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Halitosis- An overview. Part 1: Classification, etiology and Pathophysiology of halitosis
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ABSTRACT: BACKGROUND: Halitosis is an unpleasant odour emanating from the oral cavity. Mouthwashes, which are commonly used for dealing with oral malodour, can be generally divided into those that neutralize and those that mask the odour. OBJECTIVES: To investigate the effects of mouthrinses in controlling halitosis. SEARCH STRATEGY: We searched the following databases: Cochrane Oral Health Group Trials Register (to August 2008); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3); MEDLINE (1950 to August 2008); EMBASE (1980 to August 2008); and CINAHL (1982 to August 2008). There were no language restrictions. SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing mouthrinses to placebo in adults over the age of 18 with halitosis and without significant other comorbidities or health conditions. Five RCTs, involving 293 participants who were randomized to mouthrinses or placebo, were included in this review. In view of the clinical heterogeneity between the trials, pooling of the results and meta-analysis of the extracted data was not feasible and therefore only a descriptive summary of the results of the included trials is provided.0.05% chlorhexidine + 0.05% cetylpyridinium chloride + 0.14% zinc lactate mouthrinse significantly reduced the mean change (standard deviation (SD)) of organoleptic scores from baseline compared to placebo (-1.13 (1.1) P < 0.005 versus -0.2 (0.7)) and also caused a more significant reduction in the mean change (SD) in peak level of volatile sulfides.
Key words: Halitosis, Mouthrinses; Evidence-Based Dentistry.
To compare the presence of Helicobacter pylori (H. pylori) infection by stool antigen test in children with and without halitosis.
Comparative study.
Department of Paediatrics, Fatih University Hospital, Ankara, Turkey, between December 2008 and June 2009.
Fifty-three patients aged between 3-15 years who presented to paediatrics outpatient clinic with halitosis and 55 healthy children aged between 4-15 years without halitosis were included in the study. Halitosis was confirmed with organoleptic test. Stool antigen test was performed in both groups. Intergroup proportions were compared using chisquare and Fisher exact tests with significance at p < 0.05.
The H. pylori stool antigen test was positive in 11 out of 53 patients (20.8%) with halitosis and 12 of 55 healthy controls (21.8%). The rate of positive H. pylori stool antigen test results were similar between two groups (p > 0.05). Twoweeks eradication treatment was administered to 11 patients with H. pylori infection and halitosis. After treatment, the symptoms of 8 patients with halitosis (72.7%) completely resolved and persisted in 3 patients (27.3%). Seven of the 11 patients who were administered eradication treatment also had abdominal pain along with halitosis. Both symptoms completely resolved in all those patients after treatment.
Although no statistically significant difference existed between the rate of H. pylori infections among those with and without halitosis. Eradication treatment was found beneficial in the treatment of children with halitosis and positive H. pylori stool antigen test.
Halitosis is an unpleasant condition that causes social restraint. Studies worldwide indicate a high prevalence of moderate halitosis, whereas severe cases are restricted to around 5% of the populations. The etiological chain of halitosis relates to the presence of odoriferous substances in exhaled air, especially the volatile sulphur compounds (VSC) produced by bacteria. The organoleptic diagnosis is the gold standard and clinical management includes oral approaches, especially periodontal treatment and oral hygiene instructions, including the tongue. When oral strategies are not successful, referral to physicians is warranted.
To determine whether there is a correlation between halitosis and mouth breathing in children.
Fifty-five children between 3 and 14 years of age were divided into two groups (nasal and mouth breathing) for the assessment of halitosis. A descriptive analysis was conducted on the degree of halitosis in each group. The chi-square test was used for comparison between groups, with a 5% level of significance.
There was a significantly greater number of boys with the mouth-breathing pattern than girls. A total of 23.6% of the participants had no mouth odor, 12.7% had mild odor, 12.7% had moderate odor and 50.9% had strong odor. There was a statistically significant association between halitosis and mouth breathing.
The occurrence of halitosis was high among the children evaluated, and there was a statistically significant association between halitosis and mouth breathing.
