Fetor Oris - A Review on Classification and Management
K. Siva Priyah1, Sherlyn Sheeba2, Dhanraj Ganapathy3
1Graduate Student, Saveetha Dental College, Saveetha University, Chennai.
2Tutor, Department of General Anatomy, Saveetha Dental College, Saveetha University, Chennai.
3Professor and Head of the Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai.
*Corresponding Author E-mail: sherlynsheeba@gmail.com
ABSTRACT:
Fetor oris or halitosis is an offensive or disagreeable odour that emanates from the mouth.Several etiological factors can contribute to this phenomenon with microbial factors being the most predominant entity.Microbial putrefaction of food debris, cells, saliva, blood leads to production of volatile sulfur compounds (VSCs) that cause bad breath. Understanding the different types and etiology of halitosis helps in providing better health care to patients burdened with bad breath. The treatment methods include mechanical and chemical reduction of microorganisms and other non-oral methods.
KEYWORDS: Halitosis, Fetor oris, volatile sulphur compounds, malodour, microbes.
INTRODUCTION:
Fetor oris or halitosis is an offensive or disagreeable odour that emanates from the mouth. It is also termed as bad breath, oral malodour, foul breath or fetor ex oris[1]. Halitosis was described by Howe in 1874 until which it did not become a clinical entity[2]. Halitosis can be classified into genuine halitosis, pseudo-halitosis or halitophobia. Genuine halitosis can be physiological or pathological based on its origin[3]. Based on the etiology, it is classified as halitosis due to local factors and systemic factors of pathological and non-pathological origin, halitosis due to drug administration and xerostomia[4]. Over 600 species of microorganisms have been identified to have association with halitosis. Some of them are Treponema denticola, Porphyromonas gingivalis, Porphyromonas endodontalis, Prevotella intermedia, Bacteroides loescheii, Enterobacteriaceae, Tannerella forsythia, Centipeda periodontii, Eikenella corrodens, Fusobacterium nucleatum, Micromonas micros, Campylobacter rectus and Eubacterium species[5].
They act on sulfur containing amino acids like methionine, cysteine and methylcysteine to produce volatile sulfur compounds (VSCs) like hydrogen sulphide, methyl mercaptan and dimethyl sulphide[1] [6]. Halitosis is considered to an important social problem that affects the individual’s self-esteem. Bad breath is usually more of a nuisance rather than a serious medical condition. Most individuals with bad breath can treat and eliminate the condition on their own. Additionally, they also seek dentists and physicians to help with chronic bad breath. The standard treatments like prescription of mouthwashes provide only a temporary relief. Understanding the etiology of halitosis plays a major role in eliminating it. As halitosis is primarily a result of microbial metabolism, ways to eliminate the microbial growth can help to reduce malodour. The oral cavity provides an environment for growth of hundreds of microbial species with differing nutritional preferences. Analysing the presence of anaerobic Gram-negative proteolytic bacteria in the deep crevices of the tongue and hard and soft tissues of the oral cavity and treating them accordingly is important. In this review, the classification and characteristics of each odour are described, (Table 1) so that the etiology of malodour can be better assessed for further management. In addition, the available management methods of genuine halitosis are presented (Table 2) so that it may be useful to the oral health care providers to plan the treatment, educate, and counsel the patients who are burdened with halitosis.
Table 1:Classification Of Halitosis With Treatment Needs[3]
Classification |
Treatment |
Description |
I. Genuine Halitosis |
|
1. Intense malodour that is obvious and beyond socially accepted levels |
A.Physiologic Halitosis |
TN-1 |
1. Malodor through putrefactive process within the oral cavity. No specific disease or pathologic disease that may be the cause of halitosis is found. 2. The main origin is the dorsoposterior region of tongue. 3. Halitosis caused temporarily due intake of certain diet like onion, garlic should be excluded. |
B.Pathological Halitosis |
|
|
i) Oral |
TN-1, TN-2 |
1. Halitosis caused by disease, pathologic condition or malfunction of oral tissues. 2. Halitosis derived from tongue coating modified by pathologic condition (e.g.: periodontal disease, xerostomia) is included in this subdivision. |
ii) Extra-oral |
TN-1, TN-3 |
1.Halitosis originates from nasal, paranasal and laryngeal regions. 2.Malodour originates from pulmonary tract or upper digestive tract 3.Malodor originates from disorders anywhere in the body whereby the odor is blood borne and emitted via the lungs. (e.g.: diabetes mellitus, internal bleeding) |
II. Pseudo-Halitosis |
TN-1, TN-4 |
1 Patient obsessively complaining of non existent malodour . 2. Condition is improved by counseling (using literature support, education and explanation of examination results) and simple oral hygiene measures.* |
III. Halito-Phobia |
TN-1, TN-5 |
1. Even after receiving treatment for Fetor oris, the patient perceives halitosis. 2. No physical or social evidence exists to suggest that halitosis is present. |
Table 2:Treatment Needs[3]
Etiological classification:
Halitosis can be divided into the following categories:[4]
(1) Halitosis due to local factors of the pathological origin :
The local factors include poor oral hygiene, periodontal diseases, extensive dental caries, food impaction, habits like smoking and chewing of tobacco can cause oral malodour. Pathologies like Vincent’s disease, hairy tongue and fissured tongue also are causes of halitosis. The oral mucosa with some ulceration or necrotic tissue, healing extraction wounds, or any cyst or abscess draining into the oral cavity produce bad breath. Other conditions which can lead to halitosis include chronic sinusitis, rhinitis, pharyngitis, oral, nasal or tracheal tumours, cancrum oris and syphilitic ulcers[7] [8].
