Malodor or bad breath lead the patient to poor social life and should be treated as soon as the cause is identified

1. PERIODONTIC UNIT
ORALMALODOR
(SEMINAR PRESENTATION)
BY : 1.ADDISU DABI
2. DEREJE ASFAW
3.Yohannes H/mariam
1. Yemane Brhane
2. Temesgen Haregot
3. Winta Solomon
10/23/2018 1oral malodor

2. Contents
• Definition
• Classification
• Pathway of bad breath
• Causes(I/O & E/O)
• Physiology of malodor detection
• Diagnosis
• Treatment
10/23/2018 2oral malodor

3. DEFINITIONS
 Breath odor can be defined as the subjective perception after
smelling someone’s breath.
 It can be pleasant, unpleasant or even disturbing, if not repulsive.
 If unpleasant, Synonyms:
 breath malodor
 halitosis
 bad breath,
 fetor ex ore
Carranza (11th edition)
• Breath malodor means an unpleasant odor of the expired air,
whatever the origin may be.
Jan Lindhe (4TH edition)10/23/2018 3oral malodor

4. Halitosis is derived from:
The Latin word "Halitus“ --bad breath
 The Greek word "Osis“ -- disease or condition.
Halitosis, also termed fetor ex ore, fetor oris, and
oral malodor, is foul or offensive odor emanating
from the oral cavity. Carranza (9th edition)
3rd most frequent reason for seeking dental aid,
following tooth decay and periodontal disease.
 (Loesche WJ et al 2002)
10/23/2018 4oral malodor

5. EPIDEMIOLOGY
There are few studies that document the
prevalence of oral malodor.
Indicated higher prevalence of bad breadth among
women than men
No association was found between increased age
and oral malodor.
Age may range from 5-80 years.
10/23/2018 5oral malodor

6. CLASSIFICATION
ADA classification based on the etiological
pathways involved :
Extrinsic pathways - Tobacco, alcohol and foods like
onions, garlic and certain spices.
Intrinsic pathways – Oral origin (90 %)
– Systemic origin (10 %)
10/23/2018 6oral malodor

7. Halitosis can be categorised into three
main types
Genuine halitosis
• When the breath malodor really exists and can be
diagnosed organoleptically or by measurement of the
responsible compounds.
Pseudo-halitosis
• When an obvious malodor cannot be perceived by others,
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
pseudohalitosis.
• It is a recognized psychiatric condition.
10/23/2018 7oral malodor

8. ETIOLOGY
In the vast majority, breath malodor originates from
the oral cavity.
Gingivitis
Periodontitis
Tongue coating
Predominant
causative factors
10/23/2018 8oral malodor

9. 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-gas exchange).
 The second pathway involves an increase of either the
bacterial load or the amount of substrates for these bacteria
at one of the lining surfaces of the oropharyngeal cavity, the
respiratory tract, or the esophagus.
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
10/23/2018 9oral malodor

10. Odiferous Compounds
Volatile Sulfur Compounds Methyl Mercaptan, Hydrogen
Sulfide Dimethyl Sulfide
Diamines Cadaverine,Putrescine
Short-Chain Fatty Acids Butyric Acid ,Valericacid,Propionic
Acid
Indoles Indole, Methyl-Indole (Skatole)
10/23/2018 10oral malodor

11. For oral malodor, the unpleasant smell of the breath mainly
originates from VSCs.
Tonzetich first discovered the volatile sulfur compounds
(VSC).
 hydrogen sulfide (H2S)
 methyl- mercaptan (CH3SH)
 less important dimethyl sulfide [(CH3)2S].
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
volatile organic acids like butyric or propionic acid.
10/23/2018 11oral malodor

12. Production
and origin of
oral malodor
Most of these compounds result from the proteolytic degradation by
oral microorganisms of peptides present in saliva (sulfur-containing 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.
10/23/2018 12oral malodor

13.  For the extraoral causes of halitosis, other compounds besides the VSCs
may be involved, which have not all been identified yet.
 Bad smelling metabolites can be formed/absorbed at any place in the body
(e.g., the liver, the gut) and be 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 extraoral causes are much more difficult to detect, although they can
sometimes be recognized by a typical odor.
Bad smelling
metabolites(volati
le) in any place of
the body
Blood circulation Lungs Exhalation
malodor
10/23/2018 13oral malodor

