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Halitosis- Revisited

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Indian Journal of Dental Sciences.
December 2011 Issue:5, Vol.:3
www.ijds.in Review Articles
All rights are reserved

Indian Journal
of Dental Sciences
E ISSN NO. 2231-2293
P ISSN NO. 0976-4003

1
Anoop Kapoor
Halitosis - Revisited 2
Vishakha Grover
3
Abstract Ranjan Malhotra
4
Oral malodor is a common problem among general population and evidences reveal that it forms about Supreet Kaur
5
85% of all bad breath. Bad breath can have a distressing effect that may become a social handicap and Kishan Singh
the affected person may avoid socializing. The condition is multifactorial in etiology and may involve both 1
Professor, Dept of Periodontology & Oral Implantology
oral and non-oral conditions. Volatile sulphur compounds (VSC), namely hydrogen sulphide (H2S) and Bhojia Dental College & Hospital, Baddi, HP
2
methyl mercaptan (CH3SH) are the main cause of oral malodor. These substances are by-products of Professor, Dept of Periodontology & Oral Implantology
the action of bacteria on proteins. Gram-positive bacteria produce little or no malodor; most Gram- National Dental College & Hospital
Gulabgarh, Derabassi, Mohali, PB.
negative bacteria are potent producers of odoriferous compounds. Treatments corresponding to the 3
Professor and Head of the Department
causes of oral malodor include mechanical or chemical tongue cleaning, periodontal disease treatment, Department of Periodontology & Oral Implantology
oral hygiene instruction and mouth rinses or mouthwashes. National Dental College & Hospital, Gulabgarh, PB.
4
Senior Lecturer
Department of Periodontology & Oral Implantology
Sri Guru Ram Das Dental College And Hospital, ASR
5
Principal and HOD, Department of Prothosothodontics
Key Words Shree Bankey Bihari Dental College & Research Centre
malodor, volatile sulphur, hydrogen sulphide, gram-negative Address For Correspondence:
Dr. Vishakha Grover
3192, Ground Floor, Sector 37-D, Chandigarh
vishakha_grover@rediffmail.com
0172-2626160, 09814277780
Date of Submission : 8th October 2011
Date of Acceptance : 5th November 2011

Bad breath as they say is better than no habits, morning breath, secondary to present.
breath at all. And as "George Orwell" said, xerostomia caused by physiologic factors.
"the road to wigan pier". You can have Pathologic halitosis occurs secondary to Psychogenic Halitosis3,4
affection for a murderer, but you cannot pathologic conditions or oral tissues like Psychogenic Halitosis is the one which is
have affection for a man/woman whose gingival and periodontal diseases like imagined. In this a person believes that his
breath stinks. periodontitis, acute necrotizing ulcerative breath smells bad when it actually does not.
gingivitis, residual post-operative blood, This problem may occur in people who tend
Yet, halitosis is a common and universal debris under dental appliances, ulcerative to exaggerate normal body sensations.
problem that can lead to a significant lesions of the oral cavity, Halitosis may be Sometimes this is caused by a serious mental
amount of social disharmony and associated with coated tongue, may occur disorder such as schizophrenia. A person
embarrassment1. Halitosis term originates due to xerostomia secondary to salivary with obsessional thoughts may have an
from the Latin "halitus" means "breath" and gland diseases, tonsilloliths. overwhelmed sense of feeling dirty. A
the Greek "osis" means "abnormal" or person who is paranoid may have the
"diseased". Pseudohalitosis3 delusion that his organs are rotting. Both
Patients who suffer from pseudohalitosis these persons feel their breath smells bad.
In simple words also known as "Bad Breath, complain of the existence of halitosis Such people may be helped by having a
Foul Odor, Fetor ex ore, Fetor oris” though it is not perceived by others. This doctor or dentist assures them that they do
condition can be managed effectively by not have bad breath. If the problem
Introduction counseling (using literature support, continues, person benefit from seeing a
Halitosis, breath malodor or colloquially education and explanation of examination psychotherapist.
known as "bad breath" can be subdivided as results) and simple oral hygiene measures.
real halitosis, pseudohalitosis and The term oral malodor characterizes
halitophobia2. Halitophobia3 malodor that has its origin in the oral cavity.
Some individuals continue to insist that they Clinical surveys have shown that over 90%
True halitosis3 have halitosis even after they have been of all breath malodor originates in the
Real halitosis can be further subdivided into treated for genuine or pseudo-halitosis. mouth5 (Delanghe et al 1997, van
physiological and pathological halitosis. Such individuals are categorized as Steenberghe 1997).
Physiologic halitosis includes halitosis halitophobic. Halitophobia may be
caused by dietary components, deleterious considered when no physical or social History
evidence exists to suggest that halitosis is The references of oral malodour have been

