INTRODUCTION:

Halitosis is an nasty modification of the halitus for the person who has the sign and for related people either, being a pathological condition or not¹ is also known as fetid halitus, stinking mouth, bad breath or oral malodor^2,3. Halitosis is a common complaint among adults of both genders all over the world. It has a multifactorial etiology, but its main cause is the decomposition of the organic material by microorganisms of the oral cavity. One of the pioneers in halitosis research was ‘Howe’ who termed this symptom in 1874 and since then, halitosis has been considered a clinical entity¹. The majority of the citations concerning to halitosis before 1930 were not confirmed by facts or studies, however were perpetuated by literature⁴ .In 1934, Fair and Wells created an instrument called osmoscope, which was used for measurements of odor density in a subjective and semi quantitative way⁴.

Oral malodor is a common problem among general population and evidences reveal that it forms about85% of all bad breath. Bad breath can have a distressing effect that may become a social handicap and the affected person may avoid socializing. The condition is multifactorial in etiology and may involve both oral and non-oral conditions. Volatile sulphur compounds (VSC), namely hydrogen sulphide (H₂S) and methyl mercaptan (CH₃SH) are the main cause of oral malodor. These substances are by-products of the action of bacteria on proteins. Gram-positive bacteria produce little or no malodor; most Gram-negative bacteria are potent producers of odoriferous compounds. Treatments corresponding to the causes of oral malodor include mechanical or chemical tongue cleaning, periodontal disease treatment, oral hygiene instruction and mouth rinses or mouthwashes. Halitosis, breathe malodor or colloquially known as "bad breath" can be subdivided as real halitosis, pseudo halitosis and halitophobia⁵.

1.1. True halitosis:⁶

Real halitosis can be further subdivided into physiological and pathological halitosis. Physiologic halitosis includes halitosis caused by dietary components, deleterious habits, and morning breath, secondary to xerostomia caused by physiologic factors. Pathologic halitosis occurs secondary to pathologic conditions or oral tissues like gingival and periodontal diseases like Periodontitis, acute necrotizing ulcerative gingivitis, residual post-operative blood, debris under dental appliances, ulcerative lesions of the oral cavity, Halitosis may be associated with coated tongue, may occur due to xerostomia secondary to salivary gland diseases, tonsilloliths.

1.2. Pseudo halitosis⁶

Patients who suffer from pseudo halitosis complain of the existence of halitosis though it is not perceived by others. This condition can be managed effectively by counseling (using literature support, education and explanation of examination results) and simple oral hygiene measures Halitophobia⁶. Some individuals continue to insist that they have halitosis even after they have been treated for genuine or pseudo-halitosis. Such individuals are categorized as halitophobic. Halitophobia

may be considered when no physical or social evidence exists to suggest that halitosis is present.

1.3. Psychogenic Halitosis:^{6, 7}

Psychogenic Halitosis is the one which is imagined. In this a person believes that his breath smells bad when it actually does not. This problem may occur in people who tend to exaggerate normal body sensations. sometimes this is caused by a serious mental disorder such as schizophrenia. A person with obsessional thoughts have an overwhelmed sense of feeling dirty. A person who is paranoid may have the delusion that his organs are rotting. Both these persons feel their breath smells bad. Such people may be helped by having doctor or dentist assures them that they do not have bad breath. If the problem continues, person benefit from seeing psychotherapist.

2. Main causes of halitosis:

2.1.1. Oral Diseases Related To Halitosis:

Oral cavity pathologies that can cause halitosis are, among others: dental cavities, periodontal disease, tongue coating, exposed tooth pulps, extractions/healing wounds, interdentally food impaction, dentures kept at night or not regularly cleaned, restorative crowns which are not well adapted, cysts with fistula draining into the mouth, oral cancer and ulcerations. Most of these factors cause halitosis due to tissue breakdown, putrefaction of amino acids and decreasing of saliva flow. All these conditions result in the release of VSC^{8, 9}.

