halitosis - dr sanjana ravindra
TRANSCRIPT
Halitosis: Current concepts
on etiology, diagnosis
and management
E U R J D E N T 2 0 1 6 ; 1 0 : 2 9 2 - 3 0 0 .
Journal club : 12
PROLOGUE
An unpleasant or offensive odour
emanating from the breath regardless of whether the odour
originates from oral or non-oral sources.
G Campisi, A Musciotto. Halitosis: could it be more than mere bad breath?; Intern Emerg
Med (2011) 6:315–319.
AIM
Succinctly focuses on the development of a systematic flow of events to come to the
best management of the halitosis from the primary care
practitioner’s point of view.
INTRODUCTION
It was described as a clinical entity by HOWE (1874).
Halitosis should not be confused with the generally temporary oral odour caused by intake of certain foods, tobacco, or medications.
Originates from two
Latin words
◦ Halitus → breath
◦ Osis → disease
Armstrong BL, Sensat ML, Stoltenberg JL. Halitosis: A review of
current literature. J Dent Hyg 2010;84:65-74.
SYNONYMS
Bad or foul breath
Breath malodour
Oral malodour
Foetor ex-ore
Foetor oris
Stomato dysodia
van den Broek AM, Feenstra L, de Baat C. A review of the current literature on aetiology
and measurement methods of halitosis. J Dent 2007;35:627-35
DEFINITIONS
Halitosis is the general term used to describe a foul odor emanating from the oral cavity, in which proteolysis, metabolic products of the desquamating cells and bacterial putrefaction are involved.• Marita et al., 2001
Halitosis is the general term used to describe any disagreeable odor in expired air, regardless of whether the odorous substances originate from oral or non-oral sources. • -Tangerman, 2002
Halitosis is also termed as fetor ex ore or fetor oris. It is a foul or offensive odor emanating from the oral cavity.• Carranza(2003)
Unpleasant odor of the expired air whatever the origin may be. Oral malodor specifically refers to such odor originating from the oral cavity itself.• Jan Lindhe(2003)
J lindhe. Clinical periodontology and implant dentistry; vol 1: 5th edition
Newman ,Takei, Carranza. Clinical periodontology ; 10th and 11th edition
DEFINITIONS
Breath malodor, defined as foul or offensive odor of expired air, may be
caused by a number of factors, both intra-oral & extra-oral (gingivitis/
periodontitis, nasal inflammation, chronic sinusitis, diabetes mellitus, liver
insufficiency etc.,) & can be linked to more serious underlying medical
problems including primary biliary cirrhosis, uremia, lung carcinoma,
decompensated liver cirrhosis & trimethylaminuria.
Quirynen, Zhao, Avontroodt et al., 2003
HISTORY
The problem of halitosis has been reported for many years.
References were found in papyrus manuscripts dating back to 1550
BC.
During Christianity, the devil's supreme malignant odor smelled of sulfur & it was presumed that sins produced a more or less bad
smell.
Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6:2-7
A treaty in Islamicliterature from the year
850 talked about dentistry, referring to the treatment of fetid
breath & recommended the use of siwak when breath had changed or
at any time when getting out of bed.
Buddhist monks in Japan also
recommended teeth brushing & tongue
scraping before the first morning prayers.
HISTORY
Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6:2-7
HISTORY
The Hindus consider the mouth as
the body's entry door and, therefore,
insist that it be kept clean, mainly
before prayers. The ritual is not
limited to teeth brushing, but
includes scraping the tongue with a
special instrument and using
mouthwash.
Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6:2-7
EPIDEMIOLOGY
Miyazaki concluded that there was increased
correlation between older age and malodour with
aging resulting in greater intensity the of odor. In
above 60 years age group of the Turkish individuals, the incidence was around
28%.
A recent study had revealed a prevalence
of self-reported halitosis among Indian dental students ranging from 21.7% in males to
35.3% in females.
In the general population, halitosis
has a prevalence ranging from 50%
in the USA to between 6% and
23% in china,
Japan study 2,672 Individuals 6-23% of subjects had oral malodour (VSC) as in expired air at some period during the day (Miyazaki 1996).