14. INTRAORAL CAUSES
Tongue and Tongue Coating.
The dorsal tongue mucosa shows a very irregular surface topography.
 The posterior part exhibits a number of oval cryptolymphatic units.
 The anterior part exhibits high number of papillae: the filiform papillae ,the
fungiform papillae, the foliate papillae, the vallate papillae.
 A fissurated tongue and a hairy tongue
 These innumerable depressions (irregular surface) in the tongue surface are ideal
niches for bacterial adhesion and growth, sheltered from cleaning actions.
 Desquamated cells and food remnants also remain trapped in these retention sites
and consequently can be putrefied by the bacteria.
10/23/2018 14oral malodor

15. The accumulation of food remnants
 intermingled with exfoliated cells and
bacteria causes a coating on the tongue
 dorsum.
The dorsal posterior surface of the tongue is the
primary source of breath malodor.
High correlations have been reported between
tongue coating and odor formation.
Quirynen M et al suggested that oral malodor is
associated with the total bacterial load of anaerobic
bacteria in both saliva and tongue coating.10/23/2018 15oral malodor

16. PERIODONTAL INFECTIONS
Niles and Gaffer (1995)- Gram negative bacteria can cause
unpleasent smell by production of sulfur compounds.
Rosenberg M et al (2005) – Gram positive Streptococcus
salivarius also contributes to oral malodor.
VSC levels in the mouth correlate positively with the depth of
periodontal pockets (the deeper the pocket, the more
bacteria, particularly anaerobic species)
 Amount of VSCs in breath increases with the number, depth,
and bleeding tendency of the periodontal pockets.
10/23/2018 16oral malodor

17. .
Exposing the underlying connective
tissues of the periodontium to
bacterial metabolites
enhances interstitial collagenase production,
interleukin-1 (IL-1) production by mononuclear
cells, and cathepsin B production, thus further
mediating connective tissue breakdown.
10/23/2018 17oral malodor

18. The prevalence of tongue coating is 6 times higher
in patients with periodontitis.
Other relevant malodorous pathologic
manifestations of the periodontium are:
1. Pericoronitis (the soft tissue “cap” being retentive
for microorganisms and debris)
2. Major recurrent oral ulcerations
3. Herpetic gingivitis
4. Necrotizing gingivitis/periodontitis.
10/23/2018 18oral malodor

19. Dental Pathologies
1. Deep carious lesions with food impaction and
putrefaction
2. Extraction wounds
3. Purulent discharge
4. Interdental food impaction
5. Acrylic dentures.
- The denture surface facing the gingiva is porous
and retentive for bacteria, yeasts, and debris,
which are all factors that cause putrefaction.
10/23/2018 19oral malodor

20. Dry Mouth/xerostomia
 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 as gases when saliva is drying up explain the
strong breath malodor.
10/23/2018 20oral malodor

21. EXTRORAL CAUSES
Ear-nose-throat: During chronic and purulent tonsillitis, deep
crypts of the tonsils accumulates debris and
bacteria,especially periopathogens, resulting in putrefaction.
Gastrointestinal tract: Helicobater pylori produces hydrogen
sulfide and methylmercaptan which results in halitosis. (Lee H
et al)
Liver : hepatocellular failure
 metabolizing function of the liver fails.
Kidney: kidney insufficiency caused by chronic
glomerulonephritis which leads to increase of the amines
dimethylamine and trimethylamine, which causes a typical
fishy odor of the breadth.
10/23/2018 21oral malodor

22. Systemic metabolic disorders- uncontrolled
diabetes mellitus- accumulation of ketones ehich
have a sweet smell like the odor of rotten apples.
Trimethylaminuria – it is hereditary metabolic
disorder that leads to typical fishy odor of breadth ,
urine, sweat and other bodily secretion.
Hormonal cause- during menstrual cycle- typical
breadth odor develops. VSC levels increases 2-4 fold
around the day of ovulation and in the
perimenstrual period.
10/23/2018 22oral malodor

23. PHYSIOLOGY OF MALODOR DETECTION
 Some gases can cause a striking odor at very low concentrations, whereas
others need to be present in much higher quantities.
 The perception of the molecules depends on the following factors:
1. The odor itself (olfactory response) can be pleasant, unpleasant, or even
repulsive.
2. Each particular molecule has its specific concentration before it can be
detected (threshold concentration).
3. The odor power is the extent of concentration that is necessary to increase
the odor score with one unit.
4. The volatility of the compound: malodorous molecules only express
themselves when they become volatile.
5. The substantivity: the capacity of the molecule to stay present and thus to
remain the cause of smell.
10/23/2018 23oral malodor

