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«IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume 13, Issue 5 Ver. III. (May. 2014), PP 55-61 ...»

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IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume 13, Issue 5 Ver. III. (May. 2014), PP 55-61


HALITOSIS – A Social Malady

Dr. Meena Anand Kukkamalla, 1 Dr. Sonali Maria Cornelio, 1 Dr. Khandige

Mahalinga Bhat, 1 Dr. Meera Avadhani, 1 Dr. Ruchika Goyal1


(Department of periodontology, Manipal College of Dental Sciences, Manipal University, India)

Abstract: Halitosis is a common and universal affliction suffered by many people irrespective of age, sex, and social status. Halitosis is estimated to be the third most frequent reason for seeking dental aid, following tooth decay and periodontal disease. It is one of the biggest proscriptions in the society. Halitosis may be an important factor in social communication therefore; it may be the origin of concern not only for a possible health condition but also for frequent psychological alterations leading to social and personal isolation. Causes of halitosis include certain foods, poor oral health care, dry mouth, deep carious lesions, periodontal disease, oral infections, peri-implant disease, pericoronitis, mucosal ulcerations, tongue coating, tobacco products and medical conditions. The present review was to describe the etiological factors, and the therapeutic approaches related to halitosis.

Key words: halitosis, tongue coating, volatile Sulphur compounds, halimeter, triclosan

I. Introduction:

Halitosis is one of the most personal and often embarrassing problems commonly faced by millions of people. It is one of the society‘s oldest and most troublesome social maladies, which can lead to a significant amount of social disharmony and embarrassment and has been recorded in literature for thousands of years. 1 The other terminologies used for bad breath is halitosis, fetor oris, ozostomia, or stomatodysodia.

In 90% of cases the causes of halitosis are located in the mouth and can be attributed to deep carious lesions, periodontal disease, oral infections, periimplant disease, pericoronitis, mucosal ulcerations, impacted food or debris, factors causing decreased salivary flow rate and mainly, tongue coating. 2 Halitosis may be an important factor in social communication therefore; it may be the origin of concern not only for a possible health condition but also for frequent psychological alterations leading to social and personal isolation.3 Sufferers often make desperate attempts to mask their oral malodour with mints and chewing gum, compulsive brushing, and repeatedly rinsing with mouthwashes. 4

II. Historical Background:

Odours are essential clues in the creation and conservation of social bonds, as they are loaded with cultural values. Hindus consider the mouth as a body‘s entry door and therefore insist that it be kept clean namely before prayers. During Christianity devils supreme malignant odour smelt of sulfur, and it was presumed that sins produced more or less bad smell. Islamic literature recommended the use of siwak which contains sodium bicarbonate and tannic acid that exert beneficial effects on oral health for fetid breath. The problem is discussed at length in the Jewish Talmud and has been described by Greek and Roman writers.5 Other folk cures include parsley, cloves, guava peels, and eggshells.6 Since the 1960s, the preeminent researcher in this field has been Tonzetich. He and coworkers established that oral malodour is associated with the presence of volatile sulfur compounds, primarily hydrogen sulfide and methylmercaptan.7, 8

III. Etiology Of Halitosis:

Oral malodour has complex etiology. Extrinsic causes include tobacco, alcohol and certain foods such as onions, garlic and certain spices.9 Oral odour can be affected by the intake of food and drinks, which can either dry the mouth, such as alcohol-containing liquids and cigarettes. Moreover, ‗morning breath‘ is related to the decreased saliva production and secretion resulting in the transient desiccation of the mouth. 10

Tongue coating:

