Halitosis: From Diagnosis to Management (Aylıkcı & Çolak 2013) PDF

[Downloaded free from http://www.jnsbm.org on Monday, July 5, 2021, IP: 195.194.4.65] R evi e w A r tic le Halitosis: From diagnosis to management Departments of Periodontology and 1Operative Dentistry, Kırıkkale University Dent...

[Downloaded free from http://www.jnsbm.org on Monday, July 5, 2021, IP: 195.194.4.65] R evi e w A r tic le Halitosis: From diagnosis to management Departments of Periodontology and 1Operative Dentistry, Kırıkkale University Dental Faculty, Kırıkkale, Turkey Bahadır Uğur Aylıkcı, Hakan Çolak1 Address for correspondence: Dr. Bahadır Uğur Aylıkçı, Research Assistant, Kırıkkale University Dental Faculty, Department of Periodontology, Kırıkkale, Turkey. E-mail: [email protected] Abstract Halitosis is formed by volatile molecules which are caused because of pathological or nonpathological reasons and it originates from an oral or a non-oral source. It is very common in general population and nearly more than 50% of the general population have halitosis. Although halitosis has multifactorial origins, the source of 90% cases is oral cavity such as poor oral hygiene, periodontal disease, tongue coat, food impaction, unclean dentures, faulty restorations, oral carcinomas, and throat infections. Halitosis affects a person’s daily life negatively, most of people who complain about halitosis refer to the clinic for treatment but in some of the people who can suffer from halitosis, there is no measurable halitosis. There are several methods to determine halitosis. Halitosis can be treated if its etiology can be detected rightly. The most important issue for treatment of halitosis is detection etiology or determination its source by detailed clinical examination. Management may include simple measures such as scaling and root planning, instructions for oral hygiene, tongue cleaning, and mouth rinsing. The aim of this review was to describe the etiological factors, prevalence data, diagnosis, and the therapeutic mechanical and chemical approaches related to halitosis. Key words: Diagnosis, etiology, halitosis, humans, prevention and control INTRODUCTION diagnosis, and the therapeutic mechanical and chemical approaches related to halitosis. Human breath is composed of highly complex substances with numerous variable odors which can PREVALENCE generate unpleasant situations like halitosis. Halitosis is a latin word which derived from halitus (breathed Halitosis is very common in general population and nearly air) and the osis (pathologic alteration), and it is used more than 50% of the general population have halitosis. to describe any disagreeable bad or unpleasant odor In a Swedish study of 840 men, halitosis assessment was emanating from the mouth air and breath. Foetor oris, only present in around 2% of the population. However, oral malodor, mouth odor, bad breath, and bad mouth halitosis prevalence in a China study which involved more odor are the other terms which are used to describe and than 2500 participants was assessed above 27.5%. Also characterize the halitosis.[2-4] This undesirable condition in the literature, the prevalence of halitosis reported as is a common complaint for both genders and for all age ranging from 5% to 75% of tested children.[9,10] Origin of groups. It creates social and psychological disadvantages halitosis in 90% of the patient is oral cavity; 9% of patient for individuals, and these situations affect individual’s source of halitosis is non-oral reasons such as respiratory relation with other people. In present review we system, gastrointestinal system, or urinary system. In 1% describe the etiological factors, prevalence data,etiology, of patients, the cause of the halitosis is diets or drugs.[11,12] Access this article online Quick Response Code: ETIOLOGY OF HALITOSIS Website: www.jnsbm.org Halitosis is formed by volatile molecules which are caused because of pathological or nonpathological reasons, and it DOI: originates from an oral or a non-oral source. These volatile 10.4103/0976-9668.107255 compounds are sulfur compounds, aromatic compounds, nitrogen-containing compounds, amines, short-chain fatty Journal of Natural Science, Biology and Medicine | January 2013 | Vol 4 | Issue 1 14 [Downloaded free from http://www.jnsbm.org on Monday, July 5, 2021, IP: 195.194.4.65] Aylıkcı and Çolak: Halitosis: From diagnosis to management acids, alcohols or phenyl compounds, aliphatic compounds, In addition, some of the bacteria produce hydrogen sulfide and ketones [Table 1].