Halitosis

Etiology and Pathogenesis

Presented By,
Prathusha. U
CRI
B- Batch
Department Of Public Health Dentistry
Chettinad Dental College And Research Institute
 SYNOPSIS
• Introduction
• Classification
•Etiology
– Intra oral causes
–Extra oral causes
• Role of volatile sulphur compounds in the pathogenesis of halitosis
• Correlation between the presence of a pathogenic microflora in the
subgingival microbiota and halitosis
• Articles
• Conclusion
• References
 INTRODUCTION

• Halitosis, also termed fetor ex ore, fetor oris,

and oral malodor, is foul or offensive odor
emanating from the oral cavity. Carranza (9th
edition)
• Halitosis is derived from:
• The Latin word "Halitasia“ --bad breath
• The Greek word "Osis“ -- disease or
condition.
 CLASSIFICATION
ADA classification based on the etiological pathways involved :

• Extrinsic pathways - Tobacco, alcohol and

foods like onions, garlic and certain spices.

• Intrinsic pathways – Oral origin (90 %)

• – Systemic origin (10 %)
 Two pathways for bad breath.
• The first one involves an increase of certain
metabolites in the blood circulation (e.g., due to a
systemic disease), which will escape via the alveoli of
the lungs during breathing (blood-gas exchange).

• The second pathway involves an increase of either

the bacterial load or the amount of substrates for
these bacteria at one of the lining surfaces of the
oropharyngeal cavity, the respiratory tract, or the
esophagus.
 Oral related conditions and diseases
• TONGUE COATING
• Malodor can arise from the patients even with good oral hygiene and the
source is from the posterior dorsal tongue, as the large, papillary surface
area of the dorsum of tongue can retain large amounts of desquamated
cells, leukocytes, salivary constituents, and microorganisms and can
facilitate putrefaction.
• Though, the microbial content of the tongue is greater,it is not necessarily
different for the people with and without periodontitis.
 Pericoronitis
Adult and
aggressive Dry socket
periodontitis

Acute
Xerostomia
gingivitis

Oral
ANUG
ulceration

Food Oral Oral

impaction diseases malignancy

9
 EXTRAORAL CAUSES
• Ear-nose-throat: During chronic and purulent tonsillitis, deep
crypts of the tonsils accumulates debris and bacteria,especially
periopathogens, resulting in putrefaction.

• Gastrointestinal tract: Helicobater pylori produces hydrogen

sulfide and methylmercaptan which results in halitosis.
• Liver : hepatocellular failure
metabolizing function of the liver fails.

• Kidney: Renal insufficiency caused by chronic

glomerulonephritis which leads to increase of the amines
dimethylamine and trimethylamine, which causes a typical
fishy odor of the breadth.
• Systemic metabolic disorders- Uncontrolled diabetes
mellitus- accumulation of ketones which have a sweet smell
like the odor of rotten apples.

• Trimethylaminuria – it is hereditary metabolic disorder that

leads to typical fishy odor of breadth , urine, sweat and other
bodily secretion.

• Hormonal cause- during menstrual cycle- typical breadth odor

develops. VSC levels increases 2-4 fold around the day of
ovulation and in the perimenstrual period.
EXAMPLES OF SYSTEMIC PATHOLOGICAL
CONDITIONS WITH THEIR
CHARACTERISTIC ODOUR
Drugs associated with halitosis
Etiopathogenesis of Halitosis
 Production
and origin
of oral
malodor

