A seminar on
Dr. Dandu Sivasai prasad
I Year M.D.S
Department of periodontics
Mamata dental college
– Intra oral causes
– Extra oral causes
• Role of volatile sulphur
compounds in the pathogenesis
• Association between halitosis
and periodontal disease
• Correlation between the
presence of a pathogenic
microflora in the subgingival
microbiota and halitosis
• Diagnosis of malodor
• Preventive measures
• Treatment of oral malodor
• Halitosis is a general term used to define an unpleasant or
offensive odour emanating from the breath regardless of
whether the odour originates from oral or non-oral sources.
• Originates from two Latin words
– Halitus → breath
– Osis → disease
• It was described as a clinical entity by HOWE (1874).
• Halitosis should not be confused with the generally
temporary oral odour caused by intake of certain foods,
tobacco, or medications.
• Bad or foul breath
• Breath malodour
• Oral malodour
• Foetor ex-ore
• Foetor oris
• Stomato dysodia
• Halitosis is the general term used to describe a foul odor emanating from the
oral cavity, in which proteolysis, metabolic products of the desquamating cells
and bacterial putrefaction are involved.
– Marita et al., 2001
• Halitosis is the general term used to describe any disagreeable odor in expired
air, regardless of whether the odorous substances originate from oral or non-
• Halitosis is also termed as fetor ex ore or fetor oris. It is a foul or offensive
odor emanating from the oral cavity.
• Unpleasant odor of the expired air whatever the origin may be. Oral malodor
specifically refers to such odor originating from the oral cavity itself.
– Jan Lindhe(2003)
• Breath malodor, defined as foul or offensive odor of expired air,
may be caused by a number of factors, both intra-oral & extra-oral
(gingivitis/ periodontitis, nasal inflammation, chronic sinusitis,
diabetes mellitus, liver insufficiency etc.,) & can be linked to
more serious underlying medical problems including primary
biliary cirrhosis, uremia, lung carcinoma, decompensated liver
cirrhosis & trimethylaminuria.
– Quirynen, Zhao, Avontroodt et al., 2003
• Odors are essential clues in the creation & conservation of
social bonds, as they are loaded with cultural values. The
problem of halitosis has been reported for many years.
References were found in papyrus manuscripts dating back
to 1550 BC.
• During Christianity, the devil's supreme malignant odor
smelled of sulfur & it was presumed that sins produced a
more or less bad smell.
• A treaty in Islamic literature from the year 850 talked
about dentistry, referring to the treatment of fetid breath &
recommended the use of siwak when breath had changed
or at any time when getting out of bed.
• Buddhist monks in Japan also recommended teeth
brushing & tongue scraping before the first morning
• The Hindus consider the mouth as the body's entry door
and, therefore, insist that it be kept clean, mainly before
prayers. The ritual is not limited to teeth brushing, but
includes scraping the tongue with a special instrument and
– Anand Choudhary, 2012
• Bad breath has been a common problem for thousands of years.
• It is a considerable social problem.
- Its incidence remains poorly documented in most countries.
- In vast majority- The cause is originated from the oral cavity
i.e. gingivitis, periodontitis, and tongue coating.
• Japan study 2,672 Individuals 6-23% of subjects had oral
malodour (VSC) as in expired air at some period during
the day (Miyazaki 1996).
• Another study in the United States involving individuals
older than 60 years found 24% had oral malodour
• The prevalence of persistent oral malodor in a Brazilian
study was reported to be 15%, was nearly three times
higher in men than in women (regardless of age) and the
risk was slightly more than three times higher in people
over 20 years of age compared with those aged 20 years
or under, controlling for gender .
• Genuine halitosis
• Physiologic halitosis
• Pathologic halitosis
• Pseudo halitosis
• Physiological halitosis
– Morning breath odour, tobacco smoking & certain
foods & medications.
• Pathological halitosis
– intra oral or extra oral origin
– 90% of patients → oral cavity
– Bacteria, volatile sulphur compounds.
• Intra oral origin
– poor oral hygiene, dental caries, periodontal diseases in
particular NUG, NUP, periodontitis, pericoronitis, dry
socket, other oral infections, tongue coating & oral
• The role of tongue coatings in the
aetiology of oral malodour has been
• Tongue coatings include desquamated
epithelial cells, food debris, bacteria and
salivary proteins and provide an ideal
environment for the generation of VSCs
and other compounds that contribute to
• Extra oral origin
– gastro intestinal diseases
– infections or malignancy in respiratory tract
– Chronic sinusitis and tonsillitis
– stomach, intestine, liver or kidney affected by systemic
Examples of systemic pathological conditions
that cause halitosis
• Diabetes mellitus
• Renal failure
• Liver failure
• Tuberculosis/ lung abscess
• Internal hemorrhage/ blood
• Fever , dehydration
• Acetone , sweet fruity.
