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HALITOSIS

HALITOSIS. Dr Debbie Macdonald. Extremely common. Majority of adult population have had it at some point in time! Up to ¼ on a regular basis. [1] Very subjective “ it’s a perception rather than a real thing, everybody’s breath smells to a certain extent”.

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HALITOSIS

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  1. HALITOSIS Dr Debbie Macdonald

  2. Extremely common. • Majority of adult population have had it at some point in time! Up to ¼ on a regular basis.[1] • Very subjective “it’s a perception rather than a real thing, everybody’s breath smells to a certain extent”. • Unpleasant condition which creates huge embarrassment with potentially grave consequences. • Most seek help from GP initially, not the dentist!

  3. WHO SEEKS HELP ? • Most have been oblivious to the problem ! • Studies show that people are poor judges of their own breath odour (? adaptation/desensitisation due to chronic exposure).[2] • Some may have exaggerated concerns ! • poor judgement, personal experiences, childhood memories, perception of other people’s behaviours etc leading to preoccupation with concealing perceived malodour, social avoidance etc. Concept of “HALITOPHOBIA”.

  4. WHERE DOES IT COME FROM ? • 85-90% comes from the mouth itself. • Formed by bacterial putrefaction of food debris, cells, saliva and blood. • Proteolysis of proteins peptides  aminoacids  free thiol groups & volatile sulphides. • Results from any form of sepsis : increased anaerobic activity of pathogens (inc. Treponema denticola, P.Gingivalis and Bacteroides forsythus). • Despite rigorous hygiene, good dentition, posterior dorsum of tongue is often a source (? Post nasal drip related).

  5. MOST WANTED LIST • Compounds commonly produced by mouth bacteria and their odours. • Hydrogen Sulphide Rotten Eggs • Methyl mecaptan Faeces • Skatole Faeces • Cadaverine Corpses • Putrescine Decaying meat • Isovaleric acid Sweaty Feet

  6. Sleep. Food (onions, garlic). Drugs: ISDN, disulfaram. Xerostomia: anxiety, pyrexia, anticholinergics, antihistamines, TCA’s, Sjögren’s Syndrome. Poor dental hygiene; gingivitis, periodontitis, dentures. PN drip, sinusitis, nasal polyps, adenoids, foreign bodies, tonsillitis & tonsilliths. Naso-oropharyngeal mal. CAUSES

  7. Association with H.Pylori Pharyngeal pouch Gastric outlet probs Severe Reflux DKA Renal dysfunction Hepatic dysfunction Respiratory disease Delusional halitosis Hallucinatory feature of psychotic illness Temporal Lobe Epilepsy Trimethylaminuria

  8. HISTORY • Clinical Challenge ! • Is c/o malodour justified; is the presenting odour originating in the mouth or elsewhere? • Think about systemic causes. • Physiological halitosis, oral pathological halitosis or pseudo halitosis ??

  9. EXAMINATION • Try to distinguish oral from non-oral. • Compare smell coming from mouth with that exiting the nose. • Examination of nose, post nasal space & all mucosal surfaces of pharynx. • Examine oral cavity, dentition, look for tonsilloliths, dentures etc. • Can take scraping from posterior dorsum of tongue. • “Dangerous to assume dental, periodontal, dietary causes. Early oral & oropharyngeal carcinomas have few symptoms”.[4]

  10. INVESTIGATIONS • Instrumental analysis • Level of intra oral Volatile Sulphur Compounds can be estimated using portable sulphide monitors. Concentration of VSC’s correlate well with level of malodour reported by observers.[2] • Gas Chromatography.

  11. MANAGEMENT • Identify & eliminate obvious causes. • Cheapest/ most effective option is improvement of oral hygiene. • Referral to dentist for full oral/dental examination and provision of education (brushing, flossing, mouthwash use – 0.2 % chlorhexidine gluconate). • Chlorhexidene/ hydrogen peroxide mouthwashes reduce concentrations of VSC’s measured quantitatively & by level of malodour reported by observer.

  12. Clinical Evidence • No RCT’s looking at effectiveness/comparisons of: • Tongue cleaning, brushing, scraping • Sugar free chewing gum • Zinc toothpastes • Artificial saliva • Chlorhexidene-containing mouthwashes have shown in several studies to reduce odour levels significantly (p<0.001) for long periods following use.[3]

  13. ENT referral • ? Antral washout, adenoidectomy, tonsillectomy, biopsy etc. • Gastroenterology referral • Rare despite common belief ! • Psychology/psychiatric referral • ? Halitophobia. • Empirical treatment with metronidazole

  14. Visit dentist regularly. See dental hygienist. Denture education. Mouthwash advise. Chew sugar-free gum. Drink plenty of fluids. Ask confidant to tell you when you have bad breath. Don’t let it affect your life – GET HELP ! Facilitate access to patient education & information resources. Do’s & Don’ts

  15. REFERENCES [1] Tonzeitch J. Production and origin of oral malodour; a review of methods and mechanisms analysis; 1977 ;48:13-17 [2] Rosenberg M. Bad breath; diagnosis & treatment Dent J:1990; 3:7-11 [3] Bosy A et al. Relationship of malodour to periodontitis: J Peridontol:1994;65:37-46 [4] Scully C. What to do about halitosis. BMJ: 1994; 308;217-218 Bad Breath Research Website British Dental Association Fact File Website. Clinical evidence.com

  16. Thank you for listening !

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