The oral biology of bad breath

DENT 5301
Introduction to Oral Biology
Dr. Joel Rudney

Why is it important?
Mouth odor can be a sign of undiagnosed disease
Mouth odor has negative connotations in many cultures
Affects patient's self-image
Affects others attitudes towards patient
Bad breath is big business
Mouthwashes, mints, drops, gums, toothpastes
Commercials reinforce existing attitudes
Dentists are consulted for advice, treatment
Active marketing of "breath treatment clinic" franchises

What smells?
Products of bacterial activity
Volatile sulfur compounds (VSC)
Hydrogen sulfide (H2S) - rotten eggs
Methyl mercaptan (CH3SH) - natural gas
Major components of mouth odor in most persons
Cadaverine - diamino acid - spoiled meat
Also important
Produced independently of VSC
Organic acids - goaty smells
Acetic, propionic, butyric, isovaleric

What smells too?

Products of metabolic activity
Volatile food components
Garlic, onions, etc.
Broccoli, cauliflower (sulfur-rich)
Ketones (acetone)
Low carb diets
Trimethylamine (fishy odor)
Tobacco smoke
Beer, wine, and liquor

How much does it smell?

Instruments for odor detection
Gas chromatography of breath samples
Most informative
Extremely sensitive and precise
Expensive and cumbersome
Limited to research centers
Portable sulfide meter (the Halimeter)
Can be used in a dental office
Detects only VSC
Must be calibrated regularly to maintain accuracy

Who smells it?

Organoleptic ratings - the odor judge
Trained noses partly agree with sulfide meters
May be more relevant clinically
Requires extensive training, periodic calibration
Mainly for research, specialized clinics
The jury of one's peers
Your spouse or your best friends
Your dentist (or your patient)
Relevant to the social consequences of mouth odor
Self-incrimination - least reliable
Many cannot detect odors apparent to others
Some perceive odors no one else can detect

Where does it smell?

Posterior tongue
Odor scores associated with degree of tongue coating
Tongue anatomy may increase risk (deep fissures)
May be primary source of odor in younger patients
Worse with dry mouth, after sleeping
Periodontal pockets in periodontal disease
Odor scores associated with disease/severity
VSC can be measured in fluid from deep pockets
Mouth odor/VSC proposed as early sign of periodontitis
Not all periodontal patients have mouth odor
Other oral lesions (e.g. abcesses, impactions)
Oral candidiasis - "Sweet, fruity odor"

Tongue coating

http://www.dent.ohio-state.edu/oralpath2/Tongue/25_2.jpg

Which bacteria are smelly?

Tongue bacteria
Streptococcus salivarius - a sign of health?
May be dominant in persons w/o halitosis (n = 5)
Gram-negative, proteolytic anaerobes
May predispose towards halitosis
Many novel species (n = 6)
Digest nasal discharges, food debris,
saliva components, sloughed cells
Produce VSC, cadaverine
BANA hydrolysis test (Perioscan) used for
detection
Periodontal pathogens

Systemic smells
About 90% of halitosis originates in the mouth
The other 10%
Systemic disease
Diabetes - ketoacidosis - acetone smell
Cirrhosis, liver failure - "mousy", "musty" smells
Renal failure - fishy smell
Leukemia - "decaying blood" smell
Respiratory system
Exhalation of volatile food compounds
Volatile medications - DMSO, amyl nitrate
Nasal/sinus/lung infections
Tonsils and tonsiloliths (may not contribute to mouth odor)
Treated by laser cryptolysis
Carcinoma

Other systemic smells

Gastrointestinal system (considered rare)
Reflux
Carcinoma
Helicobacter pylori infection (gastric ulcers)
Genetic disorders (enzyme deficiencies)
Trimethylaminuria (fishy odor) - autosomal recessive
Cystinuria, cystathionuria heterozygotes
Recessive defects in cysteine metabolism
Very high VSC levels (gut bacteria)

Iatrogenic/idiopathic smells
Frustrating to diagnose and treat - expensive
Iatrogenic odors
Gauze pad left behind after cleft palate surgery
Foreign objects
Inserted up the nose
Young children and developmentally disabled
If undetected, may lead to odor in adults
Idiopathic odors
Detectable by others, no apparent oral or non-oral cause
Cause presumed rare, not yet defined