(2) Halitosis due to local factors of non-pathological origin:
Decreased salivary secretion in the night which inhibits self cleansing of the oral cavity and lack of movement of cheek and tongue during sleep can lead bad breath in the morning which is commonly called as ‘morning breath’ [4]. Dentures can produce a type of halitosis referred to as ‘denture breath’. This is more evident in patients wearing dentures made up of vulcanite those wearing acrylic dentures. This is because the porous nature of vulcanite dentures tend to trap more food debris leading to moral malodour[9].
Patients undergoing endodontic treatment can sometimes complain of bad breath due to leakage of eugenol and creosote placed in tooth. Children aged 2 to 5 years may have a sweetish fetid odour emanating from the tonsillar crypts which traps the food debris. Men and women in their middle age suffer from severe morning breath. Improper maintenance of the dentures and stagnation of saliva can lead to halitosis in old patients [9] [10].
(3) Halitosis due to systemic factors of pathologic origin:
Uncontrolled diabetes mellitus, diabetic acidosis or hyperglycemic coma can lead to a sweet, fruity odour in breath known as ‘ketone breath’. In patients with uremia or kidney failure, the odour of ammonia in breath is present. Hepatic failure patients can have a sweetish feculent odour resembling a fresh cadaver. This is known as ‘fetor hepaticus’[4]. An acid sweet odour is seen in patients with acute rheumatic fever, whereas a foul putrefactive breath resembling odourous rotting meat is suggestive of lung abscess or bronchiectasis[8]. Other systemic diseases causing halitosis includetoxemia, eosinophilic granuloma, polycythemia vera, anaemia, acute and chronic scurvy, aplastic anaemia, Letterer-Siwe disease, and Hand-Schiiller-Christian disease, gastrointestinal disorders, gangrene of the lung and pulmonary tuberculosis[7]. Patients under physical or mental stress tend to neglect oral hygiene that leads to halitosis[11].
(4) Halitosis due to systemic factors of non-pathologic origin:
People who consume a vegetarian diet tend to pruoduce less halitosis than those who take excessive meat. This is because fewer waste products are produced by degradation of vegetable proteins than meat. Certain food like garlic, onion, leeks and alcohol may produce malodour. People may also experience odour during hinger sensations due to putrefaction of pancreatic juices in stomach called ‘hunger odour’[9].
(5) Halitosis due to systemic administration of drugs:
Drugs like isosorbide dinitrate, antineoplastic agents, antihistamines, amphetamines, tranquilizers, diuretics, phenothiamines and atropine are known to cause halitosis. Atropine and anti-neoplastic drugs decrease the salivary flow, thereby decreasing the self-cleansing ability of the oral cavity leading to malodour. Patients who inhale amylnitrite also produce an objectionable odor. Phenothiazine, occasionally causes black or white hairy tongue which is difficult to clean and encourages the lodging of food debris. Dimethyl sulfoxide is pre- scribed for some patients suffering from muscle pain. Though it is colorless and odorless, once metabolized, it is reduced to dimethyl sulphide that gives a distinct garlic-like odor [4].
(6) Halitosis due to xerostomia:
Apart from the above mentioned drugs, salivary gland conditions like Sjogren’s syndrome, salivary gland aplasia, Mikulicz’s disease, radiation therapy exceeding 800 rads, macroglobulinemia with salivary gland involvement can lead to xerostomia.Other conditions that may cause halitosis include mouth breathing, high fever with dehydration, menopause and emotional disturbances can cause oral malodour[9][11].
