Quintessence International, 05/1999

The diagnosis and management ofbad breath can be easily incorporated in routine dental care by attending dentists. This article outlines the information necessary to establish a differential diagnosis of oral malodor. This includes evaluation ofmedical, dental, and halitosis history. It also includes the examination of extraoral and intraoral tissues and a thorough periodontal examination. The presence ofbad breath is established with organoleptic and hydrogen sulfide-monitor (Halimeter) measurements. The treatment of malodor resulting from oral overgrowth of anaerobic organisms in the oral cavity consists of mechanical and chemical reduction of the microbial flora by methods that are supported by scientific evidence. Keywords: bad breath clinics, chlorhexidine, Halimeter, oral malodor, tongue scraping

To treat halitosis, clinicians must examine the psychologic condition ofa patient as well as the disease history and plausible causes of oral malodor, such as periodontal disease. However, it is not easy for a practitioner to carry out a psychologic examination other than the normal inquiry concerning oral malodor itself. Hence, a questionnaire that appears to be a normal inquiry, rather than one containing psychologic questions, was composed to survey the causes of halitosis and psychosomatic tendencies. Keywords: counseling, halitophobia, halitosis, psychosomatic dentistry, psychosomatic disease, questionnaire

Objective: This study was undertaken to assess patients' response to their treatment at a multidisciplinary oral malodor clinic. Method and materials: In 4 years, a multidisciplinary breath odor clinic in Belgium examined 406 patients. The team consisted of an ear, nose, and throat specialist, a periodontologist, occasionally a specialist in internal medicine, and, more recently a psychiatrist. After the initial visit, each patient was scheduled for a follow-up appointment 2 to 6 months later; however, only 143 patients (35%) showed up for this control visit. The remaining 65% of the patients answered a mailed questionnaire. Results: About half of the patients who returned no longer had complaints, white 17% reported no improvement. This group was characterized by imaginary bad breath and manifest psychologic problems. There was also disbelief of their eure, although clinical examination (organoleptic evaluation and volatile sulfide measurement by means ofa portable monitor) did not reveal any oral malodor. Some also insufficiently performed the recommended oral hygiene measures (tongue brushing and interdental cleaning). Most of the patients who returned the questionnaire were disappointed by the Suggestion that their halitosis was the result of insufficient oral hygiene. Conclusion: Better education ofboth the public and dental Professionals as to the most frequent cause of halitosis, insufficient oral hygiene, might elevate the level of compliance by patients. Keywords: follow-up, Halimeter, halitosis, oral malodor, questionnaire, volatile sulfur compounds

This study was undertaken to review the rationale behind the usage of antibacterial mouthrinses to control oral malodor and to evaluate the claims made for antibacterial mouthrinses against the Statements of US Food and Drug Administration regulations. The literature from 1960 to August 1997, found in a MEDLINE search on oral malodor, halitosis, and tongue microbiology, was examined. Clinical trials that were double blind and had selected subjects who exhibited a detectable level of oral malodor were evaluated. Individuais who experience oral malodor resulting from the overgrowth of proteolytic, anaerobic bacteria on their tongue surfaces can be successfully treated by a regimen that includes tongue brushing and toothbrushing, often in combination with use ofa mouthrinse containing an antibacterial agent. Several candidate mouthrinses containing essential oils, zinc chloride, or an oil-water-cetylpyridinium chloride mouthrinse have reduced the organoleptic scores of individuals with moderate levels of oral malodor in the absence of tongue brushing. Very little long-term data beyond 6 weeks of usage are available. These mouthrinses should be marketed as oral deodorants that are analogous in purpose to the usage of deodorant soaps to control and/or eliminate body malodors. Keywords: antibacterial mouthrinses, cosmetic claims, halitosis, oral deodorants, oral malodor, tongue microbiology, US Food and Drug Administration regulations

