Health

Halitosis: Current concepts on etiology, diagnosis and management

Abstract

Halitosis or oral malodor is an offensive odor originating from the oral cavity, leading to anxiety and psychosocial embarrassment. A patient with halitosis is most likely to contact primary care practitioner for the diagnosis and management. With proper diagnosis, identification of the etiology and timely referrals certain steps are taken to create a successful individualized therapeutic approach for each patient seeking assistance. It is significant to highlight the necessity of an interdisciplinary method for the treatment of halitosis to prevent misdiagnosis or unnecessary treatment. The literature on halitosis, especially with randomized clinical trials, is scarce and additional studies are required. This article succinctly focuses on the development of a systematic flow of events to come to the best management of the halitosis from the primary care practitioner’s point of view.

INTRODUCTION 

Halitosis, also commonly known as “bad breath,”; is a concern of many patients seeking help from health care professionals. The health care workers have neglected the subject of oral malodor but recently, along with the growing public and media interest in oral malodor; health care professionals are becoming more aware of their patient’s concern. A patient with halitosis is most likely to contact primary care practitioner for the diagnosis and management. Most physicians and dental practitioners are inadequately informed about the causes and treatments of halitosis. The present article succinctly focuses on the development of a systematic flow of events to come to the best management of the halitosis from the primary care practitioner’s point of view. The epidemiological research on halitosis is inadequate since it is still a considerable but underrated taboo. The reasons for the lack of scientific data are the difference in cultural and racial appreciation of odors for patients and investigators, and there is the absence of uniformity in evaluation methods, as for organoleptically as for mechanical measurements. Moreover, there are no universally accepted standard criteria, objective or subjective, that define a halitosis patient. There are few studies documenting the prevalence of halitosis in population-wide or community-based samples. In the general population, halitosis has a prevalence ranging from 50% in the USA to between 6% and 23% in China, and a recent study had revealed a prevalence of self-reported halitosis among Indian dental students ranging from 21.7% in males to 35.3% in females. Miyazaki concluded that there was increased correlation between older age and malodor with aging resulting in greater intensity the of odor. In above 60 years age group of the Turkish individuals, the incidence was around 28%. A thorough literature search reveals a lack of studies on halitosis in India, especially among the general population.

WHAT IS THE TRULY PROBABLE SOURCE OF HALITOSIS? 

It is imperative to understand the origin of halitosis as multidisciplinary therapy typically is required in halitosis with emphasis on the causative factor. Halitosis can be broadly classified on the basis of its origin as Genuine Halitosis and Delusional Halitosis.

Physiological halitosis (foul morning breath, morning halitosis) is caused by stagnation of saliva and putrefaction of entrapped food particles and desquamated epithelial cells by the accumulation of bacteria on the dorsum of the tongue, recognized clinically as coated tongue and decrease in frequent liquid intake.

Intraoral conditions are the cause of 80–85% of halitosis cases. Periodontal infections are characterized by a tremendous increase in Gram-negative bacteria that produce volatile sulfur compounds (VSCs). The association between anaerobic bacteria that produces VSCs and halitosis has been well-documented. Most important VSCs are hydrogen sulfide (H2S), methyl mercaptan and dimethyl sulfide. The dorsum of the tongue is the biggest reservoir of bacteria as a source of malodorous gases. Pericoronitis, oral ulcers, periodontal abscess, and herpetic gingivitis are some of the pathologies that result in increased VSCs. Diamines such as putrescine and cadaverine are also responsible for oral malodor as with the increase in periodontal pocket depth; oxygen tension decreases which results in low pH necessary for the activation of the decarboxylation of amino acids to malodorous diamines.

Odontogenic infections include retention of food debris in deep carious lesions and large interdental areas, malaligned teeth, faulty restorations, exposed necrotic pulp, over wearing of acrylic dentures at night, wound infection at the extraction site and ill-fitting prosthesis. The absence of saliva or hypofunction results in an increased Gram-negative microbial load, which increases VSCs, a known cause of malodor. Several mucosal lesions such as syphilis, tuberculosis, stomatitis, intraoral neoplasia and peri-implantitis allow colonization of microorganisms that releases a large amount of malodors compounds.

HOW IS HALITOSIS DIAGNOSED AND EVALUATED?

