Halitosis Clinical Diagnosis, Management, and Research

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HalitosisClinical Diagnosis, Management, and
Research

• Antonio J. Moretti, DDS, MS

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Facts on Halitosis

• It is estimated that halitosis affects
  approximately half of the North American
  population
• This percentage may be different in other
  countries
• Twenty percent of the population views mouth odor
  as a serious concern

Brunette et al, 1998
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Oral Malodor

• May rank only behind dental caries and
  periodontal disease as the cause of patients
  visits to the dentist
• Currently appearance of Fresh Breath Clinics
  and Breath Clinics is changing its view
• Microbial causation is still poorly understood
• Current treatment is mostly based on anecdotal
  findings due to US FDA consider this as a
  cosmetic problem

Loesche Kazor, 2002
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Facts on Halitosis

• Patients go through extensive testing in order to
  identify the cause of halitosis
• Patients may use products that have not yet been
  evaluated for safety and efficacy
• Halitosis is usually the result of oral causes
• Halitosis should be managed by the dental
  profession

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Halitosis and Dental Profession

• Some dentists are not very sympathetic on this
  issue
• Maybe dentists dont perceive halitosis as being
  as common or as intense as it is
• Usually patients perform good oral hygiene right
  before a dental visit

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Halitosis and Dental Profession

• Dentists becoming involved in managing breath
  disorders may need to be prepared to receive some
  negative comments from colleagues
• Increased education on oral malodor will result
  in our professions responsibility of diagnosis
  and treatment of halitosis

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Oral Causes of Halitosis

• Plaque accumulation
• Dorsal tongue
• Putrefaction of volatile organic compounds
• Sulfurous (H2S, CH3SH, SO2, CH32S)
• Nonsulfurous (indole, skatole, cadaverine,
  amines, and ammonia)
• Severe periodontal disease

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Loesche Kazor, 2002
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What are we smelling?

• 90 is H2S and CH3SH
• 10 all other components

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Bacterial Putrefaction
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Non-Oral Causes of Halitosis

• Pulmonary diseases
• Metabolic disorders
• Trimethylaminuria
• Ketosis
• Sinusitis
• Tonsilitis
• Pharyngitis
• Psychological
• G.I.

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Questions to Ask

• Do you feel you have bad breath?
• Transient or non pathologic
• Chronic or pathological
• Is bad breath your chief complaint?

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Bad Taste and Bad Breath

• Some patients assume that bad taste is related to
  bad breath
• Taste disorders may have other causes and may
  alter the perception of smell

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Relevant Dental History

• Poor restorations
• Poor oral hygiene
• Malpositioned teeth
• Food impaction
• Severe periodontal disease

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Relevant Dental History

• Oral ulcers
• Autoimmune disorders
• Reactive lesions
• Neoplasms
• Oral infections
• Odontogenic bacterial infections
• Recurrent viral infections
• Fungal infections

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Relevant Dental History

• Xerostomia
• Aging
• Drug induced
• Cancer treatment
• Systemic diseases
• Taste alterations

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Diet and Habit History

• Alcohol
• Tobacco
• Illicit substances
• Garlic, onion, and spices
• Ethnic foods
• Odorigenic food
• High protein diet

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Psychosocial History

• Psychogenic factors
• Depression
• Phobias
• Obsessive/compulsive disorder
• Body dysmorphic disease
• Psychotic disorder

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Oral Malodor History

• How does the patient conclude that he or she has
  bad breath?
• Confidante plays a very important role
• Is it associated with certain periods of the day?
• How does halitosis affect your life?

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Extra and Intraoral Examination

• Complete routine examination
• Soft tissue assessment
• Radiographs to evaluate carious lesions
• Periodontal examination
• Tongue examination

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Assessment of Oral Malodor

• Patient should refrain from drinking, eating,
  chewing, rinsing, gargling, and smoking 4 hours
  prior to appointment.
• Both patient and examiner should not wear any
  perfume/cologne.
• Patient taking antibiotic is seen two weeks after
  discontinuation of medication.

