMARY
Breath malodor has important socioeconomic consequences and
can reveal important diseases. A proper diagnosis and determina-
tion of the etiology allow initiation of the proper etiologic treat-
ment. Although tongue coating and (less frequently) periodontitis
and gingivitis are by far the most common causes of malodor, a
clinician cannot take the risk of overlooking other, more challeng-
ing diseases. This can be done by a multidisciplinary consultation
or if this is not feasible a trial therapy to deal quickly with intraoral
causes (e.g., the full-mouth one-stage disinfection, including the
use of the proper mouthrinses, tongue scrapers, and toothpastes).
For more detailed information, the reader is encouraged to consult
van Steenberghe 124 and recent review papers.96· 106•125
References can be found on the companion
Expert ONSULT website at www.expertconsult.com.
J