HALITOSIS - CURRENT CONCEPT WHICH ALL SHOULD KNOW

Human breath consists of extremely complicated substances with varied variable odors which might generate unpleasant things like halitosis. 

Halitosis may be a general term describing unhealthy or unpleasant smells from the rima oris or outside the oral cavity. halitosis came to fruition once the words “halitus” (breath) in Latin and “osis” (pathological process) in Greek came together. 

Halitosis, additionally unremarkably called “bad breath,” is a concern of the many patients seeking help from health care professionals. 

The term ‘Oral malodor’ involves all of the oral odors reminiscent of ozostomia, stomatodysodia, halitosis and odor oris / ex-ore. 

Oral malodor is an embarrassing condition that affects a large share of the human population. 

This condition usually leads to nervousness, humiliation, and social difficulties, reminiscent of the lack to approach people and speak to them. 

CLASSIFICATION

1.DELUSION HALITOSIS

Delusional halitosis (monosymptomatic hypochondriasis; imaginary halitosis) is a situation wherein patients consider that their breath is stinky and offensive. 

The social stress of getting clean smelling breath will increase the range of people which are preoccupied with this situation. 

However, the belief of oral malodor does not constantly reflect real clinical oral malodor.

1A. PSEUDOHALITOSIS

Pseudohalitosis, the affected person complains of halitosis however the affected person's oral malodor isn't always felt with the aid of using others and the halitosis analysis cannot be made objectively. 

In this case, explanation of halitosis and instructions for oral hygiene (assist and reinforcement of a affected person’s very own self-take care of similarly development in their oral hygiene), rationalization of examination data, similarly expert instruction, education, and reassurance may be remedy choices for pseudohalitosis.

1B. HALITOPHOBIA

Halitophobia is a worry that the affected person's breath may be regarded as awful odor by different people. 

Interestingly, this group of sufferers present with signs and symptoms of halitosis withinside the absence of objective oral malodor. 

This symptom can be as a result of a form of delusion or monosymptomatic hypochondriasis (self-oral malodor, halitophobia, phantom awful breath). 

This situation may be diagnosed with the aid of using questionnaire approach and require psychological investigation or guidance rather than a dental remedy.

2.GENUINE HALITOSIS

Genuine halitosis is in addition subdivided into 

• Physiological 
• Pathological halitosis. 

Physiological halitosis (foul morning breath, morning halitosis) is due to saliva retention, in addition to the putrefaction of entrapped food debris. 

Meanwhile, intra- and extra-oral reasons are accountable for pathological halitosis.

2A. PHYSIOLOGICAL HALITOSIS

Physiological halitosis (foul morning breath, morning halitosis) is due to stagnation of saliva and putrefaction of entrapped food particles and desquamated epithelial cells through the accumulation of micro organism at the dorsum of the tongue, diagnosed clinically as lined tongue and reduce in common liquid intake. 

There is no systemic sickness or pathological condition which could cause halitosis. 

It develops because of bacterial activity throughout the night time even as sleeping. 

Physiological halitosis may be eliminated via way of means of correcting oral hygiene. 

Transient halitosis can arise because of exogenous reasons (ingesting alcoholic beverages, smoking, ingesting a few foods). 

Smoking reasons and a boom in VSCs awareness withinside the mouth, hyposalivation and periodontal diseases. 

Alcohol reasons hyposalivation. 

Foods including onions and garlic have an excessive sulfur content. 

Sulfur passes blood movement through the intestinal tract and is felt as a scent throughout exhalation from the lungs.

2B. PATHOLOGICAL HALITOSIS

2B.a INTRA ORAL HALITOSIS

In 85% of sufferers with odor, the problem changed into determination to originate from the bacterial activity withinside the oral cavity. 

The essential reasons of terrible breath are 

• Tongue biofilm
• Terrible oral hygiene
• Dental abscess
• Hyposalivation because of medications
• Sjogren syndrome
• Meals impactions
• Candidiasis
• Smooth diet
• The usage of orthodontic appliances
• Gingival & Periodontal illnesses (gingivitis, periodontitis, acute necrotizing ulcerative gingivitis, pericoronitis) 
• Most cancers treatment
• Bone diseases (alveolitis, osteomyelitis, osteonecrosis) 
• Malign illnesses. 

Tongue coating can also additionally compose of desquamative epithelial cells, leukocytes from periodontal pockets, blood metabolites, one of a kind food residues, and micro organism. 

