Journal of Dentistry and Oral Sciences
Journal of Dentistry and Oral Sciences
Journal of Dentistry and Oral Sciences
ISSN: 2582-3736
Conceicao M, et al., 2020-J Dent Oral Sci
Review Article
Degree Description
0 - Absence of odor No odor is perceived by the examiner at a distance of up to 15 centimeters.
(No Halitosis)
1 - Natural Breath It is clear that there is an odor in the breath, but it is not considered to be
(No Halitosis) halitosis, perceived at a distance of up to 15 centimeters.
2 - Slight Halitosis A slight halitosis odor is detected if the examiner approaches the mouth of
(or intimate the patient slowly exhales the air through the nose, perceived at a distance of
halitosis) up to 15 centimeters.
3 - Moderate A halitosis odor is detected if the examiner approaches the mouth of the
halitosis (or patient or when the patient exhales the air through the nose, perceived at a
interlocutor's distance of 30 centimeters.
halitosis
4 - Strong halitosis There is a halitosis odor if the examiner approaches the patient, perceived at
(or social halitosis) a distance of 1 meter.
5 - Severe halitosis Aside from halitosis being easily perceived throughout the environment, it is
also difficult for the examiner or people close by to tolerate the odor.
Note: degrees 0.5, 1.5, 2.5, 3.5, or 4.5 are accepted and considered intermediate to the levels
above.
The technique to Determine the Origin At a 15-centimeter distance, the examiner
of Halitosis should sniff the odor and provide its
corresponding degree, according to Halitus
The oral organoleptic test is presented in oral and nasal organoleptic scale. If no bad
Figure 1. The patient must stay for two odor is noticed, the examiner can move
minutes with the mouth closed and then closer, to a 10 to the 5-centimeter distance
stop breathing through the mouth or nose
to check if there is breath alteration.
for at least 15 seconds and open it widely.
Figure 1: How to perform an oral organoleptic test.
Although these tests intend to be safer For a safer test, patients must be taught
than the existing ones, as their droplet how to perform the tests. In this sense,
emissions have not yet been tested there is patients must be trained by the dental
still a potential cross-infection risk that professional before the tests, to hold their
must be evaluated. Hence, all organoleptic breath for 15 seconds, and also to exhale
tests should be suspended until the the air through their nose at a very slow
COVID-19 pandemic situation has speed. A flame of a candle or lighter can be
normalized and the risk of the different used as a parameter for it, as shown in
organoleptic methods is assessed. Figure 3, that should not be disturbed
while performing the tests, to offer the
Safety Guidelines to Perform the minimum risk of spreading virus or
Organoleptic Oral and Nasal Tests bacteria.
Conceicao M | Volume 2; Issue 4 (2020) | Mapsci-JDOS-2(4)-049 | Review Article
Citation: Conceicao M, Marocchio L, Giudice F. Diagnostic Technique for Assessing Halitosis Origin Using Oral and Nasal
Organoleptic Tests, Including Safety Measures Post Covid-19. J Dent Oral Sci. 2020;2(4):1-19.
DOI: https://doi.org/10.37191/Mapsci-2582-3736-2(4)-049
Figure 3: How to open the mouth widely while holding the breath and slowly exhale the air through the
nose, without disturbing the flame of a candle or lighter, to offer the minimum risk of spreading virus or
bacteria.
If correctly performed, the oral the examiner's nose, so that he/she can
organoleptic test will yield no exhalation of smell the odor of the breath and give the
air, theoretically offering no risk of score, according to Halitus oral and nasal
spreading droplets and the nasal organoleptic scale. If no bad odor is
organoleptic test exhaling air through the noticed, the examiner can move closer, to a
nose, with very slow speed, will also have a 10 to the 5-centimeter distance to check if
virtually zero droplet emission, according there is breath alteration. And, if a halitosis
to Asadi et al. [30,34]. odor is already noticed, the examiner can
Another option for doing the oral move away up to a distance of 30
organoleptic test, that can be performed by centimeters while the patient is blowing, to
patients with their family confidants, is to check if halitosis degree is 2 or 3. According
ask the patient to stay for two minutes with to Figure 4, it is also important to train the
the mouth closed, at a distance of 15 expiration speed of the oral organoleptic
centimeters, and then blow a jet of air test, using a flame as a parameter, without
through the mouth, very slowly, towards disturbing the flame.