Another study in the United States involving individuals older than 60 years found 24% had oral malodour (Rosenberg 1996).
Epidemiology
The prevalence of persistent oral malodor in a Brazilian study was reported to be 15%, was nearly three times higher in men than in women (regardless of age) and 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 gender .
CLASSIFICATION
CLASSIFICATION
Genuine halitosis
Physiologic halitosis
Pathologic halitosis
Intraoral Extraoral
CLASSIFICATION
PHYSIOLOGIC HALITOSIS
Morning breath odour
Decrease in
frequent liquid intake
Stagnation of saliva and putrefaction of
entrapped food particles and desquamated
epithelial cells by the accumulation of bacteria on the dorsum of the
tongue,
Genuine halitosis
Physiologic halitosis
Pathologic halitosis
Intraoral Extraoral
CLASSIFICATION
Pathologic halitosis
poor oral hygiene,
dental caries,
periodontal diseases in
particular NUG, NUP,
periodontitis,
pericoronitis, dry socket
tongue coating
oral carcinoma.
Intra oral origin
Pathologic halitosis
OTHER ORIGINS OF HALITOSIS
The resulting breath takes on a different odor that may last several hours
Transient oral malodor
Porter SR, Scully C. Oral malodour (halitosis). BMJ 2006;333:632-5.
• 10-20%• gastro intestinal diseases• infections or malignancy in respiratory tract• Chronic sinusitis and tonsillitis• stomach, intestine, liver or kidney affected by
systemic diseases
Extra oral origin
Pathologic halitosis
Maximally 10% of the oral malodor cases originate from the ears, nose and throat (ENT) region, from which 3% finds its origin at the tonsils.
The presence of acute/chronic tonsillitis and tonsilloliths represents a 10-fold increased risk of abnormal VSC levels due to deep tonsillar crypts formation.
Foreign bodies in the nose can become a hub for bacterial degradation and hence produce a striking odor to the breath
Pathologic halitosis
Examples of
systemic
pathological
conditions
that cause halitosis
Pathologic halitosis
CLASSIFICATION
Delusional halitosis
Pseudo halitosis Halitophobia.
Condition in which a subject believes that their breath odor is offensive and is a cause of social nuisance, however, neither any clinician nor any other confidant can approveof its existence
• Monosymptomatic
• Hypochondriasis
• Imaginary halitosis
Interestingly, advertisements of oral hygiene products are responsible for the increase in a number of patients with delusional halitosis.
IMAGINARY OR DELUSIONAL HALITOSIS
IMAGINARY OR DELUSIONAL HALITOSIS
•Pseudo halitosis
–Apparently healthy individuals
•Haltophobia
– exaggerated fear of having halitosis
– also referred as delusional halitosis
– considered variant of monosymptomatic hypochondrial
psychosis.
Yaegaki K, Coil JM. Genuine halitosis, pseudo-halitosis and halitophobia: classification,
diagnosis, and treatment. Compend Cont Educ Dent 2000; 21(10A):880–886
Pseudo-halitosis patients complain of having oral malodor without actually suffering from the problem and eventually gets convinced of a disease free state during diagnosis and therapy
28% of patients complaining of bad breath did not show signs of bad breath
IMAGINARY OR DELUSIONAL HALITOSIS
Halitophobia is fear of having bad breath seen in at least 0.5–1% of adult population
Such patients need psychologicalcounseling and should be given
enough time duringthe consultation.
IMAGINARY OR DELUSIONAL HALITOSIS
OLFACTORY REFERENCE SYNDROME
Psychological disorder in which there is a preconceived notion about one having foul mouth breath or emits offensive body odor.
Halitosis generally arises as a result of the bacterial decomposition of food particles, cells, blood and some chemical compounds of the saliva.
Moss, 1998
Etiology
Yaegaki K, Sanada K. Volatile sulphur compounds in mouth air from clinically healthy
subjects and patients with periodontal disease. J Periodontol Res 1992;27:233-8.
Volatile sulphur compounds → hydrogensulphide [H2S, rotten egg smell], dimethyl sulphide [(CH3)2S, rotten cabbage smell, and methyl mercaptan [CH3SH, fecal smell].