Halitosis is a common human condition for which the exact pathophysiological mechanism is unclear. It has been attributed mainly to oral pathologies. Halitosis resulting from gastrointestinal disorders is considered to be extremely rare. However, halitosis has often been reported among the symptoms related to Helicobacter pylori infection and gastroesophageal reflux disease.
To retrospectively review the experience with children and young adults presenting with halitosis to a pediatric gastroenterology clinic.
A retrospective chart review of patients diagnosed with halitosis as a primary or secondary symptom was conducted. All endoscopies were performed by the same endoscopist.
A total of 94 patients had halitosis, and of the 56 patients (59.6%) who were recently examined by a dental surgeon, pathology (eg, cavities) was found in only one (1.8%). Pathology was found in only six of 27 patients (28.7%) who were assessed by an otolaryngology surgeon. Gastrointestinal pathology was found to be very common, with halitosis present in 54 of the 94 (57.4%) patients. The pathology was noted regardless of dental or otolaryngological findings. Most pathologies, both macroscopically and microscopically, were noted in the stomach (60% non-H pylori related), followed by the duodenum and the esophagus. Fifty-two of 90 patients (57.8%) were offered a treatment based on their endoscopic findings. Of the 74 patients for whom halitosis improvement data were available, some improvement was noted in 24 patients (32.4%) and complete improvement was noted in 41 patients (55.4%).
Gastrointestinal pathology was very common in patients with halitosis regardless of dental or otolaryngological findings, and most patients improved with treatment.
Halitosis is an unpleasant odour emanating from the oral cavity. Mouthwashes, which are commonly used for dealing with oral malodour, can be generally divided into those that neutralize and those that mask the odour.
To investigate the effects of mouthrinses in controlling halitosis.
We searched the following databases: Cochrane Oral Health Group Trials Register (to August 2008); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3); MEDLINE (1950 to August 2008); EMBASE (1980 to August 2008); and CINAHL (1982 to August 2008). There were no language restrictions.
Randomised controlled trials (RCTs) comparing mouthrinses to placebo in adults over the age of 18 with halitosis and without significant other comorbidities or health conditions.The primary outcomes considered were self expressed and organoleptic (human nose) assessments of halitosis, and the secondary outcomes included assessment of halitosis as measured by a halimeter, portable sulphide monitor or by gas chromatography coupled with flame-photometric detection.
Two independent review authors screened and extracted information from, and independently assessed the risk of bias in the included trials.
Five RCTs, involving 293 participants who were randomised to mouthrinses or placebo, were included in this review.In view of the clinical heterogeneity between the trials, pooling of the results and meta-analysis of the extracted data was not feasible and therefore only a descriptive summary of the results of the included trials is provided.0.05% chlorhexidine + 0.05% cetylpyridinium chloride + 0.14% zinc lactate mouthrinse significantly reduced the mean change (standard deviation (SD)) of organoleptic scores from baseline compared to placebo (-1.13 (1.1) P < 0.005 versus -0.2 (0.7)) and also caused a more significant reduction in the mean change (SD) in peak level of volatile sulphur compounds (VSC) (-120 (92) parts per billion (ppb) versus 8 (145) ppb in placebo). The chlorhexidine cetylpyridinium chloride zinc lactate mouthrinse showed significantly more tongue (P < 0.001) and tooth (P < 0.002) staining compared to placebo.However, in view of the incomplete reporting of results in three of the trials and the sole use of the halimeter for assessment of VSC levels as outcomes in two further trials, caution should be exercised in interpreting these results.
Mouthrinses containing antibacterial agents such as chlorhexidine and cetylpyridinium chloride may play an important role in reducing the levels of halitosis-producing bacteria on the tongue, and chlorine dioxide and zinc containing mouthrinses can be effective in neutralisation of odouriferous sulphur compounds.Well designed randomised controlled trials with a larger sample size, a longer intervention and follow-up period are still needed.
