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How can I treat halitosis?

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This question was submitted by a general dentist: how can I treat halitosis? 

Dr. Eric Stoopler, University of Pennsylvania, in collaboration with Dr. Suham Alexander, Oasis Clinical Editor, provided this quick initial response

Halitosis is fairly common in the general population with an estimated prevalence of bigstock-face-of-beautiful-woman-coveri-45874801~25%. It affects men and women in similar proportions; although, women are more likely to seek treatment for it more quickly as the condition can cause social embarrassment.

There is a lack of scientific evidence in the area of halitosis given there is a subjective nature to the condition. Differences exist in cultural as well as racial appreciation of the odours for both patients as well as researchers. Additionally, there is no uniform method of evaluation for organoleptic and mechanical measurements.

To date the most widely accepted measurement is organoleptic scoring which involves smelling the breath/odour of the patient. Objective measurements include: analysis of breath samples by gas chromatography, or portable VSC analyzers such as The Halimeter (Interscan Corp.) or OralChroma (Abimedical Corp.).

In approximately 85% of all cases of halitosis, the origin of the malodour is the oral cavity. Microbial degradation of predominantly Gram-negative anaerobic bacteria and the release of volatile sulphur compounds (VSC) (eg. hydrogen sulphide, methyl mercaptan and dimethyl sulphide) account for the unpleasant odour. Diamines (indole, skatole) or polyamines (putrescin, cadverin) are less significant molecules contributing to the condition.

Causes

  1. Oral Pathology and Conditions
    • Dorsum of the tongue with its irregular surface collects desquamated epithelial cells and food remnants form a coating which is difficult to remove and results in degradation and malodour
    • Reduced salivary flow and production at night leads to increased malodour also, but will disappear once oral hygiene resumes upon waking
    • Poor oral hygiene, dental plaque/caries and accumulation of food debris in uncleaned acrylic dentures
    • Gingivitis and periodontitis (positive correlation between pocket depth and the concentration of VSCs)
    • Xerostomia often leads to an increased amount of plaque and tongue coating in afflicted patients
    • Stomatitis, intra-oral neoplasia, extraction wounds, crowded teeth, pericoronitis/implantitis, recurrent oral ulcerations and herpetic gingivitis
  2. ENT & Pulmonary Pathology
    • Contributes to 10% of cases of halitosis
    • Acute tonsillitis is the major contributing factor as anaerobic bacteria are detectable in tonsilloliths
    • Post-nasal drip, foreign bodies in the nasal cavity as well as atrophic rhinitis
    • Bacterial sinusitis
    • Bronchiectasis, lung abscesses and endobronchial chronic disorders
  3. Gastrointestinal Pathology
    • Zenker’s diverticulum
    • Stomach infections with H. pylori may be a contributing cause, but no strong correlation currently exists
    • Intestinal obstruction
  4. Metabolic disorders
    • Diabetes mellitus and ketoacidosis leads to the production of a sweet smelling odour
    • Trimethylaminuria leads to a fishy odour
    • Renal failure, cirrhosis of the liver
  5. Hepathology & Endocrinology
    • Reduced liver function can cause a sweet, excremental odour
    • Tyrosinemy, a hereditary disease, causes production of a cabbage-like odour
  6. Medications
    • Medications which lead to dry mouth
    • Bisphosphonates can contribute to malodour as a result of jawbone necrosis

Dental Management

Management of halitosis caused by oral conditions or pathology should focus on:

  • Reducing the number of microorganisms and their nutrients mechanically
    • Tongue-scraping and cleaning the posterior aspect of the tongue
    • Scaling and root planning with chlorhexidine (CHX)
  • Chemical reduction of microorganisms
    • CHX rinse (0.2%) will reduce of VSCs
    • Essential oils produce short-term and restricted effects up to 3 hours and a limited reduction of odour-producing bacteria
    • Chlordioxide can lead to a reduction in odour for up to 4 hours
    • Triclosan reduces of VSCs after 3 hours
    • Hydrogen peroxide (3%) can cause a 90% reduction in VSCs after 8 hours
    • Toothpastes with triclosan, zinc or stannous fluoride
  • Conversion of volatile components into non-volatile ones
    • Rinses containing zinc, mercury and copper are useful in reducing VSCs
    • Commercial rinse with 0.005% CHX, 0.05% cetylpyridinium and 0.14% zinc lactate is more effective than CHX alone
    • Rinsing products, chewing gums and mints have a transient effect on malodour

Medical Management

Patients should consult their physician for advice and further investigations to rule out other systemic causes for halitosis.