2.1.2. Otolaryngology and Respiratory Diseases Related to Halitosis:

Halitosis is a very common complaint among ENT patients. The main causes of halitosis related to the oro-nasal cavity are acute viral or bacterial pharyngitis, chronic/purulent tonsillitis, retropharyngeal abscesses, deep crypts of the tonsils, caseous retention, chronic/purulent sinusitis, post-nasal drip, foreign body in nasaloro-sinusal cavity and ozena. These pathologies cause halitosis mainly due to bacterial action, which lead to putrefaction of the tissues and production of VSC^10,8. Fetid samples of the tongue dorsum coating were compared with nasal mucus and showed the same composition¹¹. Nasal obstruction leads to mouth breathing causing dryness of the mouth. A dry mouth causes more epithelium cells exfoliation, xerostomia, tongue coating and therefore increases the production of VSC⁸.

2.1.3. Digestive Diseases Related to Halitosis:

Many digestive diseases are traditionally associated with halitosis. Reflux esophagi is, hiatal hernia, Zencker diverticulum, achalasia are associated. Actually, steatorrhea or other malabsorption syndromes, which cause excessive flatulence, are the most important causes of halitosis concerning gastrointestinal diseases^10,8. Specialists and internists often require gastroenterological assessment when facing a halitosis complaint. Endoscopy is one of the most widely requested tools in halitosis investigation¹².

2.1.4. Temporary halitosis:

It results from hot/spicy food, certain drinks, alcoholic beverages, coffee and most common from garlic, onion, salty foods, spices, curries, cured foods like salamis and cooked food such as kippers⁸. Tobacco consumption causes moldy odor and Hypo salivation/Xerostomia (dry mouth) also leads to bad breath¹³.

2.1.5. Morning breath:

Everybody has a degree of halitosis, first thing in the morning. There is a physiological reason for this. During sleep, the flow of saliva is reduced drastically and tongue and cheek move very little. This allows food residues to stagnate in the mouth and dead cells that are normally shed from the surface of tongue and gums and from the inside of cheek to accumulate. As bacteria starts to work on them and digest them, an unpleasant smell is generated. This process is biologically known as putrefaction/rotting. Although normal, anyone suffering from nasal congestion whose mouth breathes is more likely to suffer from these actions to a greater extent. Luckily, this morning breath generally disappears after breakfast and after brushing the teeth because saliva starts to flow again and any leftover residues are washed away and swallowed¹⁴.

2.1.6. Smoking (cigarettes/cigars):

Breath smells like ash tray. Smoking also reduces the flow of saliva and therefore further exacerbates the problem¹⁵.

2.2. Crash dieting/fasting:

When the body is no longer supplied with energy giving carbohydrates it first breaks down glucose stored in the muscles and liver in the form of glycogen. But this does not last long. After a few hours, the body begins to breakdown its fat stores and the waste product of their metabolism, ketones, endows the breath with a distinctive sweet and sickly smell. This can be seen in those who has vigorously worked out and exercised and not taken sufficient carbohydrates before or after. People on a strict caveman or high protein diet experience the same effect for similar reasons.

2.3. Oral source of halitosis

Malodor that arises from the mouth is the consequence of microbial putrefaction of food debris, cells, saliva, and blood. The oral microbes most likely to cause the oral malodor are Gram negative bacteria and include Prevotella (Bacteroides) melaninogenica, Treponemadenticola, Porphyromonasgingivalis, Porphyromonasendodontalis, Prevotellaintermedia, Bacteroidesloescheii, Enterobacteriaceae, Tannerellaforsythensis (Bacteroidesforsythus), Centipedaperiodontii, Eikenellacorrodens, Fusobacteriumnucleatumvincentii, Fusobacteriumnucleatumnucleatum, Fusobacteriumnucleatumpolymorphum, and Fusobacteriumperiodonticum^16,17.However, no obvious association exists between oral malodor and any specific bacterial infection, suggesting that halitosis reflects complex interactions between several oral bacterial species. The agents that give rise to oral malodor include especially the VSC, demines, and short chain fatty acids.

These bacterial interactions are most likely to occur in the gingival crevices and periodontal pockets, but oral malodor can also arise from the posterior dorsal tongue (and this explains why oral malodor may sometimes occur in people with good oral hygiene). As a consequence of its large and papillary surface area, the dorsum of the tongue canretain large amounts of desquamated cells, leucocytes, and micro-organisms (and presumably salivary constituents). The microbial content on the tongue may be greater^{18, 19} but not necessarily different, in people with periodontal disease than in others.

