Transcript The oral biology of bad breath

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
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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