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DEFINITIONS:

Carranza (2003) - Halitosis is also termed as fetor ex ore or fetor

oris. It is a foul or offensive odor emanating from the oral cavity.

Jan Lindhe (2003) - Breath malodor means an unpleasant odor of

the expired air whatever the origin may be.

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 CLASSIFICATION
• There are three main categories of halitosis:
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.
 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 there is bad
breath after treatment of genuine halitosis or
diagnosis of pseudo-halitosis, one considers
halitophobia, which is a recognized psychiatric
condition.
 ETIOLOGY
• In the vast majority, breath malodor
originates from the oral cavity.
• The predominant causative factors are:
– Gingivitis,
– Periodontitis and
– Tongue coating
• Extra-oral causes
– 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.
• The extraoral causes are much more difficult
to detect, although they can sometimes be
recognized by a typical odor.
Disease Odor characteristics

Diabetes Acetone, fruity

Liver failure Sweetish, musty

Acute rheumatic fever Acid, sweet

Lung abscess Foul, putrefractive

Blood dyscrasias Resembling decomposed blood

Liver cirrhosis Resembling decayed blood

Uremia Ammonia or urine

Toxemia, G.I.T. disorder, neuropsychiatric Varies, poor oral hygiene intensifies the odor

Fever, dehydration, macroglobulinemia Odor due to xerostomia with poor oral hygiene and
accumulation of toxic waste products.

Sjogrens syndrome Fetid

Eosinophilic granuloma, Hand-Schuller – Fetid breath and unpleasant taste

Christian disease

Scurvy Foul breath from stomach inflammation

Wegner’s granulomatosis Necrotic, putrefactive

Kidney failure Ammonia or urine

Syphilis Fetid 12
• In general, one can identify 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.

• All types of infections, ulcerations, or tumors

at one of the previously mentioned areas can
thus lead to bad breath.
• The most commonly involved bacteria
are:
– Porphyromonas gingivalis,
– Prevotella intermedia/nigrescens,
– Aggregatibacter actinomycetemcomitans
– Campylobacter rectus,
– Fusobacterium nucleatum,
– Peptostreptococcus micros,
– Tannerella forsythia,
– Eubacterium spp,, and
– spirochetes.
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 Factors Involved In The Etiology of Halitosis:

Sulphur containing gases:

VSCs (i.e., hydrogen sulphide, methyl mercaptan, and dimethyl

sulphide) are the gases that have demonstrated a higher

correlation with halitosis.

Non-Sulphur containing gases :

Volatile aromatic compounds (indole, skatole),

Organic acids (acetic, propionic), &

Amines (cadaverine 20, putrescine).

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Halitosis can be:

Due to local factors of pathologic origin,

Due to local factors of non-pathologic origin,

Due to systemic factors of pathologic origin,

Due to systemic factors of non-pathologic origin,

Due to systemic administration of drugs,

Due to Xerostomia.

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I. Halitosis due to local factors of pathologic origin:
Food Impaction,
Excessive smoking,
Healing extraction wounds,
Necrotic tissues from ulceration,
Alcoholic drinks,
Hairy or coated tongue,
Vincent's disease,
Chronic periodontal disease,
Chronic sinusitis
Abscess,
Tonsillitis,
Pharyngitis.
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Halitosis due to local factors of nonpathologic origin:

Stagnation of saliva ( Morning breath),

Young children 2-5 yrs - exhibit malodor due to tonsil crypts lodging food

& debris.

Denture breath: Due to vulcanite resins – because of its porous nature which

encourages accumulation of food,

Endodontic patients – due to leakage of cresol & eugenol in teeth.

Old age group – due to unclean dentures & putrefecation of stagnated saliva.
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Halitosis due to systemic factors of pathologic origin:

Diabetes – due to accumulation of ketones in blood, excreted through

Resp. system.

Vonwillebrand disease, thrombocytopenia – due to decomposed blood

from spontaneous bleeding in oral cavity.

Vit.C deficiency – have typical foul breath of fusospirochetal

infections.

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Halitosis due to systemic factors of nonpathologic origin:

Vegetarian less tendency for halitosis – fewer degraded waste byproducts

of protinaceous substances.

Meat – contains fat & volatile fatty acids produced in GIT – absorbed

into blood – excreted in breath.

Garlic, onion, alcohol – absorbed into circulatory system and exhaled

through lungs.

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 Excessive alcohol intake – alteration in microbial flora & causes

proliferation of odor fermenting organisms.

Halitosis cannot originate from gastric contents except – in belching &

Vomiting since the odor & gas cannot escape when oesophagus is in

normal closed condition.