• Urine or ammonia
• Fresh cadaver
• Foul, putrefactive
• Decomposed blood
• Odour due to xerostomia
and poor oral hygiene.
-Lu DP.oral surgery 1982;54:521-526
• Pseudo halitosis
– Apparently healthy individuals
– exaggerated fear of having halitosis
– also referred as delusional halitosis
– considered variant of monosymptomatic hypochondrial
• Halitosis generally arises as a result of the bacterial
decomposition of food particles, cells, blood and some
chemical compounds of the saliva.
– Moss, 1998
• Volatile sulphur compounds → hydrogensulphide [H2S,
rotten egg smell], dimethyl sulphide [(CH3)2S, rotten
cabbage smell, and methyl mercaptan [CH3SH, fecal
• Non - sulphur containing substances → diamines
[cadaverine (cadaver smell) and putrescine (rotting meat
smell), acetone and acetaldehyde
• Food impaction
• Acute necrotising
• Acute gingivitis
• Adult and aggressive
• Dry socket
• Oral ulceration
• Oral malignancy
Common causes of halitosis
1) Local Causes
B. Respiratory disease
C. Volatile foodstuffs
• Spiced foods
• Acute febrile illness
• Respiratory tract infection
• Helicobacter pylori infection
• Gastro-oesophageal reflux disease
• Pyloric stenosis or duodenal
• Hepatic failure (fetor hepaticus)
• Renal failure (end stage)
• Diabetic ketoacidosis
• Menstruation (menstrual breath)
2) SYSTEMIC CAUSES
Role of volatile sulphur compounds in
the pathogenesis of halitosis
Major compounds implicated in halitosis
• VSC’s - Methylmercaptan, Hydrogen sulfide, dimethyl
sulfide & Dimethyl disulfide.
• Polyamides - Putrescein, Cadaverine, Skatole, Indole.
• Short chain FA - Butyric, Propionic, Valeric & Isovaleric
• Others - Acetone, Acetaldehyde, Ethanol diacyl.
• It increases the permeability of oral mucosa and crevicular
epithelium. It impairs oxygen utilization by host cells, and
reacts with cellular proteins, and interferes with collagen
• It also increases the collagen solubility.
• It decrease the DNA synthesis.
• It increases the secretion of collagenases, prostaglandins from
• VSC reduce the intracellular pH; inhibit cell growth, and
periodontal cell migration.
Diet, bacteria, epithelial
Pathogenesis of oral
CORRELATION BETWEEN THE PRESENCE OF A
PATHOGENIC MICROFLORA IN THE SUBGINGIVAL
MICROBIOTA AND HALITOSIS:
• In 1981, Pitts et al studied the correlations between odor
scores and microbiological findings in crevicular samples of
periodontally healthy subjects. They found that odor scores
were significantly correlated with the concentration of
overall bacterial populations and that higher levels of
crevicular bacteria were associated with greater odor scores.
• In patients with periodontitis, more sulfur-containing
protein substrate is available through increased exfoliation
of epithelial cells and crevicular effusion of leukocytes.
• Sato and colleagues found that the number of leukocytes
increased in the saliva of patients with periodontitis and
that the level of methyl mercaptan produced correlated
with bleeding on probing, pocket depth and gingival
Self assessment tests
Whole mouth malodor (Cupped breath)
The subjects are instructed to smell the odor emanating
from their entire mouth by cupping their hands over their
mouth and breathing through the nose. The presence or
absence of malodor can be evaluated by the patient
Wrist lick test
Subjects are asked to extend their tongue and lick their
wrist in a perpendicular fashion. The presence of odor is
judged by smelling the wrist after 5 seconds at a distance
of about 3 cm.
Plastic spoon is used to scrape and scoop material from the
back region of the tongue. The odor is judged by smelling
the spoon after 5 seconds at a distance of about 5 cm
Dental floss test
Unwaxed floss is passed through interproximal contacts.
Saliva odor test
Involves having the subject expectorate approx. 1-2 ml of
saliva into a petridish. The dish is covered immediately,
incubated at 370
C for five minutes and then presented for
odor evaluation at a distance of 4 cm from the examiner’s
• Organoleptic measurement
• Gas chromatography (GC)
• Sulphide monitoring
Organoleptic measurement (sniff test)
• Organoleptic measurement is a sensory test scored on the basis of the
examiner’s perception of a subject’s oral malodor.
• Organoleptic measurement can be carried out simply by sniffing the
patient’s breath and scoring the level of oral malodor.
• By inserting a translucent tube (2.5 cm diameter, 10 cm length) into
the patient’s mouth and having the person exhale slowly, the breath,
undiluted by room air, can be evaluated and assigned an organoleptic
• The tube is inserted through a privacy screen (50cm-70cm) that
separates the examiner and the patient. The use of a privacy screen
allows the patient to believe that they have undergone a specific
malodor examination rather than the direct-sniffing procedure.
