Halitosis / Bad breath

Dr Kh Eremba *

Bad breath, fetor oris, oral malodor also called halitosis, is a common condition and sometimes a distressing source of embarrassment. Halitosis is a latin word which derived from halitus (breathed air) and the osis (pathologic alteration) and is used to describe any disagreeable bad or unpleasant odor emanating from the mouth air and breath. One out of four people suffer from halitosis and frequently causes embarrassment, may affect interpersonal social communication.

Different type of halitosis and their causes:

Morning breath: Oral malodor is common on awakening (morning breath), and is transient and rarely of any special signiûcance, probably resulting from increased microbial metabolic activity during sleep that is aggravated by a physiological reduction in salivary ûow, lack of nocturnal physiologic oral cleansing (e.g. movement of the facial and oral muscles) and variable oral hygiene procedures prior to sleep.

Starvation: Starvation leads to dehydration which decreased saliva flowand therefore cannot "wash" away plaque and bacteria. These bacteria may be trapped on teeth or tongue and cause a bad smell. Digestive juices in the stomach are still produced but as there is no food, these acidic juices begin to break down, causing a foul smell. Starvation again leads to excessive breakdown of fats from the body where ketones are released causing halitosis.

Foods: Halitosis can also result from ingestion of certain food (aromatic foods) and drinks, such as spices, garlic, onion etc. Food that is absorbed into the bloodstream is transferred to the lungs, where it is expelled, often with the odor still recognizable. Odors continue until the body eliminates the food. Additionally, during the digestion process, the odor may make its way back up the esophagus and is expelled during talking and breathing.

Habits and lifestyle: Halitosis also results from habits such as smoking, use of tobacco,alcohol consumption etc. Tobacco smoke contains volatile sulfur compounds, which are at least partly responsible for the oral malodor of smokers,not only this, tobacco products also predispose to dry mouth and periodontal disease – further increase the causes of malodor.

Intra oral causes for halitosis:

1) Poor Oral Hygiene
2) Deep carious lesions with food impaction and putrefaction
3) Extraction wound filled with blood clot and purulent discharge
4) Periodontal infections like gingivitis and periodontitis
5) Rough surface of tongue coated with food remnants, exfoliated cells and bacteria
6) Increased microbial load in xerostomia patients
7) Acrylic dentures which are not regularly cleaned
8) Traumatic ulceration
9) Dental Abscess
10) Herpetic Infections
11) Apthous Ulcers
12) Candidiasis
13) Oral Cancer
14) ANUG
15) Other factors that contribute to halitosis are endodontic, surgical, and pathologic factors such as exposed tooth pulps and non-vital tooth with fistula draining into the mouth, oral cavity pathologies, prosthetics or dentition factors such as orthodontic fixed appliances, restorative crowns which are not well adapted, noncleaning the bridge body.

Extra oral causes for halitosis:

There are other medical conditions that contribute to mouth odor.
Respiratory system (microbial etiology):
Sinusitis, Antral malignancy, Cleft palate, Foreign bodies in the nose, Nasal malignancy Tonsilloliths, Tonsillitis, Pharyngeal malignancy, Lung infections, Bronchitis, Bronchiectasis Lung malignancy

Gastrointestinal tract:
Esophageal diverticulum, Gastro-esophageal reûux disease, Malignancy
Metabolic disorders (blood borne)
Uncontrolled diabetes -Acetone-like smell
Renal failure- Uremic breath
Liver disease- Foetorhepaticus
Trimethylaminuria -ûsh odor syndrome
Drugs (blood borne):
o Amphetamines
o Chloral hydrate
o Cytotoxic agents
o Nitrates and nitrites
o Phenothiazines
o Solvent abuse etc.

Why the bad breath?

