Oral Malodor

BY – DR MONISHA KAUSHIK
2ND YR MDS
 Semantics

 Breath odor can be defined as the subjective perception after

smelling someone's breath. It can be pleasant, unpleasant, or
even disturbing, if not repulsive.
 If unpleasant, the terms breath malodor, halitosis, bad
breath, or fetor ex ore can be applied.
 These terms are not synonymous to oral malodor ( origin in
oral cavity) this not always the case for all breath malodors
 Oral malodor is thus too restrictive
 Classification

 The three main categories

of halitosis are
1. genuine halitosis
2. pseudo-halitosis
3. 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.
 Physiologic Halitosis- ex- (do not reveal a health
problem).
1. Transient disturbing odors caused by food intake
2. smoking, or medications (e.g., metronidazole)
3. “morning” bad breath, as habitually experienced
on awakening
 This malodor is caused by decreased salivary
flow and increased putrefaction during the night,
and it spontaneously disappears after breakfast
or after oral hygiene measures.
 Pathologic Halitosis- A persistent breath malodor, by
definition, does reflect some pathology
 When the origin of pathologic halitosis can be found in
the oral cavity, known as oral malodor.
 Pseudo-halitosis -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.
 Halitophobia -If the patient still believes that bad
breath is present after treatment of genuine halitosis or
diagnosis of pseudo-halitosis, one considers
halitophobia, which is a recognized psychiatric
condition.
 Epidemiology

 Only few studies have documented the prevalence of oral malodor.

 There is a large scale japanese study invovling more than 2500

subjects (18-64yr) in which M.O. Measured by Portal volatile
Sulfur Monitor at several time during a day. The VSC reached
higher level after food intake, increased with age , tongue coating
and periodontal influence. About 1 out of 4 sub exhibit VSC value
higher than 75ppb ( limit for social acceptance)

 Rosenberg M et al. indicate a higher prevalence in women than

men.
 Etiology

In most patients, breath malodor originates from

the oral cavity.
-- Tongue coating (predominant cause)
--periodontal diseases (gingivitis and periodontitis)
Quirynen M et al. a large-scale study including 2000
patients with halitosis showed that for 76% an oral
cause could be found
--Tongue coating (43%)
-- gingivitis or periodontitis (11%)
-- combination (18%)
--4% extra -oral
 Intraoral causes

Tongue coating, poor oral hygiene, gingivitis, and periodontitis

(causative factors).

 halitosis ,Result of the degradation of organic substrates by anaerobic

bacteria.
 During the process of bacterial putrefaction,
peptides and proteins (saliva, food debris, gingival crevicular fluid,
interdental plaque, shed epithelial cells, postnasal drip, and blood)

hydrolyzed

sulfide-containing and non–sulfide-containing amino acids

further metabolized.
 sulfur-containing amino acids
(cysteine, cystine and methionine)

Proteolytic degradation by gram-ve bac’

produces sulfur-containing gases such as
--hydrogen sulfide (H2S)
--methylmercaptan (CH3SH)
-- dimethyl sulfide ((CH3)2S)
non–sulfur-containing amino acids

proteolytic degradation by oral m/o

---diamines indole and skatole

--polyamines putrescine
--cadaverine
---carboxylic acids acetic
-- butyric
--propionic acid
The most commonly involved bacteria are P. gingivalis, Prevotella
intermedia, A.a., Campylobacter rectus, Fusobacterium
nucleatum, Peptostreptococcus micros, Tannerella forsythia,
Eubacterium spp., and spirochetes.

A study by Niles and Gaffar made clear that these gram-negative

species in particular cause an unpleasant smell by the production
of sulfur compounds.

breath malodor is the result of complex interactions among several

bacterial species.

