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Halitosis- Etiology, Prevention and Treatment

Halitosis, fetor oris, oral malodour or bad breath are the general terms used to describe unpleasant breath emitted from a person’s mouth regardless of whether the odorous substances in the breath originate from oral or non-oral sources.

Breath odour can be defined as the subjective perception after smelling someone’s breath. Halitosis is an oral health condition characterized by consistently emanating odorous breath and may be caused by several agents including certain foods, poor oral health care, improper cleaning of dentures, decreased salivary flow rate, tobacco products or a medical condition.

In 90% of cases, the causes of halitosis are located in the mouth and can be attributed to

  • deep carious lesions,
  • periodontal disease,
  • oral infections,
  • peri-implant disease,
  • pericoronitis,
  • mucosal ulcerations,
  • impacted food or debris,
  • factors causing decreased salivary flow rate,
  • tongue coating.

The tongue is a major site of oral malodour production, while periodontal disease and other factors seem to be only a fraction of the overall problem. In addition, current social norms emphasize the importance of personal image and interpersonal relationships. Thus, halitosis may be an important factor in social communication and, may be the origin of concern not only for a possible health condition but also for frequent psychological alterations leading to social and personal isolation.

Although oral malodour or bad breath is an unpleasant condition experienced by most individuals, it typically results in transient discomfort.

Classification:-

There are three main categories of halitosis: genuine halitosis, pseudo-halitosis, and halitophobia.

  • Genuine halitosis is the term that is used when the breath malodor really exists and can be diagnosed organoleptically or by measuring responsible compounds.
  • When an obvious breath malodor cannot be perceived, but the patient is convinced that they suffer from it, it is called pseudo-halitosis.
  • 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:-

Breath malodor originates from the oral cavity. Gingivitis, periodontitis, and especially tongue coating are the pre-dominant causative factors.

There are two pathways identified for bad breath:

  1. The first pathway involves an increase of certain metabolites in the blood circulation (e.g., due to a systemic disease). These metabolites escape via the alveoli of the lungs during breathing (blood-breath exchange) and it is commonly referred as “extraoral halitosis.”
  2. 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.

Diagnosing Malodor:-

Anamnesis:

  • Thorough questioning about the breath malodor, eating habits, and medical and dental history either via a questionnaire and/or orally at the beginning of the consultation.
  • The patient should be asked about the frequency of the halitosis (e.g. Constantly, every day), the time of appearance during the day (e.g. After meals can indicate a stomach hernia), when the problem first appeared and whether others have identified the problem (to exclude imaginary breath odor).
  • Also the medical history has to be recorded, with an emphasis on medication, and systemic diseases of the lungs, liver, kidneys, stomach and pancreas.
  • The dental history includes questions assessing the frequency of dental visits, the use of mouth rinses, the presence and maintenance of a dental prosthesis, and the frequency and the instruments used for tooth brushing, interdental cleaning, and tongue brushing and scraping.
  • Finally, the patient is asked about his smoking, drinking, and dietary habits.

Diagnosis can be done by self-examination or oropharyngeal examination by the healthcare provider.

A) Self-Examination:

  1. Smelling a metallic or non-odorous plastic spoon after scraping the back of the tongue.
  2. Smelling a toothpick after introducing it in an interdental area.
  3. Smelling saliva spit in a small cup or spoon.
  4. Licking the wrist and allowing it to dry.

B) Oropharyngeal Examination:

  1. Inspection of deep carious lesions,
  2. Interdental food impaction,
  3. Wounds,
  4. Bleeding of the gums,
  5. Periodontal pockets,
  6. Tongue coating,
  7. Dry mouth, and
  8. The tonsils and pharynx (for tonsillitis and pharyngitis).

Assessment of breath:

  1. Organoleptic assessment by a judge is the gold standard in the examination of breath malodor. The judge smells a series of different air samples of Breath odor, Nasal breath odor, Nasal breath odor, saliva and tongue coating.
  2. Portable Volatile Sulfur Monitor. The portable volatile sulfur monitor (Halimeter, Interscan, Chatsworth, CA) is an electronic device that detects the presence of volatile sulfur compounds such as hydrogen sulfide and methylmercaptan in breath.
  3. A small, portable “gas chromatograph” (OralChroma,TM FIS Inc, Japan) has been introduced to determine halitosis.

Preventive measures:

  • Preventive measures rather than curative aspects are highly recommended.
  • Visit dentist regularly
  • Periodical tooth cleaning by dental professional.
  • Brushing of teeth twice daily with appropriate brushing techniques and for a duration of 2-3 mins.
  • Use of a tongue scraper to get rid of the lurking odour causing bacteria in the tongue surface.
  • Chemical reduction of oral microbial load: Chlorhexidine, Essential oils, Chlorine dioxide, Two-phase oil- water rinse, Triclosan, Aminefluoride/ Stannous fluoride, Hydrogen peroxide, Oxidising lozenges, chewing gums, etc.

Treatment of Oral Malodor:

  1. Masking the malodor
  2. Mechanical reduction of intraoral nutrients (substrates) and microorganisms
  3. Chemical reduction of oral microbial load
  4. Rendering malodorous gases nonvolatile

Conclusion:

Oral malodor, which is commonly noticed by patients, is an important clinical sign and symptom that has many etiologies which include local and systemic factors. Although consultation and treatment may result in dramatic reduction in bad breathe, patients may find it difficult to sense the improvement themselves.

References:
  1. Braz Oral Res 2008;22(Spec Iss 1):44-54
  2. Kapoor U, Sharma G, Juneja M, Nagpal A. Halitosis: Current concepts on etiology, diagnosis and management. Eur J Dent 2016;10:292-300.

Author

Dr Shilpa Subramanian

Dr. Shilpa Subramanian is a Periodontist and currently manages Global Pharmacovigilance Operations at Indegene Pvt Ltd. She is passionate about staying ahead of the curve in clinical and non-clinical advances in the field of pharma and healthcare.

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