HALITOSIS! WHAT YOU NEED TO KNOW

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Halitosis otherwise known as Oral malodour, bad breath, fetor oris or fetor ex ore is one of the leading causes of patient’s visit to the Dentist.Studies has shown that about 1/3rd of the population is affected by this oral condition.

It is defined as an offensive odour emanating from the mouth or the nose. Halitosis has a large social and economic impact on the majority of patients, because it causes embarrassment and it affects their social communication & life. It can impact negatively on individual resulting in complications such as Suicidal tendencies, Personal discomfort, Social embarrassment, Low self-esteem, Emotional distress, Self rejection, Depression and Depressive disorders.

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The causes of bad breath can be from sources within the mouth or it can also be indicative of an underlying systemic condition. Breath comes from the lungs and exhaled through the bronchi, trachea, larynx, nose or mouth. 90% of cases of halitosis have their origin emanating from the mouth. Gingivitis, periodontitis and especially tongue coating are the predominant causes. However in minority of cases, extra-oral causes can be identified which may include Ear Nose and Throat pathology, systemic diseases such as Diabetes Mellitus, Hormonal problems, Hepatic or Renal insufficiency, Bronchial carcinoma etc.

Classification of halitosis

True halitosis (Genuine halitosis) – Physiologic or pathological halitosis
Pseudo- halitosis (Oral maloldour does not exist but patient believes he has halitosis)
Halitophobia (aka Delusional halitosis/Imaginary halitosis): Patient still feels he has halitosis after treatment even though halitosis is not present (Psychological condition).

Etiology/Predisposing factors

This can be broadly divided into two;

1. Local factors (90%) and 2.Systemic factors (10%).
   Local factors may be physiological or pathological.
   Physiological factors includes
   Lack of flow of saliva during sleep or fasting periods, Food packing—onions, coffee garlic, meat, beans, soya beans, egg, chili pepper, etc, Smoking, Alcohol, Menstruation, Puberty, Stress, Hunger, Fever, and Dehydration etc.
   
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Pathological factors include disorders of the oral cavity e.g. Dental plaque, Dental calculus, Dental caries with large cavities, Gingivitis, Periodontitis, Stomatitis, Material alba, Pericoronitis, Pericoronal abscess, Periodontal abscess, Infections such as ANUG (Acute Necrotizing Ulcerative Gingivitis) , cancrum oris, HIV/AIDS, Dentoalveolar abscess, Gingival abscess, Candidiasis, Coating on the posterior 3rd of the tongue, Osteomyelitis, Actinomycosis, Ludwigs Angina and Dry socket.

Pathogenesis

The pathogenesis of oral malodor involves the production of volatile sulphur compounds such as hydrogen sulphide, methyl mercaptan, dimethyl disulphide and dimethyl sulphide. Other compounds include Putrescine—Rotten meat, Cadaverine-Corps, Butryic acid, Isovaleric acid-sweaty feet, Propionic acid, Acetic acid, indole and skatole. These compounds are produced by over 400 species of bacterial in the oral cavity especially in the dorso-posterior aspect of the tongue, followed by the subgingival plaque, throat, tonsils, etc.

Role of Bacterial

These bacterial are mainly Gram negative anaerobes (Actinobacillus, actinomycete mcomitans, Provotella intermedia, Bacteroides forsythus, Campylobacter species, Peptostreptococcus micros, Porphyromonas gingivalis, Fusobacterium nucleatum, Treponema denticola ), which produce putrefaction as a result of their metabolism. They feed on sulphur containing peptides, and proteins in gingival crevicular fluids, the salivary proteins, epithelial cells, food debris, mucous from the nasal passage (postnasal drip) and proteins and peptides which contain cysteine and methionine to produce the Volatile Sulphur compounds which give off the offensive odour perceived as halitosis.

Diagnosis

For the diagnosis of halitosis, several aspects have to be taken into consideration including medical history and medication, dental history and intra-oral examination, timing of bad breath, evaluation of breath etc. Questions such as; How often a patient brushes,Use of dental floss,Use of mouth rinses,How often scaling and polishing is done by the patient, any history of painful ulcer , any history of systemic diseases and Family and social history to rule out psychogenic cause can be asked. Breath analysis is difficult and the “gold standard” is the organoleptic rating which is quite subjective. Portable devices such as Halimeter or oral chroma canbe used to measure the amount of volatile sulphur gases exhaled, however it also shows significant shortcomings.

Treatment

Treatment challenges may include;

1. To determine if there is halitosis
2. To identify the source of the malodor
3. To estimate the odour
4. To determine if the level of halitosis detected is consistent with the patient’s complaint.
5. To determine if there is psychogenic basis. This sometimes involves a multidisciplinary approach involving the Periodontologist, Oral medicine specialist, Oral pathologist, Restorative Dentist, Oral and Maxillofacial surgeon, Psychotherapist, Respiratologist, Gastroenterologist, Otorhinolaryngologist, etc depending on the identified cause.

Treatment depends on the type of halitosis and the cause but generally, the following steps can be followed;

1. Educate and counsel the patient
2. Stop offending agents
3. Elimination of septic focus or any intra-oral cause found
4. Oral prophylaxis - scaling and polishing, oral hygiene instructions, plaque control, flossing, tongue scrapping.
5. Use of antibacterial mouth rinses e.g. chlorhexidine
6. Psychiatric counseling
7. Regular recalls and check up
8. Referral to appropriate quarters if extra-oral cause is identified.

References

1. ADA Council on Scientific Affairs. J Am Dent Assoc. 2003;134 ( 2): 209 – 214.
2. SR Porter, C Scully. OralMaolodour (Halitosis). BMJ 2006; 333:632 – 635.
3. Lee SS, Zhang W, Li Y. Halitosis Update: A Review of Causes, Diagnosis and Treatments. CDA Journal. 2007; 35(4): 259 – 268