Sterer N, Rosenberg M indicated that some gram-positive m/o, such as

Streptococcus salivarius, also contribute to oral malodor production by
deglycosylating salivary glycoproteins, thus exposing their protein core to
further degradation by gram-negative microorganisms
 Tongue Coating
The innumerable depressions in the tongue surface are ideal niches for
bacterial adhesion and growth, sheltered from cleaning actions.
desquamated cells and food remnants also remain trapped in these
retention sites and consequently can be putrefied by the bacteria.
Accumulated food remnants intermingled with exfoliated cells and bacteria
form a coating on the tongue dorsum. The latter cannot be easily removed
because of retention by the irregular surface of the tongue dorsum .
As such, the two factors essential for putrefaction (bacteria and their
nutrients) are united.
Coil J et al.(1992), Rosenberg M et al. (1996) identified the dorsal posterior
surface of the tongue as the primary source of oral malodor.
 Periodontal Infections

A relationship between periodontitis and oral malodor has

been shown.
periodontally healthy patients can suffer from halitosis, not
all patients with gingivitis and/or periodontitis complain
about bad breath.
 Bacteria associated with gingivitis and periodontitis are
indeed able to produce VSCs.
Several studies have shown that VSC levels in the mouth
correlate positively with the depth of periodontal pockets (the
deeper the pocket, the more bacteria, particularly anaerobic
species) .
Persson S et al., Yaegaki K et al., Coil J et al. amount of VSCs
in the breath increases with the number, depth, and bleeding
tendency of the periodontal pockets.
 VSC aggravate periodontitis
by increasing the permeability of the pocket and mucosal epithelium-- therefore
exposing the underlying connective tissues of the periodontium to bacterial
metabolites.
 Methylmercaptan enhances interstitial collagenase
production,
interleukin-1 production by
mononuclear cells, and cathepsin B production, thus further
mediating connective tissue breakdown.
 Furthermore, the reaction of hydrogen sulfide with collagen can alter
the protein structure, thereby rendering the periodontal ligament and
bone collagen more susceptible to destruction by proteases.
 Investigators have shown, in cases of gingivitis and periodontitis, a
decrease in the content of acid-soluble and total collagen in the
affected tissues.
These findings suggest that increased production of VSCs may accelerate
the progression of periodontal disease. Toxic VSCs are able to damage
the periodontal tissues and create even more loss of attachment.
 A mutual reinforcement of the loss of periodontal attachment and
production of VSCs occurs, resulting in a vicious cycle.
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
-- necrotizing gingivitis/periodontitis.
 Microbiologic observations indicate that ulcers infected with gram
negative anaerobes (i.e., Prevotella and Porphyromonas species) are
significantly more malodorous than non-infected ulcers.
 Dental disorders

Possible causes within the dentition are

1. deep carious lesions with food impaction and putrefaction,
2. extraction wounds filled with blood clots,
3. purulent discharge leading to important putrefaction.
4. interdental food impaction in large interdental areas
5. crowding of teeth favoring food entrapment and
accumulation of debris.
6. Acrylic dentures, especially when kept continuously in the
mouth at night or not regularly cleaned, can lead to
infections (e.g. candidiasis), which produce a typical smell.
7. The denture surface facing the gingiva is porous and
retentive for bacteria, yeasts, and debris, which are
compounds needed for 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 extensive tongue coating.

The increased microbial load and the escape of VSCs when salivary
flow is reduced explain the strong breath malodor.

Several studies link stress with VSC levels, but it is not clear whether
this can simply be explained by a reduction of salivary flow.
 Extraoral Causes

For a minority of patients, extraoral causes can be identified,

including
-- ENT disorders
-- systemic disease (e.g., diabetes or kidney disease),
-- metabolic or hormonal changes
--hepatic or renal insufficiency,
-- bronchial and pulmonary diseases
--Gastroenterologic disorders.
Moreover, multiple causes may be present at the same time,
and over the course of time the etiology may shift.
The extraoral causes are much more difficult to detect,
 although they can sometimes be recognized by a typical
odor.
Extraoral halitosis can be subdivided into two types:
--non–bloodborne halitosis - uncommon, and most information
about it comes from case reports. for example, throat
infections, nasal infections etc.
-- blood-borne halitosis-
result of bad-smelling metabolites that can be formed or
absorbed at any place in the body (e.g., the liver, the gut) and
transported by the bloodstream 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.
Liver -hepatocellular failure and/or portosystemic shunting of blood
may acquire a sweet, musty, or even slightly fecal aroma of the
breath, termed fetor hepaticus, which result in accumulation of
dimethyl sulfide.

Kidney -insufficiency primarily caused by chronic

glomerulonephritis, leads to an increase of the amines
dimethylamine and trimethylamine, causing a typical fishy odor of
the breath.