The principal components of halitosis are volatile sulfide compounds (VSC), especially hydrogen sulfide, methyl mercaptan and dimethylsulfide or compounds such as butyric acid, propionic acid, putrescine, and cadaverine. These compounds result from the proteolytic degradation by predominantly anaerobic Gram- negative oral microorganisms of various sulfur containing substrates in food debris, saliva, blood and epithelial cells. Substrates for volatile sulfide compounds production are sulfur-containing amino-acids such as cysteine, cystine and methionine present in saliva or gingival fluid which produce a stream of foul air that is gravely offensive to the people in their vicinity.

Diagnosis:
Self examination: Smelling a plastic spoon after scraping back of tongue
Smelling a toothpick after introducing it in an interdental area
Smelling saliva spit in a cup
Clinical examination: Patient's oral hygiene status, caries and periodontal status.
Radiographic examination: Evidence of dental caries, alveolar bone defects and defective restorations.
Special tests: Performed to detect the foul-smelling Volatile Sulphur Compounds along with the associated bacteria.
1. ORGANOLEPTIC MEASUREMENT (a trained judge sniffs the expired air and asses it)
2. GAS CHROMATOGRAPHY (Measures sulfide levels in breath)
3. HALIMETER EXAMINATION (Asses the concentration of hydrogen sulfide and methyl merceptain in breath)
4. DARK FIELD MICROSCOPY (Detects motile organisms and spirochetes from smear in patients of periodontal disease)
5. SALIVA INCUBATION TEST

The contributing conditions, once identified, are referred for treatment accordingly.

MANAGEMENT:

The management comprises of elimination of the causative factors and improvement of the oral health status. The treatment of oral malodor can therefore be focused on the reduction of the intraoral bacterial load and/or the conversion of VSC to nonvolatile substrates.
1. The management of halitosis depends largely on the cause.
2. Avoid smoking, drugs and foods that might be responsible for halitosis.
3. Chewing gum, mint, cloves and the use of proprietary fresh breath preparations, may help, however they merely provide a competing and temporary smell that may mask the unfavourable odor.

Since dry-mouth can increase bacterial build up and cause or worsen bad breath, chewing sugarless gum can help with the production of saliva, and thereby help to reduce bad breath. Chewing may help particularly when mouth is dry, or when cannot perform oral hygiene procedures after meals. These aids in provision of saliva, which washes away oral bacteria, and promotes mechanical activity, which helps, cleanse the mouth

4. Periodic professional cleaning (oral prophylaxis).
5. MAINTAINING PROPER ORAL HYGIENE: Proper tooth brushing, cleaning the tongue surface, inter-dental cleaning/brushing and flossing. This home care removes residual food particles and organisms that cause putrefaction.

Gently cleaning the tongue surface: Twice daily is the most effective ways to keep bad breath in control; that can be achieved using tooth brush, tongue cleaner or tongue brush/scraper to wipe off the bacterial biofilm, debris, and mucus.
Gargling: Gargling right before bedtime with a plain water or salt water is effective.

6. CARE OF DENTURE: Dentures should be properly cleaned and soaked overnight in antibacterial solution.
7. RESTORATION OF CARIOUS TEETH- to avoid progression of caries and food lodgments.
8.CONTROL OF GINGIVITIS AND PERIODONTITIS: Professional periodontal treatment (oral prophylaxis and periodontal therapy) is mandatory. Thus, initial periodontal therapy in moderate periodontitis patients can be expected to improve breath odor parameters by reducing the number of periodontal pathogens

9. ENDODONTIC TREATMENT.
10. CONTROL OF ORAL INFECTION
11. USE OF PROPER ORTHODONTIC BRUSHES: If othodontic treatments are done brushing should be done properly with help of orthodontic brushes.
12. MOUTHRINSES: Mouthrinses can reduce halitosis by chemically neutralizing odor compounds, including VSCs.

Often used active ingredients in these products are Chlorhexidine (CHX), Essential oils (eos), Triclosan and Cetylpyridinium chloride (CPC).

The treatment of halitosis involves an appropriate diagnosis, professional therapy, mechanical plaque control, including tooth brushing and tongue cleaning, possibly combined with the use of an effective antimicrobial mouthrinse.

Halitosis as a result of extra-oral causes is managed through the treatment of the underlying cause.