[13-17] and methyl mercaptan from serum. The bacteria which are the most active VSC producers are shown Table 3. Volatile sulfur compounds (VSCs) are mainly responsible for intra-oral halitosis. These compounds are mainly The other VSC is dimethyl sulfide which mainly responsible hydrogen sulfide and methyl mercaptan. They produce for extra-oral or blood-borne halitosis, but it can be a bacteria by enzymatic reactions of sulfur-containing amino contributor to oral malodor. Ketones such as acetone, acids which are L-cysteine and L-methionine [Table 2]. benzophenone, and acetophenone are present in both alveolar (lung) and mouth air; indole and dimethyl selenide are present in alveolar air.[16,21] These compounds are also Table 1: Odoriferous components cause factors for Halitosis occurrence and it may be simply halitosis classified their origins into three categories; oral causes, Family group Compound name non-oral causes, and the other causes. Volatile sulfur compounds (VSCs) Hydrogen sulfide Methyl mercaptan Dimethyl sulfide Halitosis originates from oral cavity Volatile aromatic compounds and amines Indole Although halitosis has multifactorial origins, the source Skatole of 90% cases is oral cavity. In oral cavity, temperatures Pyridine Picoline may be reached up to 37°C (and changed between 34 and Urea 37°C). During exhaling also humidity may be reached Ammonia up to 96% (and changed between 91% and 96%) in oral Methylamine exhalations. These conditions may provide a suitable Dimethylamine Trimethylamine environment for bacterial growth. The number of bacterial Putrescine species, which are found in oral cavity, are over 500, and Cadaverine most of them are capable to produce odorous compounds Short/medium-chain fatty acids or organic Propionic acid acids Butyric acid which can cause halitosis. In these conditions, poor oral Acetic acid hygiene plays a key factor for multiplication of halitosis Valeric acid causative bacteria and causes an increase in halitosis. Isovaleric acid Esanoic acid These bacteria include especially Gr-negative species and Alcohols Methanol proteolytic obligate anaerobes [Table 4],[24-27] and they Ethanol mainly retained in tongue coating and periodontal pockets. Propanol Volatile aliphatic compounds Cyclopropane [5,28] Among healthy individuals, with no history of halitosis Cyclobutane and no periodontal diseases, some show halitosis because Pentane of retention of bacteria on the tongue surface. These Aldehydes and ketones Acetaldehyde bacteria degrade organic substrates (such as glucose, Acetone mucins, peptides, and proteins present in saliva, crevicular Benzophenone fluid, oral soft tissues, and retained debris) and produce Acetophenone odorous compounds.[5,30,31] Table 2: Enzymatic way of the hydrogen sulfide and methyl mercaptan Proteinogenic amino acids Enzyme Products L-Cysteine L-cysteinedesulfhydrase Pyruvate + ammonia + hydrogen sulfide L-Methionine L-methionine α-deamino-γ-mercaptomethane-lyase α-Ketobutyrate + ammonia + methyl mercaptan Table 3: Bacteria which is active producers of volatile sulfur compounds in vitro (adapted from Persson et al.) Hydrogen sulfide from cysteine Methyl mercaptan from Hydrogen sulfide from Methyl mercaptan from methionine serum serum Peptosteptococcus anaerobius Fusobacterium nucleatum Prevotella intermedia Treponema denticola Microsprevotii Eubacteriumlimosum Fusobacterium periodonticum Prevotella loescheii Porphyromonas gingivalis Bacteroides spp. Eubacterium spp. Porphyromonas gingivalis Porphyromonas endodontalis Centipedia periodontii Bacteroides spp. Treponema denticola Selenomonas artermidis 15 Journal of Natural Science, Biology and Medicine | January 2013 | Vol 4 | Issue 1 [Downloaded free from http://www.jnsbm.org on Monday, July 5, 2021, IP: 195.194.4.65] Aylıkcı and Çolak: Halitosis: From diagnosis to management Table 4: Bacteria which contribute halitosis and periodontal diseases like