PODJ - Imraan and Farzeen
PODJ - Imraan and Farzeen
PODJ - Imraan and Farzeen
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Halitosis
PERIODONTOLOGY
REVIEW ARTICLE
HALITOSIS
1
FARZEEN TANWIR, BDS, C orth, PhD
2
IMRAN ABDUL MOMIN, BDS
ABSTRACT
Halitosis is a broad term describing a range of unpleasant or offensive odours emitted in the
breath, due to multiple causes.2 Volatile sulphur compounds may be the main source of oral malodor.
The source may be oral or non-oral. Non-oral causes of bad breath are mostly related to systemic
conditions and/or drugs prescribed by the physicians to treat medical conditions such as diabetes,
liver disorder, kidney malfunctioning, pulmonary disease etc. Medications which reduce salivary flow
like antipsychotics, narcotics, antidepressants, decongestants, antihistamines and antihypertensives
may also be responsible.3 Oral causes of bad odor are mainly the gram-negative anaerobic bacteria,
especially those localized at posterior surface of the tongue and within the surface of tongue and in
throat.
Oral malodours were drastically reduced after treating chronic periodontitis. Diagnosis can be
confirmed by one of the 3 techniques which are; Organoleptic measurement, Gas Chromatography and
Sulphide Monitoring. The treatment plan comprises elimination of the causative agent and improve-
ment of the oral health status.
Key words: Halitosis, Periodontitis, Organoleptic score, Volatile sulphur compounds, Malodor
INTRODUCTION Classification
Bad breath usually originates in the oral cavity. Yaegaki and Coil (2000)5 classified halitosis into
It has different names; oral malodor, foetor ex ore, three categories: Genuine halitosis, Pseudo-halitosis
or halitosis. Bacterial products from deep periodontal and Halitophobia.
pockets, food stagnating in dental cavities and tongue Genuine Halitosis is an oral malodor beyond socially
coating cause bad breath. Bacterial products from acceptable levels and can be subdivided into Physiologi-
tonsils and pharynx may also be involved.1 Role of cal halitosis and Pathological halitosis and in some
anaerobic oral bacteria is important. They can flourish cases both may exist concurrently. Physiological Hali-
and survive in an atmosphere where oxygen is not tosis occurs through digestive process in the GI tract
present. They live in between the papillae (fibers) e.g intake of garlic or spicy foods, or through normal
that make up the tongue. These bacteria assist in putrefactive processes in oral cavity2,6,7 and is not asso-
digestion by breakdown of proteins found in specific ciated to systemic disease or any pathology.2 Pathologi-
food, blood, diseased oral tissue and mucous. Proteins cal Halitosis may have intra-oral and extra-oral etiol-
are amino acids; two basic types Cysteine and Methion- ogy. Intra-oral causes could be compromised periodon-
ine are rich in sulphur. In some circumstances these tal status, or pathology of mucous membranes, whereas
oral bacteria start breaking down proteins at a very extra-oral causes include respiratory tract infections
rapid rate hence more sulphur deposits and worse or systemic disorders, such as uncontrolled diabetes
aroma.3,4 mellitus, liver cirrhosis and kidney diseases.2,7
1
For Correspondence: Dr Farzeen Tanwir, Director of Postgraduate Studies and Research, Assistant
Professor & Incharge of Periodontology Department, Ziauddin University, 4/B, Shahrah-e-Ghalib, Clifton
Karachi–76500, Pakistan. Tel: (9221) 35862937-9, Fax: 35862940, Cell: 0301-2229469, Email:
[email protected], [email protected]
2
Lecturer, Department of Periodontology
Pakistan Oral & Dental Journal Vol 31, No. 2 (December 2011) 304
Halitosis
Pseudo-Halitosis is described as a condition in present in the oral cavity. Amongst these variety of
which patient believes significant malodour is pre- bacterial organisms the most associated with periodon-
sent but on examination there is no evident pungent tal and periapical inflam-mations and infections in-
odour.2 clude Prophyromonas gingivalis, Treponema denticola
and Prophyromonas endodontalis which are rarely
Halitophobia is a psychic problem characterized by
found in healthy oral cavity.10
patients assumption that he or she is having halitosis
in spite of reassurance, treatment and necessary coun- Physical and chemical conditions of the oral
seling.2,6,9 Halitophobia patients should be referred to cavity in producing malodour
psychiatrists.6
The pH, pO2 (oxygen level), and Eh (oxidation-
Etiology of Halitosis reduction potential) varies depending on bacterial
metabolism. If the sources of nutrient for bacterial
Oral conditions like acute necrotizing ulcerative
metabolism are carbohydrates, their fermentation