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Breath AnalysisOrganoleptic Examination (Sniff
Test)

• Breath test (mouth and nasal air)
• Wrist-lick test
• Spoon test
• Supragingival plaque odor
• Salivary incubation test

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Organoleptic Measurements(Rosenberg et al., 1991)

• 0 no appreciable odor
• 1 barely noticeable odor
• 2 slight but clearly noticeable odor
• 3 moderate odor
• 4 strong odor
• 5 extremely foul odor

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Breath Analysis

• Gas chromatography
• VSC detection test (Halimeter)
• BreathAlert
• Electronic nose

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Gas chromatographer
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Differential Diagnosis

• Oral or nonoral origin
• Diet
• Xerostomia
• Patient is evaluated after 7 to 14 days of
  intensive treatment, when a more definitive
  diagnosis is given

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Patients with Post-Nasal Drip

• Accompanying symptoms
• cough, mildly productive cleansing of the throat,
  heavy coating on the posterior dorsal tongue,
  obstruction and congestion
• Suspicion of chronic sinusitis
• refer to ENT for evaluation
• allergy vs. obstruction
• Nasal irrigation

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Treatment of Halitosis

• Mechanical tongue cleaning
• Chemical mouthwashes
• Nutrient interference, bactericidal, binding
  mechanism
• Most effective chemical product
• Chlorhexidine gluconate
• Others cetylpyridium chloride, benzethonium
  chloride, chlorine dioxide, triclosan, and zinc
  chloride

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Tongue scrapers for mechanical debridment of the
tongue
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Patients Requesting Specific Treatment

• It is the dentists obligation to inquire into
  the truth and accuracy of effectiveness claims of
  products
• Treatment should be recommended based on
  scientific evidence

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Patients Without Halitosis

• Before the diagnosis of imaginary or
  delusional halitosis is made, the patient
  should receive a repeat examination
• Treatment should never be instituted if the
  diagnosis of oral malodor cannot be made

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Bad or Altered Taste

• Causes oral infections, periodontal disease,
  candidiasis, dental appliances, or poor oral
  hygiene.
• Reasons for dysgeusia (altered taste) or dysomia
  (altered smell) sinusitis, lesions of nasal
  cavity, head trauma, nose surgery, chemotherapy,
  radiation therapy, salivary dysfunction, etc.

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Treatment Protocol

• Initial visit
• complete evaluation and initiation of therapeutic
  regimen
• Follow up in 3 to 4 weeks
• alter treatment regimen if necessary
• Second follow up in 3 to 4 weeks
• Third follow up in 3 to 4 weeks
• Appropriate referrals

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Failure of Treatment

• Malodor is not of dental origin
• Review medical history
• Most likely cause is with the nose and sinuses
• Lack of compliance motivation, dexterity
• Halimeter may give additional reassurance

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Evaluation of a portable breath monitor for
self-diagnosis of halitosis

• Wilson CP, Moretti AJ, Flaitz CM, Chen JW

IADR/AADR, 2002
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Purpose

• To determine the accuracy of a novel,
  pocket-sized device for measuring breath odor
  (BreathAlert) by comparing it to two established
  methods (Halimeter and Organoleptic)

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Materials and Methods

• Convenience sample of healthy adults
• Able to follow instructions
• Excluded if serious diseased, respiratory
  infection, heavy smoker
• Refrained from drinking, eating, etc at least 2
  hours prior to appointment
• Dental and medical questionnaire

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Materials and Methods

• Breath evaluation
• Organoleptic
• BreathAlert
• Halimeter
• Intraoral examination
• Tonsil size, tongue coating, anomalies, caries,
  restorations, gingival inflammation)
• Statistical analysis (Descriptive, Pearson, Chi
  Square, Spearmans Rho)