gingivitis and periodontitis. Gram-positive organisms The inflammation of gingival and periodontal tissues creates All Actinomyces spp. typical sources for oral malodors [32,33] and plaque-related A. israelii periodontal disease can increase the severity of halitosis. A. odontolyticus However, the other forms of periodontal disease, especially A. radingae A. turicensis acute and aggressive forms such as acute necrotizing ulcerative Actinomyces sp. (not identified) gingivitis, pericoronitis, Vincent’s disease or aggressive forms Bifidobacterium breve of periodontitis, can increase unpleasant breath odor. Collinsella aerofaciens All Eubacterium spp. The type of gingival enlargement which is dependent on E. lentum inflammation or drugs (such as phenytoin, cyclosporine E. saburreum or calcium channel blockers) may increase the risk of bad E. timidum odor. The severity of halitosis is affected from periodontal Eubacterium group (not identified) All Lactobacillus spp. conditions, also periodontal conditions are affected by L. oris halitosis. The previous studies showed a relationship between L. plantarum oral halitosis and periodontal disease. Periodontal diseases Lactobacillus sp. (not identified) may be developed by the volatile sulfur-containing compound Peptostreptococcus spp. P. anaerobius transition to periodontal tissues.[35-37] However, it is still not P. micros well understood what is the relationship between periodontal Propionibacterium avidum health and oral malodors.[38-40] Gram-negative organisms Bacteroidesureolyticus All Campylobacter spp. Besides periodontal conditions, untreated deep carious C. concisus lesions also create the retention area for food debris and C. gracilis dental bacterial plaque and may cause halitosis. Another C. mucosalis C. rectus important factor in halitosis is the flow of saliva. The intensity Bacteroides loescheii of sulfur compounds is increased because of salivary flow Centipeda periodontii reduction or xerostomia. Saliva functions as a buffering Dialister pneumosintes or a cleaning agent and keeps bacteria at a manageable level Eikenella corrodens Enterobacteriaceae in the mouth. Reduction of the salivary flow has negative Fusobacterium spp. effects on self-cleaning of the mouth and inadequate Fusobacterium nucleatum cleaning of the mouth causes halitosis.[43-47] Reduction of Fusobacterium nucleatum vincentii Salivary flow may be affected from many reasons such as Fusobacterium nucleatum nucleatum Fusobacterium nucleatum polymorphum medications (e.g., antidepressants, antipsychotics, diuretic, Fusobacterium periodonticum and antihypertensive), salivary gland diseases (e.g., diabetes, Leptotrichia buccalis Sjorgen’s syndrome), chemotherapy, or radiotherapy.[48-51] All Porphyromonas spp. P. catoniae P. endodontalis Other factors that contribute to halitosis are endodontic, P. gingivalis surgical, and pathologic factors such as exposed tooth All Prevotella spp. pulps and non-vital tooth with fistula draining into the P. buccae P. corporis mouth, oral cavity pathologies, oral cancer and ulcerations, P. dentalis extractions/healing wounds or prosthetics or dentition P. intermedia/nigrescens group factors such as orthodontic fixed appliances, keeping P. loescheii at night or not regularly cleaning dentures, restorative P. melaninogenica P. oris crowns which are not well adapted, noncleaning the P. pallens bridge body, and interdental food impaction. All these P. tannerae factors [Table 5] cause food or plaque retention area, Prevotella sp. (not identified) raising bacterial amount, tissue breakdown, putrefaction All Selenomonas spp. S. flueggei of amino acids, and decreasing of saliva flow. All these S. infelix conditions result in the release of volatile compounds Veillonella sp. and cause halitosis.