©Indian Journal of Dental Sciences. (December 2011 Issue:5, Vol.:3) All rights are reserved. 102
found in scripts of Eber papyrus as early as same way garlic rubbed into the soles of feet live in person's mouth. Bacteria, just like
1550 B.C., and in the Talmud (a book can later be detected in trace amounts in the humans, go through their lives consuming
containing ancient Jewish civil and religious breath. Spicy foods also create recognizable food and excreting waste. The waste
law). Hippocrates (460-400 B.C.) had odor in some people's pungent exhalations. products produced by some oral bacteria are
developed a mouthwash of unadulterated sulfur compounds. These odoriferous waste
wine, anise, dill seed and myrtle. Maccius Etiology products usually lie at the root of person's
Platus (254-184 B.C.) a Roman dramatist Temporary halitosis: It results from bad breath problem.
who was sufficiently offended by his wife's hot/spicy food, certain drinks, alcoholic
halitosis to find it just cause for infidelity.5 In beverages, coffee and most common from The stench associated with rotten eggs is
19th century Joseph Howe, a physician, garlic, onion, salty foods, spices, curries, caused by hydrogen sulfide. The stinky
introduced his well-written and informative cured foods like salamis and cooked food smell emanating from feed lots and
book. He believed that halitosis was the such as kippers10. Tobacco consumption barnyards is one produced by methyl
result of sulphuretted hydrogen, which is causes mouldy odor and Hyposalivation/ mercaptan and odor associated with ocean is
found in great abundance in the intestinal Xerostomia (dry mouth) also leads to bad that of dimethyl sulfide. Each of this is
canal as well as in decayed teeth, dead teeth breath11. excreted as a waste product by bacteria that
and inflamed gums. He also postulated that live in our mouths. Together dentist refer to
stress, in the form of fear, excitement or Morning breath: Everybody has a degree of them as Volatile Sulfur Compounds
tension may sufficiently alter the body halitosis, first thing in the morning. There is (VSC'S). Term volatile simply describes the
systems to produce a disagreeable breath a physiological reason for this. During fact that these compounds evaporate readily
odor.6 sleep, the flow of saliva is reduced even at normal temperatures. The extreme
drastically and tongue and cheek move very volatility of these compounds explains how
Epidemiology little. This allows food residues to stagnate they have the ability to offend around us
Information regarding the prevalence of oral in the mouth and dead cells that are normally instantly.
halitosis is scarce due to lack of shed from the surface of tongue and gums
epidemiological studies. An early study and from the inside of cheek to accumulate. Production of VSC's
from The Netherlands among 11625 As bacteria starts to work on them and digest The unpleasant smell of breath mainly
individuals revealed a prevalence of them, an unpleasant smell is generated. This originates from VSC's which comprise of
approximately 25% in subjects older than 60 process is biologically known as hydrogen sulfide (H2S), methyl mercaptan
years of age (de Witt 1966). In subjects putrefaction/rotting. (CH3SH), dimethyl sulfide (CH3)2SH,
under 20 years, the prevalence of oral dimethyl disulfide (CH 3 ) 2 S 2 , as first
halitosis was 10%, indicating that the Although normal, anyone suffering from discovered by Tonzetich. They all are thiols;
prevalence of this condition increases with nasal congestion whose mouth breathes is containing a characteristic -SH group which
age. Several studies in industrialized more likely to suffer from these actions to a is formed when the oxygen atom in hydroxyl
countries report an incidence as high as greater extent. Luckily, this morning breath group is replaced by sulfur. Oral thiols are
50%, with a various degree of intensity. In generally disappears after breakfast and toxic byproducts of gram negative
China the incidence of oral halitosis was after brushing the teeth because saliva starts anaerobic bacterial metabolism of sulfur
surveyed in a sample of 2000 individuals to flow again and any left over residues are containing amino acids (cystine, cysteine
aged 15-64 years. Oral halitosis was washed away and swallowed12. and methionine) that reside in saliva, GCF,
measured in 27.5%of the subjects with the gingival and periodontal pocket and
organoleptic measurements (Liu et al Smoking (cigarettes/cigars): Breath smells tongue surface. This bacterial metabolism is
2006).7 Bornstein et al. 2009 reported 20% like ash tray. Smoking also reduces the flow of putrefactive nature and leads to oxygen
prevalence of detected chronic halitosis of saliva and therefore further exacerbates depletion14.
among 626 male army recruits of the problem13.
Switzerland. Yokoyama et al (2010) Volatile fatty acids such as valerate, butyrate
reported 42% prevalence of halitosis Crash dieting/fasting: When the body is no and propionate are all malodorous. When
experience (anxiety or consciousness of the longer supplied with energy giving hormonal, gastro-intestinal, renal, or
problem at least once) and 39.6% carbohydrates it first breaks down glucose metabolic pathologies are the cause,
prevalence of clinically detectable stored in the muscles and liver in the form of additional malodorous molecules can be
malodour in 474 senior high school students glycogen. But this does not last long. After a produced; these circulate in the blood and
of Japan.8 few hours, the body begins to breakdown its are expressed through the expired air or
fat stores and the waste product of their GCF.
Fact file metabolism, ketones, endows the breath
Breath smells only when certain aromatic with a distinctive sweet and sickly smell. Other waste products are
compounds are found dissolved in it. These This can be seen in those who has vigorously Cadaverine: Smell associated with corpses
include methyl mercaptan, hydrogen worked out and exercised and not taken Putrescine: Produced by decaying meat;
sulphide, cadaverine, putrescine, skatole sufficient carbohydrates before or after. Skatole: Human faecal matter;
and isovaleric acid9. People on a strict caveman or high protein Isovaleric acid: Sweaty feet.
diet experience the same effect for similar
Some of these may be absorbed from the reasons. The above wonderful mixture of
bowel in the bloodstream and then compounds emanates from mouth of human
circulated around the body until they are Oral Malodor and no one is exception. Everyone has some
excreted via the lungs in the breath. In the Bad breath is usually caused by bacteria that level of these unpleasant compounds in their