Systemic Metabolic Disorders- Uncontrolled diabetes mellitus results in

the accumulation of ketones, which have a sweet smell, like the odor of
rotten apples. Insulin resistance leads to an increase of triglycerides and
free fatty acids, and ketones (e.g., acetone, acetoacetate, and
hydroxybutyrate) are formed during lipolysis
 Trimethylaminuria -a hereditary metabolic disorder that
leads to a typical fishy odor of the breath, urine, sweat, and
other bodily secretions. Trimethylaminuria is an enzymatic
defect that prevents the transformation of trimethylamine to
trimethylaminoxide, resulting in abnormal amounts of this
molecule
 Hormonal Causes At certain moments during the menstrual
cycle, a typical breath odor can develop. VSC levels in the
expired air are increased twofold to fourfold around the day
of ovulation and in the perimenstrual period. Increases in
VSCs are smaller in midfollicular phases.
Ear, Nose, and Throat-During chronic or purulent
tonsillitis, the deep crypts of the tonsils accumulate debris
and bacteria, especially periopathogens, resulting in
putrefaction.
Bronchi and Lungs Pulmonary causes include chronic
bronchitis, bronchiectasis (infection of standing mucus
secretion in cystic dilations through walls of bronchioles),
pneumonia, pulmonary abscess, bronchial carcinoma, and
carcinoma of the lung
Gastrointestinal Tract- rare, t, H. pylori produce
hydrogen sulfide and methylmercaptan which result in
development of halitosis.
 Pseudo-halitosis or Halitophobia

If a patient presents with complaints but no objective halitosis can be detected,

one speaks of pseudo-halitosis or imaginary breath odor, which can lead to
halitophobia.

The latter is the case when, even after repeated diagnosis of an absence of bad
breath, the patient cannot accept the absence of halitosis. This condition has
been associated with obsessive-compulsive disorder and hypochondria.

In recent study of department with 2000 pt., 16% were diagnosed with
pseudohalitosis or even halitophobia. (Qurynen M et al. 2009)
 Fundamentals of Malodor Detection

The breath of a person contains up to 150 different molecules

The characteristics of the expired molecules determine whether
we can smell them or not.
The perception of the molecules depends on the following factors:
1. The odor itself can be pleasant, unpleasant, or even repulsive
(olfactory response).
2. Each particular molecule has a specific concentration before it
can be detected (threshold concentration).
3. odor power is the concentration that is necessary to increase
the odor score by one unit.
4. volatility of the compound: Malodorous molecules only express
themselves when they become volatile.
5. substantivity: The capacity of the molecule to stay present and
thus remain the cause of smell.
 In a study by Kleinberg and Codipilly,aqueous solutions of
oral odoriferous volatiles were placed on the skin of the
back of the hand. Afterward, odor scores were given
(organoleptic score; see earlier). All metabolites caused an
explicit odor, which decreased in intensity over time.
 Some molecules disappeared very fast (e.g., hydrogen
sulfide and methylmercaptan), whereas others produced
an unpleasant smell for a longer period of time (e.g., indole
and skatole, for 10 minutes and longer).
 Diagnosis of Malodor

MEDICAL HISTORY CLINICAL AND

-Frequency ( eg every LABORATORY
month) EXAMINATION
-Time of appearance •Self examination
during the day( after •Oropharyngeal
meal indicate stomach examination
hernia) •Organoleptic rating
-Time when the problem
•Portable volatile
first appeared sulfur monitor
•Gas chromatography
-Medication
•Dark-field or phase-
-Factors such as mouth contrast microscopy
breathing, dry mouth, •Saliva incubation
allergies & nasal
test
problem.
•Electronic nose
 Self examination

 it can be worthwhile to involve the patient in monitoring

the results of therapy by self-examination.
This can motivate the patient to continue the oral hygiene
instructions.
 The following self-testing can be used:
1. Smelling a metallic or nonodorous plastic spoon after
scraping the back of the tongue.
2. Smelling a toothpick after introducing it in an
interdentalarea.
3. Smelling saliva spit in a small cup or spoon (especially
when allowed to dry for a few seconds so that putrefaction
odor scan escape from the liquid).
4. Licking the wrist and allowing it to dry.
 OROPHARYNGEAL EXAMINATION

Inspection of deep carious lesions

 Interdental food
Impaction
 Wounds
Bleeding of the gums
 Periodontal pockets
Tongue coating
Dry mouth
Tonsils and pharynx (for tonsillitis and
pharyngitis).
 Organoleptic Rating

"Gold standard" in the examination of breath malodor.