[52-56] Treponema denticola Tannerella forsythensis Halitosis originates from non-oral sources Nearly 8% of the halitosis cases caused from an extraoral By the poor oral hygiene, food debris and dental bacterial source. This type halitosis has many sources, but it is rarely plaque accumulate on the teeth and tongue, and cause caries seen. Respiratory system problems, gastrointestinal disease, Journal of Natural Science, Biology and Medicine | January 2013 | Vol 4 | Issue 1 16 [Downloaded free from http://www.jnsbm.org on Monday, July 5, 2021, IP: 195.194.4.65] Aylıkcı and Çolak: Halitosis: From diagnosis to management Table 5: Reasons of halitosis which is originated Table 6: Non-oral cause of halitosis from oral cavity Non-oral cause of halitosis Oral cause of halitosis Respiratory disease Poor oral hygiene Foreign body (nose/lung) Food impaction Sinusitis Tongue coating Tonsillitis Periodontal pockets Tonsilloliths Acute necrotizing ulcerative gingivitis Malignancy (e.g., antral, pharyngeal) Gingivitis Bronchiectasis Adult and aggressive periodontitis Subphrenic abscess Pericoronitis Gastrointestinal and hepatic disease Vincent’s disease Pharyngeal pouch Drysocket Zenker diverticulum Xerostomia Pyloric stenosis or duodenal obstruction Oral ulceration Aorto-enteric anastomosis Oral malignancy Gastroesophageal reflux disease and Helicobacter pylori Exposed tooth pulps infection Nonvital tooth with fistula Hepatic failure (foetorhepaticus) Dentures/prostheses Hematological Leukemias Renal disease Table 7: Other causes of halitosis Renal failure (usually end-stage renal failure) Endocrine Other causes of halitosis Diabetic ketoacidosis Volatile food stuffs Menstruation (menstrual breath) Garlic Metabolic Onions Trimethylaminuria Spiced foods Hypermethioninemia Drugs Alcohol Tobacco excessive flatulence or Helicobacter pylori infection causes Betel Solvent abuse gastric ulcers [53,60] and VSC levels increase in oral breath. Chloral hydrate Levels of VCS’s in oral breath may be higher in patients Nitrites and nitrates with erosive than nonerosive oesophagogastro-duodenal Dimethyl sulfoxide mucosal disease although VSC levels are not influenced by Disulphiram Somecytotoxics the degree of mucosal damage.[27,61] Phenothiazines Amphetamines Also, hepatic or hematological diseases which are hepatic Suplatasttosilate failure (foetorhepaticus) and leukemia’s, renal failure Paraldehyde (usually end-stage renal failure), endocrine system disorders which are diabetic ketoacidosis or menstruation (menstrual hepatic disease, hematological or endocrine system disorders breath), metabolic disorder which are trimethylaminuria and metabolic conditions can all be the causes of halitosis. and hypermethioninemia may cause halitosis [Table 6]. Respiratory system problems can be divided into upper Other causes of halitosis and lower respiratory tract problems. They are sinusitis, Dietary products such as garlic, onions, spiced foods cause antral malignancy, cleft palate, foreign bodies in the nose transient unpleasant odor or halitosis. Therewithal drugs or lung, nasal malignancy, subphrenic abscess, nasal such as alcohol, tobacco, betel, solvent abuse, chloral sepsis, tonsilloliths, tonsillitis, pharyngeal malignancy, hydrate, nitrites and nitrates, dimethyl sulfoxide, disulphiram, lung infections, bronchitis, and bronchiectasis lung somecytotoxics, phenothiazines, amphetamines, suplatast malignancy.[45,57-59] Bacterial activity in this pathology causes tosilate, and paraldehyde may create the same effect [62,63] halitosis which leads to putrefaction of the tissues or [Table 7]. causes tissue necrosis and ulcerations and production of malodorous gases, which are expired causing halitosis. [53,55] ASSESSMENT OF HALITOSIS Gastrointestinal diseases cause halitosis. Pyloric stenosis, duodenal obstruction, aorto-enteric anastomosis, Halitosis affects a person’s daily life negatively, most of pharyngeal pouches, zenker’s diverticulum, hiatal hernia people who complain about halitosis refer to the clinic cause food retention. Reflux esophagitis, achalasia, for treatment but in some of the people who can suffer steatorrhea, or other malabsorption syndromes may cause from halitosis, there is no measurable halitosis. Assessment 17 Journal of Natural Science, Biology and Medicine | January 2013 | Vol 4 | Issue 1 [Downloaded free from http://www.jnsbm.org on Monday, July 5, 2021, IP: 195.194.4.65] Aylıkcı and Çolak: Halitosis: From diagnosis to management methods of halitosis ensure discrimination of pseudo- from saliva, tongue coating, or expired breath. In this halitosis and halitophobia. For these reasons, diagnosis of method, measurements are performed