Non - sulphur containing substances → diamines [cadaverine (cadaver smell) and putrescine (rotten meat smell), acetone and acetaldehyde
ETIOLOGY
Yaegaki K, Sanada K. Volatile sulphur compounds in mouth air from clinically healthy
subjects and patients with periodontal disease. J Periodontol Res 1992;27:233-8.
ROLE OF VOLATILE SULPHUR COMPOUNDS IN THE PATHOGENESIS OF HALITOSIS
MAJOR COMPOUNDS IMPLICATED IN HALITOSIS
VSC’s - Methylmercaptan, Hydrogen sulfide, dimethyl sulfide & Dimethyl disulfide.
Polyamides - Putrescein, Cadaverine, Skatole, Indole.
Short chain FA - Butyric, Propionic, Valeric & Isovaleric acid.
Others - Acetone, Acetaldehyde, Ethanol diacyl.
Miyazaki H, Sakao S, Katoh Y, Takehara T. Correlation between volatile sulphur compounds
and certain oral health measurements in the general population. J Periodontol 1995;66:679-84
It increases the permeability of oral mucosa and crevicular epithelium. It impairs oxygen utilization by host cells, and reacts with cellular proteins, and
interferes with collagen maturation.
It also increases the collagen solubility.
It decrease the DNA synthesis.
It increases the secretion of collagenases, prostaglandins from fibroblasts.
VSC reduce the intracellular pH; inhibit cell growth, and periodontal cell migration.
Miyazaki H, Sakao S, Katoh Y, Takehara T. Correlation between volatile sulphur compounds
and certain oral health measurements in the general population. J Periodontol 1995;66:679-84
Pathogenesis of oral malodor
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
The role of tongue coatings in the aetiology of oral malodour has been
extensively documented.
Tongue coatings include desquamated epithelial cells, food debris, bacteria and salivary proteins and provide an ideal environment for the generation of VSCs and other compounds that
contribute to malodour
The purulent discharge from the paranasal sinuses, seen in regurgitation esophagitis, gets collected at the dorsum of the tongue resulting in halitosis.
Atrophic rhinitis is caused by Klebsiella ozenae, which inhibits the self-cleaning property of nasal mucosa. Acute pharyngitis and sinusitis, caused by streptococcal species, are also responsible for producing halitosis.
Carcinoma of the larynx, nasopharyngeal abscess, and lower respiratory tract infections such as bronchiectasis, chronic bronchitis, lung abscess, asthma, cystic fibrosis, bronchiectasis, interstitial lung diseases, and pneumonia have been known to cause halitosis
Pathologic halitosis
Kinberg et al. published a review in 2010, in which they examined 94 patients having halitosis out of which 54 had gastrointestinal pathology suggesting that gastrointestinal is one of the common extra oral causes of halitosis.
Gastrointestinal causes like Zenker’s diverticulum, Gastro-esophageal reflux disease (GERD),Gastric and peptic ulcers have been known to cause halitosis.
Helicobacter pylori is known to cause a gastric and peptic ulcer and is recently associated with oral malodor.
Congenital broncho esophageal fistula, gastric cancer, hiatus hernia, pyloric stenosis, enteric infections, dysgeusia, duodenal obstruction, and steatorrhea are some of the sources of pathological mouth odor
Pathologic halitosis
Metabolic disorders like Trimethylaminuria (fish odor syndrome) is characterized by the presence of trimethylamine (TMA), whose odor resembles of rotting fish in the urine, sweat and expired air.
Individuals with TMAuria have diminished the capacity to oxidize the dietary-derived amines TMA to its odorless metabolite TMA N-oxide resulting in an increased excretion of large amounts of TMA in body fluids.
In hypermethioninemia the body produces a peculiar odor, which resembles that of, boiled cabbage and is emanated through sweat, breath and urine.
If this condition is present, the extraoral origin should be determined, because the latter requires medical investigation and support in therapy.
Pathologic halitosis
MICROBIOLOGY AND BREATH MALODOR
Fusobacterium nucleatum,
Treponema denticola,
Prevotella intermedia,
Porphyromonas gingivalis,
Bacteroides forsythus,
Eubacterium.
