This document provides an overview of halitosis (bad breath), including its classification, etiology, diagnosis, and management. It discusses the role of volatile sulfur compounds and certain bacteria in causing halitosis. Diagnostic tools include organoleptic measurement, gas chromatography, and volatile sulfide monitoring to detect these compounds. Treatment involves identifying and addressing the underlying causes, such as periodontal disease, dry mouth, dental caries, or systemic conditions. Preventive measures focus on proper oral hygiene and avoiding foods that can cause temporary halitosis.

1. 1

2. GUIDED BY:-
Dr. Anita Panchal
Dr. Hardik Mehta
Dr. Sachin K.
Dr. Bhaumik
Nanavati
PRESENTED BY:-
Dr. Ganesh Nair
First Yr. PG
Dept. of Periodontology
and Implantology 2

3. INDEX
• Introduction
• Classification
• Etiology
• Intra oral causes
• Extra oral causes
• Role of volatile sulphur compounds in the pathogenesis of halitosis
• Correlation between the presence of a pathogenic microflora in the
subgingival microbiota and halitosis
• Diagnosis of malodor
• Preventive measures
• Treatment needs
• Management of oral malodour
• Conclusion
• References 3

4. INTRODUCTION
 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.
 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
 Originates from two Latin words
 Halitus → breath
 Osis → disease
4

5. SYNONYMS
 Bad or foul breath
 Breath malodour
 Oral malodour
 Foetor ex-ore
 Foetor oris
 Stomato dysodia
5

6. DEFINITIONS
 Halitosis is also termed as fetor ex ore or fetor oris. It is a foul or
offensive odor emanating from the oral cavity.
 Carranza’s clinical periodontology 10th edition
 Unpleasant odor of the expired air whatever the origin may be. Oral
malodor specifically refers to such odor originating from the oral cavity
itself.
 Clinical periodontology and implant dentistry 5th edition
6

7. HALITOSIS: Oral odor that is unpleasant or offensive to others. Caused by
a variety of factors including periodontal disease, xerostomia, bacterial
or fungal coating of tongue or dental prostheses (dentures), systemic
disorders (e.g., diabetes, upper respiratory infections), different types of
food, and use fo tobacco products. Also known as fetor ex ore, fetor oris,
and stomatodysodia, and commonly referred to as "bad breath".
-American academy of periodontology: Glossary
7

8. CLASSIFICATION
Pseudo halitosis
Genuine halitosis
Physiological
halitosis
Tongue coating
Pathological
halitosis
Periodontium
ANUG
ANUP
Periodontitis
Others
Xerostomia
Caries
Temporary
halitosis(morning
bad breath)
Lu, D.P. (1982). Halitosis: an etiologic
classification, a treatment
approach, and prevention. Oral Surgery,
Oral Medicine and
Oral Pathology 54, 521–526. 8

9. GENUINE 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.
9

10.  Pseudo halitosis
 Apparently healthy individuals
 Haltophobia
 exaggerated fear of having halitosis
 also referred as delusional halitosis
 considered variant of monosymptomatic hypochondrial psychosis or
Ekbom syndrome.
10

11. ETIOLOGY:-
 Intra oral origin- 80-90%
 poor oral hygiene, dental caries, periodontal diseases in particular
NUG, NUP, periodontitis, pericoronitis, dry socket, other oral
infections, tongue coating & oral carcinoma.
11

12.  The role of tongue coatings in the
aetiology of oral malodour has been
extensively documented.
 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
malodour
12

13.  Extra oral origin-10-20%
 gastro intestinal diseases
 infections or malignancy in respiratory tract
 Chronic sinusitis and tonsillitis
 stomach, intestine, liver or kidney affected by systemic diseases
13

14.  Common causes of halitosis
 1) Local Causes
Oral
diseases
Food
impaction
ANUG
Acute
gingivitis
Adult and
aggressive
periodontitis
Pericoronitis
Dry socket
Xerostomia
Oral
ulceration
Oral
malignancy
A.
14

15. B.
15

16. VOLATILE
FOOD
STUFF
GARLIC ONIONS SPICES
C.
16

17. 2) SYSTEMIC CAUSES
 Acute febrile illness
 Leukemia
 Respiratory tract infection
(usually upper)
 Helicobacter pylori infection
 Pharyngo-oesophageal
diverticulum
 Gastro-oesophageal reflux
disease
•Pyloric stenosis or duodenal
obstruction
•Hepatic failure (fetor
hepaticus)
•Renal failure (end stage)
•Diabetic ketoacidosis
•Trimethylaminuria
•Hypermethioninaemia
•Menstruation (menstrual
breath) 17

