Halitosis or oral malodor

Definition
Offensive odor originating from the oral cavity or air-filled cavities such as the nose, sinuses, and pharynx.

Epidemiology
Breath malodor considered as social problem. Poorly documented in most countries. Japanese study reported that VSCs increase with age , tongue coating & periodontal inflammation.

Volatile Sulfur Compounds

Protein metabolism by the bacteria; production of sulfur-containing gases known as volatile sulfur compounds (VSCs). Exhaling these gases causes "bad breath" The primary VSCs produced in the oral cavity are methyl mercaptan (CH3SH) and hydrogen sulfide (H2S) and dimethyl sulfide[(CH3)2S]. Other compounds in mouth air may also be offensive such as indole , skatole and butyric or propionic acid.

Intra oral causes

Dentition. Periodontal infections. Tongue and tongue coating. Dry mouth (Xerostomia).

Dentition
Deep carious lesions. Extraction wounds filled with a blood clot. Crowding of teeth. Acrylic dentures.

Periodontal infections
In deep pockets, there is increased production of VSCs

Tongue and tongue coating

The dorsal tongue shows a very irregular surface topography. Contain high number of papillae (filiform 0.5mm in length , fungiform 0.5 to 0.8mm , vallate 1mm in length). A fissured tongue and a hairy tongue have and even rougher surface.

Xerostomia
Causes:
Medications:
antihistamines, antidepressants, antipsychotics, benzodiazepines, anti-Parkinson agents, diuretics, systemic bronchodilators, beta-blockers, and anticholinergic. alcohol-containing mouth-rinses, cancer, high fever, severe dehydration

mouth breathing

Xerostomia; leads to Halitosis:

less mechanical washing. pH raise above 7.0. Reduced salivary antibacterial components.

Extra Oral Causes

Postnasal drip.

Tonsils.
Gastrointestinal Tract. Diabetes. Liver Diseases. Upper Respiratory Tract. Trimethylaminuria: It is a genetic disorder in which the body is unable to break down trimethylamine, a compound derived from the diet. it is characterized by an offensive body odor that smells like rotting fish.

Postnasal drip
Accumulation of mucus in the postnasal space caused by: hypersecretion from the paranasal sinuses or a disturbance of normal drainage The result of; allergic rhinitis, acute or chronic sinusitis anatomic obstructions; nasal polyps, enlarged adenoids in children, septal deflections, congenital abnormalities, foreign bodies

Tonsils
Causes transient odors especially with the production of small, soft, whitishyellowish secretions called tonsilloliths. Tonsilloliths migrate from the tonsil area into the oral cavity onto the dorsum of tongue. A foul odor is emanated as they break up.

Gastrointestinal Tract
Rarely Responsible for bad breath. The following pathologies might be responsible for less than 1% of malodor :diverticulum. Gastric hernia. Regurgitation esophagitis *ZD. is a pouch that forms at the back of the throat at the junction of the pharynx and the esophagus
 Zenkers

Diabetes & Liver Diseases

Diabetic ketoacidosis and hyperglycemia produce a sweet, fruity breath malodor. Liver failure is associated with a characteristic sweet amine odor that is related to the amount of expired dimethyl sulfide produced by bacterial action on sulfurcontaining amino acids.

Upper Respiratory Tract

Halitosis may be a manifestation of infection, inflammation, or malignancy of any part of the upper respiratory tract including bronchitis, pneumonia, bronchiectasis, and tuberculosis.

Trimethylaminuria
Hereditary metabolic disorder. Typical fishy odor of breath, urine, sweat, expired air, and other body secretions.

Psychosomatic halitosis
Imaginary halitosis. Needs reassurance; psychological management.

Examination for Halitosis

Organoleptic measurement. Portable Gas chromatography. Portable Sulfide monitor. Electronic Nose.

Organoleptic measurement
Sensory test; scored on the basis of the examiners perception of a subjects malodor. Sniffing the patients breath and scoring the level of oral malodor. 0= no odor. 1=barely noticeable odor. 2=slight but clearly noticeable odor. 3=moderate odor. 4=strong offensive odor. 5=extremely foul odor.

Organoleptic measurement
Patients must abstain from:
Antibiotics; 3 weeks before test Eating garlic, onion and spicy foods; 48hrs Scented cosmetics; 24hrs Ingesting any food, oral hygiene practices, oral rinse, smoking; 12hrs

Examiner refrain from:

Drinking coffee, tea or juice Smoking Using scented cosmetics before assessment

Portable Gas chromatography

Small amount of breath sample. Aspirated with a plastic syringe. Injected into the input port of the GC. The Computer displays the detection and amount of the three important VSCs (in ppb) within 8min.

 One part per billion is like one sheet in a role of toilet paper stretching from New York to London.

Portable Sulfide monitor

Electronic device analysis the concentration of H2S&CH3SH. Should be done after at least 4hrs of fasting and after keeping the mouth closed for 3min. Absence of breath malodor leads to readings of 100ppb or lower.

Electronic Nose
An artificial Nose that has the same capacities as the human Nose. Currently significant improvement still need to be made.

Treatments of Halitosis
Treat the underling cause. Mechanical Reduction of intraoral nutrients and micro organisms. Chemical Reduction of oral microbial load. Masking the malodor.