Objective: Chewing gum may act as a masking or a therapeutic agent against the different chemical compounds that are responsible for oral malodor. An open-label exploratory study investigated the effect of mastication and aromatic components of chewing gum on reducing oral volatile sulfur compounds. Method and materials: Twelve dental students (5 males and 7 females) acted as their own controls. Toothbrushing stopped 12 hours before observations. Measurements included organoleptic and volatile sulfur compound scores and the pH of the anterior and posterior zones of the dorsal tongue. Measurements were made at 9 AM and 12 PM on 1 day for 3 successive weeks: week 1, no gum (control); week 2, test gum; week 3, unsweetened gum base. This open-label study was then completed by an observerblind study, aecording to the same schedule; the recorded measurement was the plaque index. Results: The pH, volatile sulfur compounds, and organoleptic scores were similar for all groups. The pH was more basic in the posterior part than in the anterior zone of the dorsal tongue, irrespective of time and presence or absence of chewing gum. In addition, the volatile sulfur compound score rose transiently immediately after the test gum, and the organoleptic score feil in the first hour only after the test gum. The two chewing gum groups seemed to have a greater reduction in plaque index than did the control (no gum) group. Conclusion: Chewing gum may have a valuable mechanical role in cleaning dental suriaces, and the test gum may temporarily control bad breath. After 3 hours, similar volatile sulfur compound scores were observed for subjects who chewed either test or unsweetened gum base and control subjects. Keywords: chewing gum, masking effect, organoleptic measurement, volatile sulfur compounds

Objective: In an initial study, subjects complaining ofbad breath were generally unable to score the level of their own oral malodor in an objective fashion. Subjects were taught several techniques for self-measurement of bad breath. One year following the initial consultation, subjects were recalled to determine whether their ability to assess their own oral malodor had improved. Method and materials: In the study, subjects were blinded to their own scores 1 year earlier, to the odor-judge scores, and to the results of the clinical laboratory tests. Thirty-two of 43 subjects in the original study who presented with a complaint of oral malodor agreed to participate in the follow-up study. Odor-judge scores and self-assessments of oral malodor (whole-mouth odor, tongue odor, and saliva odor) were compared with one another as well as with clinical parameters. Results: Objective improvements were noted in both oral health parameters and malodor levels of subjects. Despite this, self-assessments generally remained unrelated to objective parameters (odor-judge scores, clinical indices, and laboratory tests). Self-assessments were all significantly correlated with one another, and also were significantly associated with corresponding self-estimates made 1 year earlier. Conclusion: Subjects with a complaint of oral malodor remain largely unable to score their own bad breath in an objective fashion. In addition, they are not capable of sensing reductions in oral malodor 1 year following the original assessment, even though, from a clinical Standpoint, improvements have taken place. Keywords: halitosis, odor judge, oral malodor, self-assessment

Patients affected by psychosomatic halitosis never wish to visit a psychologic specialist, because they cannot recognize their own psychosomatic condition. They also never doubt that they have offensive oral malodor. Other people's behavior, such as covering the nose oraverting the face, is interpreted by these patients as an indication that their breath is offensive, and these behaviors or attitudes reinforce their belief that they have a strong oral malodor. To clarify whether the patient's perception of another individual's attitude is affected by his or her delusion, this article is focused on the relationship between the behavior toward oral malodor and the psychologic profiles of patients with psychosomatic halitosis. If a patient expects simple avoidance behavior from other individuals, the development of psychosomatic halitosis may be accelerated, as it becomes a self-fulfilling prophecy. Individuals who are concerned with their own oral malodor but exhibit no oral malodor may have latent psychosomatic tendencies and may be mentally immature. A protocol for referring a patient to a psychologic specialist is presented. Keywords: halitophobia, halitosis, psychosomatic dentistry, psychosomatic disease

Genetics, experience, environment, and health can all affect the anatomic and Physiologie components of the olfactory System and thereby influence olfactory Performance. Large individual differences exist among subjects with respect to olfactory sensitivity and identification ability, which may result in both qualitative and quantitative differences in perceptual ability. Keywords: chemical senses, odor coding, olfaction, olfactory dysfunction