©Indian Journal of Dental Sciences. (December 2011 Issue:5, Vol.:3) All rights are reserved. 103
breath. Fortunately however, low levels of products from their meals are precisely the Even in a relatively healthy mouth,
these compounds cannot be detected by compounds that cause bad breath. There is anaerobic environment both around and in
human nose. It is only when the levels always naturally occurring protein food between the teeth and underneath the gum
become elevated, others nose can detect sources floating around in our mouth such as line can be found. This anaerobic
them. dead skin cells or protein compounds found environment is more in people who suffer
in the saliva. And then also especially for from gum diseases such as gingivitis and
Bad breath is caused by waste products of those who are not diligent with brushing and periodontitis (Periodontal Disease). In
anaerobic oral bacteria (more specifically flossing, there is always the left over food periodontal disease the deep recesses of the
gram negative anaerobic bacteria15 e.g.: debris from yesterdays meal and the meal periodontal pockets are difficult to clean.
prevotella intermedia, porphyromonas before that…..and the one before that……. This creates the ideal anaerobic
gingivalis etc.). Term anaerobic describes environment for the bacteria that causes bad
that they best grow in environments devoid High protein foods include meat, fish, sea breath.
of oxygen. Person's mouth is a home for food and eggs; dairy foods such as milk, Other reasons for oral malodor are
hundreds of different species of bacteria and cheese, yoghurt; cereal grains and products; Candidiasis, deep carious lesions
on going in our mouth is a constant battle for desserts especially cakes and pies. (particularly after food impaction), exposed
living space between type of bacteria which pulps and open root canals, extraction
do create waste products that causes bad Where do the bacteria that cause bad wounds, interdental food impaction,
breath and those that don't and it's the precise breath live? necrotizing ulcerative gingivitis (NUG),
balance between the relative number of For most of us bad breath causing bacteria necrotizing ulcerative periodontitis (NUP),
these type of bacteria that determine the live on the surface of tongue. Secondary acrylic prosthesis and Vincent's angina.
quality of person's breath. locations can be at or below person's gum
line16. Yoneda M et al have reported a case of oral
Plaque accumulation (the whitish film that malodor associated with internal
is formed above and below gum line and Bacteria that live on person's tongue resorption.18
also on tongue) can tip the scales in favor of Most common odor producing region of the
odor causing bacteria. A layer of plaque as tongue is its posterior region. covered by a Association of oral malodor with
thin as 0.1-0.2 mm becomes depleted to whitish layer, dental plaque and its chocked periodontitis
oxygen, precisely in which anaerobic full of anaerobic bacteria that cause bad A correlation has been found between VSC
bacteria flourish. So, as more and more breath. The precise surface texture found on concentration in mouth air and increased
plaque builds up, bacteria causing bad individual's tongue will influence the pocket depth in periodontitis patients.19,20
breath gain available living space and amount of coating that tends to accumulate. The uptake of volatile sulphurs by epithelial
proliferate, thus increasing the level of odor. Fissured tongue, grooved tongue, and lingua cells may play an important role in the
Solis-Gaffar et al. examined eight plicata have more potential to accumulate pathogenesis of periodontal disease: it has
prominent Gram-positive and four Gram- bacteria laden coating than those with been proposed that volatile sulphurs may
negative bacteria for their ability to produce smoother tongue surface. alter the permeability of affected cells and
volatile sulfur compounds. All of the Gram- facilitate the access of toxic metabolites into
negatives and none of the Gram-positives Refer table 1 for classification of severity the underlying connective tissue thereby
produced H2S, CH3SH, and (CH3)2S6. and extent of tongue coating (Van contributing to collagen degradation. There
Tonzetich and McBride examined strains of Steenberghe, 2004). There is a direct is also general agreement that the VSC
B. melaninogenicus for their ability to correlation between the amount of coating content of exhaled mouth air and the
produce volatile sulfur metabolites and that exists on persons tongue and total concentration of VSC precursors increases
found collagenase and protease positive number of anaerobic bacteria17. with the severity of periodontal disease.21
strains (asaccharolyticus) produced more of
Table 1 - Classification of severity and extent
these cell and tissue destructive compounds of tongue coating (van Steenberghe, 2004) Source of VSC production in periodontitis
than strains (var. melaninogenicus) that did patients12
Degree 0 No visible coating
not have collagenase and protease activities. In 1998, Yaegaki et al carried out a study
F. nucleatum, an anaerobic Gram-negative Degree 1 < 1/3 covered by easily removable coating aimed to investigate the VSC production of
rod, is another prominent organism in the tongue coating in relation to the severity of
Degree 2 < 2/3 covered by easily removable coating and
microflora of the crevices of humans periodontal disease. They analyzed the
e s p e c i a l l y t h o s e w i t h < 1/3 covered by not easily removable coating VSCs in mouth air using gas
gingivitis/periodontitis that can metabolize chromatography before and after removing
cysteine and methionine and produce the Degree 3 > 2/3 covered by easily removable coating the tongue coating. They concluded the
sulfur volatiles that contribute to malodor.9 Degree 4 > 2/3 covered by not easily removable plaque tongue coating might be a main site of oral
malodor production in slight or moderate
What is the food source for anaerobic periodontal disease, whereas, the
bacteria that cause bad breath? Bacteria that live at and below person's gum periodontal pocket would be the main origin
Most of the odoriferous compounds that line of VSCs only in severe periodontal disease.
cause bad breath are waste products created When we floss the teeth, at times we are
by anaerobic bacteria, as they digest dredged up with foul taste or odor. This odor Role of VSCs in the pathogenesis of
proteins. This means that as we consume is more noticeable in the posterior part of the destructive periodontitis
food items such as meat and fish, bacteria mouth, as the bacteria that cause bad breath In addition to being a major contributor to
living in our mouth also get meal and waste often find a cozy home here. oral malodor, VSCs have been implicated in

©Indian Journal of Dental Sciences. (December 2011 Issue:5, Vol.:3) All rights are reserved. 104
the disruption of oral mucosa and may carcinoma of the larynx.
contribute to the progression of periodontal Gastric hernia:
disease. Some studies suggest that the Halitosis of Lower Respiratory Tract: It may Fundus of stomach protrudes through
production of VSCs by these be because of bronchitis, bronchiectasis, diaphragm with relative sphincter
microorganisms may contribute to the pneumonia, pulmonary abscess and insufficiency allowing gases to escape and
progression of periodontal disease via carcinoma of the lungs (Attia and contents to flow back to the esophagus can
breakdown of the oral mucosa leading to Marshall1982, Lu 1982, Durham et al 1993, cause reflex of the gastric contents up to the
bacterial invasion. Ng and Tonzetich found McDowell and Kassebaum 1993) oropharynx. This is sometimes combined
that the permeability of porcine sublingual with ructus, where air from stomach
mucosa increased 75 percent and 103 Gastrointestinal tract: suddenly regurgitates.
percent following exposure to hydrogen Unpleasant odor from the lower
sulfide and methyl mercaptan, respectively. gastrointestinal tract is only detectable Gastric Reflux:
This finding suggests that the VSCs of oral during belching or vomiting, because the It is a common cause of morning halitosis. In
malodor could contribute to the esophagus is normally collapsed (Attia and this, there is reflux of gastric juice, bacteria
pathogenesis periodontitis.22 Marshall 1982). The stomach is therefore and digested food into the pharynx.
not considered to be contributory to the
VSCs are highly toxic to tissues even at halitosis, except in rare circumstances Intestinal gas production:
extremely low concentrations and, (Rosenberg 1996). The following
therefore, may play a role in the pathologies might be responsible for less Others:
pathogenesis of inflammatory conditions than 1% of malodor cases: Extraoral halitosis might also be a
affecting the periodontium, such as manifestation of a serious systemic disease,
periodontitis. They also alter the Zenker's Diverticlum: such as hiatus hernia, hepatic cirrhosis or
metabolism of fibronectin and interfere in It is hernia in esophageal wall, allowing diabetes mellitus (Tangermann 2002).
the enzymatic and immunological reactions accumulation of food and debris and thus Tangerman A, Winkel EG (2007) provided
leading to tissue destruction while showing putrefaction. It can cause a significant evidence that the VSC, CH3SH and to a
an increase in the release of Interleukin-1 breath odor because it is not separated from lesser extent H2S are the main contributors
(IL-1) and PGE2 .12 oral cavity by any sphincter. to intra-oral halitosis and that CH3SCH3 is