With the aim of investigating a possible relationship between "objective" halitosis (established by sulfide levels in the breath) and Helicobacter pylori, we performed a study in 58 dyspeptic patients reported to suffer from "bad breath." Furthermore, we evaluated the effects on halitosis of eradication therapy (only for H. pylori-positive patients) and chlorhexidine antiseptic mouth rinses (in all patients). Sulfide compound assay indicated objective halitosis in 52/58 patients, 30 of whom were positive and 22 negative for H. pylori. In 19/30 eradication by double therapy provoked a decrease to below the cutoff value of sulfide levels in 15. In the other 11 of the 30 subjects, in whom H. pylori positivity persisted, halitosis parameters did not change. Chlorexidine reduced sulfides to below the cutoff value in 16/22 H. pylori-negative patients, but did not provoke any change in the 11 unsuccessfully treated H. pylori-positive subjects. In these, objective halitosis disappeared only after a successful eradication by triple therapy (9/11). Our results show a possible association between halitosis and H. pylori since bacterial eradication may resolve the symptom. Antiseptic mouthwashes may be effective only in absence of H. pylori, when halitosis may be due to oral putrefactive microbial activity. In a small number of subjects the cause and treatment of halitosis need to be clarified.
This study was conducted on 5554 children aged 5-13 years old with the objectives of recording the prevalence of oral habits among North Indian children according to sex. These children were selected from the schools of Delhi. The sample represented the entire school-going population of Delhi in the age group of 5-13 years. Statistical analysis was carried out using BMDP software and sex differences were calculated by using Fisher's exact test. The results showed that the prevalence of oral habits in Delhi school going children was 25.5%. Tongue thrust was the commonest habit (18.1%) followed by mouth breathing (6.6%). Thumb sucking was relatively less common habit and seen in only 0.7% of children. There were no significant differences between boys and girls for the prevalence of oral habits. However, for the specific habit types there was a sex difference. Thumb sucking was more common in girls (1.0%) when compared with boys (0.4%) and this difference was statistically significant (P < 0.001). There was a reverse trend for the mouth breathing, which was more common (P < 0.001) in boys (7.8%) than girls (5.3%). There were no differences for tongue thrust habit between boys (17.5%) and girls (18.6%).
The purpose of this study was to investigate the occurrence and clinical parameters that are associated with halitosis in pediatric dental patients and compare these findings with those found for the patients' mother.
Children aged 5 to 12 years old were evaluated with mothers present during a dental visit. Each mother completed the child's medical history and a breath odor questionnaire. The mother and an oral breath judge (OBJ) evaluated the child's oral breath using organoleptic methods. A commercial breath analyzer (CBA) measured the oral and nasal levels of volatile sulfur compounds (VSCs) for child and mother before and after tongue debridement. A number of oral parameters were recorded for the children.
Thirty children (mean age=8.8 years) and 18 mothers participated. Halitosis (VSC>100 parts per billion, or ppb) was found in 23% of children and 11% of mothers, but was not significantly correlated. In contrast, 61% of mothers reported halitosis in themselves and their child. Significant differences were found between VSC levels and frequency of tooth-brushing (P<.05, univariate ANOVA). There was significant correlation in the detection of breath odor between mother and OBJ (P<.05, Pearson); however, there was no significant correlation between evaluators and CBA. A positive correlation existed between the presence of interproximal restorations and breath odor by OBJ (P<.05, Pearson).
Halitosis may be a problem in some healthy children, but it does not correlate well with mothers' breath odor or common oral parameters. The organoleptic and CBA results were inconsistent, suggesting factors other than VSCs may be associated with halitosis in children.