2.4. Miscellaneous Causes:

Renal impairment is normally a result of a chronic glomerulonephritis, which damage the glomerular function, leading to an increased urea level in the blood. Breathed air is described as ammonium-like breath and generally is accompanied by complaints of dysgeusia (salty taste)²⁰. Diabetes can result in accumulation of ketene bodies, which are breathed out producing a very characteristic halitus, moreover, diabetes causes dry mouth. In addition, diabetes and other insulin-resistance states are related to impaired secretion of body fluids, like tear and saliva. There is a decrease in saliva production and xerostomia can occur²¹. Trimethylaminuria or “fish odor syndrome” is agenetic metabolic disorder characterized by a failure in the oxidation route from trim ethylamine (TMA) to trim ethylamine N-oxide (TMA-O) in the liver. This occurs due to a mutation in the FMO gene²². High levels of TMA in urine and others body fluids confer that typical unpleasant, intermittent characteristic fishy odor to the breath²⁰. Examples of drugs that may cause oral malodor include alcohol, tobacco, betel, solvent misuse, chloral hydrate, nitrites and nitrates, dimethyl sulphoxide, disulphiram, some cytotoxic agents, phenothiazines, amphetamines etc.

3. Professional diagnosis for halitosis:

Scientists have long thought that smelling one's own breath odor is often difficult due to acclimatization, although many people with bad breath are able to detect it in others. Research has suggested that self-evaluation of halitosis is not easy because of preconceived notions of how bad we think it should be. Some people assume that they have bad breath because of bad taste (metallic, sour, fecal, etc.), however bad taste is considered a poor indicator. Patients often self-diagnose by asking a close friend²³.

One popular home method to determine the presence of bad breath is to lick the back of the wrist, let the saliva dry for a minute or two, and smells the result. This test results in overestimation, as concluded from research, and should be avoided²⁴. A better way would be to lightly scrape the posterior back of the tongue with a plastic disposable spoon and to smell the drying residue. Home tests that use a chemical reaction to test for the presence of polyamines and sulfur compounds on tongue swabs are now available, but there are few studies showing how well they actually detect the odor. Furthermore, since breath odor changes in intensity throughout the day depending on many factors, multiple testing sessions may be necessary.

3.1.1. Halimeter:

a portable sulfide monitor used to test for levels of sulfur emissions (to be specific, hydrogen sulfide) in the mouth air. When used properly, this device can be very effective at determining levels of certain VSC-producing bacteria. However, it has drawbacks in clinical applications. For example, other common sulfides (such as mercaptan) are not recorded as easily and can be misrepresented in test results. Certain foods such as garlic and onions produce sulfur in the breath for as long as 48 hours and can result in false readings. The Halimeter is also very sensitive to alcohol, so one should avoid drinking alcohol or using alcohol-containing mouthwashes for at least 12 hours prior to being tested. This analog machine loses sensitivity over time and requires periodic recalibration to remain accurate²⁵.

3.1.2. Gas chromatography:

Portable machines, such as the OralChroma, are currently being introduced. This technology is specifically designed to digitally measure molecular levels of the three major VSCs in a sample of mouth air (hydrogen sulfide, methyl mercaptan, and dimethyl sulfide). It is accurate in measuring the sulfur components of the breath and produces visual results in graph form via computer interface.

3.1.3. BANA test:

This test is directed to find the salivary levels of an enzyme indicating the presence of certain halitosis-related bacteria.

3.1.4. β-Galactosidase test:

Salivary levels of this enzyme were found to be correlated with oral malodor.

Although such instrumentation and examinations are widely used in breath clinics, the most important measurement of bad breath (the gold standard) is the actual sniffing and scoring of the level and type of the odor carried out by trained experts ("organoleptic measurements"). The level of odor is usually assessed on a six-point intensity scale^26-41.