and equipped with a the halitosis, and assessment of its severity (conditions that flame photometric detector or by producing mass spectra. patients have, is it genuine halitosis or pseudo-halitosis or The concentration of each VSC (ng/10 mL mouth air) halitophobia) are very important. Therefore, the diagnostic was determined based on a standard of hydrogen sulfide way and tools were developed. Organoleptic measurement, and methyl mercaptan gas prepared with a permeater. gas chromatography, sulfide monitoring, the BANA test, and chemical sensors have most commonly used than the other In the gas chromatography method, the patient close the methods such as quantifying β-galactosidase activity, salivary mouth and hold air 30 s, then mouth air (10 mL) is aspirated incubation test, ammonia monitoring, or ninhydrin method. using a gas-tight syringe. After collections of samples, it is injected into the gas chromatograph column at 70°C. Organoleptic measurement The results are precise and reliable, but this method takes The oldest way for unpleasant odor detection is by smelling a long time to run. Moreover, it is expensive and not used with the nose. Measurement of unpleasant odors by commonly in chairside, and requires a skilled operator.[6,69,70] smelling the exhaled air of the mouth and nose is called Mostly, the results of the gas chromatography method organoleptic measurement. It is the simple way for the show high correlation to organoleptic measurements but detection of halitosis. gas chromatography has high sensitivity and it can detect low concentration molecules. Therefore, sometimes we The measurement method is the organoleptic test; the may see low correlation between gas chromatography and patient takes breathe deeply by inspiring the air by nostrils organoleptic measurements.[71,72] and holding awhile, then expiring by the mouth directly or via a pipette, while the examiner sniffs the odor at a distance Sulfide monitoring of 20 cm (the purpose of using a pipette is to lessen Gas chromatography has high accuracy and sensitivity, the intensity of expiring air) and the severity of odor is but the application method in chairside is difficult and classified into various scales, such as a 0- to 5-point scale (0: expensive. In order to avoid these disadvantages, a new no odor, 1: barely noticeable, 2: slight but clearly noticeable, portable device which is a sulfide monitor was developed 3: moderate, 4: strong, and 5: extremely strong)[45,64,65] or to measure VSCs. more widely point scale from 0 to10 point. In this method before taking measurement, patients should This measurement is considered to be the gold standard for close the mouth and refrain from talking food for 5 min measuring and assessing bad breath because of no-cost, prior to measurement, then a disposable tube of the sulfide and being practical and simple. However, it has some monitor is inserted into patient’s mouth to collect mouth difficulties. It may be difficult to calibrate the practitioner air. Meanwhile, the patient is breathing through the nose and to gain the correct result; in clinical practice, the patient and the disposable tube is connected to the monitor. should avoid from eating odiferous foods for 48 h before Sulfur-containing compounds in the breath can generate the assessment and that both the patient and the examiner an electro-chemical reaction. This reaction related directly should refrain from drinking coffee, tea or juice, smoking with levels of volatile sulfur-containing compounds.[73-75] and using scented cosmetics before the assessment. Also the other problem is the way of measurement, it The sensitivity and specificity of the sulfide monitor is is unlikeable situations for the examiner because of less than the gas chromatography but correlations of smelling unpleasant odor and inconvenient conditions measurements are highly significant. On the other hand, for the patient. To lessen unpleasant situations instead the sulfide monitor and organoleptic measurements show of expiring air to examiners, the patient can breathe the low correlation because of volatile compounds such as air inside the bag a while, then the examiner sniff this alcohols, phenyl compounds, alkenes, ketones, polyamines. odor from the bag and classify its severity. By this way the Short-chain fatty acids can be detected by organoleptic unpleasant side of organoleptic measurement becomes a measurements, but cannot be detected by the sulfide more acceptable one. monitor so the correlations between measurements may be inconsistent.