Some of the evidence in support of periodontal disease is indirect, as it is based on the in vitro ability of species indigenous to the sub-gingival plaque to produce VSC’s.
produce large amounts of CH3
SH and H2 S from methionine,
cysteine, or serum proteins
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
DRUGS ASSOCIATED WITH HALITOSIS
DIAGNOSIS
Complaint,
Medical, dental and halitosis history,
Information about diet and habits,
Confirming an objective basis to the complaint
Discretely and intermittently recorded.
Questions such as frequency, duration, time of appearance within a day,
Whether others have identified the problem (excludes pseudo-halitosis from genuine halitosis),
List of medications taken,
Habits (smoking, alcohol consumption)
Other Symptoms (nasal discharge, anosmia, cough, pyrexia, and weight loss) should be carefully recorded
DIAGNOSIS
DIRECT
1. By directly sniffing the bad breath2. Determination of odoriferous sulfurcontaining substances by gas chromatography or halimetry and other methods
INDIRECT
These methods assess the products produced by microorganisms in vitro or identify odor producing microorganisms.
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
1. Self-assessment, 2. Whole mouth breath test, 3. Spoon test, 4. Dental floss odor
test, 5. Saliva odor test.
Direct tests - Organoleptic
Direct sniffing of the expired air (“organoleptic” and “hedonic”
assessment) is the simplest, most common method to evaluate oral
malodor. An organoleptic examination involves the dentist assessing the odor at a range of
distances from the patient
Organoleptic measurement is highly recommended for initial diagnosis.
One potential risk of the organoleptic measurement is the transmission of diseases via the expelled air
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
ORGANOLEPTIC MEASUREMENT (SNIFF TEST)
Organoleptic measurement is a sensory test scored on the basis of the examiner’s perception of a subject’s oral malodor.
Organoleptic measurement can be carried out simply by sniffing the patient’s breath and scoring the level of oral malodor.
By inserting a translucent tube (2.5 cm diameter, 10 cm length) into the patient’s mouth and having the person exhale slowly, the breath, undiluted by room air, can be evaluated and assigned an organoleptic score.
The tube is inserted through a privacy screen (50cm-70cm) that separates the examiner and the patient.
The use of a privacy screen allows the patient to believe that they have undergone a specific malodor examination rather than the direct-sniffing procedure.
Organoleptic Scores (0- 5)
0 - No appreciable odor1 - Barely noticeable odor
2 - Slight but noticeable odor 3 - Moderate odor
4 - Strong odor 5- Extremely
foul odor
By Rosenberg , Mulloch Et Al
1991.
Yaegaki & coil 2000
DIAGNOSIS
The subjects are instructed to smell the odor emanating from their entire mouth
by cupping their hands over their mouth and breathing through the nose.
The presence or absence of malodor can be evaluated by the patient
himself/herself.
SELF ASSESSMENT TESTS
Whole mouth malodor (Cupped breath)
Subjects are asked to extend their tongue and lick their wrist in a perpendicular
fashion.
The presence of odor is judged by
smelling the wrist after 5 seconds at a distance of about 3
cm.
Wrist lick test
Plastic spoon is used to scrape and scoop material
from the back region of the tongue.
The odor is judged by smelling the spoon after 5 seconds at a
distance of about 5 cm organoleptically.
Spoon test
Unwaxed floss is passed through interproximal contacts.
Dental floss test
Involves having the subject expectorate approx. 1-2 ml of
saliva into a petridish.
The dish is covered immediately, incubated at 370 C for five
minutes and then presented for odor evaluation at a distance of 4 cm from the examiner’s nose.
Saliva odor test
BANA TEST
If any of the these species are present, they hydrolyze the BANA enzyme-producing B-naphthylamide which in turn reacts with imbedded diazo dye to produce a permanent blue color indicating a positive test
It is a chair side, enzyme-based assay, which is used to determine the proteolytic activity of certain oral anaerobes that contribute to oral malodor and which are considered as active H2 SO4 producers.
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
VOLATILE SULFIDE MONITOR
This electronic (Haiimeter, InterScan, Chatsworth, Calif)
analyzes concentration of hydrogen sulfide and methyl-mercaptan , but
without discriminating between them.