3.2. Proposal for a rational protocol:

The intention of this protocol is to assess the main causes of halitosis concerning their frequency and importance. A logical knowledge organization must be kept to avoid diagnosis failures and useless/expensive tests. Initially a physician must have in mind that halitosis complaint is very common in the general population. Nevertheless, there is a bias concerning differences between true halitosis and “bad taste in the mouth”. Some patients look for halitosis treatment due to relatives/friends warnings and others due to self-awareness. It has to be considered the level of confidence in the information given by relatives/friends. In our experience, some cases have been mistreated due to biased information given by an unhappy consort. Moreover, there is physiologic halitosis, which is sometimes misinterpreted as a disease, and it can be normal. The halitosis most people experience when wake up is considered physiologic once it disappears after eating and/or brushing teeth. It is considered physiologic because of the decreased salivary flow, the increased putrefaction process at night and because of the long period of starvation while sleeping. If it persists even after eating or brushing teeth, further investigation is necessary⁴².

4. Food source for anaerobic bacteria that cause bad breath:

Most of the odoriferous compounds that cause bad breath are waste products created by anaerobic bacteria, as they digest proteins. This means that as we consume food items such as meat and fish, bacteria living in our mouth also get meal and waste products from their meals are precisely the compounds that cause bad breath. There is always naturally occurring protein food sources floating around in our mouth such as dead skin cells or protein compounds found in the saliva. And then also especially for those who are not diligent with brushing and flossing, there is always the leftover food debris from yesterday’s meal and the meal before that and the one before that. High protein foods include meat, fish, sea food and eggs; dairy foods such as milk, cheese, yoghurt; cereal grains and products; desserts especially cakes and pies.

4.1. Where do the bacteria that cause bad breath live?

For most of us, bad breath causing bacteria live on the surface of tongue. Secondary locations can be at or below person's gum line. Bacteria that live on person's tongue, the most common odor producing region of the tongue is its posterior region; covered by a whitish layer, dental plaque and its chocked full of anaerobic bacteria. The precise surface texture found on individual's tongue will influence the amount of coating that tends to accumulate. Fissured tongue, grooved tongue, and lingua plicata have more potential to accumulate bacteria laden coating than those with smoother tongue surface.

5. Correlation studies:

5.1. Association of oral malodor with Periodontitis:

A correlation has been found between VSC concentration in mouth air and increased pocket depth in Periodontitis patients.^43,44 The uptake of volatile sulphurs by epithelial cells may play an important role in the pathogenesis of periodontal disease: it has-been proposed that volatile sulphurs may alter the permeability of affected cells and facilitate the access of toxic metabolites into the underlying connective tissue thereby contributing to collagen degradation. There is also general agreement that the VSC content of exhaled mouth air and the concentration of VSC precursors increases with the severity of periodontal disease.

5.2. Correlation between halitosis and mouth breathing in children:

Lara Jansiski Motta et al., has carried out a correlation study between halitosis and mouth breathing in children.⁴⁵Accordingly, fifty five children between 3 and 14 years of age were divided into two groups (nasal and mouth breathing) for the assessment of halitosis. There were a significantly greater number of boys with the mouth-breathing pattern than girls. Based on their study, a total of23.6% of the participants had no mouth odor, 12.7% had mild odor, 12.7% had moderate odor and 50.9% had strong odor. There was a statistically significant association between halitosis and mouth breathing. Thus the occurrence of halitosis was high among the children evaluated, and there was a statistically significant association between halitosis and mouth breathing.

6. Treatment of oral malodor⁴⁶

It includes investigating and managing possible systemic (non-oral) source if organoleptic method detects malodor from both mouth and nose; improving oral hygiene by professional and patient administered tooth cleaning; regularizing atraumatic tongue cleaning; to use regularly the antimicrobial toothpastes and mouthwashes; rinsing with oil-water; having regular clinical review to ensure maintenance of effective oral hygiene etc,.