[13,74,76-79] Gas chromatography Measurement with the gas chromatography method Chemical sensors is considered to be highly objective, reproducible, and Because of difficulties of gas chromatography and less reliable. Using gas chromatography we can measure sensitivity of sulfide monitors, a more sensitive and easy VSCs. It separates and analyzes compounds that can be device was made. Chemical sensors have an integrated vaporized without decomposition; samples are collected probe to measure sulfur compounds from periodontal Journal of Natural Science, Biology and Medicine | January 2013 | Vol 4 | Issue 1 18 [Downloaded free from http://www.jnsbm.org on Monday, July 5, 2021, IP: 195.194.4.65] Aylıkcı and Çolak: Halitosis: From diagnosis to management pockets and on the tongue surface. The working principle and of ELISA the 9% rate of false-positive results was of chemical sensors is similar to sulfide monitors. Through found.[93,94] The BANA test results reflect periodontal the sulfide-sensing probe, sulfide compounds generate an disease activity which may cause halitosis by bleeding electrochemical voltage and this voltage is measured by gums. an electronic unit. The measurement is shown on device’s screen as a digital score.[35,80,81] Quantifying β-galactosidase activity Deglycosylation is the removed link of glycosyl groups Using the new chemical sensors, ammonia and methyl from glycoproteins. Deglycosylation of glycoproteins mercaptan compounds can be measured from breath air are the initial step in oral malodor production. By and some new types of sensors measure each volatile deglycosylation of glycoproteins, proteolytic bacteria sulfur-containing compounds separately. The sensitivity is degrade proteins which are especially salivary glycoproteins similar to gas chromatography and results of the measures and cause halitosis. Proteolysis of glycoprotein depends on are highly close to organoleptic scores so chemical sensors the initial removal of the carbohydrate side-chains which are called the electronic nose.[74,82-85] are O- and N-linked carbohydrates. β-Galactosidase is one of the important enzymes which are responsible for BANA test the removal of both O- and N-linked carbohydrate side- The BANA test is practical for chair-side usage. It is a chains.[96,97] test strip which composed of benzoyl-DL-arginine-a- naphthylamide and detects short-chain fatty acids and β-Galactosidase activity can be easily determined by proteolytic obligate gram-negative anaerobes, which the use of chromogenic substrates absorbed onto a hydrolyze the synthetic trypsin substrate and cause halitosis. chromatography paper disc.[74,95,98] In order to measure It detects especially Treponema denticola, P. gingivalis, and T. β-galactosidase activity, saliva was taken in a paper disc forsythensis that associated with periodontal disease. By using and discoloring of the paper disc changes based on the BANA test, we can detect not only halitosis, but also β-galactosidase activity and these changes are recorded; periodontal risk assessment.[13,64,86-88] no color: 0, faint blue color: 1, moderate to dark blue color: 2. Sterer et al. found a positive correlation between To detect halitosis, the tongue is wiped with a cotton swab. organoleptic scores and β-galactosidase. For periodontal risk assessment, the subgingival plaque is obtained with a curette. To evaluate, the samples are placed Salivary incubation test on the BANA test strip, which is then inserted into a slot on The salivary incubation is one of the assessment methods a small toaster-sized incubator. The incubator automatically to measure halitosis indirectly. First time, Marc Quirynen heats the sample to 55° for 5 min. If T. denticola, P. gingivalis, et al. carried out a study to evaluate salivary incubation and or B. forsythus are present, the test strip turns blue or the bluer. halitosis. To measure halitosis with the salivary