 In an organoleptic evaluation, a trained and preferably
calibrated "judge" sniffs the expired air and assesses
whether it is unpleasant by using an intensity
rating,normally from 0 to 5.
(Rosenberg and McCulloch)
Based on the olfactory organs of the clinician
0 = no odor present,
1 = barely noticeable odor,
2 = slight but clearly noticeable odor,
3 = moderate odor,
4 = strong offensive odor,
5 = extremely foul odor
Judge smell series of different air samples:
1. Oral cavity odor: subjects opens the mouth and refrains
from breathing while the judge places his or her nose
close to the mouth opening.
2. Breath odor: subject expires through the mouth while
the judge smells both the beginning and the end of the
expiration.
3. Saliva: patient lick his/her wrist. After drying judge
gives a score.
4. Tongue coating : judge smell the tongue scraping.
5. Nasal breadth odor: subjects expires through the nose
while mouth is closed. Nasal/paranasal cause suspected.
Specific character of the odor:
1. Smell of sulfur:- intraoral origin of
halitosis.
2. Smell of sulfur:- also points to liver
diseases. sometimes combined with sweet
odor(accumulation of ketones.)
3. Smell of rotten apples:- unbalanced insulin
dependent diabetes which leads to
accumulation of ketones.
4. Fishy odor:- kidney insufficiency
 Portable Volatile Sulfur Monitor

The Halimeter -electronic device that detects the presence of VSCs such as H2S & CH3S in breath.
This can not discriminate among different sulfur compounds.

The sensitivity for CH3SH is five times lower than for H2S, and the device is almost insensitive to
dimethyl sulfide.

To allow an increase in conc’ of VSCs, the patient has to keep his or her mouth closed for 2 to 3
minutes before sampling.

The mouth air is aspirated by inserting a drinking straw fixed on the flexible tube of the instrument .
The straw is kept inside the mouth, preferably above the posterior part of the tongue dorsum, not
touching the oral mucosa or the tongue, while the subject keeps the mouth slightly open and breathes
through the nose.

The sulfur meter uses a voltametric sensor that generates a signal when exposed to sulfur-
containing gases.

Using a recorder or specific software, a graphic presentation can be obtained, called a haligram
which gives the response as a function of time
Portable Volatile Sulfur Monitor
 Gas Chromatography

A gas chromatograph can analyze air, saliva, or crevicular fluid.

it has very high sensitivity and specificity.
especially useful for identifying non-oral causes.
it is expensive and requires trained personnel.
A small, portable “gas chromatograph” (OralChroma, Nissha FIS,
Inc., Japan) has been introduced, which makes this technique
available for periodontal clinics .
More recently, the second generation of this portable gas
chromatograph was introduced: the OralChroma CHM-2.
 Just like the Halimeter, the OralChroma cannot detect compounds
other than sulfur compounds
Sample collection is done by use of a disposable syringe, which is
inserted two-thirds of the way into the oral cavity. The patient must
close the mouth for 30 seconds before sample collection, and
afterward the sample is injected into the gas chromatograph.
The OralChroma has the capacity to measure the concentration of the three
key sulfur compounds (hydrogen sulfide, methylmercaptan, and dimethyl
sulfide) separately.
helpful for a differential diagnosis.
 A high concentration of methylmercaptan compared with hydrogen sulfide
indicates, for example, periodontitis.
 If only hydrogen sulfide is increased, a problem with oral hygiene may
exist.
Dimethyl sulfide can indicate an extraoral cause.
 Dark-Field or Phase-Contrast Microscopy

Oral malodor is typically associated with a higher incidence of motile organisms

and spirochetes, so shifts in their proportions allow monitoring of therapeutic
progress.

