Halitosis - PowerPoint Presentation

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Halitosis

BY:Amir A. KargoshaieAssistant professor of otorhinolaryngologyIsfahan university of medical sciences

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Oral Malodor 4 Classes…. 3 Sub-types

Above Carina (URTI’s)- OZOSTOMIABelow Carina (LRTI’s)- STOMATODYSODIAHALITOSIS:

i) Physiological ii) Pathological iii) Psychological

FETOR EX ORE/ FETOR ORIS:

Oral Hygiene, Perio, and Decay

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Breath odor the subjective perception after smelling someone’s breath

pleasant, unpleasant, or even disturbing, if not repulsive. If unpleasant, the terms breath malodor, halitosis, bad breath, or fetor ex ore can be applied. not synonymous with oral malodor. This term is restricted to halitosis with an origin in the oral cavity.

three main categories of halitosis: genuine halitosis pseudo-halitosis

halitophobia

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Genuine halitosis when the breath malodor really exists and can be diagnosed

organoleptically or by measurement of the responsible compounds. physiologic halitosis The transient disturbing odor caused by food intake (e.g., garlic, onions, and certain spices), smoking, or medication (e.g., metronidazole

) do not reveal a health problem and are common examples of physiologic halitosis.The same is true for “morning” bad breath, as habitually experienced on awakening. This malodor is caused by a decreased salivary flow and increased putrefaction during the night and spontaneously disappears after breakfast or after oral hygiene measures.

pathologic halitosis .

A persistent breath malodor, reflect s some pathology

The causes of this will be discussed later

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. When an obvious breath malodor cannot be perceived, but the patient is convinced that he or she suffers from it,

halitophobia, If the patient still believes that there is bad breath after treatment of genuine halitosis or diagnosis of pseudo-halitosis,

is a recognized psychiatric condition.

pseudo-halitosis

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OZOSTOMIA… above carina

Obstruction, Nasal- discharge, Tonsillitis, Tonsoliths, Laryngitis, Dysphagia, Voice problemsPrevious ENT pathology

Sinusitis, Rhinitis, Pharyngitis, Foreign BodiesStagnation and InfectionMalignancies

 [G. ozo, to smell, + stoma, mouth] 

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STOMATODYSODIA…below carina

Tobacco SmokersBronchitisBronchiectasisLung AbscessPleuritisPneumoniaBlood

Foreign BodyNeoplasia, Mucous Stagnation/Infection

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HALITOSIS physiological

Poor hydrationMenstruationDiet ConstipationStarvation, Morning breath

Habits (Mouth breathing, thumb sucking)

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HALITOSIS pathological

Lungs release blood-borne catabolic productsStomach--Gastritis, Liver hepatitis, Kidney nephritisPancreas--Diabetes mellitus (Ketosis)Anorexia/Bulimia nervosaIgA deficiencyXerostomia (Sjogrens, Radiation therapy, Stress)

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HALITOSIS psychological

“Halitophobia” not very accurate termDelusional cacosmiaPsychogenic dysosmiaSymptomatic schizophreniaTemporal lobe epilepsy (Aura)Cerebral tumors

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Fetor ex Ore/ Fetor Oris

From Mouth: Gums &TeethGingivitis/PeriodontitisPercoronitis/Peri-implantitisDorsum of tongueInterdental areas

ANUG/NUGPost-extraction, Dry socketPlaque & Calculus Oral Hygiene, Stagnation areas

Caries: Tooth decay

Brushing and Flossing

Reduced salivary flow

Faulty fillings, Overhangs

Dental materialsCements: Eugenol, Cajeput, Creosote, Kri3

Fixed bridgework, Pontics

Appliances– Orthodontic, Prosthodontic

Denture hygiene

Oral medicine conditions

Ulcerations, Abrasions, Wounds

Neoplasias

Hemorrhagic diatheses

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Epidemiology

Breath malodor is a common complaint among the general population.(as high as 50% in some articles)

It has a significant socioeconomic impact but unfortunately has been neglected until recently by scientists and clinicians

hardly

covered in the medical

curricula

Halitosis can lead to personal discomfort and social embarrassment, and is still one of the biggest taboos of society.

Almost

$1 billion a year is

spent

in the United States on deodorant-type mouth (oral) rinses, mints, and related over-the-counter products to manage bad breath.

It would be preferable to spend this money on a proper diagnosis and etiologic care instead of short-term and even inefficient masking attempts.