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Materials and Methods

• Organoleptic (0 5)
• Halimeter
• 300-500 ppb malodor
• BreathAlert
• 1 no odor
• 2 slight odor
• 3 moderate odor
• 4 strong odor

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Demographic Results

• 30 patients
• Average age 37 years (21-83)
• 46 male, 54 female
• Ethnicity 54 Caucasian, 16 Hispanic, 16
  Asian, 14 African-American

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Questionnaire Results

• 23 of subjects believed they had halitosis, and
  the organoleptic method correlated with both
  breath smell (p0.037 r0.382 Spearmans Rho)
  and breath count (p0.034 r0.388 Spearmans
  Rho)
• 16 thought they normally had bad breath, and the
  organoleptic method correlated with both breath
  smell (p0.002 r0.568 Spearmans Rho) and
  breath count (p0.005 r0.515 Spearmans Rho)

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Intraoral Results

• Distribution of tongue coating
• Correlated with the Halimeter readings p0.014
  r0.44 (Pearson Correlation)
• No correlation with breath smell scores, breath
  count scores or BreathAlert readings
• Color of tongue coating, anomalies, tonsil size,
  caries and gingival inflammation
• No correlation with any diagnostic method used

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BreathAlert Results

• BreathAlert did not correlate with the
  Halimeter or Organoleptic Methods
• Halimeter x BreathAlert p019 r0.246 (Pearson
  correlation)
• Breath Smell x BreathAlert p0.18 r0.251
  (Spearmans Rho)
• Breath Count x BreathAlert p0.10 r0.306
  (Spearmans Rho)

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BreathAlert Results

• Internal Correlations
• Oral Breath x Right Nostril
• p0.00 r0.818 (Spearmans Rho)
• Oral Breath x Left Nostril
• p0.00 r0.766 (Spearmans Rho)

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Conclusions

• Those who believed they had chronic halitosis
  and/or current halitosis had higher organoleptic
  scores.
• Halimeter correlated well with the organoleptic
  method and with tongue coating distribution.
• BreathAlert did not correlate with the two
  established methods (i.e., Organoleptic and
  Halimeter).
• BreathAlert is practical, portable and
  inexpensive however, its accuracy at this time
  is inconclusive.

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Evaluation of Halitosis in Children and Mothers
Using Organoleptic and Halimeter Tests

• Hsuan ML, Flaitz CM, Moretti AJ, Seybold SV, Chen
  JW

American Academy of Pediatric Dentistry, 2002
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Background and Rationale

• Only two studies on halitosis in children.
• Bacteria is the main source of malodor.
• Studies have shown that caries bacterium Mutans
  streptococci is transmitted from mothers to their
  children.
• Periodontal literature has also shown the
  transmission of microorganisms among family
  members.

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Purpose

• To study the occurrence and clinical parameters
  that are associated with halitosis in pediatric
  dental patients and compare this findings with
  mother

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Materials and Methods

• Cross-sectional study, convenience sample
• ASA I or II (children and mother)
• Age 5-12
• No current upper respiratory infection
• No gagging reflex
• Questionnaire (dental/medical)
• Tongue debridement with toothbrush or plastic
  spoon
• Statistical analysis

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Results

• Thirty children (mean age 8.8 years)
• Eighteen mothers
• Children
• 67 females (n20)
• 33 Males (n10)
• 50 African-American (n15)
• 27 Hispanic (n8)
• 23 Caucasian (n7)

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Conclusions

• Breath odor as measured by VSC readings was
  detected in 23 of the healthy children, however,
  it was detected more frequently by a calibrated
  oral breath judge.
• Although mothers had halitosis, it did not
  correlate with their childs breath.
• The results from the VSC readings and
  organoleptic scores were inconsistent, suggesting
  that other factors are involved in halitosis in
  this population.

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Conclusions

• There was no correlation between childs
  halitosis and clinical parameters, except for the
  presence of interproximal restorations.
• Halitosis in children cannot be assessed
  accurately by the use of a questionnaire alone.