GAS CHROMATOGRAPHY (GC):
GC, performed with apparatus equipped with a
flame photometric detector, is specific
for detecting sulphur in mouth
air.
It measures directly the three
VSC methyl mercaptan,
hydrogen sulfide and dimethyl
sulfide.
GC is considered the GOLD
STANDARD for measuring oral
malodor.
This device can analyze air, saliva, crevicular fluid for
a volatile component.
DIAMOND PROBE
The Probe is placed directly into the periodontal pocket or tongue.
The sulfide-sensing element generates an electrochemical voltage proportional to the concentration of sulfide ions present.
The control unit reports the sulfidelevel at each site in a digital score from: 0.0 to 5.0
NINHYDRIN METHOD OF DETECTING AMINE
COMPOUNDS
Iwanicka et al (2005)
showed that amine levels
were higher in the saliva of
subjects suffering from
halitosis and lower in
healthy controls.
Tanaka M et al used these electronic noses to clinically assess oral malodor and
examined the association between oral malodor strength and oral health status.
ELECTRONIC NOSE
HALITOX SYSTEM
Quick and simpleDetects VSCs and poly amines
TOPAS
It detects both VSC and polyamines in the
sample.
The absorbent point given with the kit is
inserted into the pocket. Left in place for 1
minute.
Submerge the absorbent point tip in the toxin
reagent .
Wait for 5 minutes and see for yellow color in the specimen on the
scale of 0-5, which is directly proportional to the level of toxins in the
sample.
PREVENTIVE MEASURES
Visit dentist regularly
Periodical tooth cleaning by dental professional.
Brushing of teeth twice daily with appropriate brushing techniques and
for a duration of 2-3 mins.
Use of a tongue scraper to get rid of the lurking odour causing bacteria in
the tongue surface.
Preventive measures rather than curative aspects are highly recommended.
Flossing after brushing to remove food particles stuck in between the tooth surfaces.
Limit intake of strong odour species.
Limit sugar and caffeine intake.
Drink plenty of liquids.
Chew sugar free gum for a minute when mouth feels dry.
Eat fresh fibrous vegetables such as carrots.
MANAGEMENT AND TREATMENT
1. Confirm the diagnosis, 2. Identify and eliminate the predisposing and modifying factors, 3. Identify any contributing medical conditions and refer for management, 4. Review and reassure.
The management of halitosis entails four steps:
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
MANAGEMENTTreatment needs (TN) for halitosis have been categorized into 5 classes in order to provide guidelines
for clinicians in treating halitosis patients:
Rosenberg M, McCulloch CA. Measurement of oral malodor: Current methods and future prospects. J Periodontol
1992;63:776-82.
Category DescriptionTN- 1 Explanation of halitosis and instruction of
oral hygieneTN- 2 Oral prophylaxis, Professional cleaning and
treatment for oral diseasesTN- 3 Referral to a physician or medical specialistTN- 4 Explanation of examination data, further professional instruction, education and reassurance TN- 5 Referral to a clinical psychologist , a psychiatrist or other psychology specialist
Mechanical reduction of
intraoral nutrients and
micro-organisms
Chemical reduction of oral microbial load
Conversions of VSCs
Masking the malodor.
MANAGEMENT
Mechanical reduction of intraoral nutrients and micro-organisms- Tongue cleaning
- Tooth brush
- Inter-dental cleaning
- Professional periodontal therapy
- Chewing gum
MANAGEMENT
2. Chemical reduction of oral microbial load
- Chlorhexidine
- Essential oils
- Chlorine dioxide
- Two-phase oil- water rinse
- Triclosan
- Aminefluoride/ Stannous fluoride
- Hydrogen peroxide
- Oxidising lozenges
-Roldan S 2005,2004,2003 scully 2006
MANAGEMENT
CHLORHEXIDINE (CHX)
Mouth rinses containing antibacterial agents such as CHX and cetylpyridinium chloride (CPC) may play an important role in reducing the levels of halitosis producing bacteria on the tongue.
Chlorine dioxide and zinc containing mouth rinses can be effective in neutralization of odoriferous sulfur compounds.