Some studies have failed to demonstrate Table 2 – Possible causes of Halitosis


positive correlations between periodontitis Specialty Cause / Basic Disease .
severity and halitosis. Rosenberg M et al
(1991)23 found a weak correlation between - Coating of the tongue - Open root canals
presence of pockets greater than 7 mm and - Sub and / or supragingival biofilm - Overhanging restoration margins
sulphide measurements. Bosy et al in 1994
did not find a relationship between Dentist - Gingivitis - Pemphigus
periodontal disease and the prevalence or - Periodontitis - Morbus Behcet
severity of halitosis. In addition to the lack
of presence/absence of periodontal disease, - Candidiasis - Erytherma exudativum multiforme
the intensity of halitosis based on VSC - Untended prosthesis - Ulcerating and decomposing tumors
concentration was 19% less in periodontally
healthy subjects (mean 111 ppb) than in - Abscesses
subjects with periodontitis (mean=136 - Tonsillitis - Debris
ppb).21
- Sinusitis - Abscesses
Malodor of Extraoral Origin3,4,24 ENT - Pharyngitis - Lues III
In only 10% of cases, cause can be traced
back to an internal (Lang and Filippi, 2005a) - Diphtheria - Chronic rhinitis
or ENT problem (Tonzetich, 1978) - Pfeiffer's Disease - Postnasal drip

Refer table 2 for the possible causes. - Angina Plaut Vincent - Ulcerating and decomposing tumors
Certain breath odors are of diagnostic - Putrid bronchitis
significance for the physician. For example,
the acetone odor of diabetic ketoacidosis, - Pneumonia - Diabetes mellitus
the ammonia smell of uremia and the rotten - Abscesses (lung) - Oesophagitis
egg smell of liver failure is due to the
inability of the liver to break down diethyl - Xenoliths - Yellow fever
sulfide, which is released due to bacterial
Internal Medicine - Gangrene of the lung - Pharmaceuticals
action. This is excreted through the lungs.
- Wagner's granulomatosis - Trimethylaminuria
Halitosis of Upper Respiratory Tract: It may
- Gastric and intestinal diseases. - Ulcerating and decomposing tumors
be because of chronic sinusitis, nasal
obstruction, nasopharyngeal abscess and - Precomatose condition and coma (uremia, coma hepaticum) - Diverticle

©Indian Journal of Dental Sciences. (December 2011 Issue:5, Vol.:3) All rights are reserved. 105
the main contributor to extra-oral or blood- Who noticed the bad breath- patient
? interdental area (area between teeth) and
borne halitosis, due to a hitherto unknown himself (halitophobia / pseudohalitosis) smell it.
metabolic disorder.25 or others?
Rosenberg M et al (2007)26 identified ? Under which circumstances was the bad Experiment 4:
predictive factors for bad breath in the breath experienced? Only in the Spit saliva in a small cup or spoon. Allow it
general adult population, by a 38-question morning (temporary bad breath), after to dry for a few seconds (so that putrefaction
self administered questionnaire, along with meals (due to certain foods or spices), or odors can escape from the liquid) and then
objective odor judge and instrumental after lying down. Halitosis after meals or smell it.
measurements and results suggested that lying down may be indicative of
that alcohol intake and body mass index may regurgitation oesophagitis (Van How Academic Researchers Test for Bad
be factors that help predict oral malodor. Steenberghe, 2004). Breath?
? The clinician should ask about the Before a dental researcher can evaluate
Medications: frequency (e.g., every month), time of various cures for bad breath, they must
Some drugs, such as metronidazole, can appearance with in the day (e.g., after measure its severity both initially and after
cause breath malodor. Metronidazole, an meals can indicate a stomach hernia) etc. the cure.
antimicrobial, also leads to the patient's One of the major challenges in judging
perception of metallic taste, which is often halitosis is that self reported halitosis is Organoleptic Testing4,24
confused with breath odor. Eucalyptus quite subjective. Thus, it may be helpful Gold standard for measuring halitosis is
containing medications impart a melon like if the patient is accompanied by organoleptic testing. In this testing, the
odor. Arsenic smells of rotten onions. candidate who is able to give more researchers are using their senses of smell
Amitriptyline (a tricyclic anti-depressant), objective picture. For example, a spouse, i.e. their nose as the means for making the
certain anti-hypertensives, sedatives, friend or family members. determination. Historically, this method has
hypnotics, anti-allergic drugs which dry up been a frequent choice among dental
saliva as a side effect, also add to the Is there a way a person can test their own researchers. Noses are readily available,
problem. breath24? inexpensive to obtain and operate and to
their credit, noses can detect up to 10,000
Do You Have Bad Breath? There are indirect routes to test your own different smells. One of the problems
At some point each of us had bad breath. For breath. associated with using this method is that it is
any individual, the exact status of their not totally objective. Another is that factors
breath is difficult to ascertain, reason for this Experiment 1: other than just breath odors can and do
is that the oral cavity, the source of our Lick your wrist, wait about five seconds influence organoleptic evaluations. Factors
breath, is connected to our nose by way of an while the saliva dries somewhat and then such as hunger, menstrual cycle, head
opening which lies in the back of our mouth smell it. This experiment tells us about the position and the degree of attentiveness and
(back in the region of soft palate). Since smell of the anterior portion of the tongue. expectation can each influence a judge's
noses tend to filter out and ignore interpretation of what they smell.
background odors, it filters out and ignores Experiment 2:
our own bad breath. This means it is quite Take a spoon. Turn it upside down and use it To assess halitosis, examiner should be
possible for a person to have bad breath, yet to scrap the very back portion of the tongue. trained and calibrated. To assess examiners
not be aware of it. Take the look at the material that has been differentiation abilities, test kits with
scraped off, usually a thick whitish material. different scents may be used (smell
Diagnosis Now take a whiff of it. This experiment tells identification test). Further, these kits
Patient's History us about the smell of posterior portion of the containing different dilutions of specific
? Patient should be asked to describe the tongue. This smell is probably the way your scents are available to assess and train
type of smell that is being noticed. breath smells to others. differentiation strength of scents (Lang and
Depending on the origin, different Filippi, 2005b). Sometimes, the examiner's
smells may be distinguished. (Refer Experiment 3: smell may be impaired due to ones own
table 3) Take a toothpick and introduce into the halitosis, or temporary deterioration of
smelling (example rhinitis).