18. EXAMPLES OF SYSTEMIC PATHOLOGICAL
CONDITIONS WITH THEIR
CHARACTERISTIC ODOUR
Systemic diseases Characteristics odour
Diabetes mellitus Acetone , sweet fruity.
Renal failure Urine or ammonia
Liver failure Fresh cadaver
Tuberculosis/ lung abscess Foul, putrefactive
Internal hemorrhage/ blood disorders Decomposed blood
Fever , dehydration Odour due to xerostomia and poor oral
hygiene.
18

19. 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 Fatty Acids - Butyric, Propionic, Valeric & Isovaleric acid.
 Others - Acetone, Acetaldehyde, Ethanol diacyl.
19

20.  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 maturation.
 It increases the secretion of collagenases, prostaglandins from
fibroblasts.
 Which in turn increases the collagen solubility.
 VSC also reduce the intracellular pH; inhibit cell growth, and
periodontal cell migration.
 It decrease the DNA synthesis.
20

21. ODOUR QUALIFICATION OF SOME COMPOUNDS
Tangerman, A. (2002). Halitosis in medicine: a review. International
Dental Journal 52 (Suppl 3), 201–206. 21

22. PATHOGENESIS OF ORAL MALODOR:
Diet
+bacteria+
epithelial
cells
Peptides/
proteins Amino acids
Putrefaction
products
Oral
malodor
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A
silent affliction!. Chron Young Sci 2012;3:251-7.
22

23. CORRELATION BETWEEN THE PRESENCE OF A
PATHOGENIC MICROFLORA IN THE SUBGINGIVAL
MICROBIOTAAND 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.
23

24.  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 exudate
 Recent studies indicate the presence of solobacterium moorei
associations with oral malodour
-Haraszthy VI, Gerber D, Clark B et al
24

25. MICROORGANISMS AND THEIR CAUSATIVE
ODOUR
25

26. SOME DRUGS THAT CAUSE HALITOSIS
 Tobacco
 Alcohol
 Chloral hydrate
 Nitrites and nitrates
 Dimethyl sulfoxide
 Disulfiram
 Cytotoxic agents
 Phenothiazines
 Amphetamines
26

27. DIAGNOSIS
 Self assessment tests(subjective 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 himself/herself.
27

28. 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.
Image courtesy- taken from Carranza’s
Clinical Periodontology, 10th Edition
28

29. Spoon test
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 about5
cm organoleptically.
29

30. Dental floss test
Unwaxed floss is passed through interproximal contacts.
30

31. OBJECTIVE TESTS
 Organoleptic measurement
 Gas chromatography (GC)
 Sulphide monitoring
 Electronic nose
 BANA test
 Tongue costing index
 Dark Field or Phase Contrast Microscopy
 Saliva Incubation Test
31

32. INSTRUCTIONS BEFORE FIRST VISIT
In these instructions, subjects are asked not to:
 1) take antibiotics for 8 weeks before assessment;
 2) consume food containing onions, garlic or hot spices for 48 hours
before the baseline measurements;
 3) drink alcohol or smoke in the previous 12 hours;
 4) eat and drink in the previous 8 hours (drinking water up to 3 hours
before examinations is allowed);
32

33.  5) perform oral hygiene, including tooth brushing, interdental and
tongue cleaning, and not to use mouthrinses the morning of the
examination;
 6) use scented cosmetics or after-shave lotions on the morning of the
examination.
If the patient has any condition like diabetes, which will be
aggravated by fasting for the period of time indicated, please contact the
dentist about alternative methods of preparation.
33

34. 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.
34

35. METHODOLOGY
 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
score.
 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.
35

36. 36
Image
courtesy-
Clinical
periodontology
and implant
dentistry 5th
edition and

37. ORGANOLEPTIC SCORES (0- 5) BY
ROSENBERG , MULLOCH ET AL 1991
Yaegaki, K. & Coil, J.M. (2000). Examination, classification, and
treatment of halitosis; clinical perspectives. Journal of the
Canadian Dental Association 66, 257–261. 37

38. VOLATILE SULFIDE MONITOR:
 This electronic (Haiimeter, InterScan, Chatsworth, Calif) analyzes
concentration of hydrogen sulfide and methyl-mercaptan , but without
discriminating between them.
Image courtesy- taken from Carranza’s
Clinical Periodontology, 10th Edition 38

39. GAS CHROMATOGRAPHY (GC):
 GC, performed with apparatus equipped with a flame photometric
detector, is specific for detecting sulphur in mouth air.
 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 volatile
component.
39

40. Image courtesy- taken from Carranza’s
Clinical Periodontology, 10th Edition
40

41. HALITOXTM
SYSTEM:
 Quick and simple
 It detects both VSC and polyamines in the sample.
 The absorbent point given with the kit is inserted into the pocket.
 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
0-3, which is directly proportional to the level of toxins in the sample.
HALITOX - HALITOSIS LINKED TOXIN DETECTION ASSAY, BY
PENDERGRASS, JAMES, CURTIS
41