The floor of the tongue includes papillaries and fissures thus the morphology of the tongue is extraordinarily irregular. 

The morphological papillary shape of the dorsum of the tongue in particular the intensity of papillae impacts the presence of tongue biofilm. 

This structure gives the perfect anaerobic environment for bacterial growth, stopping the cleansing impact of saliva in those areas. 

2B.b EXTRA ORAL HALITOSIS

The usage of 

• Chemotherapy drugs
• Acetaminophen
• Chloral hydrate
• Dimethyl sulfoxide
• Disulfiram
• Nitrate and nitrites
• Phenothiazines, halitosis may be observed.

Metabolic illnesses that could cause halitosis consist of diabetes, kidney failure, liver failure, trimethylaminuria, hypernatremia, and cystinosis. 

Gastrointestinal illnesses including gastroesophageal reflux, gastric carcinoma, esophageal diverticulum may be the purpose of halitosis. 

Enterococcus faecalis and Helicobacter pylori (H. pylori) may be determined withinside the periodontal pockets withinside the oral cavity and cause halitosis. 

The odor is due to nostrils and sinuses, Foreign Bodies (FB), tonsils, pharynx, and lungs. 

Diseases of the breathing system cause the expiration of gas that offers off terrible scent from the oral cavity and nostril. 

The scent expired from the mouth and nostril ought to be properly distinguished. 

The lifestyles of any FB within the nostril reasons inflammation, secondary contamination and terrible smell. 

Pseudomonas aeruginosa in breathing system illnesses, bronchitis, bronchiectasis and lung illnesses, 2-aminoacetophenone is excreted and this purpose halitosis in adults.

ETIOLOGY OF MALODOR 

1. INTRAORAL CAUSES

VOLATILE SULFUR COMPOUNDS 

Halitosis-forming gases are for the most part Volatile Sulfur Compounds (VSCs). 

Volatile sulfur compounds (VSCs) are principally answerable for intra-oral halitosis.

These gases are hydrogen sulfide, methyl mercaptan, and dimethyl sulfide. 

Volatile sulfur compounds may be cytotoxic for human cells even at low concentrations. 

They contain thiols (-SH groups) that act with alternative proteins and support the negative interaction of microorganism antigens and enzymes. 

The results of this result is chronic inflammation, periodontal gingivitis, and periodontitis. Pericoronitis, oral ulcers, periodontal abscess, and herpetic gingivitis are a number of the pathologies that end in increased VSCs. 

Studies have shown that volatile sulfur compounds are the main contributors to bad breath. 

Volatile sulfur compounds (VSCs), diamines and short chain fatty acids are made thanks to this microbial breakdown of amino acids by enzymes, leading to oral malodour (For e.g.: Breakdown of cysteine, cysteine, and methionine turn outs VSC). 

They produce bacteria by catalyst reactions of sulfur-containing amino acids that are L-cysteine and L-methionine. 

A number of the bacteria produce sulphide and methyl radical mercaptan from serum.

Increased amounts of H2S by the activation of proliferation, migration, and invasion can even cause carcinogenesis. 

MAJOR CONTRIBUTION OF BACTERIA 

Gram-positive microorganisms can support gram-negative anaerobic bacteria within the production of VSC. 

They bring to an end sugar chains from glycoproteins and supply proteins that are necessary for proteolytic processes. 

Strep salivarius has an impression on the deglycosylation of secretion glycoproteins, principally mucins, which may next be degraded to VSC by Porphyromonas gingivalis. 

Fusobacterium nucleatum and Porphyromonas gingivalis belong to the foremost essential malignant neoplastic disease oral bacteria manufacturing VSCs.

The most active producers of sulphide are gram-negative anaerobes Porphyromonas gingivalis, treponema denticola, and Tannerella forsythia (red complex). 

Furthermore, the red complex microorganisms are related to periodontal disease. 

Sulphide and alkyl radical mercaptan are produced in massive quantities in periodontic inflammations. 

Throughout periodontitis, Porphyromonas spp., Prevotella spp., and treponema denticola might play the foremost crucial role in providing amino acids to different anaerobic microorganisms. 

Through this process, anaerobes acquire the chance to provide H2S and CH4S. 

Fusobacterium nucleatum and Porphyromonas gingivalis belong to the foremost essential carcinogenic oral bacteria manufacturing VSCs. 