Diagnosis:
Organoleptic measurements rank the intensity of odours are ranked by organoleptic measurements(Table 3).This is considered as the criterion standard for the measurement of malodour. In general, two separate judges evaluate the degree of halitosis. The intensity of malodour is marked either on a 5 point or 10 point scale.The intensity is based on Rosenberg scale, which rates odor intensity and is as follows:
Table 3: Organoleptic Scoring Scale[3]
Category |
Description |
0: Absence of odour |
Odour cannot be detected. |
1 Questionable odour |
Odour is detachable although the examiner couldn't recognize it as malodor. |
2 Slight malodour |
Odour is deemed to exceed the threshold of malodor recognition. |
3 Moderate malodour |
Malodour is definitely detectable. |
4 Strong malodour |
Strong malodour is detected, but can be tolerated by examiner. |
5 Severe malodour |
Overwhelming malodour is detected and cannot be tolerated by the examiner. |
MANAGEMENT:
The best possible treatment is to identify the cause and eliminate it. So the treatment depends on the cause and often involves multiple modalities of treatment.
Masking agents:
Masking agents like mint, toothpastes, mouth rinses, sprays and chewing gums with pleasant flavours and smell can mask the malodour[6].
Mechanical reduction of microorganisms:
Bad breath caused due to fasting overnight or for long periods can cause bad breath is commonly referred to as ‘morning breath’. The stagnation of food debris and epithelial cells over the tongue can cause bad breath. When food is consumed, as it passes, it removes the coating over the tongue[12]. Studies reveal that people who had solid breakfast showed 60% less VSCs one hour after breakfast[13]. A change in diet can also help in reducing halitosis. Intake of high protein diet reduces the substrates for production of VSCs thereby reducing malodour. Preventing intake of food that cause bad breath like onion, garlic, prevention of drying of oral cavity, proper hydration are the necessary steps to be followed. Also, stimulation of salivary flow by using chewing gum can improve bad breath due to the presence of lysosomes in saliva that causes inhibition of bacterial growth[14].
Brushing the teeth, flossing, scraping of the tongue and using toothpicks are few mechanical methods which are used to reduce malodour. They reduce the amount of oral bacteria and their substrates, thereby reducing malodour[15]. All these methods can reduce the concentrations of VSCs for at least one hour. But in patients with high malodour, the limited duration of the effect makes the efficacy of these methods questionable [16].
Professional oral health care can be provided by the dentists and dental hygienists. Usage of hand scalers, electric toothbrush, interdental brush and cleaning of dentures can be carried out[6]. Full mouth disinfection with scaling and root planning and usage of Chlorhexidine for patients with periodontitis is recommended[17]. Elimination of habits like smoking and tobacco chewing can reduce halitosis
Chemical reduction of microorganisms:
Antimicrobial toothpastes and mouthrinses can reduce the number of micro-organisms chemically thereby reducing oral malodour. Often used active ingredients in these products are chlorhexidine, triclosan, essential oils and cetylpyridinium chloride[12][18]. Other effective chemical agents are allylpyrocatechol, L-trifluoromethionine and dehydroascorbic acid[6].
Active ingredients present in toothpastes, mouthrinses, lozenges and other products such as metal ions (zinc, sodium, iminium, stannous and magnesium and oxidizing agents are thought to interact with sulphur, neutralizing the VSCs and reduce malodour[6][19][20]. Combinations like Chlorhexidine and zinc, Cetylpyridinium chlide and zinc, Sodium and zinc, Iminium and zinc produce synergistic effectiveness in reducing halitosis. Full strength oxidizing lozenges like dehydroascorbic acid were effective in reducing tongue malodour[6] [21].
Non-oral management:
Tonsillectomy may be indicated in patients in whom even after proper management of tonsillitis, odiferous substances are still present in deep tonsillar crypts. Management of Helicobacter pylori that causes erosive and ulcerative changes in the gastrointestinal mucosa can improve halitosis [22]. Suspension of non-pathogenic Escherichia coli can be given to recolonize the intestinal tract with normal bacteria to suppress bacteria forming malodorous gases that can cause halitosis[6] [23].
CONCLUSION:
Halitosis is an unpleasant odor which is the result of volatile sulfur compounds (VSCs) produced by the microbial putrefaction of food debris, cells, saliva, blood. It is important to understand the pathogenesis, different types and etiology of halitosis to effectively treat it, Often, oral malodour is a result of more than one factor. Hence, the treatment also involves multiple entities to achieve clinical success.
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Received on 20.11.2017 Modified on 20.12.2017
Accepted on 23.01.2018 © RJPT All right reserved
Research J. Pharm. and Tech 2018; 11(5):2127-2130.
DOI: 10.5958/0974-360X.2018.00394.3