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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