incubation Deepening of the blue color shows existence of the higher test, saliva was collected in a glass tube and then incubating the concentration and the greater the number of organisms. the tube at 37°C in an anaerobic chamber under an The close relationships are found between the BANA atmosphere of 80% nitrogen, 10% carbon dioxide, and test and organoleptic measurements, but the relationship 10% hydrogen for 3-6 h. After incubation, an examiner between the BANA test and sulfur monitor measurements evaluates the odor. Although this method has some are poor. Performing multiple-regression analysis with similarities with the organoleptic measurements, it has some organoleptic measurements and the BANA score as the advantages over them. The most important advantage is dependent variable, both peak VSC levels and BANA that the salivary incubation test has much less influenced by scores factored into the regression, yielding highly external parameters such as smoking, drinking coffee, eating significant associations.[88,89] This result may be caused by garlic, onion, spicy food, and scented cosmetics. However BANA-positive microorganisms which contribute halitosis in organoleptic measurements, external parameters have via non-sulfur odorants, such as cadaverine. negative effects on the result so the patient and examiner should avoid some odiferous food and drink before 48 h. The BANA test results demonstrate a significant positive The other advantages are unpleasant conditions of these correlation with the increasing pocket depth. [90-92] measurements compared to organoleptic methods. The Periodontal conditions can be assessed by this way, but results of the salivary incubation test are shown a strong periodontal conditions can be changed by BANA-negative correlation with the organoleptic measurement. If the microorganisms or the percentage of BANA-positive hardness of the incubation process does not be counted, microorganisms may be below the detection limit of the the salivary incubation test could be one of the valuable BANA test. Comparing the sensitivity of the BANA test tests for halitosis measurements. 19 Journal of Natural Science, Biology and Medicine | January 2013 | Vol 4 | Issue 1 [Downloaded free from http://www.jnsbm.org on Monday, July 5, 2021, IP: 195.194.4.65] Aylıkcı and Çolak: Halitosis: From diagnosis to management Ammonia monitoring Impact of daily life Besides VSCs, ammonia is another important factor in People interact with each other every day, and halitosis has halitosis. Sulfur compounds can be detected by a portable a negative effect on a person’s social life. The person who sulfide monitor, but unfortunately ammonia cannot be has halitosis may not be aware of this situation because measured using this method. Ammonia is the major basic this person may have developed tolerance or olfactory gas in a variety of important sample matrixes, for example, disturbance. Due to this cause, the patient generally cannot the ambient atmosphere, indoor air, and human breath. identify his/her halitosis and it is identified by his/her Comparatively, breath contains high levels of ammonia; it partner, family member, or friends. This condition causes is 1 ppmv in the breath of a healthy individual or may be a distressing effect on persons who have halitosis and so higher in individuals with renal failure. the affected person may avoid socializing. To perform measuring halitosis, a newly portable monitor Self-care products has been developed. This monitor detects ammonia quantity Halitosis interferes with normal social interactions. For these which is producing by oral bacteria. At least 2 h before reasons, self-care products are used by halitosis patients for measurements, the patients should refrain from eating and preventing unpleasant odor. However, by these products drinking activity. Then patients use special mouth rinse for direct treatment of halitosis is not possible; these products 30 s and close the mouth for 5 min. This rinse include urea such as chewing gum and mints, toothpastes, mouth rinses, solution and the bacteria produce ammonia from urea. To and sprays decrease the odor and attempt to mask halitosis measure the concentration of ammonia a disposable mouth with pleasant fragrances. The use of chewing gum may piece which is part of the device is placed inside a patient’s decrease halitosis, especially through increasing the salivary mouth. This disposable part connected to an ammonia gas secretion. Mouth rinses containing chlorine dioxide and detector which contained a pump that drew 50 mL of air zinc salts have a substantial effect on masking halitosis, not through an tube and the concentration of ammonia is noted allowing the volatilization of the unpleasant odor.