42. Image courtesy- Google
images 42

43. ELECTRONIC NOSE:
 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.
Image courtesy-
Google images 43

44. BANA TEST:
 Used to determine the proteolytic activity of certain oral anaerobes that
contribute to oral malodor.
 The test works on the principle that certain periopathogenic bateria have
the capability to reduce N-benzoyl DL-arginine β-napthylamide(BANA)
which can be detected using a chair side test.
Image courtesy-
Google images44

45. 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.
 Another advantage of direct microscopy is that the patient becomes
aware of bacteria being present in plaque, tongue coating, and saliva.
45

46. SALIVA INCUBATION TEST
 0.5 ml of unstimulated saliva is collected in a glass tube (diameter 1.5
cm) and
 the tube is flushed with carbon dioxide (CO2) and sealed.
 It is incubated at 37° C in an anaerobic chamber under an atmosphere of
80% nitrogen, 10% carbon dioxide, and 10% hydrogen over 3 hours.
 The organoleptic ratings highly correlate with VSC and organoleptic
rating of the patient's breath.
 Applying the saliva incubation test instead of organoleptic ratings can
reduce the number of patients needed to reach statistical significance of
50%. 46

47. TONGUE COATING INDEX
Miyazaki et al. (1995) divides the tongue into three
sections and the presence or absence of tongue
coating is registered as follows:
0 = none visible;
1 = less than one third of tongue dorsum is covered;
2 = between one and two thirds;
3 = more than two thirds.
(Miyazaki et al. 1995; Gomez et al. 2001; Winkel et al. 2003; Lundgren et
al. 2007).
47

48. 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.
48

49.  Flossing after brushing to remove food particles stuck in between the
tooth surfaces.
 Limit intake of strong odour spicies.
 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.
49

50. 50

51. MANAGEMENT OF ORAL MALODOUR:-
(i) Mechanical reduction of intraoral nutrients and micro-organisms
(ii) Chemical reduction of oral microbial load
(iii) Rendering malodorous gases nonvolatile
(iv) Masking the malodor.
(v) Use of a confidant
51

52. 1. Mechanical reduction of intraoral nutrients and micro-organisms
- Tongue cleaning
- Tooth brush
- Inter-dental cleaning
- Professional periodontal therapy
- Chewing gum
Image courtesy- Google images52

53. 2. Chemical reduction of oral microbial load
- Chlorhexidine
- Essential oils
- Chlorine dioxide
- Two-phase oil- water rinse
- Triclosan
- Aminefluoride/ Stannous fluoride
- Hydrogen peroxide
- Oxidising lozenges
Image
courtesy- 53

54. 3.Conversion of volatile sulfide compounds
- Metal salt solutions (eg of metal salts
HgCl2=CuCl2=CdCl2>ZnCl2>SnF2>SnCl2>PbCl2
- Toothpastes
- Chewing gum
Image courtesy-
Google images
54
Young A, Jonski G, Rolla G, et al:Effects of metal salts on the oral production
of volatile sulfur containing compounds(VSCS). J Periodontal 28:776,2001

55. 4. Masking the malodor
-Rinses
-Mouth sprays
-Lozenges containing volatiles
-Chewing gum
Image courtesy- Google images55

56. 5. Use of a Confidant
 Research shows that the patients are generally unable to rate the
intensity of their own halitosis.
-Rosenberg et al 1995
 Therefore, the patient cannot reliably assess the effectiveness of the
prescribed therapy.
 The recommended course of action is to ask them to use another person
as a confidant.
 A confidant could be a spouse, a family member or a close friend, who
is willing to smell the patient’s breath and provide straightforward
feedback.
56

57. CONCLUSION:
 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
57

58. REFERENCES:
 Newman ,Takei, Carranza. Clinical periodontology ; 10th and 11th edition
 J lindhe. Clinical periodontology and implant dentistry; vol 1: 5th edition
 British Dental Association, Bad Breath FactFile. April 2008.
 Yaegaki K, Coil JM. Genuine halitosis, pseudo-halitosis and halitophobia:
classification, diagnosis, and treatment. Compend Cont Educ Dent 2000;
21(10A):880–886.
 Vineet vaman kini, Richard pereira, Ashvini Padhve, Sachin Kanagotagi,
Tushar Pathak, Himani Gupta 10.5005/jp-journals-10031-1018; review
article; Diagnosis and treatment of Halitosis: An Overview
 Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron
Young Sci 2012;3:251-7.
 HALITOX - HALITOSIS LINKED TOXIN DETECTION ASSAY, BY
PENDERGRASS, JAMES, CURTIS, 2001
 Young A, Jonski G, Rolla G, et al:Effects of metal salts on the oral production of volatile
sulfur containing compounds(VSCS). J Periodontal 28:776,2001
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