Figure 7: Oral halitosis most common causes in their respective niches, where bacterial plaques sources
of VSC are formed, and also an important indirect halitosis cause, postnasal drip, that can accumulate
on vallecula.
Figure 9: Extraoral halitosis – first exception; corresponds to extraoral non-bloodborne halitosis (except
nasal causes); derives from problems originating in the digestive system (oropharynx, hypopharynx,
esophagus and stomach). Although the altered breath is eliminated by exhaled air through the mouth
as well as through nose, with the same odor, there are no odoriferous particles from blood circulation
eliminated by pulmonary via [15].
Figure 10: Extraoral halitosis – second exception; corresponds to extraoral non-bloodborne halitosis
(except nasal causes); derives from problems originating from low respiratory tract diseases. Although
the altered breath is eliminated by exhaled air through mouth as well as through nose, with the same
odor, there are no odoriferous particles from blood circulation eliminated by the respiratory tract [15].
Figure 11: Nasal halitosis – corresponds to extraoral non-bloodborne halitosis with causes in the
nasopharynx, nasal cavity, sinuses and surrounding areas. Nasal halitosis manifests only by exhaled air
through the nose.
Finally, if the test is positive to the exhaled extraoral halitosis occurring simulta-
air through mouth and nose, with two neously, which is rare when compared to
different odors, two concomitant causes oral and extraoral halitosis alone; it has
might be happening. been verified to account for only
approximately 3% of Halitus Clinic patients
Oral and Extraoral Halitosis Occurring [15] (Figure 12). With this kind of halitosis,
Simultaneously the odor of the exhaled air through the
The fifth possibility of results in oral and mouth is stronger than that exhaled
nasal organoleptic tests is the oral and through the nose.
Oral and Nasal Halitosis Occurring In case the oral exhaled air is stronger, this
Simultaneously could suggest oral and systemic halitosis
occurring simultaneously; the differential
The sixth possibility of results in oral and diagnosis is only possible after controlling
nasal organoleptic tests is oral and nasal the oral component of halitosis. If a light
halitosis occurring simultaneously (Figure
oral odor remains and is very similar to the
13). It is very rare and it was verified with
nasal expired air, this rather indicates that
only one case among more than 4,000
oral and systemic halitosis are happening
Halitus Clinic patients (less than 0.025%) simultaneously. However, if only a nasal
[15]. With this kind of halitosis, either the odor remains, that means an oral and nasal
air exhaled through the mouth or the nose malodor is occurring concomitantly.
may be responsible for the strongest odor.
Figure 13: Oral and nasal halitosis occurring simultaneously. In this case, either the exhaled air through
the mouth or nose may be stronger. The differential diagnosis is only possible after controlling oral
halitosis. If a light oral odor remains, equal to nasal odor, it indicates oral and systemic halitosis
happening simultaneously. However, if only a nasal odor remains, it points to oral and nasal halitosis
occurring concomitantly.
Figure 14: Safety of other organoleptic tests prescribed by Conceição MD (2013) when verified with a
flame, offering a bigger risk of spreading droplets.
Xu et al. [40] highlight that the positive saliva. According to van Doremalen et al.
rate of COVID-19 in patients’ saliva can [41] SARS-CoV-2 transmission by aerosols
reach 91.7%, and that saliva samples can is plausible as it can remain suspended in
also cultivate the virus, suggesting that the air throughout at least 3 hours. In that
COVID-19 transmitted by an asymptomatic way, challenges for Dentistry now emerge
infection may originate from infected with COVID-19 and future
Conceicao M | Volume 2; Issue 4 (2020) | Mapsci-JDOS-2(4)-049 | Review Article
Citation: Conceicao M, Marocchio L, Giudice F. Diagnostic Technique for Assessing Halitosis Origin Using Oral and Nasal
Organoleptic Tests, Including Safety Measures Post Covid-19. J Dent Oral Sci. 2020;2(4):1-19.
DOI: https://doi.org/10.37191/Mapsci-2582-3736-2(4)-049
recommendations and safety protocols exhaling air through the nose at a very slow
need to consider the reduction of droplets speed, as recommended in the nasal
and aerosols production, such as by using organoleptic test, could theoretically offer
high-volume saliva ejectors, as well as by a lower risk of airborne disease
avoiding aerosol-generating procedures transmission.