Roldan. S et al. evaluated five different commercial mouth rinses with respect to their anti-halitosis effect and anti-microbial activity on salivary bacterial counts.
Formulations that combine CHX and CPC achieved the best results, and a formulation combining CHX with NaF resulted in the poorest.
Essential oils: Listerine was found to be only relatively effective against oral malodor (±25% reduction vs. 10% of placebo) and caused a sustained reduction in level of odorigenic bacteria
Chlorine dioxide: It is a powerful oxidizing agent that oxidizes the sulfides of the VSC’s to nonodorous sulfates and raises the oxidation/reduction ratio of the saliva toward the more oxidizing state.
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
TWO-PHASE OILWATER RINSE: The efficacy of
oilwater CPC formulation is
thought to result from the
adhesion of a high proportion
of microorganisms to the oil droplet which is further enhanced by the
CPC.
TRICLOSAN: A broad-spectrum
antibacterial agent, has been
found to be effective against
most oral bacteria and has
a good compatibility
with other compounds used
for oral home care
AMINEFLUORIDE/STANNOUS
FLUORIDE (AMF/SNF2 ): The
association of AmF/SnF2 resulted in
encouraging reduction of
morning breath odor, even when oral hygiene is
insufficient
HYDROGEN PEROXIDE: Suarez et al. reported that
rinsing with 3% H2 O2 produced
impressive reductions
(±90%) in sulfurgas that persisted
for 8 h.
OXIDIZING LOZENGES: The
anti-malodor effect of lozenges may be
caused by the activity of
dehydroascorbicacid which is generated by
peroxide-mediated oxidation of
ascorbate present in the lozenges.
Marawar PP, Sodhi NA, Pawar BR, Mani AM. Halitosis: A silent affliction!. Chron Young Sci 2012;3:251-7.
MANAGEMENT
3.Conversion of volatile sulfide compounds
- Metal salt solutions
- Toothpastes
- Chewing gum
MANAGEMENT
Metal salt solutions: Metal ions with affinity for sulfur are rather efficient in capturing the sulfur-containing gases. Zinc is nontoxic, noncumulative, and gives no visible discoloration
Tooth paste: Baking soda dentifrices have been shown to be effective, with a 44% reduction of VSCs level 3 h after tooth brushing versus a 31% reduction for fluoride dentifrices (Brunnet et al. 1998)
Chewing gums: Tsunoda et al. (1996) investigated the beneficial effects of chewing gums containing tea extract for its deodorizing mechanism.
MANAGEMENT
4. Masking the malodor
-Rinses
-Mouth sprays
-Lozenges containing volatiles
-Chewing gum
MANAGEMENT
Herbs and essential oils can be made into very
effective mouthwash remedies to sweeten
breath and help keep gums and teeth
healthy fennel not only improves digestion, but
also can reduce bad breath and body odor that originates in the intestines.
Give raw carrots as a midday treat to help scour
teeth of bacteria-laden plaque, a common cause
of bad breath.
Cardamom tea contains cineole, a potent antiseptic
that kills bad-breath bacteria and sweetens
breath.
Herbal treatment: MANAGEMENT
Thymol, one of the constituents of thyme, is contained in antiseptic
mouthwashes.
Neem leaf powder can be used as an effective tooth powder to
fight plaque and gingivitis when mixed with astringent herb powders and/or baking
soda.
A few drops of Tea tree oil , lemon or peppermint
essential oils can be added to warm water for an
effective mouth rinse to freshen breath
Herbal treatment: MANAGEMENT
CONCLUSIONIt’s a common complaint that may periodically affect most of the
adult population. Oral maldor, which is commonly noticed by patients, is an
important clinical sign and symptom that has many etiologies which include local and systemic factors.
It is often difficult for the clinician to find the underlying pathologies.
Although consultation and treatment may result in dramatic reduction in bad breathe, patients may find it difficult to sense the
improvement themselves
The field of halitosis research would benefit from: • More reliable, portable instruments for measuring VSC’s, • A
standard scale for assessing oral malodor, • Further studies with larger sections of the population, and • Development of
site-specific measurements.
REASON FOR
CHOOSING THIS
ARTICLE?
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