Tongue coating is accumulation of desquamated and exfoliated or ready to exfoliate epithelial cells inter-mingled with blood cells, food remnants and bacteria. Under magnification, the tongue was compared to the ―surface of the moon after a rain shower.11 Researchers reported that a single epithelial cell in the oral cavity can harbor up to 25 bacteria, whereas 1 epithelial cell on the dorsum of the tongue can harbor up to 100 bacteria.12 The dorsum of the tongue and its bacteria has been the subject of several studies.13, 14, 15 According to a study of the topographic distribution of bacterial types on the tongue surface, the dorsal posterior to the circumvallate papillae consistently carried the highest load of all bacterial groups. 16 Several www.iosrjournals.org 55 | Page HALITOSIS – A social Malady investigations have identified the dorsal posterior surface of the tongue as the primary contributor to bad breath in healthy people.17 Yaegaki and Sanada using gas chromatography methods found that VSC production is reduced by onehalf when the tongue coating is removed with small spoon.18 The examination of the composition of the microbiota in tongue biofilm suggested that the major species of H 2S-producing bacteria were Veillonella, Actinomyces, and Prevotella.19 Hess et al proposed a mathematical model in which each papilla is cluster of strands protruding perpendicularly from the tongue. The biofilm metabolizes oxygen gradually. 20 Researchers have suggested that various glycosidases, such as the β-galactosidase produced by Gram-positive oral bacteria, cleave carbohydrate side-chains of salivary glycoproteins and contribute to VSC-production by Gram-negative oral bacteria.21 Masuo et al quantified β-galactosidase activity in the saliva of subjects complaining of halitosis, and reported a positive correlation between enzymatic activity in whole saliva and OLS and VSC concentrations. 22


Saliva plays a central role in the formation of oral malodour. Periodontal pockets can cause food debris to accumulate and the rate of foul-odour production to increase.23 Medications may cause xerostomia and result in oral malodour, especially those with anticholinergic activity. 24In any individual, bad breath levels during the day are inversely related to saliva flow.25 When saliva flow is low, bad breath rises.

Bacteria / Microorganisms:

Malodor producers are members of the oral microbial ecosystem, which is regulated by numerous interactions among the inhabitants. The principal bacteria that are implicated in the creation of oral malodour include Fusobacterium nucleatum, Prevotella intermedia, and Tannerella forsythensis. Prophyromonas gingivalis and Treponema denticola.26 Most of the protein found in mouth is in the form of glycoprotein and sugar-feeding microbes can cleave residues from these glycoproteins, leaving naked peptides to be digested by other bacteria.27 These bacteria proteolyse the sulphur-containing amino acids from the proteins in the saliva, shed epithelium, food debris, gingival crevicular fluid, interdental plaque, and postnasal drip thereby releasing the VSCs.28 Bacterial strains forming large amounts of H2S from L-cysteine were found in the genera Peptostreptococcus, Eubacterium, Salenomonas, Centipeda, Bacteroides, and Fusobacterium, and CH 3SH from L-methionine was formed by some members of the genera Fusobacterium, Bacteroides, Porphyromonas, and Eubacterium. 29 Awano et al detected the presence of T. forsythensis, P. gingivalis, Aggregatibacter actinomycetemcomitans, and P. intermedia by PCR in the saliva of patients complaining of halitosis. 30 Grampositive oral bacteria, primarily streptococci, may also promote VSC production by Gram-negative bacteria.31

Periodontal disease:

It has been demonstrated under exaggerated conditions in the experimental gingivitis model, where discontinuation of tooth brushing resulted in bad breath before the development of clinical gingivitis. 32 As the bacterial plaque matures the oxygen level drops to zero favouring reduced conditions and production of odiferous volatiles.33 The fetid odour characteristic of acute necrotizing ulcerative gingivitis is an extreme example of malodour from periodontal pathogens.34

Extra oral causes:

Pathologic oral malodour also can originate from non-oral causes, like diabetic ketosis and acidosis, uremia and regurgitations, hepatic and renal failure, and certain types of cancer, such as leukemia. Bad breath, from the nasal passages have the telltale odour can be smelt most strongly from the nose, rather than the mouth.

In some cases, craniofacial anomalies, such as cleft palate, may be involved. 35 A typical nasal malodor usually has a slightly cheesy odour and differs appreciably from other types of bad breath. 36 Halitosis of upper respiratory tract may be due to chronic sinusitis, nasal obstruction, nasopharyngeal abscess and carcinoma of the larynx and halitosis of lower respiratory tract may be because of bronchitis, bronchiectasis, pneumonia, pulmonary abscess and carcinoma of the lungs. 37 Extraoral halitosis might also be a manifestation of a serious systemic disease, such as hiatus hernia, hepatic cirrhosis or diabetes mellitus.38 Tangerman A, Winkel EG provided evidence that dimethylsulfide (CH3SCH3) is the main contributor to extra-oral or blood-borne halitosis, due to a hitherto unknown metabolic disorder.39 In premenopausal women elevated VSC were found in mouth air during mid-cycle and around menstruation.40 Bacteria feed on this blood creating odorous volatile sulfur particles. Social habits and behaviors which could increase the risk of suffering halitosis, like alcohol and tobacco consumption.41 www.iosrjournals.org 56 | Page HALITOSIS – A social Malady Liquor consumption reduces saliva production, resulting in dry mouth. A study by Suzuki N et al, found an association between daily alcohol consumption and strong malodour, especially related to periodontal disease. 41 Few studies in the literature have highlighted the links between halitosis and emotions, e.g. anxiety. 42 The relation between anxiety and halitosis have been analyzed with clinical observations suggesting that anxious situations may increase VSC concentration thus causing halitosis.43