gingivitis (ANUG), severe periodontitis, dry socket,
ulcers and other oral diseases are most likely to cause move the oral environment to an acidic side on pH
scale, and it ultimately limits the volatile sulphur
oral malodour.10 Delanghe et al presented the scientific
compound production. Whereas if the source is simply
information regarding the origin of oral malodour.11
They examined 260 patients and reported that 87% of a protein whose metabolic end result like nitrogenous
compounds e.g, urea shift the oral environment to a
the patients had halitosis which were of oral origin, 8%
higher pH scale. Therefore the neutral or alkaline
of them had malodour which originated from ears, nose
and throat whereas in 5% of the patients etiology was nature of the oral cavity favors the volatile sulphur
compound production hence causing halitosis and typi-
unknown. Amongst the group of oral origin halitosis,
cal bad breath.10
41% of them had tongue coating, 31% were having
gingivitis and remaining 28% were periodontally com- Role of Substrates
promised patients.10, 11 Halitosis can be due to the result
of serious systemic illness. Anaerobic infections of Saliva is a composite of discharge from salivary
upper respiratory tract like tonsillitis and sinusitis, glands along with different species of bacteria, desqua-
abscess in lungs or any neoplasm can be the cause of mated epithelium, leukocytes and food debris. Saliva is
oral malodour. Systemic causes are unusual but are odorless under normal circumstances. When the pH of
very important in dealing with a patient of bad breath. saliva fluctuates it develops a pungent smell. Saliva is
Such conditions include liver failures or infections, rich in urea and proteins under normal conditions and
diabetic acidosis and trimethylaminuria.10 glucose and carbohydrates components are in very
little amounts. High protein proportion in saliva aids in
Aromatic gases expelled continuously from the
oral cavity are also the cause of halitosis. Volatile
sulphur compounds like hydrogen sulphide, methyl
mercaptan, and dimethyl sulphide are the gases which
are mostly involved in causing halitosis. Other non-
sulphur gases are also known to be involved in causing
bad breath as Volatile aromatic compounds like indole,
skatole, organic acids like acetic and propionic and
amines like cadaverin and putrescine.10, 12
The odoriferous compounds responsible for Halito- Flow Chart – 1: Production of Volatile Sulphur
sis are formed only because of suitable microorganisms Compounds (VSCs) 10
Pakistan Oral & Dental Journal Vol 31, No. 2 (December 2011) 305
Halitosis
Pakistan Oral & Dental Journal Vol 31, No. 2 (December 2011) 306
Halitosis
Pakistan Oral & Dental Journal Vol 31, No. 2 (December 2011) 307
Halitosis
3. Using a mouthwash to control halitosis. 10 Marino Sanz, Silvia Roldan, David Herrera. Fundamentals of
Breath Malodour 2001;2(4):1-13.
4. Dietary guidance to emphasize mouth cleaning 11 Delanghe G, Bollen C, van Steenberghe D, et. al. foetor ex ore.
after eating or drinking dairy products, fish, Ned. Tijdsch. Tandheelkd. 1998;105:314-17.
meat, garlic, onion, coffee, and smoking. 12 Goldberg S, Kozlovsky A, Gordon D, et al. Cadaverine as a
putative component of oral malodor. J Dent Res 1994 Jun;
5. Regular follow up visits.28 73(6):1168-72.
tically reduced after scraping of tongue was done along 15 Mel Rosenberg: 1996 Jun; http://www.tau.ac.il/~melros/bda/
with periodontal therapy provided to the patients. index.html
Tongue coating could re-build up therefore oral hy- 16 Morita M, Wang HL. Association between Oral malodor and
adult periodontitis. J Clin Periodontal. 2001 Sep;28(9):
giene instructions should be given to the patients to 813-19.
control it. Thus results indicated that tongue scraping
17 Morita M, Wang HL. Relationship between sulcular sulphide
can improve malodor extensively. The study shows level and oral malodor in subjects with periodontal disease. J
that halitosis is highly associated with bad oral hy- Periodontol. 2001 Jan;72(1):79-84.
giene, periodontitis and tongue coating. It is not easy 18 H Takeuchi, M Machigashira, D Yamashita et al. The Associa-
to assess to what extent periodontal treatment alone is tion of Periodontal disease with oral malodour in a Japanese
population. Oral Dis. 2010 Oct;16(7):702-06.
helpful in controlling halitosis. Therefore periodontal
therapy in combination with tongue scraping appears 19 Ratcliff PA, Johnson PW. The relationship between oral
malodor, gingivitis, and periodontitis. A review. J Periodontol.
fruitful in controlling oral pathogenic halitosis. 1999 May;70(5):485-89.
Pakistan Oral & Dental Journal Vol 31, No. 2 (December 2011) 308