the oral biology of bad breath l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
The oral biology of bad breath PowerPoint Presentation
Download Presentation
The oral biology of bad breath

Loading in 2 Seconds...

play fullscreen
1 / 22

The oral biology of bad breath - PowerPoint PPT Presentation


  • 277 Views
  • Uploaded on

The oral biology of bad breath. DENT 5301 Introduction to Oral Biology Dr. Joel Rudney. Why is it important?. Mouth odor can be a sign of undiagnosed disease Mouth odor has negative connotations in many cultures Affects patient's self-image Affects others’ attitudes towards patient

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'The oral biology of bad breath' - benjamin


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
the oral biology of bad breath

The oral biology of bad breath

DENT 5301

Introduction to Oral Biology

Dr. Joel Rudney

why is it important
Why is it important?
  • Mouth odor can be a sign of undiagnosed disease
  • Mouth odor has negative connotations in many cultures
    • Affects patient's self-image
    • Affects others’ attitudes towards patient
  • Bad breath is big business
    • Mouthwashes, mints, drops, gums, toothpastes
    • Commercials reinforce existing attitudes
  • Dentists are consulted for advice, treatment
    • Active marketing of "breath treatment clinic" franchises
what smells
What smells?
  • Products of bacterial activity
    • Volatile sulfur compounds (VSC)
      • Hydrogen sulfide (H2S) - rotten eggs
      • Methyl mercaptan (CH3SH) - natural gas
      • Major components of mouth odor in most persons
    • Cadaverine - diamino acid - spoiled meat
      • Also important
      • Produced independently of VSC
    • Organic acids - goaty smells
      • Acetic, propionic, butyric, isovaleric
what smells too
What smells too?
  • Products of metabolic activity
    • Volatile food components
      • Garlic, onions, etc.
      • Broccoli, cauliflower (sulfur-rich)
    • Ketones (acetone)
      • Low carb diets
    • Trimethylamine (fishy odor)
  • Tobacco smoke
  • Beer, wine, and liquor
how much does it smell
How much does it smell?
  • Instruments for odor detection
  • Gas chromatography of breath samples
    • Most informative
    • Extremely sensitive and precise
    • Expensive and cumbersome
    • Limited to research centers
  • Portable sulfide meter (the Halimeter®)
    • Can be used in a dental office
    • Detects only VSC
    • Must be calibrated regularly to maintain accuracy
who smells it
Who smells it?
  • Organoleptic ratings - the odor judge
    • Trained noses partly agree with sulfide meters
    • May be more relevant clinically
    • Requires extensive training, periodic calibration
    • Mainly for research, specialized clinics
  • The jury of one's peers
    • Your spouse or your best friends
    • Your dentist (or your patient)
    • Relevant to the social consequences of mouth odor
  • Self-incrimination - least reliable
    • Many cannot detect odors apparent to others
    • Some perceive odors no one else can detect
where does it smell
Where does it smell?
  • Posterior tongue
    • Odor scores associated with degree of tongue coating
    • Tongue anatomy may increase risk (deep fissures)
    • May be primary source of odor in younger patients
    • Worse with dry mouth, after sleeping
  • Periodontal pockets in periodontal disease
    • Odor scores associated with disease/severity
    • VSC can be measured in fluid from deep pockets
    • Mouth odor/VSC proposed as early sign of periodontitis
    • Not all periodontal patients have mouth odor
  • Other oral lesions (e.g. abcesses, impactions)
  • Oral candidiasis - "Sweet, fruity odor"
tongue coating
Tongue coating

http://www.dent.ohio-state.edu/oralpath2/Tongue/25_2.jpg

which bacteria are smelly
Which bacteria are smelly?
  • Tongue bacteria
    • Streptococcus salivarius - a sign of “health”?
      • May be dominant in persons w/o halitosis (n = 5)
    • Gram-negative, proteolytic anaerobes
      • May predispose towards halitosis
      • Many novel species (n = 6)
      • Digest nasal discharges, food debris,