The aim of this paper was to present baseline data on various saliva properties among a group of Saudi children aged 5 to 11 years and to study the relationship of these properties to some oral micro-organisms as well as to lip and oral mucosa dryness. The results showed a mean of resting and stimulated flow rate of 0.54 +/- 0.40 and 1.23 +/- 0.59 respectively and mean pH value of 7.27 +/- 0.38 and 7.5 +/- .035 respectively. Fluoride concentration was estimated to be 0.151 +/- 0.07 and 0.145 +/- 0.06 in resting and stimulated saliva respectively. Children with dry lip represented 33.9% of the sample population, whereas, those with dry mucosa represented only 0.8%. No significant sex difference was evident in all parameters. 59.1% of children showed medium buffering capacity in the resting saliva, whereas, the majority of children (73.7%) showed high stimulated buffering capacity. Children showed generally high Lactobacillus counts (Lb) in the resting and stimulated saliva (57.9% and 60.5% of children). The presence of yeast also in resting and stimulated saliva seemed high in general (40% and 53% of children had high count). However, Streptococcus mutans (S. mutans) counts showed no discriminating trend in both types of saliva. The data showed no significant association between flow rate and Lb counts in both resting and stimulated saliva although there was a trend toward higher counts associated with low flow rate. The same trend was observed in resting saliva although not significant. Similarly, low resting buffering capacity was associated with high counts of Lb among a high proportion of children (68.6% of children) although not significant. A significant reverse relation was evident between S. mutans counts and stimulated flow rate (p=0.049). The majority of children with normal level of saliva pH showed no yeast colonization (62.1%). The association was significant (p=.024). Similarly, the same association was observed in the medium and high buffering group (66.2%) (p=.040). It was concluded that salivary Lb count seems to be primarily affected by some local factors other than salivary properties, such as diet. Significant inverse relationship was found between S. mutans and stimulated salivary flow. Children in general showed high percentage of yeast reflecting the affect of poor diet among the studied population group. Buffering capacity and pH had an important role in yeast colonization.
This series provides an overview of current thinking in the more relevant areas of oral medicine for primary care practitioners, written by the authors while they were holding the Presidencies of the European Association for Oral Medicine and the British Society for Oral Medicine, respectively. A book containing additional material will be published. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders, or discussion of disorders affecting the hard tissues. Approaching the subject mainly by the symptomatic approach--as it largely relates to the presenting complaint--was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made. Guidance on management and when to refer is also provided, along with relevant websites which offer further detail.
Oral malodour (halitosis) is common; most people have some element of transient unpleasant oral odour at some time.1 w1 In the developed world, 8-50% of people perceive that they have persistent recurrent episodes of oral malodour. This article provides a succinct review of oral malodour relevant to medical practitioners.
Oral malodour is common and can affect people of all ages. When severe or longstanding, it may decrease self confidence and social interactions.w2
Oral malodour on awakening is common and generally not regarded as halitosis. Longstanding oral malodour is usually caused by oral, or sometimes nasopharyngeal, disease (box 1). The most likely cause of oral malodour is the accumulation of food debris and dental bacterial plaque on the teeth and tongue, resulting from poor oral hygiene and resultant gingival (gingivitis) and periodontal (gingivitis/periodontitis) inflammation. Although most types of gingivitis and periodontitis can give rise to malodour, acute necrotising ulcerative gingivitis (Vincent's disease, trench mouth) causes the most notable halitosis. Adult periodontitis, characterised by gradual plaque related loss of periodontal attachment, can cause variable degrees of oral malodour.2 Aggressive periodontitis, typified by rapid loss of periodontal bone and resultant tooth mobility, can cause intense oral malodour.
Lack of oral cleansing because of xerostomia (dryness of the mouth) also has the potential to cause or enhance malodour,w3 and some evidence indicates that wearing dentures may sometimes cause oral malodour, possibly by virtue of increased tongue coat deposits.w4
Mild transient oral malodour often arises after sleep and is sometimes termed “morning halitosis.” This may be more likely in people with nasal obstruction—for example, due to upper respiratory tract infection—or when people sleep in a hot, dry atmosphere. Transient oral malodour can also arise after someone has eaten volatile foods such as garlic, onions, or spices (durian is reputed to …
Oral malodor one of the most common complaints with which patients approaches us thinking it can be detrimental to his self-image and confidence. Even though majority of oral malodor is of oral origin, there are multiple other systemic causes that have to be addressed while we diagnose and treat this condition. Most of these patients look up to oral care physicians for expert advice, it is critical for us to have the knowledge base and communication techniques to provide quality clinical assessment and implement effective intervention programs. This article reviews the various causes and the diagnostic modalities which will help us treat this multifaceted condition.
Oral malodorous compounds including hydrogen sulfide (H2S) are causative agents of periodontitis because the toxicities are similar to that of cyanate. Previous studies demonstrated that volatile sulfur compounds (VSCs) were highly toxic to periodontal tissues, causing a large reduction in the amount of collagen in human gingival fibroblasts and extracellular matrix as well as, for example, apoptosis, immunologic responses, and matrix metalloproteinase production. The objective of this study was to determine the effect of H2S on the proliferation of osteoblasts and a signaling transduction pathway through the mitogen-activated protein kinase (MAPK).