Table 3 - Different types of breath malodor according to their most likely origin Prerequisites: Going to the dentist to
(Preti et al, 1992; van Steenberghe, 2004)
classify the halitosis can be quite
Type of Odor Origin embarrassing, so high level of privacy has to
be maintained. Patient and examiner have to
Like rotten eggs Indicates volatile sulfur compounds (VSC), which in most cases are associated with periodontitis or coated tongue.
abstain from substances that cause
Sweet (like dead mice) Cirrhosis of the liver: besides VSC, aliphatic acids (butyric, propionic acid), methylmercaptan, ethanethiol, temporary malodor, 12 hours before the
examination. Substances that mask halitosis
dimethyl sulphide accumulate.
may have to be avoided (e.g. shampoo,
Like rotten apples Not well controlled insulin-dependant diabetes: accumulation of ketones perfume, mouth rinses). Classify it in four
degrees of severity (Refer table 4). Further
Like Fish Kidney insufficiency or trimethylaminuria (very rare metabolic disease): uremia and accumulation of the clinical examination should follow a
di- and trimethylamine certain sequence in order to distinguish the
origin of malodor (Table 5).

©Indian Journal of Dental Sciences. (December 2011 Issue:5, Vol.:3) All rights are reserved. 106
Table 4 - Classification of Subjectivity perceived Halitosis (Seemann, 2002)
with halimeters ability to make a
Degree 0 From approximately 10 cm distance, have the patient say "A". No unpleasant smell is perceived. measurement.
Advantages: It requires no special training
Degree 1 From approximately 10 cm distance, have the patient say "A". An unpleasant smell is perceived. to use, is portable, measurements can be
Degree 2 From approximately 30 cm distance, an unpleasant smell is perceived during a conversation. made quickly and apparatus is
comparatively inexpensive.
Degree 3 From approximately 1m distance, i.e. during the anamnesis talk, an obvious bad breath is perceived. Uses: For follow ups, psychological support
during treatment and many patients trust the
Table 5- Sequence of the clinical examination result of a device more than dentists nose
Smelling Perceived air Originates From (Seeman 2002).
Rosenberg M et al (1991)23 elucidated that
- the air or the oral cavity while the patient holds his breath - the oral cavity although assessment of steady-state
- the air expected through the mouth - the mouth or the lungs
sulphide levels by the sulphide monitor does
not constitute a direct measure of oral
- the air when a patient forms a forced expiration - the bronchi and / or the lungs malodor, its relation to organoleptic
- the air while the patient counts from 1 to 20 - (most likely) the oral cavity; counting leads to drying
measurement, superior reproducibility,
objectivity, and sensitivity support the use of
of the mucosa setting free VSC that are solved in the saliva the sulphide monitor in clinical studies.
- the anterior 2/3 of the tongue; patient licks his wrist at which the - the anterior part of the tongue
Based on the superior reproducibility and
sensitivity of the sulphide measurements
examiner smells after a while of drying compared with organoleptic measurements,
- the coating from the posterior 1/3 of the tongue, that was scrapped - the posterior part of the tongue
the sulphide monitor may be a valuable tool
for assessment of oral malodor. The
by the scrapper, periodontal probe or spoon sulphide monitor also presents other
advantages such as: (i) no need for skilled
- the plaque and debris removed from some interdental spaces by a - the interproximal spaces
personnel; (ii) non-invasive; (iii) low
tooth pick, interdental brush or a periodontal probe likelihood of cross-infection; (iv)
portability; (v) relatively inexpensive; and
- saliva spat into a small cup - the saliva
(vi) rapid turnaround time of one to two min
- the air expelled by the nose - the nose or the sinuses between measurements. However, it lacks
the specificity of gas chromatography, since
- the air from one and then the other nostril - just the nose or sinus of one side
it cannot distinguish between the
proportions and species of different VSC's.
Demerits: Each judge participating won't be It is a specialized type of sulfide monitor and
able to make equivalent comparison. And it produces a mean by which tester can The BANA Test
when we are repeatedly exposed to a bad quantify degrees of bad breath in parts per Bacteria that produce bad breath can be
odor our sense of smell acclimates to the billion (ppb). These machines first detected by performing BANA test.
odor and therefore loses much of its introduced in 1991, measure the level of Bacteria, in question have the characteristic
sensitivity. Bad breath that was exceedingly sulfide gas found in persons breath i.e. of being able to produce an enzyme that
objectionable at the beginning, may seem VSC'S. Halimeters showing high levels of degrades the compound BANA (benzoyl-D,
quite less as the evaluation continues. sulfide suggest a correlating high levels of L-arginine-napthylamide). When sample of
VSC although doesn't test for individual patient's saliva that contains these bacteria is
Instrument assessment24 type of VSC's specifically. placed in the BANA testing compound, they
It has been used by dentist to study bad The examination should preferably be done cause it to break down. As a result, the
breath and definitely quantify the precise after at least 4 hours of fasting and after testing compound changes color. The results
level of specific compound present in keeping the mouth closed for 3 minutes. The of a study by Kozlovsky A et al (1994)
someone's breath. This device can analyze mouth air is aspirated by inserting a drinking suggested that the BANA test, a simple,
air, (incubated) saliva, or crevicular fluid for straw fixed on the flexible tube of the adjunct assay together with volatile sulphide
any component. instrument. This straw is kept about 2cm determination which provides additional
Use: Primarily for scientific purpose. behind the lips, without touching any quantitative data contributing to the overall
Demerits: Relatively expensive, requires surface and while the subject keeps the
association with odor judge estimation.27
personnel with special training to operate mouth slightly open and breathes normally.
Utilizing Chemiluminescence
them, not portable equipment and time Absence of breath malodor leads to readings
One of the most recent methods for
consuming. of 100 ppb or lower. Patients with elevated
detecting the compounds associated with
Recently a small, portable gas levels of VSC's easily reach 300-400 ppb.
bad breath. Method was introduced in 1999.
chromatograph (Oral Chroma, Abilit, Disadvantages: It test for a fewer no. of
When a sample containing sulfur compound
Henderson, Nevada) has been introduced, compounds (sulfides only) than gas
is mixed with the tests mercury compound,
which makes this technique available for chromatographs and in fact tests for no
the resulting reaction causes fluorescence.
periodontal clinics. It has the capacity to individual compounds at all but just sulfide
Advantage: It provides better selectivity and
measure the concentration of three key as a class. Additionally compounds such as
sensitivity when measuring low levels of
sulfides separately. ethanol (alcohol) and essential oils (both of
sulfur compounds as compared to
Halimeter4,24 which are found in mouthwashes) interfere
halimeters.