References

  1. Bollen, Curd ML, Beikler, Thomas. Halitosis: the multidisciplinary approach. International Journal of Science (2012) 4, 55-63.
  2. Fedorowicz, Z, Aljufairi, H, Nasser, M, Outhouse, TL, Pedrazzi, V. Mouthrinses for the treatment of halitosis (Review). The Cochrane Collaboration (2008) 4.
  3. Ata, N, Ovet, G, Alatas, N. Effectiveness of radiofrequency cryptolysis for the treatment of halitosis due to caseums. Am J Orolaryngol-Head and Neck Med and Surg (2014).

 

Do you have any particular question on this topic? Do you have any comments or suggestions? Email us at oasisdiscussions@cda-adc.ca

You are invited to comment on this post and provide further insights by posting in the comment box which you will find by clicking on “Post a reply” below. You are welcome to remain anonymous and your email address will not be posted. 

4 Comments

  1. VR February 19, 2014

    Your conversation doesn’t mention anything about microbiological testing which we do at our office. We also use a system called OraVital and combine it with Soft Tissue Management to get control of oral flora balance (gram negative and positive).

    We know that stress plays a huge role in hormone imbalance which can contribute to oral imbalance.

    Looking forward to your comments.

    Thanks for the detailed post.

    Reply
    1. Jennifer MacLellan February 20, 2014

      In addition to all of the treatments mentioned, increased water consumption can also be beneficial if the halitosis is secondary to xerostomic medications. From a pediatric perspective, this is beneficial for adolescent patients on antidepressants or Accutane.

  2. Dr Jim Hyland December 24, 2014

    There is a great deal of scientific research By Anne Bosy RDH MsEd who wrote extensively on this subject. Your article fails to mention the use of antibiotic rinses to target the Gm-ve biofilms throughout the whole mouth. This technique penetrates these biofilms unlike all the other chemicals that are mentioned. They are good maintenance rinses but will not predictably control breath odour. Reference
    Treatment of malodor and periodontal disease using an antibiotic rinse. Dr Ken Southward. AGD July 13
    Jim Hyland

    Reply
  3. Dr.Gene Jensen January 12, 2015

    As an orthodontist I have treated several patients who have experienced a cessation of halitosis following the correction of a dento-skeletal deformity, especially those patients afflicted with skeletal class 11, class 111, crossbite, openbite, deep overbite, asymmetrical and severely crowded class 1, 11, and class 111 malocclusions, as well as, those patients experiencing psychological stress,which is clinically manifested in the form of clenching, grinding and/or bruxing . Masticatory inefficiency and/or oral debilitations are usually associated with these types of malocclusions. These aforementioned maladies are often the etiologic factors with regard to TMJ dysfunction, jaw pain, jaw joint pain, cheek, lip and/or tongue biting, palatal mucosal incisor impingement, absent incisal and/or occlusal contact, severely deviated and/or subluxated mandibular condylar movements, myospasm of the masticatory musculature, and last, but not least, the negative and compensatory reactions of the autonomic nervous system. The stomach, via the sympathetic nervous system, automatically senses the type, consistancy and amount of food within it`s walls. Consequently, when the food, that is ingested is not pulverized sufficentlly, by an inefficient chewing mechanism, it will not pass through the pyloric sphincter, without great difficulty. However, once the food, manages to pass through the pyloric valve, it will then be moved along, by the waves of the phenomenon known as peristalsis, into the duodeum and jejenum portions of the GIT for active absorption by the bloodstream. If the food cannot be broken down sufficently by the occlusion before it reaches the stomach, then the glands located within the stomach wall will be triggered by the sympathetic nervous system to secrete excessive amounts of hychloric acid, gastric juice and bile. These latter secretions in turn, contribute to gastroenteritis, heartburn, indigestion, ulceration, intusseption, regurgitation, acid reflux, and ultimately halitosis. To lend credence to this evidence-based finding, I personally had this problem, for ten years, prior to having my severe Angle`s dento-skeletal class 111 malocclusion corrected by means of a combination of orthodontic, orthognathic-surgical, plastic-surgical, restorative, and prosthodontic treatment; since then, I haven`t had a sign or symptom of halitosis, or any other oral maladies, for that matter, and that was forty years ago, when we were still pioneering in dentistry. By the way, I also had a complete unilateral cleft of the lip, alveolus, hard and soft palates repaired at various intervals along the way. Needless to say, it was a rewarding, educational and game-changing experience for me, for my dental students, and for my future patients. Notwithstanding, I am a strong proponent of holistic dentistry, as it relates to the total health and well-being of the patient. Halitosis, like the phenomenon of tinnitis, is not well understood, nor easy to cure, however, I hope this short disertation will shed some light on the subject of halitosis, and possibly add one more explanation with which to enlighten your patients and your medical colleagues. If you have any questions, concern or comments please feel free to Email dr.jensen@ns.sympatico.ca Best Regards, Dr.Gene Jensen DDS,MSc,FRCD(C)

    Reply

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