Medications that are taken for a long duration time contribute to bad breath and taste disorders like medications include antihistamines, tricyclic antidepressants, diuretics, anti-hypertensives and analgesics.24 Disulfuram, is a drug used in treating alcoholics, which is metabolized to carbon dusulfide. Dimethyl sulphoxide is prescribed for patients suffering from interstitial cystitis. 44 It is metabolised and reduced to dimethyl sulfide, giving off the garlic –like odour of dimethyl sulphide. Cysteamine is used in patients with nephropathic cystinosis and can be metabolised to dimethyl sulphide. Certain drugs can also alter the sense of taste and smell causing subjective halitosis or may diminish saliva production thereby stimulating oral putrefaction and thus oral malodour.37 Certain foods including garlic, onion and some spices are absorbed from the intestine, possibly metabolized in the liver released into the bloodstream and excreted via the lungs and other routes. For garlic it was found that halitosis may be oral or gut origin. 45 This was explained by assuming a rapid metabolism of these thiols by gut mucosa and liver tissue.46 Onions does contain large concentrations of propyl mercaptan. The gut component of onion halitosis consisted of methyl propyl mercaptan.47 In the fish odor syndrome oxidation of trimethylamine to the odorless trimethylamine N- Oxide is impaired, leading to elevated trimethylamine levels in blood urine sweat and breath. 48



Complaints of bad breath should be taken seriously by the dental practitioner, whether they are justified or not.49 Depending on the origin, different smells may be distinguished like rotten eggs, sweet, rotten apples or fish.50 Certain questions like who noticed the bad breath- patient himself or others? Under which circumstances was the bad breath experienced? Only in the morning, after meals, after lying down, all these should be evaluated. Halitosis after meals or lying down may be indicative of regurgitation oesophagitis. 51 The patient should be instructed to refrain from drinking, eating, chewing, rinsing, gargling, and smoking for at least two hours prior to the appointment. Malodour examinations should not be performed on patients taking antibiotics.49

Organoleptic test:

Organoleptic measurements are considered to be the gold standard for measuring and assessing bad breath.52 The offensiveness of the odour can be measured on Rosenberg scale from 0 to 5, which is as follows: 0 = no odour; 1 = barely noticeable odour; 2 = slight but clearly noticeable odour; 3 = moderate odour; 4 = strong offensive odour; and 5 = extremely foul odour; with a score ≥ 2 equalling halitosis. 53 Hedonic scale in which a score of +2 = like very much; +1 = like; 0 = do not like or dislike; -1 = dislike; and -2 = dislike very much.54 In whole mouth breath assessment, the subjects are instructed to breathe out through the mouth at the distance of approximately 10cm from the nose of the judge who is blinded. 55 Spoon test is evaluated at the distance of approximately 5 cm from examiners nose. 5 The dental floss odour test determines the presence of interdental plaque odour. 5 In saliva odour test, the subject expectorates approximately 1 -2 ml of saliva into a petri dish which is covered immediately, incubated at 370 °C for 5 minutes and then is presented for odour evaluation at a distance of 4cm from the examiners nose.56 Lick the wrist, wait about five seconds while the saliva dries then it has to be smelt. 57

Sulfide meter:

The sulfide meter records a score based on VSC levels in parts per billion (ppb) based on electrochemical and voltametric sensors. There are three categories of scores: Normal = 80 ppb to 160 ppb;

Weak = 160 ppb to 250 ppb; and Strong = 250 ppb. ―Weak‖ signifies malodour at a close distance, and ―Strong‖ signifies malodour at a greater distance. This method is repeated three times, and the mean of the scores is taken.53

Gas chromatography:

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