24.  The odor power is the strongest for hydrogen sulfide and methylmercaptan.
 If the concentration of these products increases fivefold to tenfold, the odor will
receive a higher organoleptic rating.
 For some other compounds, increases of 25 to 100 times are needed to reach a
similar effect.
 Skatole and methyl mercaptan are detected at the lowest concentrations.
 In a study of Kleinberg and Codipilly, aqueous solutions of oral odoriferous
volatiles were placed on the skin of the back of the hand.
 Afterward, odor scores were given (organoleptic score).
 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)
10/23/2018 24oral malodor

25. DIAGNOSIS OF MALODOR
MEDICAL HISTORY CLINICAL & LABORATORY
EXAMINATION
Frequency (e.g., every month),
Time of appearance during the day
Time when the problem first appeared,
Whether others (nonconfidants) have
identified the problem,
Medications
Factors such as mouth breathing, dry
mouth, allergies, and nasal problems. “listen
to the patient and
the patient will tell you the diagnosis.”
SELF EXAMINATION
OROPHARYNGEAL EXAMINATION
ORGANOLEPTIC RATING
PORTABLE VOLATILE SULFUR MONITOR
GAS CHROMATOGRAPHY
DARK-FIELD OR PHASE-CONTRAST
MICROSCOPY
listen to the patient and the patient
will tell you the diagnosis.
10/23/2018 25oral malodor

26. SELF EXAMINATION
It can be worthwhile to involve the patient in monitoring the
results of therapy by self-examination.
This can motivate the patient to continue the oral hygiene
instructions.
The following self-testing can be used:
1. Smelling a metallic or nonodorous 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 (especially when
allowed to dry for a few seconds so that putrefaction odors
can escape from the liquid).
4. Licking the wrist and allowing it to dry.
10/23/2018 26oral malodor

27. OROPHARYNGEAL EXAMINATION
Inspection of deep carious lesions
Interdental food
Impaction,
Wounds,
Bleeding of the gums,
Periodontal pockets,
Tongue coating,
Dry mouth,
Tonsils and pharynx (for tonsillitis and pharyngitis).
10/23/2018 27oral malodor

28. Organoleptic Rating
• “Gold standard” in the examination of breath malodor.
• In an organoleptic evaluation, a trained and preferably
calibrated “judge” sniffs the expired air and assesses
whether it is unpleasant by using an intensity rating,
normally from 0 to 5.
(Rosenberg and McCulloch)
• Based on the olfactory organs of the clinician
0 = no odor present,
1 = barely noticeable odor,
2 = slight but clearly noticeable odor,
3 = moderate odor,
4 = strong offensive odor,
5 = extremely foul odor.
10/23/2018 28oral malodor

29. • Judge smell series of different air samples:
1. Oral cavity odor: subjects opens the mouth and
refrains from breathing while the judge places his
or her nose close to the mouth opening.
2. Breadth odor: subject expires through the mouth
while the judge smells both the beginning and the
end of the expiration.
3. Saliva: patient lick his/her wrist. After drying judge
gives a score.
4. Tongue coating : judge smell the tongue scraping.
5. Nasal breadth odor: subjects expires through the
nose while mouth is closed. Nasal/paranasal cause
suspected.
10/23/2018 29oral malodor

30. • Specific character of the odor:
1. Smell of sulfur:- intraoral origin of halitosis.
2. Smell of sulfur:- also points to liver diseases.
-sometimes combined with sweet
odor (accumulation of ketones.)
3. Smell of rotten apples:- unbalanced insulin
dependent diabetes which leads to accumulation
of ketones.
4. Fishy odor:- kidney insufficiency (characterized by
uremia and accumulation of dimethylamine and
trimethylamine).
10/23/2018 30oral malodor

31. 10/23/2018 31oral malodor

32. Portable Volatile Sulfur Monitor.
Halimeter is an electronic device that analyzes the
concentration of hydrogen sulfide and methyl
mercaptan but without discriminating them.
The sulfur meter uses a voltametric sensor that
generates a signal when exposed to sulfur-containing
gases
ELEVATED CONCENTRATION:
300-400ppb.
Absence of mal odor: 150ppb
or lower.
10/23/2018 32oral malodor

33. Drawbacks:
Detects only sulfur compounds therefore only used for
intraoral causes of halitosis.
Absence of VSCs does not prove that there is no
breadth odor.
Instrument has no specificity thus cannot discriminate
among different sulfur compounds.
Sensitivity for methylmercaptan is five times lower than
hydrogen sufide .
Insensitive to dimethyl sulfide.
10/23/2018 33oral malodor

34. Gas Chromatography
A gas chromatography device can analyze air, saliva,
or crevicular fluid .
 About 100 compounds have been isolated from the
headspace of saliva and tongue coating, from
ketones to alkanes and sulfur-containing
compounds to phenyl compounds.
10/23/2018 34oral malodor