Another advantage of direct microscopy is that the patient becomes aware of

bacteria present in plaque, tongue coating, and saliva. Too often, patients
confuse plaque with food remnants.
 Saliva Incubation Test

 0.5ml unstimulated saliva collected in a glass tube. The tube is flushed with
co2 and sealed.
  it is incubated the tube at 37 ◦C in an anaerobic chamber under an
atmosphere of 80% nitrogen, 10% carbon dioxide, and 10% hydrogen for 3–6
h.
 It is a less invasive test, especially for the patient, than smelling breath in
front of the oral cavity.
Electronic Nose
 An electronic nose identifies the specific components of an odor and analyzes
its chemical makeup.
 It consists of a mechanism for chemical detection, such as an array of
electronic sensors, and a mechanism for pattern recognition.
 It is smaller, less expensive, and easier to use
 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
 Diamond probe

 The Diamond Probe/Perio 2000 System is a periodontal probe that

combines advanced ion selective electrode technology with the
standard "Michigan O" style probe.
 intended to measure probing depths, to evaluate the presence or
absence of bleeding on probing, as well as to detect the presence of
sulfides in periodontal pockets
BANA test
 The BANA test is practical for chair-side usage.
 It is a test strip which composed of benzoyl-DL-arginine-a-
naphthylamide and detects short-chain fatty acids and
proteolytic obligate gram-negative anaerobes, which
hydrolyze the synthetic trypsin substrate and cause halitosis.
 It detects especially Treponema denticola, P. gingivalis,and
T. forsythensis that associated with periodontal disease.
 By using the BANA test, we can detect not only halitosis, but
also periodontal risk assessment.
 Treatment of Oral Malodor

The treatment of oral malodor (with an 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 m/o, the following general treatment
strategies can be applied:
-- • Mechanical reduction of intraoral nutrients
(substrates) and m/o
-- • Chemical reduction of oral microbial load
-- • Rendering malodorous gases nonvolatile
-- • Masking the malodor
T/t should be centered on reducing the bacterial load and
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 CHX 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, gastrointestinal
disease, or metabolic abnormalities (e.g., diabetes), should be
investigated.
 Mechanical Reduction of Intraoral Nutrients and M/o

TONGUE CLEANING--Cleaning of the tongue can be done with a

normal toothbrush, but preferably with a tongue scraper if a
coating is established.
Tongue cleaning using a tongue scraper reduces halitosis levels by
75% after 1 week.( Pedrazzi V et al.) 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.
Tongue cleaning should be repeated until almost no coating
material can be removed.
The gagging reflex is often present, especially when using brushes,
practice helps to prevent this. It can also be helpful to pull the
tongue out with a gauze pad.
Tongue cleaning has the additional benefit of improving taste
sensation
Interdental cleaning and tooth brushing are essential mechanical means of
dental plaque control.
Both remove residual food particles and organisms that cause putrefaction.
Clinical studies have shown that the mechanical action of tooth brushing
alone has no appreciable influence on the concentration of VSCs.
In a short term study, Tonzetich showed a short-term effect on bad breath
after brushing with a sodium monofluorophosphate toothpaste. However,
the effect was half of what was observed when combined with tongue
brushing .
When chronic oral malodor arises as a consequence of periodontitis,
professional periodontal therapy is needed.
 A one-stage full-mouth disinfection, combining scaling and root planing
with the application of CHX reduced organoleptic malodor levels up to 90%.
Quirynen M et al.(1998)
In recent study by Quirynen M et al.(2005), initial periodontal therapy
had only a weak impact on VSC levels, except when combined with a
mouth rinse containing CHX.
 Chemical Reduction of Oral Microbial Load