6.1. Alternative medicine:

According to traditional ayurvedic medicine, chewing areca nut and betel leaf is a remedy for bad breath. In South Asia, it was a custom to chew areca or betel nut and betel leaf among lovers because of the breath-freshening and stimulant drug properties of the mixture. Both the nut and the leaf are mild stimulants and can be addictive with repeated use. The betel nut will also cause dental decay and red or black staining of teeth when chewed⁴⁷. Both areca nut and betel leaf chewing, however, can cause premalignant lesions such as leukoplakia and sub mucous fibrosis, and are recognized risk factors for oral and oropharyngealsquamous cell carcinoma (oral cancer)⁴⁸. Other traditional remedies for halitosis include Guava leaves in Thailand, eggshells in China, parsley in Italy, and urine-based mouth rinse in certain European cultures⁴⁹. Practitioners and purveyors of alternative medicine sell a vast range of products that claim to beneficial in treating halitosis, including dietary supplements, vitamins, oral probiotics. Halitosis is often claimed to be a symptom of the so-called "candida hypersensitivity syndrome" or related fictitious diseases, and is claimed to be treatable with antifungal medications or alternative medications claimed to treat fungal infections.

6.2. Probiotics^{50, 51}

A diverse consortium of gram-negative and gram-positive bacteria have been found to contribute to the problem and by contrast, certain bacterial species that predominate in the mouths of healthy subjects become noticeably absent in subjects with halitosis. Current treatments focus on the use of chemical or physical antibacterial regimes to reduce the numbers of these bacteria. Antimicrobial treatment indiscriminately depletes populations of both the problematic bacteria and those bacteria that are not thought to be implicated in halitosis, but which are likely to be important in the maintenance of a normal oral micro-environment. The outcome of antimicrobial treatment is inevitably only a temporary reduction in malodor, until the halitosis-causing bacteria become re-established. Preventing the re-growth of odor-causing organisms by pre-emptive colonization of the oral cavity with nonvirulent, commensal microorganisms seems like a reasonable alternative.

Recently several studies were performed to replace bacteria responsible for halitosis with probiotics as Streptococcus salivarius, Lactobacillus salivarius or Weissellacibaria and concluded that probiotic bacterial strains, originally sourced from the indigenous oral microbiotas of healthy humans, may have potential application as adjuncts for the prevention and treatment of halitosis. The oral administration of the probiotic lactobacilli not only seemed to improve the physiologic halitosis, but also showed beneficial effects on bleeding on probing from the periodontal pockets.

7. CONCLUSION:

The prevalence of halitosis has been reported to be as high. However, only a few patients visit dental clinicians to seek help for halitosis. This fact suggests that the patients who do visit clinicians may have different psychological characteristics or values concerning their own breath than other individuals. Since the biochemical pathogenesis of oral malodor was elucidated earlier, the simple treatment measures have proven very effective in controlling halitosis. Nevertheless, halitosis treatments are generally unsuccessful in halitophobic patients because clinicians are unable to find any signs of bad breath. Patients with psychosomatic halitosis frequently receive only treatment for genuine halitosis and do not receive care from a psychological specialist. Patients’ persistent complaints about malodor are often ignored by dental clinicians. Consequently, these patients may start “doctor shopping.” Many patients with psychosomatic halitosis are not able to obtain proper treatment for their condition because of a clinician’s mismanagement. Since a few of these patients go so far as to commit suicide, they need appropriate management by a psychological specialist. Therefore, it is important for the general practitioner to distinguish between patients with real halitosis and those with psychological halitosis.

A successful protocol for distinguishing or diagnosing psychosomatic halitosis has not yet been established. Although more than 100 papers about psychosomatic halitosis have been published during the past quarter century, classification of and criteria for genuine halitosis and the psychosomatic condition remain unclear. To clarify the appropriate management of a patient with psychosomatic halitosis, a simple classification of the types of halitosis must be established. To conclude, bad breath is a major concern for many people. Because it nearly always originates from the mouth, it can and should be diagnosed and treated professionally by dentists. There is no "stand-alone" product solution for halitosis nor do traditional standards of dental or periodontal care necessarily eliminate the problem. Recent developments in the understanding of the etiologies of breath malodor have spawned new techniques for its assessment and management.

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Received on 24.11.2015 Modified on 05.12.2015

Research J. Pharm. and Tech. 8(12): Dec., 2015; Page 1707-1713

DOI: 10.5958/0974-360X.2015.00307.8