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EtiologyIn the vast majority, breath malodor originates from the oral cavity. Gingivitis, periodontitis

, and especially tongue coating are the predominant causative factors.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-breath exchange) and it is commonly referred as “

extraoral

halitosis

.” The second pathway

(intraoral halitosis

) involves an increase of either the bacterial load or the amount of substrate 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. Studies also suggest that oral malodor is associated with the total bacterial load of anaerobic bacteria in both saliva and tongue coating.

The most commonly involved bacteria are

Porphyromonas

gingivalis

,

Prevotella

intermedia

/

nigrescens

,

Aggregatibacter

actinomycetemcomitans

(previously

Actinobacillus

actinomycetemcomitans

), Campylobacter rectus,

Fusobacterium

nucleatum

,

Peptostreptococcus

micros,

Tannerella

forsythia,

Eubacterium

spp

, and spirochetes

.

A study conducted by Niles and

Gaffar

made clear that these gram-negative species in particular cause an unpleasant smell by the production

of sulfur compounds

.

However

, because of the large species diversity found in patients with halitosis, it can be suggested that breath malodor is the result of complex interactions between several bacterial species. A recent study indicates that some gram-positive microorganisms, 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

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There are few studies that document the prevalence of oral malodor. Moreover, the studies that exist used different methodologies ranging from self-reported breath malodor to more objective assessments such as the measurement of the volatile sulfur compounds (VSCs). Because self-reported halitosis correlates weakly with objective measurements and tends to overestimate the problem, data should be interpreted carefully.

The incidence of halitosis remains poorly documented in most countries. Large-scale studies have been performed for the Japanese,Swedish,and

Chinese

populations

.

Smaller investigations in

Brazilian,Polish,and

Israeli

habitants have also been reported.

Despite

the different approach of each study, if a

VSC level of 75 ppb

(limit for social acceptance

)

is used as a threshold for halitosis, the prevalence reported in the different populations can be calculated as 23% (late-morning group) and 20% for the Japanese and Chinese studies, respectively. In line with this,

prevalences

of 27.5% and 29.8% for the Chinese and the Israeli groups, respectively, can be calculated when

an

organoleptic

score of at least 2

is considered as being representative for halitosis. With the same criterion, the calculated prevalence varied between 11.0% and 29.7% for the different age groups in the Polish population. In conclusion, independent of the method used to assess oral malodor and independent of the study population, the results point out that about

one in four

subjects suffer from persistent bad breath.

From

large-scale inventories in multidisciplinary outpatient clinics for breath odor,

no gender

predominance seems to exist for bad breath, although other studies indicate a higher prevalence in

women

.

It

has also been observed that women seek treatment more often than men.

Age

can range from 5 years to more than 80 years.

No association

was found between increased age and oral malodor.

Most

of the patients had been complaining about breath malodor for several years before seeking proper advice (recent report of the department involving 2000 patients

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A recent large-scale study including 2000 patients with halitosis complaints showed that for those where bad breath could be objectively detected, the cause of it was mostly found within the oral cavity (90%)

.

Tongue

coating (51%), gingivitis/

periodontitis

(13%), or a combination (22%) accounted for the majority of the cases.

Because a large part of the population has a tongue coating or gingivitis/

periodontitis

, there is a risk that an intraoral condition is too easily considered as the cause while more important pathologies are overlooked.

Indeed

, for a minority of patients (4% in the same recent study),

extraoral

causes could be identified, including 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

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Recently, the presence of Solobacterium

moorei, a

gram positive

bacterium, has also been linked to oral malodor.

For oral malodor, the unpleasant smell of the breath mainly originates from

volatile

sulphur

compounds (VSCs),

especially hydrogen sulfide (

H2S

),

methylmercaptan

(

CH3SH

), and (less significantly)

dimethyl

sulfide [(

CH3)2S

], as first discovered by

Tonzetich

.

However, in certain conditions (e.g., when the saliva dries out on the mucosal surfaces), other compounds in mouth air may also play a role such as

diamines

(e.g.,

putrescine

,

cadaverine

),

indole

,

skatole

, and volatile organic acids like butyric or

propionic

acid.

Most of these compounds result from the

proteolytic

degradation by oral microorganisms of peptides present in saliva (

sulfurcontaining

or non–sulfur-containing amino acids)

,shed

epithelium, food debris, gingival

crevicular

fluid (GCF),

interdental

plaque, postnasal drip, and blood. In particular,

gram negative

, anaerobic bacteria possess such

proteolytic

activity

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Proteolytic

degradation by oral microorganisms of four amino acids (two containing sulfur and two not containing sulfur) to malodorous compounds. Slide19

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For the extraoral causes of halitosis, other compounds besides the VSCs may be involved.

Bad-smelling metabolites can be formed/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.

The

extraoral causes are much more difficult to detect, although they can sometimes be recognized by a typical odor.