Normal human osteoblasts (NHOst) and murine osteoblasts (cell line MC3T3-E1) were incubated with H2S. Cell proliferation was assessed by measuring [3H]thymidine incorporation. The effects of H2S on the signal transduction pathways, the MAPK cascade, that control cell proliferation were evaluated in NHOst by determining extracellular signal-regulated kinase (ERK)1/2 and p38 phosphorylation with a Western blot analysis.
After incubating NHOst with H2S for 24 hours, [3H]thymidine incorporation into the DNA significantly decreased dose-dependently with H(2)S. At a concentration of 100 ng/ml H2S, [3H]thymidine incorporation decreased 79% compared to the control. Similar results were obtained from MC3T3-E1. The phosphorylation of ERK1/2 and p38 was increased by H2S at 10 minutes after starting the treatment and then decreased time dependently. The activation of ERK1/2 and p38 induced by H2S was inhibited by the specific inhibitor of MAPK/ERK kinase ([MEK]; U0126) or p38 (SB203580).
H2S inhibited the proliferation of human osteoblastic cells through the MAPK pathway.
Epidemiological data on halitosis are rare. In this study we evaluated the prevalence of halitosis in the population of the city of Bern, Switzerland, using a standardized questionnaire and clinical examination. First of all, a standardized questionnaire was filled out by all 419 participants. In the clinical examination, 'objective' values for halitosis were gathered through two different organoleptic assessments and by the measurement of volatile sulfur compounds (VSC). Additionally, tongue coating and the modified periodontal screening index (PSI) were evaluated for each participant. The questionnaire revealed that 32% of all subjects sometimes or often experienced halitosis. The organoleptic evaluation (grade 0-5) identified 48 persons with grade 3 and higher. Measurement of VSC identified 117 subjects (28%) with readings of >or= 75 parts per billion (ppb). Tongue coating, modified PSI, and smoking were significantly associated with higher organoleptic scores, and tongue coating and smoking were associated with higher VSC values. For about one-third of the Bernese city population, halitosis seems to pose an oral health problem. Only a weak correlation between self-reported halitosis and either organoleptic or VSC measurements could be detected.
Hydrogen sulfide (H(2)S) is a main cause of physiologic halitosis. H(2)S induces apoptosis in human gingival cells, which may play an important role in periodontal pathology. Recently, it has been reported that H(2)S induced apoptosis and DNA damage in human gingival fibroblasts (HGFs) by increasing the levels of reactive oxygen species. However, the mechanisms of H(2)S-induced apoptosis have not been clarified in HGFs. The objective of this study was to determine the apoptotic pathway activated by H(2)S in HGFs. The HGFs were exposed to 50 ng/mL H(2)S, resulting in 18 ng/mL in the culture medium, which is lower than the concentration in periodontal pockets. The number of apoptotic cells after 24 and 48 h incubation was significantly higher than that in the control cultures (p < 0.05). Mitochondrial membrane depolarization and the release of cytochrome c, and caspase-3, and caspase-9 were also significantly increased after both 24- and 48-h incubation (p < 0.05), whereas caspase-8, a key enzyme in the receptor ligand-mediated pathway causing apoptosis, was not activated. The present study shows that H(2)S triggered the mitochondrial pathway causing apoptosis in HGFs but did not activate the receptor ligand-mediated pathway.
To determine the prevalence of breath malodour and to assess the relationships between breath malodour parameters such as dental caries, habitual mouth breathing, tooth-brushing, and the frequency of upper respiratory-tract infection.
A total of 628 healthy children (327 boys, 301 girls) ranging in age from 7 to 11 who were living in Kirikkale, Middle Anatolia, Turkey were included. Subjects who were taking antibiotics, having any suspicion of upper respiratory tract infection, sinusitis or tonsillitis at the time of survey were excluded from the study. Oral malodour assessment was carried out by organoleptic method. The DMFT/S was used to record caries. Pearson's correlation coefficients were calculated to determine the association of each clinical variable to organoleptic oral malodour rating. Bivariate logistic regression analysis was performed to detect the degree of association between oral malodour and various dental-habitual parameters.