Photo credit: https://www.myupchar.com/en (Wikimedia Commons)

2. SYSTEMIC CAUSES

In respiratory-related health problem like 

• Postnasal drip
• Sinus related illness and 
• Tonsillitis
• Excessive secretion 
• Phlegm 

accumulation is seen, that attracts additional bacteria. 

This reason behind halitosis is more common in youngsters, because the children are more vulnerable to postnasal drip and tonsillitis.

Two important GIT pathologies wherever association with halitosis is verified are Helicobacter pylori infection and gastroesophageal reflux disease. 

Drinking and/or smoking (active and passive), on the far side giving alcoholic and nicotinic smell on the intakers, adds to halitosis by increasing mucus and phlegm within the throat.

• Diabetes – Fruity or citrusy breath
• Trimethylaminuria – Foul fishy odor
• Nasal stench – Slightly cheesy character
• Hepatic cirrhosis of the liver – Musty or mousy odor
• Asthma or cystic fibrosis – Acidic breath
• Kidney problem – Scent of ammonia
• Bowel obstruction – faecal odor.

Atrophic inflammation is caused by enterics ozaenae, which inhibits the self-cleaning property of nasal mucosa. 

Acute sore throat and sinusitis, caused by streptococcal species, also are answerable for manufacturing halitosis. 

Malignant neoplastic disease of the larynx, cavity abscess, and lower tract infections akin to bronchiectasis, chronic bronchitis, lung abscess, asthma, cystic fibrosis, bronchiectasis, interstitial lung diseases, and pneumonia are best-known to cause halitosis.

3. FOOD RELATED CAUSES

Transient oral malodor can even arise when somebody has eaten up volatile foods reminiscent of garlic, onions, condiments, pickles, radish, spices and consumption of tobacco, betel nut and alcohol. 

When uptake of such food substance it's absorbed into the blood throughout digestion, are transferred to the lungs, and also the exhaled air is characterised by the odor of that specific food substance. 

The ensuing breath takes on a unique odor that will last several hours.

Putrescine and Cadaverine are created from amino acids, putrescine from arginine, and cadaverine from L-lysine. 

Each diamine is related to the putrefaction of food by bacteria occurring within the plaque and severe periodontitis.

4. OTHER CAUSES

Mouth breathing accounts for 40% in kids with halitus by inflicting surface drying of the tissue layer because of evaporation of water from saliva. 

Notoriously, buzzing facilitates nasal inhaling these patients by increased gas production that causes sleek muscle relaxation and vasodilation.

DETECTION OF HALITOSIS 

GAS CHROMATOGRAPHY 

Gas chromatography has excessive accuracy and sensitivity, but the making use of methods in chairside is difficult and expensive. 

All through this approach earlier than taking dimension, patients ought to close the mouth and refrain from talking food for 5 min earlier than measurement, then a disposable tube of the chemical compound revealed is inserted into the affected person's mouth to gather mouth air. 

Meanwhile, the patient is respiration thru the nostril and the disposable tube is hooked up to the reveal. Sulfur-containing compounds withinside the breath can generate an electro-chemical response. 

This response is associated without delay with tiers of unstable sulfur-containing compounds.

ORGANOLEPTIC MEASUREMENT

The oldest manner for unpleasant smell detection is with the aid of using smelling with the nose. 

Measurement of unpleasant odors with the aid of using smelling the exhaled air of the mouth and nostril is referred to as organoleptic measurement. 

It is the easy manner for the detection of halitosis.

The dimension approach is the organoleptic check; the affected person takes breathe deeply with the aid of using inspiring the air with the aid of using nostrils related protecting awhile, then expiring with the aid of using the mouth directly or through a measuring instrument, while the examiner sniffs the smell at a distance of 20 cm (the reason of using a pipette is to decrease the depth of expiring air) and additionally the severity of smell is assessed into several scales, akin to a 0- to 5-factor scale 

• 0: no odor
• 1: barely noticeable
• 2: slight however clearly noticeable
• 3: moderate
• 4: strong
• 5: extremely strong. 

CHEMICAL SENSORS 

Chemical sensors have an included probe to degree sulfur compounds from periodontal pockets and at the tongue surface. 

The operating precept of chemical sensors is much like sulfide monitors. 

Through the sulfide-sensing probe, sulfide compounds generate an electrochemical voltage and this voltage is measured with the aid of using a digital unit. 

The dimension is proven on the device's display as a virtual score.

NINHYDRIN METHOD

Ninhydrin approach turned into used for examination of amino acids and low-molecular-weight amines.

