The jurnla and specificity of the sulfide monitor is less than the gas chromatography but correlations of measurements are highly significant. Morita M, Wang HL. Advising patients on halitosis and oral hygiene At least 2 h before measurements, the patients should refrain from eating and drinking activity. Comparison of ninhydrin method of detecting amine compounds with other methods of halitosis detection. Clinical assessment of oral malodor intensity expressed as absolute value using an electronic nose.
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Metrics details Abstract Halitosis, bad breath or oral malodour are all synonyms for the same pathology. Halitosis has a large social and economic impact. For the majority of patients suffering from bad breath, it causes embarrassment and affects their social communication and life.
Moreover, halitosis can be indicative of underlying diseases. Only a limited number of scientific publications were presented in this field until Ever since, a large amount of research is published, often with lack of evidence.
Therefore, dentists and periodontologists are the first-line professionals to be confronted with this problem. They should be well aware of the origin, the detection and especially of the treatment of this pathology. In the case of halitophobia, psychiatrical or psychological problems may be present. Bad breath needs a multidisciplinary team approach: dentists, periodontologists, specialists in family medicine, ear—nose—throat surgeons, internal medicine and psychiatry need to be updated in this field, which still is surrounded by a large taboo.
This article describes the origin, detection and treatment of halitosis, regarded from the different etiological origins. Download PDF Epidemiology The amount of epidemiological research on bad breath is limited, since this topic is still a large but underestimated taboo.
There are several reasons for this lack of scientific data. First, there is the difference in cultural and racial appreciation of odours, as for patients as well as for investigators.
Men suffered more from the problem than women, especially when they were over 20 years. Man and women seem to suffer in the same proportions, whereas women seem to seek faster for professional help than men.
These results suggest that this oral malodour is caused by tongue coating in the younger generation and by periodontitis with tongue coating in the older cohorts. This large variety of data suggest that there are large shortcomings in the methodology of the overall research projects.
Therefore, a mechanical detection method should be used as golden standard for bad breath research. Origin Microbial degradation in the oral cavity is the main cause of oral malodour. Due to this process, volatile sulphur compounds VSCs are formed. These VSCs are mainly produced by Gram-negative anaerobic oral bacteria.
They seem play a less important role in the expression of bad breath. Most of these components are produced in the proteolytic degradation process of peptides. The most predominant substrates in this VSC production are cysteine, cystine and methionine. The involved bacteria in these metabolic processes are shown in Table 1.
Table 1 Bacteria responsible for VSC production Full size table Most of the responsible microorganisms in halitosis are involved in periodontitis. So, there is a positive correlation between bad breath and periodontitis: the depth of the periodontal pockets is positively correlated to the height of the VSC concentrations in the mouth. This surface is large and has a high retention capacity due to the rough and papillary structure.
The bacterial composition on the dorsum of the tongue seems to be identical to the subgingival plaque. Hence, the tongue surface seems to be an important reservoir in the recolonisation of tooth surfaces. Daily scraping or brushing of the tongue can help to reduce the substrata for putrefaction, rather than to reduce the bacterial load. Moreover, tongue cleaning improves taste sensation.
This is a non-pathological form of halitosis. The problem will disappear as soon as oral hygiene measures are taken. Snel et al. This phenomenon needs to be further investigated to understand its impact. Odontogenic halitosis Poor oral hygiene, dental plaque, dental caries, accumulation and putrefaction of food remnants and unclean acrylic dentures worn at night or not regularly cleaned or with rough surfaces contribute to bad breath.
The latter was recently concluded in a systematic review, stating that, although isolated reports, chemicals and brushing appear to be more effective than placebo in the reduction of plaque coverage and microbial counts of anaerobes and aerobes on complete denture bases. This disease is caused by opportunistic bacterial infections occurring in individuals with stress, malnutrition, insufficient oral hygiene, smoking or systemic diseases.
Therefore, dry mouth is probably a condition of systemic or extrinsic origin. Saliva seems to undergo chemical changes with aging. Dry mouth symptom can be treated with hydration and sialagogues or with artificial saliva substitutes.
Therefore, when a clinical investigation is performed, attention should first be paid to the tonsils: size, structure invaginations, coating and hyperaemia and presence of tonsilloliths. Mostly, infections with streptococci play a role, but also viral infections e. When acute tonsillitis takes place more than three times a year, a tonsillectomy can be considered. A tonsillectomy is only performed when oral hygiene measures do not result in improvement of the breath. Nasal causes Postnasal drip caused by mucus of the paranasal sinuses contacting the dorsum of the tongue is largely involved.
Also a cleft palate can be the origin of bad breath. This can be caused by tumor rescetions, radiotherapy or overuse of decongestives or cocaine. Sinusitis Bacterial sinusitis develops mostly out of acute viral sinusitis.
Streptococcus pneumonia and Haemophilus influenza are the main responsible bacteria. On radiological or computed tomography CT images, fading is perceived. When purulent mucous is produced, a typical odour appears. In these cases, the spotted bacteria are: Peptostretococcus spp. Since those bacteria are able to produce VSCs, a clear association to halitosis is available.