saliva components, sloughed cells

      • Produce VSC, cadaverine
      • BANA hydrolysis test (Perioscan®) used for detection
  • Periodontal pathogens
systemic smells
Systemic smells
  • About 90% of halitosis originates in the mouth
  • The other 10%
    • Systemic disease
      • Diabetes - ketoacidosis - acetone smell
      • Cirrhosis, liver failure - "mousy", "musty" smells
      • Renal failure - fishy smell
      • Leukemia - "decaying blood" smell
    • Respiratory system
      • Exhalation of volatile food compounds
      • Volatile medications - DMSO, amyl nitrate
      • Nasal/sinus/lung infections
      • Tonsils and tonsiloliths (may not contribute to mouth odor)
        • Treated by laser cryptolysis
      • Carcinoma
other systemic smells
Other systemic smells
  • Gastrointestinal system (considered rare)
    • Reflux
    • Carcinoma
    • Helicobacter pylori infection (gastric ulcers)
  • Genetic disorders (enzyme deficiencies)
    • Trimethylaminuria (fishy odor) - autosomal recessive
    • Cystinuria, cystathionuria heterozygotes
      • Recessive defects in cysteine metabolism
      • Very high VSC levels (gut bacteria)
iatrogenic idiopathic smells
Iatrogenic/idiopathic smells
  • Frustrating to diagnose and treat - expensive
  • Iatrogenic odors
    • Gauze pad left behind after cleft palate surgery
  • Foreign objects
    • Inserted up the nose
    • Young children and developmentally disabled
    • If undetected, may lead to odor in adults
  • Idiopathic odors
    • Detectable by others, no apparent oral or non-oral cause
    • Cause presumed rare, not yet defined
psychosomatic smells
“Psychosomatic” smells
  • Detectable only by patient - no apparent cause
  • Patients often refuse to accept objective findings
  • Associated with anxiety or depression
  • Can be confused with genetic disorders
    • Patients may show abnormalities by gas chromatography
    • Trimethylaminuria heterozygotes
      • May be more common than once thought
      • Saliva TMA detectable by patient, but not others
diagnosing smells
Diagnosing smells
  • History
  • Onset, duration?
  • Constant or intermittent, morning, how long after meals?
  • Self-report, or reported by others?
  • Dietary factors, smoking and alcohol use?
  • Systemic disease and medication
  • Neurological problems - taste and smell function?
  • Currently under stress?
  • Comprehensive oral examination
diagnosis by smelling
Diagnosis by smelling
  • No commercial mouth rinses for 1 day previous
  • No eating, drinking, brushing, gum, mints, rinses for 2 h
  • Avoid perfumes or scented products (patient; dentist)
  • 2 min rest with lips closed - exhale through nostrils
  • 2 min rest as before - close nostrils - exhale through lips
  • 2 min rest as before - exhale with lips and nostrils open
  • Sample posterior tongue with plastic spoon
  • Compare odor strength for each condition
  • Interpretation
    • Strongest odor with lips closed - suggests nose, sinuses
    • Strongest odor with nostrils closed - oral or gastric source
    • Tongue sample to confirm oral origin
    • Odor equally strong from nose or mouth - systemic
    • No discernible odor - verify with others (spouse, friend)
treating smells the basics
Treating smells - the basics
  • Non-oral etiologies - appropriate referral
  • Oral etiologies
    • Treat all existing conditions
    • Attempt to improve hygiene, flossing
    • Encourage posterior tongue hygiene
      • Commercial tongue scrapers
      • Many designs on the market
      • The gag reflex is a barrier to compliance
tongue scraping
Tongue scraping

http://www.yatan-ayur.com.au/images/tonguecleaning2.jpg

One of many designs - no endorsement implied

treating smells short term
Treating smells - short-term
  • Masking fragrances
    • Mouth rinses, drops, gums, mints, etc.
  • Chemicals that interact with VSC
    • Sold online - by dentists offering halitosis clinics
    • Oxidizing agents - products based on chlorine dioxide
      • Disinfectant - water treatment, pulp mills, cow udders
      • FDA approved for 2ndary food use (disinfecting chickens)
      • Appears to be safe at concentrations in breath products
      • Only two published studies - short-term , small Ns
    • Zinc reacts with VSC
      • Safe when not used in excess
      • More published evidence - small Ns
      • Reduces VSC levels short-term
treating smells long term
Treating smells - long-term
  • Antibacterial products
    • Should reduce bacterial odors, depending on efficacy
    • Very few clinical studies document effects on odor long term
  • Chlorhexidine is considered the gold standard
    • High substantivity - remains on oral tissues for a long time
    • Only by Rx in USA, problems with taste and staining
  • Others with published evidence for odor reduction
    • Two-phase oil-water mouthrinse (cetylpyridinium chloride)
      • Sulfides lower after 6 weeks of use
      • More effective than Listerine (essential oils) - both worked
      • Currently available in Israel and Great Britain
    • Toothpaste with substantive triclosan copolymers - short term
    • Mixtures including low dose chlorhexidine - Halita
treating smells probiotics
Treating smells - probiotics?
  • The probiotic concept
    • Replace “bad” bacteria with “good” bacteria
    • Lots of ongoing research - NIH funded
    • FDA approves human trial of probiotic S. mutans
      • Genetically engineered to be non-cariogenic
      • Lots of safeguards required
  • Probiotic treatment of bad breath in New Zealand and Australia
    • S. salivarius strain K12
      • Indigenous strain that produces antibacterial peptides (BLIS)
      • Patented, marketed as a dietary supplement (now in USA)
      • Step 1: Use chlorhexidine to knock down tongue flora
      • Step 2: Replace tongue flora with K12
    • Limited data - 2 wks., N = 13, only 3 controls, not yet published
ada halitosis standards
ADA halitosis standards
  • Must be met to get ADA seal for any bad breath claims
    • Applies to products that already have ADA seal for other claims
  • Two independent double-blind efficacy studies
    • Minimum 3-week trial period
    • Patients must have baseline organoleptic scores between 2-5
      • “Slight” to “Very Strong”
    • Gas chromatograph preferred to measure VSC
      • Sulfide monitor OK if calibration data provided
    • Multiple malodor measurements
    • Parallel evaluation of hard/soft tissue effects, microbiology
      • Long term safety data (six month follow up)
      • Must include patient-reported adverse effects (taste/staining)
    • Toxicity data (cytotoxic, mutagenic, carcinogenic effects)
why so few studies
Why so few studies?
  • No product currently has the ADA seal for halitosis
    • Some do have the ADA seal for other properties
      • Plaque control or caries prevention
    • Will the public make this distinction?
      • Is there a marketing benefit to getting the halitosis seal?
  • FDA approval
    • May be sought under less stringent standards for cosmetics
    • Ingredients already approved as safe for human use
      • Chlorine dioxide products
    • May fall under the much weaker rules for dietary supplements
      • Products containing zinc
      • S. salivarius K12
  • Manufacturers lack incentives to do the studies