©Indian Journal of Dental Sciences. (December 2011 Issue:5, Vol.:3) All rights are reserved. 107
thoroughly a food supply is provided for self-cleansing and more exposed to outside
Zinc oxide and Nitrogen chemiluminescence these bacteria over an extended period of environment, thus getting a better
detectors time. oxygenation and therefore less likely to
These chemiluminescence detectors permit How cleaning your teeth and gums can harbor large numbers of odor producing
the precise measurement of nitrogen help to cure bad breath? bacteria. Many tongue functions require that
compounds such as indole & cadaverine in As already explained the bacteria that causes the anterior portion of the tongue touches
organic matrices. This helps to determine bad breath live in dental plaque that firmly against the hard palate. This friction
whether these nitrogen compounds are accumulates on and around person's teeth, produces a cleansing action, therefore
present in mouth air.28 both at or below gum line. So a thorough preventing any significant bacterial
Electronic Noses brushing and flossing technique is needed in accumulation.
Also called as Artificial Noses, are supposed order to remove this plaque and any food The posterior portion of the tongue in
to provide quantification and classification debris. comparison only rubs up against the palate
of exact smells (Shimura et al, 1997). Make an appointment with your dentist (soft palate) relatively gently during tongue
Originally it was developed for quantitative If bad breath problem persists, even after a movements. This soft palate contact does
assessment of smells in food or beverage. period of following all of the tips and not provide enough friction to produce any
However, an application to diagnosis of suggestions, then one should schedule an significant cleansing. For this reason it is
halitosis appears reasonable. examination and cleaning appointment with typically the posterior aspect of the tongue
the dentist so that one can discuss their that is found to harbor the bacteria that cause
D a r k F i e l d o r P h a s e - C o n t r a s t problems with them. During this visit the a person's bad breath, and thus the posterior
Microscopy24 following can be accomplished: tongue is the most important area to clean.
Gingivitis and periodontitis are typically 1.) Sometimes effective brushing and By Tooth Brush:
associated with a higher incidence of motile flossing technique can be difficult to To do so, start as far back as possible and
organisms and spirochetes. These can be learn. After examining, dentist can then make brush strokes outward, toward
seen directly with the help of microscope. provide with instructions, tips, and the front of mouth. One needs to use some
Advantage: patients become aware of the pointers that will be helpful in specific pressure but of course not enough to cause
bacteria present in the plaque, tongue situation. irritation to tongue. As a way of improving
coating and saliva. 2.) Tartar (dental calculus) accumulation the effectiveness of tongue brushing efforts,
can interfere with effective brushing and one can use toothpaste.
How do you cure bad breath? flossing. Scaling and root planing will By Tongue Scraper:
The most important step a person can take remove this debris from teeth. In a study Some people believe this is more effective
towards improving the quality of breath is to by Saito Mitsuhiro et al (2000) halitosis method and produces less gagging. To do so,
clean their mouth in a manner which helps to parameters as measured by the place a tongue scraper on the posterior part
minimize the amount of food available for Halimeter, and the organoleptic of tongue. Be thorough and gentle and don't
anaerobic bacteria, minimize the total examination were improved, and the scrap so hard or vigorously that it irritates
number of these bacteria that exist, total amount of plaque was decreased. the tongue. Faveri M et al (2006) suggested
minimize the availability of type of These results suggest that improved that tongue scraping appears to be the most
environment in which these bacteria prefer gingival inflammation with periodontal important hygienic procedure to reduce
to live, make any environment in which treatment improves halitosis.29 morning bad breath in periodontally healthy
these bacteria do live less hospitable. On a 3.) Periodontal evaluation: Periodontal subjects.30
second front, a person can use products that pockets are often impossible for us to A Cochrane review (2008)31 conducted to
neutralize the odor causing volatile sulfur clean for bacteria to live. So, if provide reliable evidence regarding the
compounds. periodontal condition is evaluated, effectiveness of tongue scraping versus
Minimizing the food supply for bacteria that dentist can outline the treatment other interventions (including
causes bad breath required to control this condition. mouthwashes) to control halitosis
When anaerobic bacteria digest proteins, 4.) Dentist will check if there are any concluded that there is weak and unreliable
volatile sulfur compounds are created as untreated dental conditions that could be evidence to show that there is a small but
waste products that cause bad breath. The causing or exaggerating breath statistically significant difference in
person who maintains a vegetarian diet problems. reduction of VSC levels when tongue
mostly of fruits and vegetable has fewer 5.) Dentist will help you to determine scrapers or cleaners rather than toothbrushes
chronic breath problems than those who whether its oral or medical evaluation is are used to reduce halitosis in adults. They
consume protein rich food such as meat.It is indicated. found no high level evidence comparing
important for a person to clean one's mouth Bad Breath Cures by Tongue Scrapers or mechanical with other forms of tongue
thoroughly especially after eating protein Tongue Brushes1 cleaning. Tongue scrapers or cleaners are
rich food. This is because even after we have Most people overlook cleaning their tongue, slightly more effective than toothbrushes as
finished a meal minute particles of food still however, starting to do so on a regular basis, a means of controlling halitosis in adults.
remain in our mouth. Much of this food can be the single most beneficial treatment This review, which included 2 trials (40
debris ends up lodged between our teeth and for bad breath that a person can institute. The participants) found that, although the use of
incorporated into the coating found on the anterior portion of a person's tongue is tongue scrapers was generally well
posterior part of our tongue. Since these are usually less offensive than the smell found accepted, the effects of tongue cleaning
precisely the same locations in which the emanating from the posterior part. The using scrapers or brushes appeared to be
anaerobic bacteria that cause bad breath reason for this is related to the fact that the very short lived and there was some limited
live, if a person does not clean their mouth anterior portion of the tongue is somewhat evidence of tongue trauma which occurred