Hunger odor – due to putrefication of pancreatic juices in the stomach.

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 Drug Main therapeutic uses Mechanisms
Isosorbide dinitrate Anginal therapy Both intrinsic odor of the drug
Drugs: and end products of the drug
Ethyl alcohol Anginal therapy Odor of the breath via systemic
sedation route, objectionable odor of the
drug itself.
Medications containing Mucolytic expectorant Odor of the breath via systemic
iodine, such as iodinated route, objectionable odor of the
glycerol. drug itself.
Chloral hydrate Hypnotic, sedation Odor of the breath via systemic
route, objectionable odor of the
drug itself.
Amyl nitrate Anginal therapy Odor of the breath via systemic
route, objectionable odor of the
drug itself.
Antihistamines Allergy, Sedation

Anti neoplastic Cancer therapy

Diuretics Antihypertension

Phenothiazines and its Schizophrenia, Due to xerostomia caused by

derivatives Antiemetics and drug
Psychosedatives
Tranquilizers Sedation

Amphetamines Anorexiant, Analeptic 24

Halitosis due to Xerostomia:

Systemic drug administration

Mouth breathing

Heavy smoking

Aging

Salivary gland diseases

Radiation therapy > 800 rads

Diabetes

Emotional disturbances

Poor oral hygiene. 25

 DIAGNOSIS OF MALODOR

A saying “Listen to the patient and he will tell you the

diagnosis”. This is very true for patients with breath odor
complaints.
MEDICALHISTORY
 CLINICAL AND LABORATORY
EXAMINATION

13-12-2012 10:31 63
 SELF-EXAMINATION
• It can be worthwhile to involve the patient in
monitoring the results of therapy by self-
examination, especially when an intraoral
cause has been identified.

• This can motivate the patient to continue the

oral hygiene instructions.
• The following self-testing can be used:
MEASUREMENTS:

Self assessment.

Subjective measurement.

Organoleptic assessment.

Objective instrumental analysis:

Osmoscope.

Halimeter.

Diamond probe.

Gas chromatography.
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 SUBJECTIVE MEASUREMENT:

ORGANOLEPTIC:

This assessment made by a judge, who has been tested and calibrated

for his/her smelling acuity.

1. Oral cavity odor.

2. Breath odor.

3. Tongue coating scraping.

4. Breath odor when breathing out through the nose .

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• It is thus solely 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.
PORTABLE VOLATILE SULFUR
MONITOR
 DARK-FIELD OR PHASE-
CONTRAST MICROSCOPY
• Gingivitis and periodontitis are typically
associated with a higher incidence of motile
organisms and spirochetes, so shifts in these
proportions allow monitoring of therapeutic
progress.
• Another advantage of direct microscopy is that
the patient becomes aware of bacteria being
present in plaque, tongue coating, and saliva.
• Too often, patients confuse plaque with food
remnants.
 SALIVAINCUBATION TEST
• The analysis of the headspace above incubated saliva by gas
chromatography reveals next to VSCs also other compounds like
– indole,
– sk atole,
– lactic acid,
– methylamine,
– diphenylamine,
– cadaverine,
– putrescine,
– urea,
– ammonia,
– dodecanol,
– and tetradecanol.
 ELECTRONIC NOSE
• Electronic noses identify the specific components
of an odor and analyze its chemical makeup.
• They consist of a mechanism for chemical
detection, such as an array of electronic sensors,
and a mechanism for pattern recognition.
• They are smaller, less expensive, and easier to use
than for example gas chromatography.
MANAGEMENT:

An etiologic treatment is to be preferred.

Consists of the elimination of the pathology present, such as deepened

and inflamed periodontal pockets and/or tongue coating.

Zinc containing mouth rinses have the property to complex the

divalent sulfur radicals, reducing this important cause of malodor. Thus it

appears that the application of a Zinc chloride / Triclosan containing tooth

paste on the tongue dorsum reduces the oral malodor for some 4 hours.

Baking soda containing dentifrices (>20%) confers a significant

odor-reducing benefit up to 3 hours. 45

 Hydrogen peroxide rinse also offers positive perspectives.

To deal with tongue coating it appears that tongue brushing with CHX,

besides oral rinses with the same antiseptic, reduces the organoleptic scores

significantly.

In case of dryness, any measure to increase the salivary flow may be

beneficial. This can mean a proper fluid intake or the use of chewing gum to

trigger the parotid reflex, which originates from the mechanoreceptors in the

periodontal ligament of molar teeth and has the parotid gland as a target.

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 The pH of the saliva can also be reduced to increase the solubility of
malodorous components.
Hardly efficient are mints and other short acting “antibreath” odor
components.

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THANK YOU 48