By Dr Anand Induchoodan
Halitosis is an embarrassing condition that affects a person’s self confidence. It is usually caused by bad oral hygiene. Breath odour can be defined as the subjective perception after smelling some one’s breath.
If un-pleasant the term oral malodor, halitosis or bad breath can be applied. Breath malodor should not be confused with the momentarily disturbing odour caused by food intake (eg: onion, garlic etc) or smoking, because these odours do not reveal a health problem.
The same is true for ‘morning’ malodor which is caused by reduced salivary flow and increased putrefaction during night and disappears after proper oral hygiene.
Etiology
The unpleasant smell of breath mainly originates from volatile sulfide compounds (Vsc), especially hydrogen sulfide, methyl mercaptan and di methyl sulfide. Most of these products results from the proteolytic degradation of peptides in saliva, shed epithelieum, food debris gingival crevicular fluid and blood by the micro organisms.
The possible cause of oral malodor can be broadly classified in to:
1. Intra oral cause.
2. Extra oral cause.
Intra oral cause
Dentition: Deep carious lesion, extraction wounds filled with blood clot and purulent discharge from an abscess are some of the causes for malodor. Inter dental food impaction and crowding of teeth favours food entrapment and accumulation of debris. Acrylic dentures when kept in mouth at night and not regularly cleaned can produce a typical smell associated with candidiasis.
Periodontal infection: Bacteria associated with gingivitis and periodontitis are all most gram negative and are known to produce volatile sulfide compounds. One of the clinical signs of periodontal infection is periodontal pocket. The low oxygen tension in deep periodontal pocket along with the lowered Ph results in the decarboxylation of amino acids to malodor compounds.
Not all patients with gingivitis and periodontitis complain of malodor and vice versa. Other relevant periodontal infections which can cause malodor are pericoronitis (inflammation of the soft tissue covering the unerupted or partially erupted third molar tooth), recurrent oral ulceration and viral infection.
Dry mouth: Patients with xerostomia (dry mouth) often present with large amount of plaque on teeth, prosthesis and dorsum of tongue. The increased microbial load and the escape of volatile sulfide compounds as gases when saliva is drying up explain the strong malodor breath in these individuals.
Tongue and tongue coating: Accumulation of food remnants intermingled with bacteria causes a coating on the tongue dorsum. The debris cannot be easily removed .The dorsum of the tongue can be considered as the primary source of oral malodor.
Extra oral cause
Ear Nose Throat (ENT problems): ENT causes that can cause halitosis are acute pharyngitis, purulent sinusitis and post nasal dip. Tonsillitis is another condition which can cause a bad odour.
Lung diseases: Lung diseases like chronic bronchitis and bronchial carcinoma can cause malodor in patient’s breath.
Gastro intestinal tract: The following gastro intestinal pathologies might be responsible for less than 1% of malodor causes:
1. Zenker s diverticulum
2. Gastric hernia
3. Regurgitation esophagitis.
Liver: Liver insufficiency such as liver cirrhosis results in accumulation of ammonium in the blood and will be exhaled resulting in a malodor breath.
Kidney: Kidney insufficiency mainly leads to increased uric acid level in the blood which is expressed in the expired air with a typical ammonium like breath.
Systemic metabolic disorder: Diabetes in particular can result in accumulation of ketones; perception of breath malodor may provide a clue to its diagnosis.
Hormonal causes: Increase progesterone level during menstrual cycle can results in a typical breath odour.
Medication: Drugs such as metranidazole can cause breath malodor. Eucalyptus containing medications impart a melon like odour. Arsenic smells like rotten onions.
Diagnosis
It’s easy to self-diagnose bad breath. You can lick your wrist, let it dry for a few seconds and smell the area, or cup your hands over your mouth and sniff your own breath. If you need a second opinion, ask a friend, family member, or your physician or dentist. A proper diagnosis starts with a thorough questioning about the medical history. Some of the methods which are used to diagnose oral malodor are:
Clinical and laboratory examination: There are various methods by which oral malodor can be detected, some of them are:
1. Self examination.
2. Organoleptic rating
3. Portable volatile sulfide monitor.
4. Gas chromatography.
5. Saliva incubation test
6. Electronic nose.
Treatment
The treatment should be cause related .The following general treatment strategies are applied.
1. Mechanical reduction of intra oral nutrients and micro organisms.
2. Chemical reduction of oral microbial load.
3. Rendering mal odorous gas non–volatile.
4. Masking the malodor.
Mechanical reduction of intra oral nutrients and micro organisms
Because of the extensive accumulation of micro organisms and debris on the dorsum of the tongue, tongue cleaning has been emphasised. Cleaning can be carried out with a normal tooth brush. This should be gentle to avoid soft tissue damage. Interdental cleaning and tooth brushing are essential mechanical means of dental plaque control. Because periodontitis causes chronic oral malodor professional periodontal therapy is needed.
Chemical reduction of oral microbial load
Mouth rinsing with active ingredients helps in reducing the malodor. The active anti microbial agents used are chlorhexidine, cetyl pyridnium chloride (cpc), essential oil, hydrogen peroxide, and triclosan. All these agents have only a temporary reducing effect on the total number of microorganisms.
Tooth paste: Baking soda dentifrices have been shown to be effective with reduction of volatile sulfide compounds (VSC). Baking soda transfers VSC to non volatile state.
Chewing gums: Chewing gums can be formulated with anti bacterial agents such as fluoride and chlorhexidine thus reducing oral micro organisms by both mechanical and chemical approaches. Increasing the secretion of saliva can be achieved by using a chewing gum, which triggers the periodontal parotid reflex. Lowering the ph of saliva also result in masking these malodors this can be achieved by orange juice but the effect is short term.
Some patients suffer from halite phobia. These patients have the delusion that they suffer from bad breath when it is not actually present. They get obsessed with cleaning their mouth repeatedly with mouthwashes and keep using chewing gums and mints. They also try to keep their distance from others and avoid social interactions. These patients require psychological counselling.
Home remedies
m Brush your teeth 3 times a day and floss once daily.
m Clean your tongue before bedtime by scraping with a plastic tongue cleaner or brushing gently.
m Prevent hunger breath by eating regularly and avoiding fasting or skipping meals.
m Ask your dentist to recommend a specific cleaning system that can help clean your mouth more thoroughly than with just regular brushing.
m Keep your nose and sinuses clean.
m Stimulate saliva flow with acidic fruits such as oranges and lemons or sugarless citric gums and candy.
m Eat more fibrous foods. Chew fibrous vegetables such as parsley and wintergreen to stimulate saliva flow.
m Drink at least 8 glasses of water daily to keep your mouth moist and to help rinse away odour - forming bacteria.
m Decrease alcohol and coffee intake.
m Ask your doctor whether your medications are causing problems of dry mouth that may be leading to bad breath.
m When chewed slowly, parsley and cinnamon are the natural home bad odour remedies.
m Do consult your physician to rule out extra oral causes.
Dr Anand Induchoodan is a specialist-periodontist at Aster Medical Centre in Al Khor.