medilinkz.org  (10 May 2002)

Management of halitosis/oral malodor in primary care

Herbert Mukiibi Kiwanuka, Medical Officer,Raleigh Fitkin Memorial Hospital Manzini, Swaziland 

Correspondence to: H M Kiwanuka herbert@africaonline.co.sz

Although much of the literature available is derived from specialized departments in the more developed countries, this may be so because such societies tend to departmentalize issues in this way.

Halitosis is clearly a primary care problem that we see in daily practice.

This article covers the following topics

_ what is the magnitude of halitosis as a medical problem?

_ what reproducible/objective diagnostic criteria exist?

_ what is the realistic management of this problem in ambulatory care?

Key words: Halitosis, oral malodor, management, analysis, mouthwash, volatile sulfur compounds.

Pathologic halitosis may be derived from from impairment of normal salivary flow (e.g. parotid disease, sjogren’s syndrome), increased presentation of bacterial substrate (periodontitis, sinusitis) or a metabolic derangement (renal or hepatic failure) In rare instances, the patient is the only one to note the condition, strongly suggesting a hallucination of psychiatric or epileptic origin (1)

Studies indicate that the oral cavity is the principal source of physiological malodor associated with early morning halitosis. In all individuals regardless of age or health status of oral tissues, the most intense oral malodor is exhibited after prolonged periods of reduced salivary flow and abstinence from food and liquid. This results from normal metabolic activity in the oral cavity and is accentuated in cases with periodontal involvement. Physiologic oral malodor is transient in duration as it can be controlled to varying degrees in individuals by oral hygiene measures such as tooth brushing, dental prophylactic measure such as tongue scraping and rinsing with antiseptic mouthwashes (2)

While dental diseases have been strongly associated with this condition, there is considerable evidence that dentally healthy individuals can exhibit significant levels of mouth odor. Proteolytic activity by microorganisms residing on the tongue and teeth results in foul smelling compounds and is the most common cause of oral malodor (3)

Most of the patients we see in general practice probably fall in this category.

In a summary of experiences at a halitosis clinic in Israel, 39 patients with a primary complaint of halitosis were evaluated. Their health was established by a questionnaire, by clinical examination and by a laboratory analysis. Halitosis was evaluated organoleptically by a dentist and an otolaryngologist (odds ratio [OR] =5.7)

The volatile sulfide levels were measured with a portable sulfide monitor (Halimeter; RH-17 series, Interscan, Chatsworth, CA). Patients were found to suffer from otolaryngological disorders (26%), dental problems (23%), oral discomfort (18%) and gastrointestinal pathology (10%)

In 31% of the patients however, no clinical involvement was detected. The salivary flow rates in the patients were similar to those in healthy controls, whereas their oral candida carrier rate was low (28%). Fifty seven percent of the patients had objective halitosis by organoleptic evaluation and by halimeter measurements. The conclusion was that a high percentage of the patients who came to the clinic with a primary complaint of halitosis did not have a detectable problem (4)

Some reviews have suggested that breath malodor has been looked at more as a social and not a medical condition and therefore has been ignored by school curricula. Many desperate halitosis sufferers have turned to the dental profession for answers (5)

There are apparently healthy individuals who complain of having bad breath, which no one else can smell and for which no local or systemic condition can be found. This condition referred to as delusional halitosis, has identical features with a psychiatric disorder, monosymptomatic hypochondriacal psychosis (6)

Furthermore, one study evaluating relationship between the actual degree of malodor and the psychological condition of patients complaining of halitosis found that psychological conditions are closely associated with symptoms of patients complaining of halitosis. Psychopathological profile was determined using the Cornell Medical Index (CMI) Health questionnaire and there was significant correlation between degree of halitosis and tendency towards neurosis (7)

Although most of the patients presenting to the family physician are undifferentiated, this article will only deal in detail with those patients with primary halitosis i.e. where the symptoms are not secondary to dental, sinus or gastrointestinal (git) disease.

Organisms implicated are Porphyromonas gingivalis, Fusobacterium nucleatum, Prevotella oralis and veinonella species (11, 12, 13)

Volatile sulfur components of breath are an important cause of breath malodor (though not the sole cause). In primary care, a portable sulfide monitor is appropriate. Organoleptic and gas chromatographic diagnosis scores better than a sulfide monitor where bad breath emanates from outside the oral cavity and may not be due to sulfurous compounds (15) Objective measurements of volatile sulfur compounds are very useful and easy to perform in the outpatient setting (16)

Other methods like gas chromatography and flame photometric detection system are outside the scope of general practice (17) Some authors have advocated the use of the BANA test (perioscan, oral-B) as superior in detecting components of malodor independent of volatile sulfides (18)

In summary, it has been suggested that since oral malodor is a perceived olfactory stimulus, direct sampling by human judges may be the most logical measurement approach. (19)

In one study, organoleptic rating (OR) technique and gas liquid chromatography were compared and there was a statistically significant positive correlation between intensity of perceived malodor and the concentration of volatile sulfur compounds (VSC) emitted by individual subjects (20)

This is particularly significant in daily practice where we might not have access to advanced or expensive techniques.