Uncontrolled

diabetes mellitus can be associated with a sweet odor of

ketones

,

liver

disease can be revealed by a sulfur odor,

and

kidney failure can be characterized by a fishy odor because of the presence of

dimethylamine

and

trimethylamine

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In a special patient category, subjects imagine they have breath malodor; this is called imaginary breath odor or halitophobia. The latter has been associated with obsessive-compulsive disorders and hypochondria. Well-established personality disorder questionnaires (e.g., Symptom Checklist 90) allow the clinician to assess the patient’s tendency for illusional breath malodor.

The presence of a psychologist or psychiatrist at the malodor consultation can be especially helpful for such patients. Because of the complexity of this pathology, a malodor consultation is thus preferably multidisciplinary, combining the knowledge of a periodontologist or dentist, an ENT specialist, an internist (if necessary), and a psychologist or psychiatrist. In a recent study of 2000 patients, 16% were diagnosed with pseudo-halitosis or

halitophobia

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Biological Sources of Oral Malodor

BLOODNECROSISPUSMUCOUSBACTERIA

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Oral Malodor Volatile Sulfur Compounds

VSC mainly responsible for stenchMeasure with the Halimeter®

VSC’s include hydrogen sulfide, methyl mercaptan, and dimethyl sulfide

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Oral Malodor CLINICAL Management I

Full comprehensive Oral ExaminationDetect, record all gingival problemsGingivitis and PeriodontitisScale and Polish: Root Planing; Pocket elimination

Restore faulty restorationsOral Hygiene PIx<10%Recall: re-measure VSC’s

Outcome analysis: Results/Proof

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Oral Malodor CLINICAL Management II

OHI: Brushing, Flossing, Gargle, RinseTeeth, Gums, Tongue, Tonsils, pharynxProsthesis: Hygiene, Repair, or ReplaceRemove all plaque

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Oral Malodor CLINICAL Management III

FlossAnti-bacterial PastePeroxide pasteBicarbonate of Soda Paste

Tongue scraper --Commercial vs Spoon Pre-sleep Oral Hygiene

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Intraoral Causes

Tongue and Tongue Coating.

The dorsal tongue mucosa,

with

an area of 25

cm ,

shows a very irregular surface topography

.

The posterior part exhibits a number of oval

cryptolymphatic

units, which roughen the surface of this area. The anterior part is even rougher because of the high number of papillae: the

filiform

papillae with a core of 0.5 mm in length, a central crater and uplifted borders; the

fungiform

papillae, 0.5 to 0.8 mm in length; the foliate papillae, located at the edge of the tongue, separated by deep folds; and the

vallate

papillae, 1 mm in height and 2 to 3 mm in diameter. These innumerable depressions in the tongue surface are ideal niches for bacterial adhesion and growth, sheltered from cleaning actions.

Moreover, desquamated cells and food remnants also remain trapped in these retention sites and consequently can be putrefied by the bacteria.

A

fissurated

tongue (deep fissures on dorsum, also called

scrotal tongue or lingua

plicata

) and a hairy tongue (lingua

villosa

) have an even rougher

surface

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The accumulation of food remnants intermingled with exfoliated cells and bacteria forms a coating on the tongue dorsum. The latter cannot be easily removed because of the retention offered by the irregular surface of the tongue dorsum . As such, the two factors essential for putrefaction are united. Several investigators have identified the dorsal posterior surface of the tongue as the primary source of breath malodor.

Indeed, high correlations have been reported between tongue coating and odor formation.

Both in healthy individuals and

periodontitis

patients with or

without

complaints of oral halitosis, a significant positive correlation was found between the presence or amount of tongue coating and levels of

VSCs

and/or

organoleptic

scores of the mouth odor

.

In a group of 2000 patients visiting a multidisciplinary halitosis clinic

,

significant correlations were found between the

organoleptic

scores and tongue coating (

R = 0.52; p < 0.001).

In

another

study,

it

was also observed that the amount of tongue coating was significantly greater in the halitosis-positive group compared to the halitosis-negative group.

Morita and

Wang

found that the volume of tongue coating and the percentile of sites with bleeding on probing, were significantly associated with oral malodor

.

In 1992,

Yaegaki

and

Sanada

demonstrated that, even in patients with periodontal disease, 60% of the VSCs were produced from the tongue surface.

Recent

research showed that the strongest determinant for the presence of tongue coating is suboptimal oral hygiene. Other influencing factors were: periodontal status, presence of a denture, smoking, and dietary habits.Slide28

Different

clinical pictures of heavily coated tongues 28Slide29

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Periodontal Infections. A

relationship between periodontitis

and oral malodor has been shown. However, not all patients with gingivitis and/or

periodontitis

complain about bad breath, and there is some disagreement in the literature as to what extent oral malodor and periodontal disease are related.