35.  The most important advantage of the technique (together
with mass spectrometry) is that it can detect virtually any
compound when using adequate materials and conditions.
Moreover, it has a very high sensitivity and specificity
Portable gas chromatograph- measures and differentiates :
1. hydrogen sulfide,
2. Methymercaptan,
3. Dimethyl sulfide
 Methymercaptan> hydrogen sulfide- periodontitis
 If only hydrogen sulfide increase- poor oral hygiene
 Dimethyl sulfide- extraoral causes
10/23/2018 35oral malodor

36. Dark-Field or Phase-Contrast
Microscopy.
Gingivitis and periodontitis are typically associated
with a higher incidence of motile organisms and
spirochetes, so shifts in these proportions allow
monitoring of therapeutic progress.
Patient becomes aware of bacteria being present in
plaque, tongue coating, and saliva.
10/23/2018 36oral malodor

37. Saliva Incubation Test.
The analysis of the headspace above incubated saliva by gas
chromatography reveals next to VSCs also other compounds
like indole, skatole, lacticacid, methylamine, diphenylamine,
 cadaverine, putrescine, urea, ammonia, dodecanol, and
 tetradecanol.
By adding some proteins, such as lysine or cysteine, the
production of respectively cadaverine or hydrogen sulfide is
 dramatically increased.
Organoleptic evaluation (or assessment of the VSCs) of the
saliva headspace offers promising perspectives for monitoring
treatment results.
It is a less invasive test, especially for the patient, than
smelling breath in front of the oral cavity.
10/23/2018 37oral malodor

38. Electronic Nose
Electronic noses identify the
specific components of an
odor and analyze its chemical
makeup.
They consist of a mechanism
for chemical detection, such
as an array of electronic
sensors, and a mechanism
for pattern recognition.
An artificial nose that has the
same capacities as the
human nose would be ideal.
Tanaka M et al used these
electronic noses to clinically assess
oral malodor and examined the
association between oral malodor
strength and oral health status.
10/23/2018 38oral malodor

39. DIAMOND PROBE
Sensors are integrated
into the periodontal probe.
 Probe is placed directly
into the periodontal pocket or tongue.
 It has an electrical control unit and a disposable sensor
tip that combines a standard Michigan 0 styled dental
probe with a sulphide sensor which responds to the
sulfides present in the periodontal pocket.10/23/2018 39oral malodor

40. Treatment needs for breadth malodor
TN-1 : Explanation of halitosis for oral hygiene (support and
reinforcement of a patient’s own self care for further improvement
of their oral hygiene.
TN-2 : Oral prophylaxis, professional cleaning and treatment of oral
diseases, especially periodontal disease.
TN-3: Referral to physician.
TN-4: Explanation of examination data, further professional
instruction,education and reassurance.
TN-5: referral to clinical psychologist, psychiatrist or other psychology
specialist10/23/2018 40oral malodor

41. TREATMENT OF ORAL MALODOR
As oral malodor is caused by the metabolic degradation of
available proteins to malodorous gases by certain oral
microorganisms, the following general treatment strategies
can be applied:
Mechanical reduction of intraoral nutrients (substrates) and
microorganisms.
Chemical reduction of oral microbial load
Rendering malodorous gases nonvolatile
Masking the malodor
10/23/2018 41oral malodor

42. Mechanical Reduction of Intraoral Nutrients
and Microorganisms
Tongue cleaning:
 Tongue cleaning using a tongue scraper reduced
the halitosis levels with 75% after 1 week. (Pedrazzi
V et al).
It is best to clean as far backward as possible; the
posterior portion of the tongue has the most
coating.
10/23/2018 42oral malodor

43. Interdental cleaning and toothbrushing are essential
mechanical means of dental plaque control.
Periodontitis can cause chronic oral malodor,
professional periodontal therapy is needed.
A one-stage, fullmouth disinfection, combining scaling
and root planing with the application of chlorhexidine,
reduced the organoleptic malodor levels up to 90%.
Quirynen M et al (1998)
In a recent study by Quirynen M et al (2005), initial
 periodontal therapy had only a weak impact on the
VSC levels,except when combined with a mouthrinse
containing chlorhexidine
10/23/2018 43oral malodor

44. Chewing gum may control bad breath temporarily
because it can stimulate salivary flow.
The salivary flow itself also has a mechanical
cleaning capability.
Extremely low salivary flow rate have higher VSC
ratings and tongue coating scores than those with
normal saliva production.
Waler showed that chewing of a gum without any
active ingredient can reduce halitosis modestly.
10/23/2018 44oral malodor