The prevalence of halitosis was 14.5%. Organoleptic oral malodour ratings were significantly higher in older age groups. Gender, frequency of tooth brushing, habitual mouth breathing did not influence oral malodour ratings. D(T), DMF(T), d(s) played the most significant role in higher oral malodour ratings, followed by d(t) and df(s). The frequency of tooth brushing, habitual mouth breathing did not contribute to the prevalence of halitosis.
Age, prevalence and severity of dental caries were significantly related to breath malodour.
The amounts of volatile sulfur compounds (VSC) and methyl mercaptan/hydrogen sulfide ratio in mouth air from patients with periodontal involvement were 8 times greater than those of control subjects. Our studies demonstrated that, in patients with periodontal disease: 1) the concentration of disulfide, which is converted to VSC, increased in proportion to the total pocket depth; 2) 60% of the VSC was produced from the tongue surface; 3) the amount of tongue coating was 4 times greater than in control subjects; and 4) VSC production and the methyl mercaptan/hydrogen sulfide ratio of the tongue coating were increased. 2-Ketobutyrate, which is a byproduct of the metabolism of methionine to methyl mercaptan, was higher in the saliva of patients with periodontal disease. This implies that metabolism of methionine to methyl mercaptan increases in the oral cavity of patients with periodontal pockets. Since free L-methionine, rather than protein, is the main source for methyl mercaptan, we estimated the methionine supply from the gingival fluid into the oral cavity of patients with periodontal involvement. The results showed that the ratio of methionine to whole free amino acids was significantly higher than that of cysteine. Our studies suggest that not only microorganisms, but also the tongue coating and gingival fluid are factors which enhance VSC production in patients with periodontal disease.
Volatile sulfur compounds (VSC) in mouth air were estimated by gas chromatography. The amount of VSC and the methyl mercaptan/hydrogen sulfide ratio were significantly increased in patients with periodontal disease. These two parameters also increased in proportion to the bleeding index and probing depth. A study was also done on the effect of removal of tongue coating on VSC concentrations in mouth air from patients with periodontal involvement. VSC and the methyl mercaptan/hydrogen sulfide ratio were reduced to 49% and 35%, respectively, by removal of the tongue coating. The average amount of tongue coating removed from patients with periodontal disease was significantly higher than from controls (90.1 mg vs. 14.6 mg, p less than 0.01). Estimated production of VSC from tongue coating was 4 times higher than the control value, and the methyl mercaptan/hydrogen sulfide ratio was also markedly increased. However, a saliva putrefaction study suggested that saliva does not contribute to the elevated ratio of methyl mercaptan in mouth air. These results strongly suggest that, in addition to periodontal pockets, tongue coating has an important role in VSC production, in particular leading to an elevated concentration of methyl mercaptan, which is more pathogenic than hydrogen sulfide.
A volunteer with histologically normal gastric mucosa received pyloric campylobacter by mouth. A mild illness developed, which lasted 14 days. Histologically proven gastritis was present on the tenth day after the ingestion of bacteria, but this had largely resolved by the fourteenth day. The syndrome of acute pyloric campylobacter gastritis is described. It is proposed that this disorder may progress to a chronic infection which predisposes to peptic ulceration.
Bad breath typically originates in the mouth, often from the back of the tongue. Nasal problems also can cause bad breath; odor generated in this manner can be easily distinguished from mouth odor by comparing the odor exiting the mouth and nose. In most cases, good professional oral care combined with a daily regimen of oral hygiene--including interdental cleaning, deep tongue cleaning and optional use of an efficacious mouthrinse---will lead to improvement. This article discusses common causes of oral malodor as well as methods to assess the extent of the problem.
To determine the relationship between oral parameters and halitosis in children whose parents complained of malodorous breath.