(use of a 3-way syringe, for instance) or Even though a safer way of doing
even by averting procedures that might organoleptic tests is proposed in the
trigger coughing, such as intraoral x-ray present technique, organoleptic tests
examination [42]. should be temporarily suspended until the
Asadi et al. [30] indicated that speech is COVID-19 pandemic situation has
potential of much greater concern than normalized and for as long as the current
breathing for two reasons: released risks of contamination are not well
particles are larger on average and thus understood and health authorities
could potentially carry a larger number of maintain the ongoing restrictions.
pathogens; and much greater quantities of Moreover, it is very important to avoid
particles are emitted when compared to doing the organoleptic tests with people
breathing. They also showed that the rate that belong to risk groups, especially
of particle emission during normal human during flu seasons or epidemics, and also
speech is positively correlated with when patients have flu-like symptoms.
loudness (amplitude) of vocalization, as it These guidelines aim to diminish the risk
happens with classic oral organoleptic of spreading diseases, but also to offer a
measurement, which recommends safe method for patients to recover self-
counting out loud from zero to ten [21]. confidence in their treated breath, through
Morawska et al. [31] reported that counting successively positive results when
aloud for 10 seconds followed by 10 seconds performing oral and nasal organoleptic
of breathing, repeated over two minutes, tests with a confidant. This method uses a
releases half as many particles as 30 technique derived from behaviorist
seconds of continual coughing. But, psychology, adapted to halitosis treatment,
concerning the importance of counting called exposure in vivo [13]. The results of
from 1 to 10 whispering in oral organoleptic research with a clinical protocol to help
test Morawska et al. reported that more patients to recover their self-confidence,
particles are released when speech is spontaneity and self-esteem will be the aim
voiced, which involves vocal folds of a future publication.
vibration, rather than whispered, which Future halitosis studies using organoleptic
does not [30]. Morawska et al. also tests should use the present technique to
reported that the average particle number deduce the possible causes with higher
concentration for continuous vocalization precision, in addition to the
is higher than breathing (1.1 cm-3 for recommendation for the patients to stop
speaking and 0.1 cm-3 for breathing), a cleaning their tongues for 24 h before an
finding they interpreted to be an additional initial breath assessment [19], so that many
contribution of laryngeal particle of these patients will receive a true genuine
generation that does not occur during halitosis diagnosis, instead of pseudo-
normal breathing [31]. In this sense, halitosis. These procedures could guide
considering this information all together, future halitosis research to lead to more
Conceicao M | Volume 2; Issue 4 (2020) | Mapsci-JDOS-2(4)-049 | Review Article
Citation: Conceicao M, Marocchio L, Giudice F. Diagnostic Technique for Assessing Halitosis Origin Using Oral and Nasal
Organoleptic Tests, Including Safety Measures Post Covid-19. J Dent Oral Sci. 2020;2(4):1-19.
DOI: https://doi.org/10.37191/Mapsci-2582-3736-2(4)-049
accurate results regarding these two droplets and airborne transmission while
aspects. performing the tests.
The present technique fills a gap in the The authors declare that there is no
literature and offers a possibility to make a conflict of interest.
precise diagnosis of the origin of halitosis –
oral, extraoral or nasal – making it possible Permission to Reproduce Published
to avoid diagnostic errors and unnecessary Material
treatments. It also can help patients to
I hereby assign, consent the use of all
check their breath at home and to take
figures and tables in the present paper, as
some actions to solve or identify the
they were reproduced, adapted, and redraw
problem in case an alteration is detected,
from my book "Conceição MD. Box hálito e
as well as reinforces patients` self-
segurança! Metas essenciais no tratamento
confidence when receiving pleasant breath
da halitose [Good Breath and Self-
results after consecutive tests. Further
Confidence! Essential Goals in Halitosis
studies should evaluate the safety of
Treatment]. 1 ed: Arte em Livros: Campinas
different organoleptic test methods and
[Art in Books: Campinas]; 2013; Portuguese
refine the safety guidelines to prevent the
edition.”
spreading of diseases through saliva
References