Psychosomatic smells

Detectable only by patient - no apparent cause

Patients often refuse to accept objective findings
Associated with anxiety or depression
Can be confused with genetic disorders
Patients may show abnormalities by gas
chromatography
Trimethylaminuria heterozygotes
May be more common than once thought
Saliva TMA detectable by patient, but not others

Diagnosing smells

History
Onset, duration?
Constant or intermittent, morning, how long after meals?
Self-report, or reported by others?
Dietary factors, smoking and alcohol use?
Systemic disease and medication
Neurological problems - taste and smell function?
Currently under stress?
Comprehensive oral examination

Diagnosis by smelling

No commercial mouth rinses for 1 day previous

No eating, drinking, brushing, gum, mints, rinses for 2 h
Avoid perfumes or scented products (patient; dentist)
2 min rest with lips closed - exhale through nostrils
2 min rest as before - close nostrils - exhale through lips
2 min rest as before - exhale with lips and nostrils open
Sample posterior tongue with plastic spoon
Compare odor strength for each condition
Interpretation
Strongest odor with lips closed - suggests nose, sinuses
Strongest odor with nostrils closed - oral or gastric source
Tongue sample to confirm oral origin
Odor equally strong from nose or mouth - systemic
No discernible odor - verify with others (spouse, friend)

Treating smells - the basics

Non-oral etiologies - appropriate referral
Oral etiologies
Treat all existing conditions
Attempt to improve hygiene, flossing
Encourage posterior tongue hygiene
Commercial tongue scrapers
Many designs on the market
The gag reflex is a barrier to compliance

Tongue scraping

http://www.yatan-ayur.com.au/images/tonguecleaning2.jpg

One of many designs - no endorsement implied

Treating smells - short-term

Masking fragrances
Mouth rinses, drops, gums, mints, etc.
Chemicals that interact with VSC
Sold online - by dentists offering halitosis clinics
Oxidizing agents - products based on chlorine dioxide
Disinfectant - water treatment, pulp mills, cow udders
FDA approved for 2ndary food use (disinfecting chickens)
Appears to be safe at concentrations in breath products
Only two published studies - short-term , small Ns
Zinc reacts with VSC
Safe when not used in excess
More published evidence - small Ns
Reduces VSC levels short-term

Treating smells - long-term

Antibacterial products
Should reduce bacterial odors, depending on efficacy
Very few clinical studies document effects on odor long term
Chlorhexidine is considered the gold standard
High substantivity - remains on oral tissues for a long time
Only by Rx in USA, problems with taste and staining
Others with published evidence for odor reduction
Two-phase oil-water mouthrinse (cetylpyridinium chloride)
Sulfides lower after 6 weeks of use
More effective than Listerine (essential oils) - both worked
Currently available in Israel and Great Britain
Toothpaste with substantive triclosan copolymers - short term
Mixtures including low dose chlorhexidine - Halita

Treating smells - probiotics?

The probiotic concept
Replace bad bacteria with good bacteria
Lots of ongoing research - NIH funded
FDA approves human trial of probiotic S. mutans
Genetically engineered to be non-cariogenic
Lots of safeguards required
Probiotic treatment of bad breath in New Zealand and Australia
S. salivarius strain K12
Indigenous strain that produces antibacterial peptides (BLIS)
Patented, marketed as a dietary supplement (now in USA)
Step 1: Use chlorhexidine to knock down tongue flora
Step 2: Replace tongue flora with K12
Limited data - 2 wks., N = 13, only 3 controls, not yet published

ADA halitosis standards

Must be met to get ADA seal for any bad breath claims
Applies to products that already have ADA seal for other claims
Two independent double-blind efficacy studies
Minimum 3-week trial period
Patients must have baseline organoleptic scores between 2-5
Slight to Very Strong
Gas chromatograph preferred to measure VSC
Sulfide monitor OK if calibration data provided
Multiple malodor measurements
Parallel evaluation of hard/soft tissue effects, microbiology
Long term safety data (six month follow up)
Must include patient-reported adverse effects (taste/staining)
Toxicity data (cytotoxic, mutagenic, carcinogenic effects)

Why so few studies?

No product currently has the ADA seal for halitosis
Some do have the ADA seal for other properties
Plaque control or caries prevention
Will the public make this distinction?
Is there a marketing benefit to getting the halitosis seal?
FDA approval
May be sought under less stringent standards for cosmetics
Ingredients already approved as safe for human use
Chlorine dioxide products
May fall under the much weaker rules for dietary supplements
Products containing zinc
S. salivarius K12
Manufacturers lack incentives to do the studies