Patient education is the pillar of managing this problem in addition to therapeutic interventions.

Apparently, there is no permanent cure yet determined and this warrants further study. Emphasis will still be given to proper oral hygiene and this need not be overstated.

Although some texts have commented that oral mouth rinses do little to suppress oral flora; extensive literature gives the merits of mouthwashes (21). It seems therefore that the difference in contention is about the active components of commercial mouthwashes.

In one study, a test mouthwash, saline rinse and no treatment were evaluated for their effects on mouth odor ratings (OR) and corresponding concentrations of volatile sulfur compounds (VSC) in 62 subjects. The mouthwash was significantly superior to the saline rinse and to no treatment on reducing OR and VSC for 3 hours which was the duration of the study (22)

Chlorine dioxide
Studies have suggested that when chlorine dioxide is contained in a mouth rinse, it neutralizes volatile sulfur compounds. The efficacy of a chlorine dioxide containing mouth rinse in the reduction of malodor was evaluated in a randomized, controlled, double blind, parallel group study of 31 men and women. As measured by the sulfide monitor, the mean volatile sulfur compound concentration in the chlorine dioxide group reached its minimum level at 8 hours post rinse. This study demonstrated that a one time use of chlorine dioxide containing mouth rinse significantly improved mouth odor pleasantness, reduced mouth odor intensity and reduced volatile sulfur compound concentrations in mouth air for at least 8 hours after use (23) Another study corroborates the efficacy of oxidizing lozenges for the same purpose (24) We consider this very important information in practice.

Chlorhexidine
Chlorhexidine is a common, readily available antiseptic agent. It has been shown to be highly effective in reducing oral microbial and volatile sulfide levels, reducing mouth odor for 8-10 hours after rinsing (25) In another study, mouth rinses containing chlorhexidine (Hexidine and Listerine) were shown to reduce total aerobes and anaerobes per tooth by 58% to 53% respectively as compared to placebo (26) Both these agents are freely available from pharmacies over the counter. Other articles have articulated the efficacy of chlorhexidine either alone or in combination with other commercial products although it is to a degree inactivated by saliva (27, 28)

Other agents
Cetypyridinium chloride (CPC) and two-phase oil- water have been used. More attention however, has been paid to the latter. A two-phase water mouthwash has been recently developed to remove oral microorganisms. The oil phase consists of olive oil and other essential oils. The aqueous phase includes CPC, which is a disinfectant. This combination strongly inhibits the production of volatile sulfide and is commercially available (29, 30)

It should be emphasized therefore that the efficacy of mouthwashes should be considered on the basis of their active components. The antiodor activity of such products is due solely to their antimicrobial activity (31)

Synthesis and conclusion
Halitosis is a common problem encountered in daily practice. Management of primary halitosis is the duty of the family physician and includes evaluation, patient education and reasoned selection of an appropriate intervention plan.

Oral hygiene is the mainstay of preventing oral malodor. Although many remedies are available, with reasonable efficacy, we are yet to come up with a permanent cure for halitosis.

Contrary to earlier claims, mouthwashes are very useful and can greatly relieve the symptoms and social distress in addition to hygiene measures such as tongue scraping and brushing.

The activity of mouth rinses in controlling malodor is solely due to the antimicrobial activity of selected components. This knowledge should be vital in guiding us in recommending commercially available preparations.

Table of references

1.       Goroll: Primary Care Medicine, 3^rd ed., 1995 Lippincott-Raven Publishers:997

2.       Tonzetich J. Production and origin of oral malodor: a review of mechanism methods of analysis. J Periodontol 1977 Jan 48(1): 13-20

3.       Bosy A. Oral malodor: philosophical and practical aspects. J Can Dent Assoc 1997 Mar 63(3): 196-201

4.       Ben-Aryeh H, Horowitz G, Nir D, Laufer D. Halitosis: an interdisciplinary approach. Am J Otolaryngol 1998 Jan-Feb;19(1):8-115.       Hennessy M. Battling bad breath: a new approach to an old problem. CDS Rev 1997 Jan-Feb;90(1):46-9

6.       Iwu CO, Akpata O. Delusional halitosis. Review of literature and analysis of 32 cases. Br Dent J 1990 Apr 7;168(7):294-6

7.       Oho T, Yoshida Y, Shimazaki Y, Yamashita Y, Koga T. Psychological condition of patients complaining of halitosis. J Dent 2001 Jan;29(1):31-3

8.       De Boever EH, Loesche WJ. Assessing the contribution of anaerobic microflora of the tongue in oral malodor. J Am Dent Assoc 1995 Oct;126(10):1384-93