Bacteria associated with gingivitis and

periodontitis

are indeed able to produce VSCs.

Several

studies have shown that the VSC levels in the mouth correlate positively with the depth of periodontal pockets (the deeper the pocket, the more bacteria, particularly anaerobic species) and that the amount of VSCs in breath increases with the number, depth, and bleeding tendency of the periodontal pockets.

It is important to realize that VSCs aggravate the

periodontitis

process by, for example, increasing the permeability of the pocket and mucosal epithelium and therefore exposing the underlying connective tissues of the

periodontium

to bacterial metabolites. Moreover,

methylmercaptan

enhances interstitial

collagenase

production, interleukin-1 (IL-1) production by mononuclear cells, and

cathepsin

B production, thus further mediating connective tissue breakdown.

It was also shown that human gingival fibroblasts developed an affected cytoskeleton when exposed to

methylmercaptan

.

The

same gas alters cell proliferation and migration. VSCs are also known to impede wound healing. Thus, when periodontal surgery is planned, especially the insertion of implants, clinicians should recognize this pathologic role of VSCs

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Some studies, however, have shown that when the presence of tongue coating is taken into account, the correlation between periodontitis

and oral malodor is much lower, indicating that tongue coating remains a key factor for halitosis. The prevalence of tongue coating is six times higher in patients with periodontitis

, and the same bacterial species associated with periodontal disease can also be found in large numbers on the dorsum of the tongue, particularly when tongue coating is present.

The reported association between

periodontitis

and oral malodor may thus primarily be due to the effects of periodontal disease on tongue coating. And may explain why other articles did not find a correlation.

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, and necrotizing gingivitis/

periodontitis

. Microbiologic observations indicate that ulcers infected with

gramnegative

anaerobes (i.e.,

Prevotella

and

Porphyromonas

species) are significantly more malodorous than

noninfected

ulcers.

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Dental Pathologies

. Possible causes within the dentition are deep carious lesions with food impaction and putrefaction, extraction wounds filled with a blood clot, and purulent discharge leading to important putrefaction. The same applies to interdental food impaction in large interdental areas and crowding of teeth favor food entrapment and accumulation of debris. Acrylic dentures, especially when kept continuously in the mouth at night or not regularly cleaned, can also produce a typical smell. The denture surface facing the

gingiva is porous and retentive for bacteria, yeasts, and debris, which are compounds needed for putrefaction.

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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 an extensive tongue coating. The increased microbial load and the escape of VSCs when saliva is drying up 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

.

Other causes of

xerostomia

are medication,

alcohol

abuse,

Sjögren

syndrome (a common autoimmune rheumatic disease),

and

diabetes

.

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Extraoral

CausesEar-Nose-Throat. During chronic or purulent tonsillitis, the

deep crypts of the tonsils accumulate debris and bacteria, especially periopathogens

, resulting in putrefaction. In the crypts, even calculus (e.g.,

subgingivally

) can be formed (

tonsilloliths

or tonsil stones). Other examples include acute

pharyngitis

(viral or bacterial) and postnasal drip. The latter is a rather common condition, which is perceived by patients as a liquid flow in the throat, originating from the nasal cavity.

It is often associated with chronic sinusitis or regurgitation

esophagitis

, in which the acidic content of the stomach reaches the

nasopharynx

and causes

mucositis

.

Ozena

(caused by

Klebsiella

ozaenae

) is a rare atrophic condition of the nasal mucosa, with the appearance of crusts that causes a very strong breath malodor. Finally, a foreign body in a nasal or sinus cavity can cause local irritation, ulceration, and subsequent putrefaction (e.g., children and mentally handicapped persons tend to put objects such as peas or wet paper in the nose).

111

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Bronchi and Lungs. Pulmonary causes include chronic bronchitis, bronchiectasis (infection of standing mucus secretion in cystic dilations through walls of bronchioles), pneumonia, pulmonary abscesses, bronchial carcinoma, and carcinoma of the lung.

The relevance of an early diagnosis is evident.Slide35

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Gastrointestinal Tract. In contrast to the common public opinion, even among medical physicians, gastrointestinal pathologies are rarely responsible for bad breath. The following pathologies might be responsible for less than 1% of malodor cases:

• A

Zenker

diverticulum

(a hernia in the esophageal wall, allowing accumulation of food and debris and thus putrefaction) can cause a significant breath odor because it is not separated from the oral cavity by any sphincter.