The patient history should contain main complaint, medical, dental and halitosis history, information about diet and habits, and third part confirmation confirming an objective basis to the complaint. Halitosis history should be discretely and intermittently recorded. Questions such as frequency, duration, time of appearance within a day, whether others have identified the problem (excludes pseudo-halitosis from genuine halitosis), list of medications taken, habits (smoking, alcohol consumption) and other symptoms (nasal discharge, anosmia, cough, pyrexia, and weight loss) should be carefully recorded. The authors have designed an investigative protocol for the diagnosis of oral malodor that can be used in clinical practice and is of significance to family health care practitioners [Figure below].

The clinical assessment of oral malodor is usually subjective examination and is based on smelling the exhaled air of the mouth and nose and comparing the two (organoleptic assessment). Organoleptic assessment is considered as the “gold standard”; to diagnose halitosis in a clinical setting. Odor detectable from the mouth but not from the nose is likely to be of oral or pharyngeal origin. Odor from the nose alone is likely to be coming from the nose or sinuses. In rare instances, when the odor from the nose and mouth is of similar intensity, a systemic cause of the malodor may be likely. The advantages of organoleptically scoring are: Inexpensive, no equipment needed and a wide range of odors is detectable. 

The trained judge or clinician smells a series of different air samples of the patient as follows: Oral cavity odor is examined on the subject as he is made to refrain from breathing while the examiner places his nose 10 cm from the oral cavity. The judge smells the expired air as the patient counts from 1 to 10 as this is done to promote drying up of the palate and tongue mucosa, expressing VSCs. In saliva odor test (same as the wrist lick test), the patient licks the wrist, and it is allowed to dry up for 10 s after which the judge allots a score to it. Nasal breath odor is checked as the patient is asked to breathe normally with mouth close and the judge gives a score to the exhaled air. Scrapping from the tongue dorsum is taken using a no odorous spoon as the periodontal problem is presented to the judge. The judge and the patient both may find the method of directly assessing the exhaled air a bit uncomfortable, alternatively, the patient is asked to exhale into a paper bag, and then the judge examines the odor from the bag. Various disadvantages are the extreme subjectivity of the test, the lack of quantification, the saturation of the nose and the reproducibility of the test. 

Gas chromatography (GC) analyses air, incubated saliva, tongue debris or crevicular fluid for any volatile component and is objective, reproducible and reliable. GC is highly specific to VSCs and can detect odorous molecules even in low concentrations. However, it is expensive, bulky and a well-trained operator is required. The progression of the method takes much more time, and the machine cannot be used in daily practice and has been confined to research. Portable volatile sulfide monitor is easily operable and reproducible, but they are only sensitive to sulfur-containing compounds. As oral malodor may comprise agents other than volatile sulfur compounds, this may provide an inaccurate assessment of the source and intensity of oral malodor. 

The other objective measurement of the breath components is rarely used in routine clinical practice, as they are expensive and time-consuming. Various tests are Dark-field or Phase-Contrast Microscopy, Quantifying b-galactosidase activity, Salivary encubation test, Benzoyl-DL-arginine-a-naphthylamide (BANA) test, Ammonia monitoring, Ninhydrin method, polymerized chain reaction, Taqman DNA, Tongue Sulfide Probe and  Zinc Oxide Thin Film Conductor Sensor. BANA Test is an enzyme-linked user-friendly test that detects the presence of proteolytic obligate Gram-negative anaerobes, primarily those who form the red complex viz Treponema pallidum, Porphyromonas gingivalis and Tannerella forsythia and can be used as an adjunct to volatile sulfur measurement in the detection of halitosis. 

CONCLUSION

Halitosis is an extremely unappealing characteristic of sociocultural interactions and may have long-term detrimental aftereffects on psychosocial relationships. With proper diagnosis, identification of the etiology, and timely referrals when needed, steps can be taken to create a successful individualized therapeutic approach for each patient seeking assistance. It is significant to highlight the necessity of an interdisciplinary method for the treatment of halitosis to prevent misdiagnosis or unnecessary treatment. The literature on halitosis, especially with randomized clinical trials, is scarce and additional studies are required. Since halitosis is a recognizable common complaint among the general population, the primary healthcare clinician should be prepared to diagnose, classify, and manage patients that suffer from this socially debilitating condition.

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