HALITOSIS

Dr Debbie Macdonald
Extremely common.

Majority of adult population have had it at some
point in time! Up to on a regular basis.
[1]


Very subjective its a perception rather than a real
thing, everybodys breath smells to a certain extent.

Unpleasant condition which creates huge
embarrassment with potentially grave
consequences.

Most seek help from GP initially, not the dentist!

WHO SEEKS HELP ?

Most have been oblivious to the problem !

Studies show that people are poor judges of their own
breath odour (? adaptation/desensitisation due to
chronic exposure).
[2]


Some may have exaggerated concerns !

poor judgement, personal experiences, childhood
memories, perception of other peoples behaviours
etc leading to preoccupation with concealing
perceived malodour, social avoidance etc. Concept
of HALITOPHOBIA.

WHERE DOES IT COME FROM ?

85-90% comes from the mouth itself.
Formed by bacterial putrefaction of food debris,
cells, saliva and blood.
Proteolysis of proteins peptides aminoacids
free thiol groups & volatile sulphides.
Results from any form of sepsis : increased
anaerobic activity of pathogens (inc. Treponema
denticola, P.Gingivalis and Bacteroides forsythus).
Despite rigorous hygiene, good dentition,
posterior dorsum of tongue is often a source (?
Post nasal drip related).


MOST WANTED LIST
Compounds commonly produced by
mouth bacteria and their odours.

Hydrogen Sulphide Rotten Eggs
Methyl mecaptan Faeces
Skatole Faeces
Cadaverine Corpses
Putrescine Decaying meat
Isovaleric acid Sweaty Feet
CAUSES
Sleep.

Food (onions, garlic).

Drugs: ISDN, disulfaram.

Xerostomia: anxiety,
pyrexia, anticholinergics,
antihistamines, TCAs,
Sjgrens Syndrome.


Poor dental hygiene;
gingivitis, periodontitis,
dentures.

PN drip, sinusitis, nasal
polyps, adenoids, foreign
bodies, tonsillitis &
tonsilliths.

Naso-oropharyngeal mal.





Association with H.Pylori
Pharyngeal pouch
Gastric outlet probs
Severe Reflux

DKA
Renal dysfunction
Hepatic dysfunction

Respiratory disease


Delusional halitosis

Hallucinatory feature of
psychotic illness

Temporal Lobe Epilepsy

Trimethylaminuria

HISTORY

Clinical Challenge !

Is c/o malodour justified; is the presenting odour
originating in the mouth or elsewhere?

Think about systemic causes.

Physiological halitosis, oral pathological halitosis
or pseudo halitosis ??

EXAMINATION
Try to distinguish oral from non-oral.
Compare smell coming from mouth with that exiting the nose.

Examination of nose, post nasal space & all mucosal
surfaces of pharynx.
Examine oral cavity, dentition, look for tonsilloliths,
dentures etc.
Can take scraping from posterior dorsum of tongue.


Dangerous to assume dental, periodontal, dietary
causes. Early oral & oropharyngeal carcinomas have
few symptoms.
[4]



INVESTIGATIONS
Instrumental analysis

Level of intra oral Volatile Sulphur
Compounds can be estimated using portable
sulphide monitors. Concentration of VSCs
correlate well with level of malodour reported
by observers.
[2]

Gas Chromatography.





MANAGEMENT
Identify & eliminate obvious causes.
Cheapest/ most effective option is improvement
of oral hygiene.
Referral to dentist for full oral/dental examination
and provision of education (brushing, flossing,
mouthwash use 0.2 % chlorhexidine
gluconate).
Chlorhexidene/ hydrogen peroxide
mouthwashes reduce concentrations of VSCs
measured quantitatively & by level of malodour
reported by observer.
Clinical Evidence
No RCTs looking at effectiveness/comparisons
of:
Tongue cleaning, brushing, scraping
Sugar free chewing gum
Zinc toothpastes
Artificial saliva

Chlorhexidene-containing mouthwashes have
shown in several studies to reduce odour levels
significantly (p<0.001) for long periods following
use.
[3]

ENT referral
? Antral washout, adenoidectomy, tonsillectomy,
biopsy etc.

Gastroenterology referral
Rare despite common belief !

Psychology/psychiatric referral
? Halitophobia.

Empirical treatment with metronidazole



Dos & Donts
Visit dentist regularly.
See dental hygienist.
Denture education.
Mouthwash advise.
Chew sugar-free
gum.
Drink plenty of fluids.
Ask confidant to tell
you when you have
bad breath.
Dont let it affect your
life GET HELP !
Facilitate access to
patient education &
information
resources.



REFERENCES
[1] Tonzeitch J. Production and origin of oral malodour;
a review of methods and mechanisms analysis;
1977 ;48:13-17
[2] Rosenberg M. Bad breath; diagnosis & treatment
Dent J:1990; 3:7-11
[3] Bosy A et al. Relationship of malodour to
periodontitis: J Peridontol:1994;65:37-46
[4] Scully C. What to do about halitosis. BMJ: 1994;
308;217-218

Bad Breath Research Website
British Dental Association Fact File Website.
Clinical evidence.com









Thank you for listening !