45. Chemical Reduction of Oral Microbial Load
• All these agents have only a temporary reducing
effect on the total number of microorganisms in the
oral cavity.
Chlorhexidine
Essential oils
Chlorine dioxide
Two-phase oil-water rinse
Triclosan
Aminefluoride/stannous fluoride
Hydrogen peroxide
Oxidizing lozenges10/23/2018 45oral malodor

46. Chlorhexidine-
its strong antibacterial effects and superior
substantivity in the oral cavity, chlorhexidine rinsing
provides significant reduction in VSC levels and
organoleptic ratings.
• Rosenberg et al – 0.2% chx regimen produced 43%
reduction in VSC values and greater than 50%
reduction in organoleptic mouth odor ratings.
• Loesche et al – 1 week rinsing with 0.12% chx on
combination with tooth and tongue brushing
reduces VSC level 73%, mouth odor 69% and
tongue odor 78%.10/23/2018 46oral malodor

47. Essential oils:
Listerine was found to be only moderately effective
against oral malodor (25% reduction versus 10% for
placebo of VSCs after 30 minutes) and caused a
sustained reduction in the levels of odorigenic
bacteria.
Chlorine Dioxide.
Chlorine dioxide (ClO2) is a powerful oxidizing agent
that can eliminate bad breath by oxidation of
hydrogen sulfide, methylmercaptan, and the amino
acids(methionine and cysteine)
Studies demonstrated that single use of a ClO2–
containing oral rinse slightly reduces mouth odor10/23/2018 47oral malodor

48. Two-Phase Oil-Water Rinse.
 Rosenberg et al designed a two-phase oil-water
rinse containing CPC.
The efficacy of oil water- CPC formulations is
thought to result from the adhesion of a high
proportion of oral microorganisms to the oil
droplets, which is further enhanced by the CPC. A
twice-daily rinse with this product (before bedtime
and in the morning) showed reductions in both VSC
levels and organoleptic ratings.
10/23/2018 48oral malodor

49. Triclosan
Mouth rinse containing 0.15% triclosan and 0.84%
zinc produced a stronger and more prolonged
reduction in mouth odor than a Listerine rinse.
Aminefluoride/Stannous Fluoride
The association of aminefluoride with stannous
fluoride (AmF/SnF2) resulted in encouraging
reductions of morning breath odor, even when oral
hygiene is insufficient
10/23/2018 49oral malodor

50. Hydrogen Peroxide
Suarez et al reported that rinsing with 3% hydrogen
peroxide (H2O2) produced impressive reductions
+90% in sulfur gases that persisted for 8 hours.
Oxidizing Lozenges.-
Greenstein et al reported that sucking a lozenge
with oxidizing properties reduces tongue dorsum
malodor for 3 hours.
This antimalodor effect may be caused by the
activity of dehydroascorbic acid, which is generated
by peroxide-mediated oxidation of ascorbate
present in the lozenges.
10/23/2018 50oral malodor

51. Conversion of Volatile Sulfur Compounds
Metal Salt Solutions
Metal ions with affinity for sulfur are efficient in
capturing the sulfur-containing gases.
Zinc is an ion with two positive charges (Zn++), which
will bind to the twice– negatively loaded sulfur radicals,
and thus can reduce the expression of the VSCs. The
same applies for other metal ions such as mercury and
copper.
A rinse containing zinc chloride was remarkably more
effective than a saline rinse (or no treatment) in
reducing the levels of both VSCs (+80% reduction ) and
organoleptic scores (+40% reduction ) for 3 hours.10/23/2018 51oral malodor

52. Toothpastes
 Baking soda dentifrices have been shown to confer a significant
odor-reducing benefit for time periods up to 3 hours.
 The mechanisms by which baking soda produces its inhibition of
oral malodor might be related to its bactericidal effects and its
transformation of VSCs to a nonvolatile state.
Chewing Gum.
 Chewing gum can be formulated with antibacterial agents, such as
fluoride or chlorhexidine, thus helping reduce oral malodor
through both mechanical and chemical approaches.
 Waler compared different concentrations of zinc in a chewing gum
and found that a 2-mg Zn++ acetate–containing chewing gum that
remained in the mouth for 5 minutes resulted in an immediate
reduction in the VSC levels of up to 45%, but the long-term effect
was not mentioned.
10/23/2018 52oral malodor

53. Masking the Malodor
• Treatments with rinses, mouth sprays, and
lozenges containing volatiles with a pleasant
odor have only a short-term effect.
10/23/2018 53oral malodor

54. THANK YOU
10/23/2018 54oral malodor