Twenty-four children (ages 5 to 14) were examined at 3 appointments. After the second appointment oral hygiene instructions were given. Malodor-related parameters included odor judge scores (whole mouth, tongue, nose, and interdental areas), sulfide levels, and microbiologic tests (Oratest and BANA). Dental-related parameters included plaque index, dental index (DMFT), food impaction, bleeding, and tongue coating. Statistical analyses included analysis of variance, paired t tests, Pearson correlations, and multiple regression.
Whole mouth odor was significantly associated with plaque index levels (r = 0.64, P =.001) and Oratest (r = -0.57, P =.003). Whole mouth malodor was significantly associated with tongue dorsum posterior odor (r = 0.641, P =.001) and was higher in subjects with interdental odor (P =.003). Tongue odor was also significantly associated with nasal malodor (r = 0.57; P =.004). Sulfide levels were correlated with oral malodor levels only at the second appointment (r = 0.46, P =.02).
The data suggest that, as in adults, oral malodor in children is related primarily to oral factors. Correlations between nasal and oral malodor were evident, suggesting that postnasal drip plays a major role.
In two boys aged 4.5 and 1.5 years with halitosis a nasal foreign body was found. After removal the foetor disappeared. Little is known about the epidemiology of halitosis in children. Apart from specific odours with certain systemic disorders, local pathology such as chronic sinusitis, upper and lower respiratory tract infections and to a lesser degree gastrointestinal disorders may be the cause of the offensive smell. As in adults, bad breath in children is usually related to poor oral hygiene or disease of the oral cavity. The first-line treatment is proper oral hygiene and if necessary dental sanitization. In resistant cases further evaluation should be aimed at disclosing the causative pathology, in which case in children the possibility of a nasal foreign body should also be considered.
Patients who believe they have oral malodour often have a dry mouth condition instead. Here we have examined its relation to oral malodour, real or perceived. A direct relationship between the thickness of the film of residual saliva on mucosal surfaces throughout the mouth and perception of a dry mouth was observed. On the hard palate, the thickness of this film proved to be diagnostic for a dry mouth and corresponded to lower resting saliva flow and pH levels (P< 0.001). Intra-muscular administration of the anti-sialogogue, Robinul, accurately produced the dry mouth condition. Using a sulphide monitor, loss of volatile sulphur compounds into mouth air progressively occurred as the mouth became drier. Mouth pH and Eh on the dorsum of the tongue correspondingly fell. Mouth breathing led to tongue and palate moisture loss thus enabling escape of malodour volatiles into mouth air. Measurement of oral dryness should make it possible to differentiate genuine malodour from dry mouth related pseudo-malodour subjects, and in turn, the latter from patients that are halitophobic. This should facilitate identification of such patients and avoid error in their clinical management.
The paranasal sinuses are major producers of nitric oxide (NO). We hypothesized that oscillating airflow produced by humming would enhance sinus ventilation and thereby increase nasal NO levels. Ten healthy subjects took part in the study. Nasal NO was measured with a chemiluminescence technique during humming and quiet single-breath exhalations at a fixed flow rate. NO increased 15-fold during humming compared with quiet exhalation. In a two-compartment model of the nose and sinus, oscillating airflow caused a dramatic increase in gas exchange between the cavities. Obstruction of the sinus ostium is a central event in the pathogenesis of sinusitis. Nasal NO measurements during humming may be a useful noninvasive test of sinus NO production and ostial patency. In addition, any therapeutic effects of the improved sinus ventilation caused by humming should be investigated.
To test whether mebendazole, an antiparasitic drug, would affect recovery from halitosis.
We conducted a randomized, double-blind, placebo-controlled trial between April 1999 and September 2001.
A referral medical center.
One hundred sixty-two children aged 5 to 16 years whose parents complained about their chronic bad breath.
Children were randomly assigned to receive mebendazole (n = 82) or placebo (n = 80).
Parents whose children had halitosis were evaluated for halitosis at 2 months of treatment by questionnaire. The microbiologist investigated the stool samples of children for parasitosis at the beginning of the trial and also at the end of the trial in children who were treated with mebendazole.
