Halitosis

DR.ANAS ELHARATHI
BDS,MSC,FICOI
 Introduction
• Halitosis is a general term used to define an unpleasant or
offensive odour emanating from the breath regardless of
whether the odour originates from oral or non-oral sources.

• Originates from two Latin words

Halitus → breath –
Osis → disease –
 Definitions
• Breath malodor, defined as foul or offensive odor of expired air,
may be caused by a number of factors, both intra-oral & extra-oral
(gingivitis/ periodontitis, nasal inflammation, chronic sinusitis,
diabetes mellitus, liver insufficiency etc.,) & can be linked to
more serious underlying medical problems including primary
biliary cirrhosis, uremia, lung carcinoma, decompensated liver
cirrhosis & trimethylaminuria.
– Quirynen, Zhao, Avontroodt et al., 2003
 Epidemiology
• for thousands of years.Bad breath has been a common problem
• It is a considerable social problem.

- Its incidence remains poorly documented in most countries.

- In vast majority- The cause is originated from the oral cavity

i.e. gingivitis, periodontitis, and tongue coating.

• Japan study 2,672 Individuals 6-23% of subjects had oral
malodour (VSC) as in expired air at some period during
the day (Miyazaki 1996).

• Another study in the United States involving individuals

older than 60 years found 24% had oral malodour
(Rosenberg 1996).
 Role of volatile sulphur compounds in the pathogenesis of halitosis

Proteins are made up of Amino Acids.Two of

Amino Acids in the mouth (Cysteine &
methionine) are dense with sulphur.
When bacteria break down these compounds, the
odorous and “lousy-tasting ” Volatile sulphur
compounds (VSCs) are released ,Hydrogen
sulphide, Dimethyl sulphide & methyl with other
bad tasting compounds
Pathogenesis of oral
malodor:

Diet, bacteria, epithelial

cells

Peptides/prot
eins
Amino acids

Putrefaction products

Oral malodor
Etiopathology
 Classification
Genuine halitosis •

Physiologic halitosis •

Pathologic halitosis •

Pseudo halitosis •

Halitophobia. •
 Classification
▶ Based on etiology
1) local factors of pathologic origin, eg. Poor oral hygiene,
extensive caries,
periodontal diseases, cysts and tumours of oral n pharyngeal
cavities.
2)Local factors of non pathologic origin, eg stagnation of
saliva associated with food debris, dentures and excessive
smoking.
3)Systemic factors of pathologic origin.eg diabetes
mellitus, liver failure, lung abscess, tuberculosis.
4)Systemic factors of non-pathologic origin , eg diet like
garlic, onion, meat and meat products, excessive alcohol
consumption.
5) Xerostomia
 ▶ Based on patients criteria
1) Genuine halitosis
2) Pseudohalitosis
3) Halitophobia
Geniune halitosis
Term used when the breath malodor really exits
and can be diagnosed organoleptically or by
measurement of the responsible compounds.
Pseudohalitosis
When an obvious breath mal odor cannot be perceived, but the
patient is convinced
that he or she suffers from it, this is called pseudohalitosis.
Halitophobia
If the patient still believes that there is bad breath after
treatment of genuine halitosis a diagnosis of
pseudohalitosis, one considers halitophobia
 Etiology
Common causes of halitosis
1) Local Causes
A.Oral disease
• Food impaction • Pericoronitis
• Acute necrotising • Dry socket
ulcerative gingivitis • Xerostomia
• Acute gingivitis • Oral ulceration
• Adult and aggressive • Oral malignancy
periodontitis
 Etiology (Contd.)
B. Respiratory diseaseC. Volatile foodstuffs
• Garlic •Sinusitis

• Onions •Tonsillitis

• Spiced foods • Malignancy

• Bronchiectasis
 Etiology (Contd.)
2) SYSTEMIC CAUSES
• Acute febrile illness Pyloric stenosis or duodenal •
obstruction
• Leukaemias
• Hepatic failure (fetor hepaticus)
• Respiratory tract infection
(usually upper) • Renal failure (end stage)

• Helicobacter pylori infection • Diabetic ketoacidosis

• Pharyngo-oesophageal • Trimethylaminuria
diverticulum • Hypermethioninaemia
• Gastro-oesophageal reflux disease • Menstruation (menstrual breath)
 Diagnosis
Self assessment tests
Whole mouth malodor (Cupped breath)
The subjects are instructed to smell the odor emanating
from their entire mouth by cupping their hands over their
mouth and breathing through the nose. The presence or
absence of malodor can be evaluated by the patient
himself/herself.
 Wrist lick test
Subjects are asked to extend their tongue and lick their
wrist in a perpendicular fashion. The presence of odor is
judged by smelling the wrist after 5 seconds at a distance
of about 3 cm.
 Spoon test
Plastic spoon is used to scrape and scoop material from the
back region of the tongue. The odor is judged by smelling
the spoon after 5 seconds at a distance of about 5 cm
organoleptically.
Dental floss test
Unwaxed floss is passed through interproximal contacts.
 Saliva odor test
Involves having the subject expectorate approx. 1-2 ml of
saliva into a petridish. The dish is covered immediately,
incubated at 370 C for five minutes and then presented for
odor evaluation at a distance of 4 cm from the examiner’s
nose.
VOLATILE SULFIDE MONITOR:

• This electronic (Haiimeter, InterScan, Chatsworth, Calif)

analyzes concentration of hydrogen sulfide and methyl-
mercaptan , but without discriminating between them.
MANAGEMENT:

Mechanical reduction of intraoral nutrients and micro- (i)

organisms

Chemical reduction of oral microbial load(ii)

Rendering malodorous gases nonvolatile (iii)
Masking the malodor. (iv)
1. Mechanical reduction of intraoral nutrients and micro-organisms
Tongue cleaning -
Tooth brush -
Inter-dental cleaning -
Professional periodontal therapy -
Chewing gum -
2. Chemical reduction of oral microbial load
- Chlorhexidine
- Essential oils
- Chlorine dioxide
- Two-phase oil- water rinse
- Triclosan
- Aminefluoride/ Stannous fluoride
- Hydrogen peroxide
- Oxidising lozenges
-Roldan S 2005,2004,2003 scully 2006
3.Conversion of volatile sulfide compounds
Metal salt solutions -
Toothpastes -
Chewing gum -
4. Masking the malodor
-Rinses
-Mouth sprays
-Lozenges containing volatiles
-Chewing gum