©Indian Journal of Dental Sciences. (December 2011 Issue:5, Vol.:3) All rights are reserved. 108
with prolonged use of one tongue scraper. Rosenberg et al showed that a 0.2% adhesion of a high proportion of oral
chlorhexidine rinse provides 43% microorganisms to the oil droplets,
A study by Casemiro LA et al (2008)32 reduction in VSC levels and a greater which is further enhanced by the CPC.
compared the effectiveness of a new manual than 50% reduction in organoleptic These reductions were almost
toothbrush that has a tongue scraper on the mouth odor ratings. comparable to chlorhexidine, superior to
back of its head and a commercial tongue 2. Halita, a new solution containing 0.05% Listerine and significantly superior to a
scraper in improving breath odor and chlorhexidine, 0.05% CPC, 0.14% zinc placebo.
reducing the aerobic and anaerobic lactate and no alcohol, has been found 6. Triclosan a broad spectrum antibacterial
microbiota of tongue surface. They even more effective than chlorhexidine agent has been found to be effective
demonstrate that the adoption of methods alone, suggesting that the other against most oral bacteria and has a good
for tongue cleaning associated to compounds are also important. This is compatibility with other compounds
toothbrushing minimizes halitosis and explained by the synergistic action of used for oral home care. The anti -VSC
reduces bacterial counts on tongue surface. chlorhexidine and CPC on one hand and effect depends strongly on its
The evaluated methods (toothbrush with a by the zinc ions on the other hand. solubilizing properties. In the Carvalho
tongue scraper on the back of its head and 3. Essential oils containing mouthwash et al. (2004)33 investigation, plaque
conventional tongue scraper) were equally present in market is Listerine. It has been formation was not always directly
effective in the improving breath odor and found only relatively effective against associated with VSC measurements,
reducing the facultative aerobic and oral malodor (25% reduction vs. 10% for since the triclosan and CPC mouthrinses
anaerobic microbiota on tongue surface of placebo). In a study by Pitts G et al an were more effective in reducing bad
the studied population. essential oil mouthrinse was able to breath than in reducing supragingival
reduce the offensive gases present in plaque accumulation. Therefore, it could
Bad Breath Cure by Chemicals24 morning bad breath as measured by a be postulated that the superior reducing
Mouthwashes, when used in conjunction sulfide monitor, a result that is in effect of these specific mouthrinses on
with a regimen of effective tongue cleaning, agreement with those of a previous bad breath may be related primarily to
tooth brushing, and flossing, can play a role short-term study, in which the results their efficacy in reducing the load of
in the treatment of bad breath. Carvalho MD indicated a reduction of the organoleptic VSC-related microorganisms and oral
et al (2004)33 demonstrated the beneficial scores by essential oils, which caused a debris in the whole mouth niches rather
impact of mouthrinses on morning breath sustained reduction in the plaque than only in supragingival plaque
even in the absence of mechanical plaque odorigenic bacteria, unlike the placebo.34 reduction.35
control. In a cross-over trial conducted by An argument was made that the re- 7. Amine fluoride / Stannous Fluoride
them on college students, the VSC odoration was important to the overall 8. Hydrogen peroxide 3%
formation was inhibited in descending activity of the product only for about 30
order, 0.2% chlorhexidine, 0.12% min after treatment and, at post- Quirynen M et al (2002)37 demonstrated that
chlorhexidine, triclosan and essential oils treatment times of 60-180 min, the anti- morning halitosis can be successfully
and cetylpyridinium chloride.The odor activity of the product was due to its reduced by the sole twice daily use of 0.2%
effectiveness of a particular mouthwash will anti-microbial action. That conclusion chlorhexidine (CHX)-alcohol mouthrinse,
be founded on its possessing one or both of became the basis for the premise that 0.05% CHX +0.05% cetylpyridinium
the following characteristics: anti-VSC agents would succeed if they chloride (CPC) + 0.14% zinc lactate
had an antimicrobial component.35 mouthrinse, an amine fluoride/stannous
A) Antibacterial mouthwashes 4. Chlorine Dioxide it is a powerful (AmF/SnF2) fluoride (125ppm F-/125ppm
If a mouthwash has the ability to kill oxidizing agent that can eliminate bad F-) containing mouthrinse, which all
bacteria, so reduces anaerobic bacteria that breath by oxidation of hydrogen sulfide, significantly reduced the bacterial load in
produce VSC's and hence bad breath. methylmercaptan and the amino acids the saliva and retarded the de novo plaque
methionine and cysteine. Shinada K et al formation. The subjective ratings of the
B) Mouthwash that neutralizes VSC's (2010)36 showed that a mouthwash subjects were in general more in favour of
The ingredients found in some containing ClO2 improved morning bad CHX-CPC-Zn or AmF/SnF2 solutions.
mouthwashes have the capability to breath measured with the organoleptic
neutralize VSC's and/or the compounds measurement and reduced the Cochrane review investigating the effects of
from which they are formed. concentrations of H2S, CH3SH and mouthrinses in controlling halitosis which
(CH3)2S measured by gas included five trials (293 participants), found
Some of the different types of over-the- chromatography in healthy subjects. that there is some evidence that mouthrinses
counter mouthwashes have been employed Moreover ClO2 mouthwash used over a containing antibacterial agents such as
in the treatment of bad breath (Table 6). 7-day period was effective in reducing chlorhexidine and cetylpyridinium chloride
Following are the compounds which offer a plaque, tongue coating accumulation or those containing chlorine dioxide and
great help to reduce the oral malodor: and the counts of Fusobacterium zinc can to some extent reduce the
1. Chlorhexidine: it is most effective anti- nucleatum in saliva. unpleasant odour but the use of mouthrinses
plaque and anti-gingivitis agent. Its 5. Two- Phase Oil-Water Rinse Rosenberg containing chlorhexidine resulted in
antibacterial action can be explained by et al designed a two-phase oil-water noticeable but temporary staining of the
disruption of the bacterial cell rinse containing CPC that was shown to tongue and teeth.38
membrane by the chlorhexidine result in daylong reduction in oral
molecules, increasing its permeability malodor. The efficacy of this Herbal remedies
and resulting in cell lysis and death. formulation is thought to result from the Many natural products like yogurt, lemon