SALIVARY INTUBATION 

A salivary incubation check has much less prompting with the aid of using outside parameters inclusive of smoking, ingesting coffee, ingesting garlic, onion, highly spiced meals, and scented cosmetics.

BANA (Benzoyl-DL-arginine- α-Naphthylamide) TEST

The BANA check is wise for chair-side usage. 

It is a check strip that is composed of benzoyl-DL-arginine-a-naphthylamide and detects short-chain fatty acids and chemical action obligate gram-negative anaerobes, which alternate the artificial enzyme substrate and cause halitosis. 

It mainly detects spirochete denticola, P. gingivalis, and T. forsythensis that are associated with periodontal disease. 

TREATMENT 

CLINICAL TREATMENT

Appropriate periodontal control is the primary step. 

Necrotizing ulcerative gingivitis, gingivitis, adult and aggressive periodontitis or periodontal pockets can increase the bacterial load so periodontal health has extensive significance in controlling the quantity of halitosis due to bacteria. 

Initial periodontal remedy consists of scaling and root planing which may also alleviate the intensity of the periodontal pockets and severity of gingival irritation and it removes halitosis inflicting bacteria.

Medical conditions or records may be illuminating data approximately the purpose of halitosis. 

If halitosis originates from non oral reasons which include respiratory, gastrointestinal and hepatic, renal, endocrine or hematological disorder, sessions need to be executed with the specialist. 

If the actual disorder isn't always nicely identified and treated, the impact of halitosis will have an effect on a person's social lifestyles and will become bothersome. 

Extra-orally particular investigations need to be performed to isolate the supply that need to be both pharmaceutically (extensive spectrum antibiotic coverage for pharyngitis, pills which include proton pump inhibitors for GERD) or surgically (tonsillectomy/adenotonsillectomy, liver/kidney transplantation) managed. 

When H. pylori infections are observed, the remedy includes the consumption of omeprazole, amoxicillin and clarithromycin. In the endocrinological and metabolic disorders, the underlying illnesses need to be treated

SELF CARE

Self-care merchandise are utilized by halitosis sufferers for stopping unsightly smell. 

However, with the aid of using those products direct remedy of halitosis isn't always possible; those merchandise which include chewing gum and mints, toothpastes, mouth rinses, and sprays lower the smell and try to mask halitosis with fine fragrances. 

Proper brush, dental floss, and interdental brush utilization are very vital. 

However, sometimes despite the fact that the periodontal health is perfect, tongue coating may be a vital supply of halitosis. 

The tongue dorsum may be a shelter for those bacteria. The use of chewing gum may also lower halitosis, particularly thru growing the salivary secretion. 

MOUTH WASH

Mouth rinses containing chlorine dioxide and zinc salts have a significant impact on covering halitosis, now no longer permitting the volatilization of the unsightly smell. 

Antibacterial mouth rinsing marketers encompass chlorhexidine (CHX), cetylpyridinium chloride (CPC) and triclosan, which act on halitosis-generating bacteria. 

Mouth rinses containing CHX and CPC could inhibit manufacturing of VSCs while mouth rinses containing chlorine dioxide and zinc may also neutralize the sulfur compounds generating halitosis. 

CHX is taken into consideration because the gold preferred mouth rinse for halitosis remedy. 

CHX in mixture with CPC produce more fall in VSCs level, and each aerobic and anaerobic bacterial counts. 

Oxidation of VSCs and sulfur containing amino acids with the aid of using an oxidizing agent which include chlorine dioxide (Chloordioxide) decreased the prevalence of malodor in 29% of check topics after four h. 

PSYCHOLOGY TREATMENT

Sufferers with psychosomatic halitosis compare their oral malodor with the aid of using different people's attitudes, and that they have to be cautioned that avoidance behaviors can arise evidently through different reasons. 

Patients with halitophobia require referral for medical psychology research and remedy.

CONCLUSION

Dentists are first-line health experts in case of terrible breath and play a vital function in diagnosis, treatment, and referral of the sufferers to a doctor or a clinical expert if needed. 

With the right diagnosis, identity of the etiology, and well timed referrals whilst needed, steps may be taken to create a hit individualized healing method for every affected person in search of assistance.

Halitosis is a recognizable common criticism amongst the overall population, the number one healthcare clinician ought to be organized to diagnose, classify, and control sufferers that are afflicted by this socially debilitating condition.

REFERENCE