• Organoleptic Scores (0- 5) By Rosenberg , Mulloch Et
• 0 - No appreciable odor
• 1 - Barely noticeable odor
• 2 - Slight but noticeable odor
• 3 - Moderate odor
• 4 - Strong odor
• 5 - Extremely foul odor
Yaegaki & coil 2000
VOLATILE SULFIDE MONITOR:
• This electronic (Haiimeter, InterScan, Chatsworth, Calif)
analyzes concentration of hydrogen sulfide and methyl-
mercaptan , but without discriminating between them.
Gas Chromatography (GC):
• GC, performed with apparatus equipped with a flame
photometric detector, is specific for detecting sulphur in mouth
• It measures directly the three VSC methyl mercaptan,
hydrogen sulfide and dimethyl sulfide.
• GC is considered the gold standard for measuring oral malodor.
• This device can analyze air, saliva, crevicular fluid for a
Ninhydrin method of detecting amine compounds:
• Iwanicka et al (2005) showed that amine levels were
higher in the saliva of subjects suffering from halitosis and
lower in healthy controls.
Tanaka M et al used
these electronic noses to
clinically assess oral
malodor and examined the
association between oral
malodor strength and oral
Quick and simple
Detects VSCs and poly amines
It detects both VSC and polyamines in the sample.
The absorbent point given with the kit is inserted into the
Left in place for 1 minute.
Submerge the absorbent point tip in the toxin reagent .
Wait for 5 minutes and see for yellow color in the specimen on
the scale of 0-5, which is directly proportional to the level of
toxins in the sample.
Used to determine the
proteolytic activity of
certain oral anaerobes
that contribute to oral
Preventive measures rather than curative aspects are highly
– 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.
– Flossing after brushing to remove food particles stuck in
between the tooth surfaces.
– Limit intake of strong odour species.
– Limit sugar and caffeine intake.
– Drink plenty of liquids.
– Chew sugar free gum for a minute when mouth feels dry.
– Eat fresh fibrous vegetables such as carrots.
• Treatment needs (TN) for halitosis have been categorized into 5
classes in order to provide guidelines for clinicians in treating halitosis
• Treatment of physiologic halitosis (TN-1),
• Oral pathologic halitosis (TN-1 and TN-2), and
• Pseudo-halitosis (TN-1 and TN-4) should be the responsibility of a
• However, treatment of extra-oral pathologic halitosis (TN-3) or
halitophobia (TN-5) should be undertaken by a physician or medical
specialist such as a psychiatrist or psychologist.
(i) Mechanical reduction of intraoral nutrients and micro-
(ii)Chemical reduction of oral microbial load
(iii) Rendering malodorous gases nonvolatile
(iv) Masking the malodor.
1. Mechanical reduction of intraoral nutrients and micro-organisms
- Tongue cleaning
- Tooth brush
- Inter-dental cleaning
- Professional periodontal therapy
- Chewing gum
2. Chemical reduction of oral microbial load
- Essential oils
- Chlorine dioxide
- Two-phase oil- water rinse
- Aminefluoride/ Stannous fluoride
- Hydrogen peroxide
- Oxidising lozenges
-Roldan S 2005,2004,2003 scully 2006
3.Conversion of volatile sulfide compounds
- Metal salt solutions
- Chewing gum
4. Masking the malodor
-Lozenges containing volatiles
Herbs and essential oils can be made into very effective mouthwash
remedies to sweeten breath and help keep gums and teeth healthy
fennel not only improves digestion, but also can reduce bad
breath and body odor that originates in the intestines.
Give raw carrots as a midday treat to help scour teeth of bacteria-
laden plaque, a common cause of bad breath.
Cardamom tea contains cineole, a potent antiseptic that kills bad-
breath bacteria and sweetens breath.
Thymol, one of the constituents of thyme, is contained
in antiseptic mouthwashes.
Neem leaf powder can be used as an effective tooth
powder to fight plaque and gingivitis when mixed with
astringent herb powders and/or baking soda.
A few drops of Tea tree oil , lemon or peppermint essential
oils can be added to warm water for an effective mouth
rinse to freshen breath
• It’s a common complaint that may periodically affect most
of the adult population. Oral maldor, which is commonly
noticed by patients, is an important clinical sign and
symptom that has many etiologies which include local and
systemic factors. It is often difficult for the clinician to
find the underlying pathologies.
• Although consultation and treatment may result in
dramatic reduction in bad breathe, patients may find it
difficult to sense the improvement themselves
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The dorsum of the tongue provides a suitable environment
for the growth of these anaerobic organisms,as favourable redox potentials are found in the deep crypts of the tongue associated with the structure of the papilla