9.       Scully C, el-Maaytah M, Porter SR, Greenman J. Breath odor: etiopathogenesis, assessment and management. Eur J Oral Sci 1997 Aug;105(4):287-93

10.    Ayers KM, Colquhon AN. Halitosis: cause, diagnosis, and treatment. N Z Dent J 1998 Dec;94(418):156-60

11.    Quirynen M, Van Eldere J, Pauwels M, Bollen CM, Van Steenberghe D. In vitro sulfur compound production of oral bacteria in different culture media. Quintessence Int 1999 May;30(5):351-6

12.    Goldberg S, Kozlovsky A, Gordon D et al. Cadaverine as a putative component of oral malodor. J Dent Res 1994 Jun;73(6):1168-72

13.    Paryavi-Gholami F, Minah GE, Turng BF. Oral malodor in children and volatile sulfur compound-producing bacteria in saliva: preliminary microbiological investigation. Pediatr Dent 1999 Sep-Oct;21(6):320-4

14.    Scully C, et-Maaytah M, Porter SR, Greenman J. Breath odor: etiopathogenesis, assessment and management. Eur J Oral Sci 1997 Aug; 105(4):287-93

15.    van Steenberghe D. Breath malodor. Curr Opin Periodontol 1997;4:137-43

16.    Delanghe G, Ghyselen J, Feenstra L, van Steenberghe D. Experiences of a Belgian multidisciplinary breath odor clinic. Acta Otorhinolaryngol Belg 1997;51(1):43-8

17.    Solis-Gaffar MC, Niles HP, Rainieri WC, Kestenbaum RC. Instrumental evaluation of mouth odor in a human clinical study. J Dent Res 1975 Mar-Apr;54(2):351-7

18.    Kozlovsky A, Gordon D, Gelernter I, Loesche W J, Rosenberg M. Correlation between the BANA test and oral malodor parameters. J Dent Res 1994 May;73(5):1036-42

19.    Rosenberg M, McCulloch CA. Measurement of oral malodor: current methods and future prospects. J Periodontol 1992 Sep;63(9):776-82

20.    Schmidt NF, Missan SR, Tarbet WJ. The correlation between organoleptic mouth odor ratings and of volatile sulfur compounds. Oral Surg Oral Med Oral Pathol 1978 Apr;45(4):560-7

21.    Gorol: Primary Care Medicine, 3^rd ed, 1995 Lippincott-Raven publishers:998

22.    Schmidt NF, Tarbet WJ. The effect of oral rinses on organoleptic mouth odor ratings and levels of volatile sulfur compounds. Oral Surg Oral Med Oral Pathol 1978 Jun;45(6):876-83

23.    Frascella J, Gilbert RD, Fernandez P, Hendler J. Efficacy of a chlorine dioxide-containing mouth rinse in oral malodor. Compend Contin Educ Dent 2000 Mar;21(3):241-4, 246, 248 passim; quiz256

24.    Greenstein RB, Goldberg S, Marku-Cohen S, Sterer N, Rosenberg M. Reduction of oral malodor by oxidizing lozenges. J Periodontol 1997 Dec 68(12):1176-81

25.    Rosenberg M, Gelernter I, Barki M, Bar-Ness R. Day-long reduction of oral malodor by a two-phase oil: water mouthrinse as compared to chlorhexidine and placebo rinses. J Periodontol 1992 Jan;63(1):39-43

26.    Shah HM, Shah MN, Gokani VN, Jethal BS. A comparative, qualitative and quantitative antimicrobial efficacy of mouth rinses containing chlorhexidine gluconate and essential oils. Indian J Dent Res 1993 Jul-Dec;4(3-4):103-11

27.    Briner WW, Kayrouz GA, Chanak MN. Comparative antimicrobial effectiveness of a substantive (0.12% chlorhexidine) and a nonsubstantive (phenolic) mouth rinse in vivo and in vitro. Compendium 1994 Sep.15(9) 1158,1160,1162 Passim. quiz

28.    Spijkervet FK, vanSaene JJ, van Saene HK, Panders AK, Vermey A. Chlorhexidine inactivation by saliva. Oral Surg Oral Med Oral Pathol 1990 Apr;69(4):444-9

29.    Yaegaki K, Sanada K. Effects of a two-phase oil-water mouthwash on halitosis. Clin Prev Dent 1992 Jan-Feb;14(1):5-9

30.    Kozlovsky A, Goldberg S, Natour I et al. Efficacy of a 2-phase oil: water mouthrinse in controlling oral malodor, gingivitis and plaque. J Periodontol 1996 Jun; 67(6):577-82

31.    Pitts G, Brogdon C, Hu L, Masurat T, Pianotti R, Schumann P. Mechanism of action of an antiseptic, anti-odor mouthwash. J Dent Res 1983 Jun;62(6):738-42

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