HALITOSIS "mouth malodour"
HALITOSIS ( oral malodorous )
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 .
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.
ntraoral conditions are the cause of 80โ85% 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 .
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A list of systemic diseases with characteristic halitosis
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HOW IS HALITOSIS MANAGED?
One must keep in mind that the patient suffering of halitosis is a person looking for help, often anxious and suspicious of any treatment, due to bad experiences using traditional approaches. An accurate diagnosis of halitosis must be achieved to manage it effectively. The available methods can be divided into a mechanical reduction of microorganisms, chemical reduction of microorganisms, usage of masking products, and chemical neutralization of VSC. If periodontal disease or multiple decayed teeth are evident, they should be treated as a contributor of halitosis. Professional oral health care examination must be provided to all the patients irrespective of the type of halitosis. The authors have developed a management strategy based on the types of halitosis in
Management strategy for a patient with halitosis depending on the type and etiology (Modified from porter and scully, 2006)
Mechanical removal of biofilm and microorganisms is the first step in the control of halitosis. A systemic review by van der Sleen et al. demonstrated that tongue brushing or tongue scraping have the potential to successfully reduce breath odor and tongue coating.Tongue scrapers are shaped according to the anatomy of the tongue and reduces 75% VSCs compared to only 45% using a toothbrush.However, a Cochrane review in 2006 compared randomized controlled trials for different methods of tongue cleaning to reduce mouth odor in adults with halitosis.It was concluded that there was a faint indication that there is a minor but statistically significant difference in reduction of VSC levels when scrapers or cleaners rather than toothbrushes are used to reduce halitosis in adults. Interdental cleaning is also necessary to control plaque, and oral microorganisms as failure to floss lead to a significantly high incidence of malodor.
In a recent systematic review, no evidence of diet modification, use of a sugar-free chewing gum, tongue cleaning by brushing, scraping the tongue or the use of zinc-containing toothpaste resulted in clinically significant results for the management for intraoral halitosis.
Antibacterial mouth rinsing agents include chlorhexidine (CHX), cetylpyridinium chloride (CPC) and triclosan, which act on halitosis-producing bacteria. A systematic review, published by Cochrane, compared the effectiveness of mouth rinses in controlling halitosis. The researchers concluded that mouth rinses containing CHX and CPC could inhibit production of VSCs while mouth rinses containing chlorine dioxide and zinc may neutralize the sulfur compounds producing halitosis.
CHX is considered as the gold standard mouth rinse for halitosis treatment. CHX in combination with CPC produce greater fall in VSCs level, and both aerobic and anaerobic bacterial counts showed the lowest percentage of survival in a randomized, doubleโblind, crossโover study design. Combined effects of zinc and CHX were studied in a study conducted in 10 participants, Zinc (0.3%) and CHX (0.025%) in low concentration led to 0.16% drop in H2S levels after 1 h, 0.4% drop after 2 h and 0.75% drop after 3 h showing a synergistic effect of the two.However, patients may be reluctant to use CHX long-term as it has an unpleasant taste and can cause (reversible) staining of the teeth.
Usage of Listerine containing essential oils resulted in significant reduction in halitosis-producing bacteria in healthy subjects. Triclosan, a broadly used antimicrobial agent, is known to reduce dental plaque, gingivitis and halitosis By using triclosan dentifrice and toothbrush/tongue cleaner a significant reduction in organoleptic scores and mouth air sulfur levels were obtained. A formulation of triclosan/copolymer/sodium fluoride in 3 weeks randomized double blind trial by Hu et al. seemed to be particularly effective in reducing VSC, oral bacteria, and halitosis.
Oxidation of VSCs and sulfur containing amino acids by an oxidizing agent such as chlorine dioxide (Chlorodioxide) reduced the incidence of malodor in 29% of test subjects after 4 h. Positively charged metal ions binds with sulfur radicals inhibiting VSCs expression A recent study indicated that daily consumption of tablets with probiotic Lactobacillus salivarius WB 21 could help to control oral malodor and malodor-related factors.[57] The combination of tea tree oil (0.05%) and alphaโbisolol (0.1%) exerted a synergistic inhibitory effect on halitosis associated Gram-positive Solobacterium moorei strain. Photodynamic therapy involves the transfer of energy from the activated photosensitizer (activated by exposure to light of a specific wavelength) resulting in a reduction of the concentration of VSCs reducing by 31.8%.
Extra-orally specific investigations should be carried out to isolate the source that should be either pharmaceutically (broad spectrum antibiotic coverage for pharyngitis, drugs such as proton pump inhibitors for GERD) or surgically (tonsillectomy/adenotonsillectomy, liver/kidney transplantation) managed. When H. pylori infections are observed, the therapy consists of the intake of omeprazole, amoxicillin and clarithromycin. In the endocrinological and metabolic disorders, the underlying diseases should be treated.
The usage of masking agents like rinsing products, sprays, toothpaste containing fluorides, mint tablets or chewing gum only have a short-term masking effect.[Peppermint oil can also increase salivation, which is useful because dry mouth may result in halitosis A patient's diet is another factor that should be discussed when recommending a plan to combat oral malodor.Propolis has also been used in the management of halitosis The patient should be instructed to quit smoking, avoidance of tobacco products and usage of baking soda dentifrices.
Eli et al. reported that patients suffering from halitosis have significantly elevated scores for obsessive-compulsive symptoms, depression, anxiety, phobic anxiety, and paranoid ideation compared with similar patients without halitosis Primary healthcare clinicians must not argue with patients about whether or not oral malodor exists and must determine if a patient is conscious of other individuals' behaviors, real or perceived, toward them. In general, patients with psychosomatic halitosis evaluate their oral malodor by other people's attitudes, and they must be counseled that avoidance behaviors can occur naturally by other reasons. Patients with halitophobia require referral for clinical psychology investigation and treatment.Patients, who relate their emotional state to be a possible cause of their oral malodor, would benefit more from early referral to clinical psychologist for mental assessment and appropriate treatment.To treat delusional halitosis a multidisciplinary approach of health care practitioner, psychologists and psychiatrist are required.
When treating patients with oral malodor, clinicians should relate not only to physiological odor and associated parameters but also to the nature of the subjective complaint. In halitosis management, a well-established understanding between a patient and a primary healthcare clinician can bring a successful result. A primary healthcare clinician must exhibit attitudes of acceptance, sympathy, support, and reassurance to reduce the patient's anxiety. Professionals can improve patient quality of life as a whole, improving their social interactions and relationships. A sustained encouragement and reassurance need to be given by the patient's primary healthcare clinician, family, and friends.
Due to the multifactorial complexity of halitosis, patients should be treated individually, rather than be categorized. Diagnosis and treatment need to be a multidisciplinary approach involving the primary healthcare clinician, dentist, an ENT specialist, nutritionist, gastroenterologist and clinical psychologist. Future research is needed to test accessible methods of drawing a person's attention to his/her halitosis, being the first step of seeking treatment.
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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