• A gastric diaphragmatic hernia (the

fundus

of the stomach protrudes through the diaphragm with relative sphincter insufficiency, allowing gases to escape or contents to flow back in the esophagus) can cause reflux of the gastric contents up to the

oropharynx

. This is sometimes combined with

ructus

, in which air from the stomach suddenly regurgitates.

• Regurgitation

esophagitis

(ulceration of the mucosal lining of the esophagus by acidic stomach contents flowing back because of an improper function of the sphincter).

• Intestinal gas production: Some gases (e.g.,

dimethyl

sulfide) are absorbed but not metabolized by the intestinal endothelium and thus transported by the blood. These gases can then be exhaled through the lungs.

There

is some disagreement in the literature whether

Helicobacter pylori infection is associated with halitosis.

In a recent paper,

H. pylori was shown to produce hydrogen sulfide and

methylmercaptan

, which suggests that this microorganism can contribute to the development of halitosis

.

Tangerman

et

alfound

no association between halitosis and

H. pylori infection

.Slide36

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Liver. Patients with various degrees of 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 has been mainly attributed to the accumulation of

dimethyl

sulfide.

Moreover, if the metabolizing function of the liver fails, the concentration of certain metabolites, normally processed in the liver, will increase and they will enter the systemic circulation again and will be exhaled

.Slide37

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Kidney. Kidney insufficiency, primarily caused by chronic glomerulonephritis, will lead to an increase of the amines

dimethylamine and

trimethylamine

, which causes 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

(such as acetone,

acetoacetate

, and

hydroxybutyrate

) are formed during

lipolysis

.

Trimethylaminuria

.

Trimethylaminuria

is 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. The prevalence is unknown but approaches 1% in the United Kingdom

.Slide38

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Hormonal Causes. At certain moments during the menstrual cycle, a typical breath odor can develop; partners are often well aware of this odor. Evidence also indicates that 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.

In

a study by Kleinberg and

Codipilly

, aqueous solutions of oral odoriferous volatiles were placed on the skin of the back of the hand.

Afterwards, odor scores were given (

organoleptic

score,

cfr

. supra). The results are shown in Table 52-2. 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 a bad smell for a longer period of time (e.g.,

indole

and

skatole

, for 10 minutes and longer).

The olfactory response, rated by an

organoleptic

scale, follows an exponential curve when correlated with the concentration of different gases. In other words, when the concentrations of the molecules were compared to their

organoleptic

outcome, an optimal fit was only obtained when the concentrations of the gases were transformed to log values. The latter implies that all types of breath “measurements” (gas chromatography [GC], portable breath analyzers [e.g.,

Halimeter

]) require log transformation to be comparable with

organoleptic

scores.

40Slide39

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Oral Malodor CLINICAL Management VI

Rectify URT and LRTTreat systemic disease Diabetes, Hypertension, CCFOral Health: Teeth and Gum problems cause >90% cases of oral malodorKeep records

Record on VAS scalesNote measures of VSCEducate the patient

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OM CLINICAL Management VIIOral Irrigation A

Medicinal MouthwashShort-term for specific effectAssociated risksExamples: Peridex (Chlorhexidine gluconate); Phenol Based with oils (Listerine); Cetyl-pyridinium Cl (Cepacol) Chlorine dioxide, herbal remedies, etc.

Side effects: staining, taste changes, toxicity, overgrowth of bacteria, fungi etc.

Physiolo

gical

Daily use

Long temMinimal side effects if anyPhysiological substances: Examples: Salt, Bicarbonate of soda, Urea crystals

Fluoride rinse: correct physiological concentration 1ppm

43Slide44

OM CLINICAL Management VIII Saline Mouthwash & Gargle

PREPARATION:NaCl common Table SaltHypertonic solutions: stir one teaspoonful of salt in about 300ml water.Salt should remain at base of glass=Saturated solution

hypertonicFreshly prepared for each use.Not costly; available

MODE OF ACTION

Hypertonicity dehydrates bacteria

 bacteriostatic initialthen bacteriocidal

Edema: Swollen Cells are reduced

Saline debridement of tonsillar crypts

Washes and irrigates mucous membranes; mucolytic

Slows inflammation

44Slide45

Oral Malodor Clinics

Part of Practice: NOT isolatedMust have accurate clinical measuring devices--Halimeter® (VSC’s ppb)Must have ALL oral therapeutic back-up

Refer and COMMUNICATEClinical Protocol: Quote fees Examinations, Radiographs, Bacteriology, Histopathology, Periodontics, Endodontics, Restorative, Prosthodontics, Otolaryngology, Psychological referrals

Written Report Mandatory

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