Objective: This study examined the effects of methyl mercaptan, a produet of the bacterial putrefaction of protein in periodontal pockets, on the function of cells in culture. Method and materials: Human gingival fibroblasts and periodontal ligament cells were exposed to a constant, continuous flow of methyl mercaptan in vitro. Control and test cultures were then examined for changes in intracellular pH, an event often associated with alterations in cellular function. Intracellular pH was determined by single-cell Image analysis of cells loaded with a fluorescent, pH-sensitive dye. Periodontal ligament cells were also tested for changes in synthesis of total protein and fibronectin. Results: Test cells exhibited a consistent decrease in intracellular pH following exposure to methyl mercaptan. Measurements of total protein production showed that test periodontal ligament cell cultures produced approximately 30% less protein than control cultures (P 0.05). Western-blot analysis of fibronectin in medium demonstrated that abnormal monomeric fibronectins were a major protein in test, but not in control, cell cultures. Conclusion: Exposure to methyl mercaptan induced alterations in intracellular events that paralleled changes in extracellular matrix proteins. The observed changes in extracellular matrix proteins support the hypothesis that methyl mercaptan contributes to the progression of periodontal disease. Keywords: fibronectin synthesis, gingival fibroblasts, intracellular pH, methyl mercaptan, periodontal ligament cells, protein synthesis, volatile sulfur compounds

Objective: The purpose of this study was to detect the relative contribution of Porphyromonas gingivalis, Fusobacterium nucleatum, and Prevotella intermedia in the production of oral malodor. Method and materials: The volatile sulfur compounds produced by these bacteria in vitro were measured semiquantitatively by a portable sulfide monitor. Results: Samples from the tongue, tonsils, and pharynx showed a significantly higher production (550 ppb) oi volatile sulfur compounds during the first 6 hours after anaerobic incubation in broths (brain-heart infusion, Columbia, and Trypticase Soy) than after incubation in agar media (300 ppb) (P 0.001). After 24 hours, values in broths and agars leveled off at 350 ppb (P = 0.3) and remained constant during the next 6 days. Measurement of separate pure cultures showed that maximal volatile sulfur compound production was reached 6 hours after incubation (450 ppb for the 3 bacteria). Higher volatile sulfur compound values were measured in brain-heart infusion. When measurements of mixed cultures of the 3 pathogens were performed every 15 minutes, the maximal value was reached after only 30 minutes of incubation (nearly 500 ppb). Conclusion: The in vitro volatile sulfur compound production of oral samples is preferably measured in broths. Maximal sulfur production from mixed cultures is reached after 30 minutes of incubation. Samples should always be inoculated at the same dilution. Keywords: culture media, Halimeter, halitosis, microbiology, volatile sulfur compounds

Bacterial putrefaction is the central metabolic process involved in oral malodor and can easily be modeied in the salivary sediment system developed from centrifuged whole saliva. Methods used in this system for examining malodor have included measurement of (1) head space (gaseous-phase) and liquid-phase odors, organoleptically; (2) volatile sulfur compounds, by means of an electrochemical sensory instrument; (3) pH, Po2, and oxidation-reduetion potential with appropriate respective electrodes; (4) the malodorous compounds indole and skatole, colorimetrically; (5) substrate levels and their effects; and (6) bacterial numbers and types. The simplicity of the system permits other analyses to be easily added, if needed, and the influence of factors and agents that affect oral malodor to be assessed. Addition of odorigenic or nonodorigenic pure cultures to the mixed bacterial flora of the system enables modification of the microflora composition and high- and low-odor-producing microflora to be simulated and compared. Modeling validity has been enhanced by the use of complementary in vivo methods, such as a method used to measure the ability or potential of an oral microbial flora to produce malodor. The method involves in vivo challenge testing with cysteine, an amino acid, and measuring the hydrogen sulfide produced. Oral malodor is a multifactorial condition and models enable its systematic study and the quantitative testing of antimalodor agents. Keywords: oral malodor, organoleptic measurement, salivary sediment system, volatile sulfur compounds