•Most of these compounds result from the proteolytic degradation by

oral microorganisms of peptides present in saliva (sulfur-containing or
non–sulfur-containing amino acids) shed epithelium, food debris,
gingival crevicular fluid (GCF), interdental plaque, postnasal drip, and
blood.
•In particular, gram-negative, anaerobic bacteria possess such
proteolytic activity.
 Role of volatile sulphur compounds in the
pathogenesis of halitosis
• Major compounds implicated in halitosis
• VSC’s - Methylmercaptan, Hydrogen sulfide,
dimethyl sulfide & Dimethyl disulfide.
• Polyamides - Putrescein, Cadaverine, Skatole,
Indole.
• Short chain FA - Butyric, Propionic, Valeric &
Isovaleric acid.
• Others - Acetone, Acetaldehyde, Ethanol diacyl.
•It increases the permeability of oral mucosa and crevicular
epithelium. It impairs oxygen utilization by host cells, and
reacts with cellular proteins, and interferes with collagen
maturation.
•It also increases the collagen solubility. It
decrease the DNA synthesis.
•It increases the secretion of collagenases, prostaglandins from
fibroblasts.
•VSC reduce the intracellular pH; inhibit cell growth, and
periodontal cell migration.
 CORRELATION BETWEEN THE PRESENCE OF A
PATHOGENIC MICROFLORA IN THE
SUBGINGIVAL MICROBIOTA AND HALITOSIS:
• In 1981, Pitts et al studied the correlations between odor
scores and microbiological findings in crevicular samples of
periodontally healthy subjects.
• They found that odor scores were significantly correlated with
the concentration of overall bacterial populations and that
higher levels of crevicular bacteria were associated with
greater odor scores.
• Recent studies the presence of solobacterium moorei
associations with oral malodour
• Quirynen M, Dadamio J, Van den Velde S, et al. Characteristics of
2000 patients who visited a halitosis clinic. J Clin Periodontol.
2009;36(11):970‐975. doi:10.1111/j.1600-051X.2009.01478.x

• A recent large-scale study including 2000 patients with halitosis complaints

showed that for those where bad breath could be objectively detected, the
cause of it was mostly found within the oral cavity (90%).
• Tongue coating (43%,) gingivitis/periodontitis (11%), or a combination (18%)
accounted for the majority of the cases. Because a large part of the
population has a tongue coating or gingivitis/periodontitis, there is a risk that
an intraoral condition is too easily considered as the cause while more
important pathologies are overlooked.
• Indeed, for a minority of patients (4% in the same recent study), extraoral
causes could be identified, including ear-nose-throat (ENT) pathologies,
systemic diseases (e.g., diabetes), metabolic or hormonal changes, hepatic or
renal insufficiency, bronchial and pulmonary diseases, or gastroenterologic
pathologies.
Stephenson BM, Rees BI.Extrinsic duodenal
obstruction and halitosis.Postgraduate Medical
Journal 1990;66:568-570.
• Summary: Two siblings with extrinsic duodenal
obstruction caused by congenital peritoneal
bands are reported. Attention is drawn to the
unusual physical sign of halitosis as a presenting
feature. It is suggested that this physical sign
may be an indication for barium studies.
 Bathgate, Gabriella et al. “An unusual cause for halitosis.” BMJ
case reports vol. 2016 10.1136/bcr-2015-213271. 19 Apr. 2016,
doi:10.1136/bcr-2015-213271
• The case of a patient presenting with severe persistent halitosis
attributable to mesh erosion occurring 8 years after redo laparoscopic
hiatus hernia repair is described. Full external healing of the erosion tract
was observed such that no symptomatic oesophageal perforation
resulted. Mesh erosion is typically managed with surgical intervention. In
this case, the infected mesh was successfully removed endoscopically.
 Conclusion
• The patients with halitosis initially approach
the dentists for the betterment of the
condition and here the responsibility lies on
the dentists to treat the condition. Thus, a
thorough understanding of the etiology and
pathophysiology can upgrade us to a better
treatment option.
 References
• Aylıkcı BU, Colak H. Halitosis: From diagnosis to management. J Nat Sci Biol Med.
2013;4(1):14‐23. doi:10.4103/0976-9668.107255
• Quirynen M, Dadamio J, Van den Velde S, et al. Characteristics of 2000 patients who
visited a halitosis clinic. J Clin Periodontol. 2009;36(11):970‐975. doi:10.1111/j.1600-
051X.2009.01478.x
• M. TORSTEN, G. GÓMEZ-MORENO, A. AGUILAR-SALVATIERRA.Drug-related oral malodour
(halitosis):a literature review.European Review for Medical and Pharmacological Sciences
2017; 21: 4930-4934
• Schmidt, Jana & Krause, Felix & Haak, Rainer. (2015). Halitosis: Measurement in daily
practice. Quintessence international (Berlin, Germany : 1985). 46. 633-41.
10.3290/j.qi.a34134.
• Ajay Benerji Kotti, R. V. Subramanyam. Oral malodor: A review of etiology and
pathogenesis. Journal of Dr. NTR University of Health Sciences 2015;4(1)
• Mokeem SA. Halitosis: A Review of the Etiologic Factors and Association with Systemic
Conditions and its Management. J Contemp Dent Pract 2014;15(6):806-811.
• Carranza’s Clinical Periodontology