©Indian Journal of Dental Sciences. (December 2011 Issue:5, Vol.:3) All rights are reserved. 109
water, mint leaves, vinegar, cardamom on the formation of VSCs in the morning become socially isolated, may have their
seeds are beneficial in curing bad breath. breath of healthy individuals and suggested teeth extracted and occasionally commit
that a flavor containing dentifrice seems to suicide. However, patients often refuse to
Lodhia P et al (2008)39 have shown prevent VSCs formation in morning bad acknowledge that they may have a
significant effectiveness of green tea in breath regardless of the amount of TC in psychological problem. Therefore, the
reducing oral malodor because of its periodontally healthy subjects. involvement of a third party (e.g. a confidant
disinfectant and deodorant activities, such as a close family member or a trusted
although effect was maintained for a very How to clean dentures to reduce the friend) in the management may provide the
short duration. Green tea was found even menace? patient with additional psychological
more effective than sugarless chewing gum Dentist should provide with specific support to consider the problem in a more
and mint in reducing volatile sulphur instructions regarding the cleaning of objective manner2
compounds. dentures since dental plaque forms on
dentures just like it does on teeth, gums and General points to remember as Bad
Epigallocatechin gallate (EGCg), the main tongue. So, usually a dentist's Breath Remedies
antimicrobial tea catechin, has been recommendations will include instructions ? Drink plenty of water.
reported to inhibit growth and virulence about thoroughly scrubbing your dentures ? Rinse your mouth with water often.
factors of oral pathogens in vitro. Although with a toothbrush or specialized denture ? Stimulate your mouth's flow of saliva.
the mechanism is unclear, the potential of brush, both inside and out. After scrubbing, ? Clean your mouth well especially after
EGCg in reducing halitosis caused by they might be placed in antiseptic solution. eating high protein content food.
volatile sulfur compounds (VSCs) has been
suggested. Xu X (2010)40 study tested the For ENT and Medical Problems Conclusion
hypothesis that EGCg reduces VSCs by For infections in nose, paranasal sinuses and Oral malodor (halitosis or bad breath) is an
suppressing mgl, the gene encoding L- pharynx: Appropriate antibiotic therapy. offensive odor of oral cavity and may
methionine-á-deamino-ã- For Gastric Reflux: Antacids, H2 blockers disturb interpersonal communication and
mercaptomethanelyase, responsible for and appropriate changes in dietary habits. social activities. The oral region is the most
methyl mercaptan (CH3 SH) production by frequent origin of halitosis. Factors
oral anaerobes. They concluded that EGCg A simple classification with corresponding associated with oral malodor were oral
may represent a natural and alternative agent treatment needs was reported by Miyazaki et hygiene, periodontal disease and oral
to the antimicrobial chemicals. al.2,35 Ken Yaegaki, Jeffrey M. Coil, (2000)2 dryness. Hence health education and
suggested that treatment of physiologic preventive intervention; such as tooth
Can breath mints, lozenges, drops, halitosis (TN-1), oral pathologic halitosis brushing instruction, and treatment
sprays, and chewing gum help to cure bad (TN-1 and TN-2) and pseudo-halitosis (TN- regimens targeting periodontal disease as
breath? 1 and TN-4) would be the responsibility of well as tongue cleaning should be
dental practitioners. Oral pathologic incorporated to reduce levels of these
These products when used alone are not as halitosis is caused mainly by periodontal compounds in mouth air and are satisfactory
effective as when used in conjunction with disease, a condition managed by periodontal for cosmetic treatment.
tongue cleanser, toothbrushes and flossing, treatment. Additionally, dental treatment
especially when they contain agents that may be necessary to correct faulty
have the ability to neutralize VSC's. As an restorations that might contribute to poor References
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Source of Support : Nill, Conflict of Interest : None declared
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