Among those children who had evidence of parasites in stool samples at the beginning of the trial, 18 of 28 who were treated with mebendazole recovered from halitosis, compared with 2 of 24 who received placebo (relative risk [RR] for recovery, 7.7; 95% confidence interval [CI], 2.0-29.9). Among those who did not have stool parasites, 14 of 52 improved with mebendazole, compared with 10 of 48 taking placebo (RR, 1.3; 95% CI, 0.6-2.6). Mebendazole intake made a significant difference whether or not the children had parasites (P =.002).
Parasitosis should be considered as a possible cause of halitosis in the pediatric patient population. Mebendazole therapy seems to offer benefit to those children with parasites as a potential cause of their halitosis.
The relationship between stress, salivary flow rate and oral volatile sulfur-containing compounds (VSCs) is not clearly established. Two stressful situations were studied: psychological stress caused by a biochemistry examination (Study I) and psychophysiological stress caused by premenstrual syndrome (PMS) (Study II). Seventy-one undergraduate dental students took part in Study I and VSCs were measured 1 wk before the examination, on the day of examination and 1 wk after. In Study II, 50 women were selected (23 with and 27 without PMS) and the measurements were made during non-menstrual, premenstrual and menstrual stages. Unstimulated salivary flow was determined in the subjects of both studies. On the day of the biochemistry examination, VSCs significantly increased and salivary flow decreased compared with baseline values. Women with PMS showed higher VSC concentrations during the premenstrual stage than those without PMS (P < 0.05), but the salivary flow was not statistically different. A change in VSCs was observed during different stages of the menstrual cycle for the groups of women, but the salivary flow did not change. The results suggest that a stressful situation can be a predisposing factor for the increase of VSCs in the mouth air, but the mechanism cannot be simply explained by reduction of the salivary flow.
To assess the prevalence of persistent oral malodour in a general population in Rio de Janeiro and to find out whether sex and age are risk factors for this condition.
This was a cross-sectional survey in which university students (informants) were interviewed regarding the prevalence of persistent oral malodour in their households. To estimate the effects of sex and age logistic regression models with and without random effects for the informant were applied.
The prevalence of persistent oral malodour was 15% (95% confidence interval: 11-19). The risk of persistent malodour was nearly three times higher in men than in women, regardless of age. The risk was slightly more than three times higher in people over 20 years of age compared with those aged 20 years or under, controlling for sex.
Oral malodour is common in Rio de Janeiro, more prevalent in men and in those over 20 years of age, in both sexes. CLINICAL RELEVANCE OF THE FINDINGS: Freedom from disabling oral malodour is an outcome indicator of social well-being. Health professionals in general, and dentists in particular, should be trained to appropriately manage and treat people who suffer from persistent oral malodour.
Previous reports have suggested that gastrointestinal (GI) diseases may cause halitosis. The aim of this study was to evaluate the relationship between upper GI conditions, especially gastroesophageal reflux disease (GERD), and halitosis.
One hundred and thirty two consecutive patients complaining of upper GI symptoms were included in the study. All the patients completed a validated questionnaire that was designed to characterize and measure the severity of their symptoms. The questionnaire also contained questions about awareness and severity of oral bad breath. Following the filling of the questionnaire, the patients were physically examined and subjected to an upper GI endoscopy.
The final diagnosis among the 132 patients (M/F = 70/62, mean age 45.2 years, range 20-87 years) was GERD in 72 patients (55%), Functional dyspepsia in 52 (39%), Peptic ulcer in seven patients (5%) and gastric cancer in one patient (1%). Halitosis was significantly associated with the occurrence and severity of heartburn (P = 0.027), regurgitation (P = 0.002) sour taste (P < 0.001), belching (P = 0.001) and burburigmus (P = 0.006). Halitosis was not associated with upper abdominal pain, bloating, early satiety and chest pain. In relation to the final diagnosis, halitosis was significantly associated only with GERD (P = 0.002) but not with functional dyspepsia (P = 0.855) and peptic ulcer disease (0.765). No correlation was found between Helicobacter pylori infection status and halitosis occurrence and severity (analysis of variance F = 0.001, P = 0.977).
Halitosis is a frequent symptom of GERD and may be considered as an extra-esophageal manifestation of GERD. On the other hand, we did not find an association between functional dyspepsia, peptic ulcer disease and H. pylori infection with halitosis occurrence or severity.
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