The treatment of dentogenic problems eventual with the additional use of antibiotics decreases the anaerobic pathogens, even as the odour problem. A majority of patients and physicians still abusively believes that halitosis originates from the stomach. Oesophagus Only in specific cases, this is the origin of malodour. Also bleeding of the oesophagus can cause a musty odour. When severe regurgitation is determined, halitosis will be present. When the diagnosis is missed, carcinomatic deterioration can occur.
Stomach Infections with Helicobacter pylori can cause peptic ulcers. Moreover, it is suggested that H. When gastrointestinal pathology was treated, most of the halitosis complaints disappeared. The latter suggests that halitosis can have a gastro-intestinal origin.
In a recent comparative study among children in Turkey, it was concluded that there was a difference between the rate of H. The results, however, were not statistical significant.
It was suggested that this physical sign may be an indication for barium studies. Metabolic disorders Preti et al. Renal disease in the form of chronic renal failure is associated with high blood urea nitrogen levels and low salivary flow rates. Peritoneal dialysis decreased the problem. Also pancreatic insufficiencies can cause oral bad odours as found by Feller and Blignaut in According to Whittle et al. Trimethylaminuria is a disorder in which the volatile, fish-smelling compound, trimethylamine accumulates and is excreted in the urine, but it is also found in the sweat and breath.
Trimethylamine is formed by bacteria in the mammalian gut from reduction of compounds such as trimethylamine-N-oxide and choline. Treatment with antibiotics to control bacteria in the gut, or activated charcoal to sequester trimethylamine, may also be beneficial. If this condition is present, the extra-oral origin should be determined, because the latter requires medical investigation and support in therapy. Hepathology and endocrinology The liver can be involved in oral malodour.
Fetor hepaticus is an expression of hepatic encephalopathy. Endocrinology can also contribute to halitosis. Not only the hormonal cycle seems to influence the mouth odour, but also a lot of other intestinal diseases. Table 3 Odours in the case of metabolic or endocrinological problems Full size table Medication Next to medication resulting in a dry mouth see above ; recently the use of bisphosphonates can contribute to oral malodour.
Bisphosphonate-induced osteonecrosis is since a common problem. Often this results in jawbone necrosis, a clear origin for a filthy odour. The necrotic sequesters should be removed and it is tried to cover up the necrotic area with a steeled flap.
A more objective method is the analysis of breath samples by gas chromatography or by means of portable VSC analysers. Organoleptic scoring In expired air, more than different components have been detected. The perception of these molecules is dependent of the olfactory response, the threshold concentration, the strength of the odour and the volatility of the molecules.
When organoleptical scoring is performed, a well-trained clinician determines if the odour samples smells bad or not, giving a score to the intensity. Theses scores go from 0 up to 5 Table 4. To gather optimal test results several precautions should be taken before the examinations: the patient should refrain from spicy foods, garlic or onions the day before the examination.
As disadvantages, the extreme subjectivity of the test, the lack of quantification, the saturation of the nose and the reproducibility can be mentioned. The OralChroma is a portable gas chromatograph offering lower cost, higher performance and more user-friendly operations than conventional gas chromatographs by limiting the target gases to three types: H2S, CH3SH and CH3 2S.
Also, an interpretation of the results can be shown to the patients. The Halimeter can only give an idea of the total amount of VSCs, present in a sample.
In the Halimeter, the total amount ppb parts per billion of VSCs in the sample is marked. Furthermore, they are rather inexpensive and can be controlled by untrained staff. As disadvantage, the limited diversity in the explored gasses should be stated.
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Table 3 Bacteria which is active producers of volatile sulfur compounds in vitro adapted from Persson et al. Ketones such as acetone, benzophenone, and acetophenone are present in both alveolar lung and mouth air; indole and dimethyl selenide are present in alveolar air. The number of bacterial species, which are found in oral cavity, are over ,[ 8 ] and most of them are capable to produce odorous compounds which can cause halitosis. In these conditions, poor oral hygiene plays a key factor for multiplication of halitosis causative bacteria and causes an increase in halitosis. These bacteria include especially Gr-negative species and proteolytic obligate anaerobes [ Table 4 ],[ 24 — 27 ] and they mainly retained in tongue coating and periodontal pockets. The inflammation of gingival and periodontal tissues creates typical sources for oral malodors[ 32 , 33 ] and plaque-related periodontal disease can increase the severity of halitosis.
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Mimi It is, therefore, important for dentists and pharmacists to develop interprofessional working, e. The mouth air of chronic malodor sufferers is tainted with compounds such as hydrogen sulphide, methyl mercaptan and organic acids, which produce a stream of foul air that is gravely offensive to the people in their vicinity Management may include simple measures such as scaling and planing, good oral hygiene, tongue cleaning, and mouth rinsing. The journal of contemporary dental practice. Mechanical tongue cleaning tongue scrapingas an integral element of the daily oral hygiene regimen, can be regarded as a basic therapeutic and preventive measure for intra-oral halitosis . Relationship between stressful situations, salivary flow rate and oral volatile sulfur-containing compounds.