Together with tooth brushing, mouth rinsing has become a

common oral hygiene practice.
 Formulations have been modified to carry antimicrobial and
oxidizing agents, impacting the process of oral malodor
formation. The active ingredients usually include antimicrobial
agents such as
 chlorhexidine
cetylpyridinium chloride (CPC)
 essential oils
 chlorine dioxide
 triclosan
 amine fluoride, stannous fluoride
hydrogen peroxide
 baking soda.
 CHX- strong antibacterial effects and superior
substantivity in the oral cavity, CHX rinsing provides
significant reductions in VSC levels and organoleptic
ratings.
 Rosenberg showed that a 0.2% CHX regimen produced a
43% reduction in VSC values and >50% reduction in
organoleptic mouth odor ratings.
 De Boever and Loesche reported that 1 week of rinsing
with 0.12% chlorhexidine gluconate, in combination with
tooth and tongue brushing, significantly reduced VSC
levels, mouth odor, and tongue odor by 73%, 69%, and 78%,
respectively.
 Essential Oils Previous studies evaluated the short-term effect (3 hours) of
a Listerine rinse (which contains essential oils) compared with a placebo
rinse.
 Listerine was found to be only moderately effective against oral malodor
(±25% reduction vs. 10% for placebo of VSCs after 30 minutes) and
caused a sustained reduction in the levels of odorigenic bacteria. Similar
VSC reductions were found after rinsing for 4 days.
 Chlorine Dioxide (ClO2) is a powerful oxidizing agent that can eliminate
bad breath by oxidation of hydrogen sulfide, methylmercaptan, and the
amino acids methionine and cysteine.
 Studies demonstrated that a single use of a chlorine dioxide– containing
oral rinse slightly reduced mouth odor.
 Two-Phase Oil-Water Rinse
 Rosenberg and colleagues 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 that 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.
 Triclosan -A pilot study demonstrated that an experimental mouthrinse
containing 0.15% triclosan and 0.84% zinc (Zn++) produced a stronger and
more prolonged reduction in mouth odor than Listerine rinse. . Raven S et al.
1996
 Baking Soda Baking soda dentifrices have been shown to confer a significant
odor-reducing benefit for up to 3 hours. The mechanism by which baking soda
produces its inhibition of oral malodor is related to its bactericidal effects
 Amine Fluoride or Stannous Fluoride The association of amine fluoride
with stannous fluoride resulted in encouraging reductions of morning
breath odor, even when oral hygiene was insufficient.
 Stannous fluoride has also been shown to be effective in the management
of oral malodor as a component of a dentifrice, reducing both
organoleptic scores and VSC levels.
 Hydrogen Peroxide Suarez and colleagues reported that rinsing with 3%
hydrogen peroxide (H2O2) produced impressive reductions (±90%) in
sulfur gases that persisted for 8 hours.
 Oxidizing Lozenges Greenstein and associates reported that sucking a
lozenge with oxidizing properties reduced 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 in the lozenges.
 Conversion of Volatile Sulfur Compounds
Metal Salt Solutions

 Metal ions with an affinity for sulfur are efficient in capturing the sulfur-containing gases.
 two positive charges Zn++bind to the twice-negatively loaded sulfur radicals reduce the
expression of VSCs.
 The same applies for other metal ions such as stannous, mercury, and copper.
 Clinically, the VSC inhibitory effect was CuCl2 > SnF2 > ZnCl2
 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
 Schmidt and Tarbet 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.
 Halita,rinse containing 0.05% CHX, 0.05% CPC, and 0.14% zinc lactate, has been
even more efficient than a 0.2% CHXformulation in reducing VSC levels and organoleptic
ratings.
 special effect of Halita may result from the VSC conversion ability of Zn++, besides its
antimicrobial action. The combination of Zn++ & CHXseems to act synergistically.
 Chewing gum can be
Tsunoda et al.
formulated with investigated the
antibacterial agents, beneficial effect of
such as fluoride or
chewing gum
chlorhexidine, helping
to reduce oral malodor containing tea
through both extracts for its
mechanical and deodorizing
chemical approaches.
mechanism.

The chemical
Epigallocatech reaction between
in is the main epigallocatechin
deodorizing and
agent among methylmercaptan
the tea results in a
nonvolatile
catechins. product.
Masking the Malodor

Treatment with rinses, mouth sprays, or lozenges containing volatiles with a

pleasant odor has only a short-term effect.

Typical examples are mint-containing lozenges and the aroma of rinses

without antibacterial components.

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.

The latter can also be achieved by ensuring proper liquid intake or using
chewing gum; chewing triggers the periodontal parotid reflex, at least when
the lower (pre)molars are still present.
 Conclusion

Breath malodor has important socioeconomic consequences and can reveal

important diseases.

A proper diagnosis and determination of the etiology allow initiation of the

proper etiologic treatment.

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 challenging diseases.

This can be done with a multidisciplinary consultation or, if this is not feasible, a trial
therapy to deal quickly with intraoral causes (e.g., full-mouth one-stage disinfection,
including the use of proper mouth rinses, tongue scrapers, and toothpastes).
 References

Carranza’s clinical periodontology 11th edition

Clinical periodontology and implant dentistry Jan
lindhe 4th edition
Internet sources
Thank you