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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

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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

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

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