[103,104] directly from the scale on the detector tube. Especially dietary caused halitosis such as onion, garlic, or cigarette can be masked by these approaches. These There is no correlation between the organoleptic score and approaches should be only used as a temporarily solution the ammonia level measured with ammonia monitoring, to relieve and improve the satisfaction of the patient. but measurements of the ammonia level with ammonia Professional treatment of real halitosis has crucial severity. monitoring show significant correlation with the total level of VSCs measured with gas chromatography. Professional treatment Halitosis can be treated if its etiology can be detected Ninhydrin method properly. Therefore, the most important issue for treatment Gases which are components of halitosis were produced of halitosis is detecting of etiology or determining of its from the breakdown of peptides and glycopeptides source by detailed clinical examination. Although most by bacterial putrefaction in the oral cavity. During this of the cases are caused from oral cavity, sometimes other process, peptides are hydrolyzed to amino acids which etiologies can contribute oral halitosis. If it is not detected further are metabolized to amines or polyamines. These of the etiology accurately, the treatment can be unsuccessful molecules cannot measured by sulfide monitoring. Hence, therefore investigation and adequate diagnosis are crucial. the ninhydrin method was used for examination of amino acids and low-molecular-weight amines. In the event of oral cavity caused by halitosis, reduction of the bacterial load is essential. Appropriate periodontal Levels of low-molecular-weight amines may give management is the first step. Necrotizing ulcerative information for halitosis caused from bacterial putrefaction gingivitis, gingivitis, adult and aggressive periodontitis of low-molecular-weight amines. The ninhydrin method is or periodontal pockets can increase the bacterial load so simple, rapid, and inexpensive. This method is a kind of periodontal health has significant importance in controlling colorimetric reaction. The collected saliva is mixed with the amount of halitosis caused by bacteria. Initial isopropanol and centrifuged. The supernatant was diluted periodontal treatment includes scaling and root planning with isopropanol, buffer solution (pH 5), and ninhydrin which may alleviate the depth of the periodontal pockets reagent. The mixture was refluxed in a water bath for and severity of gingival inflammation and it eliminates 30 min, cooled to 21 8°C, and diluted with isopropanol. halitosis causing bacteria. During periodontal therapy, Light absorbance readings were determined using a usage of antiseptic mouth wash relieves reduction of the spectrometer. The results of ninhydrin methods show a bacterial load. Chlorhexidine can be used as a valuable significant correlation with organoleptic scores and sulfide antiseptic agent, but long-term uses of chlorhexidine can monitor measurements. cause staining of teeth and mucosal surfaces.[107,108] Journal of Natural Science, Biology and Medicine | January 2013 | Vol 4 | Issue 1 20 [Downloaded free from http://www.jnsbm.org on Monday, July 5, 2021, IP: 195.194.4.65] Aylıkcı and Çolak: Halitosis: From diagnosis to management Good oral hygiene instruction is another important issue management of real halitosis. Halitophobia persons avoid for oral caused halitosis. Proper brush, dental floss, and socializing and even avoiding talking with people; therefore, inter-dental brush usage are very important. However, treatment of halitophobia is very important. Prior to sometimes even if the periodontal health is perfect, tongue treating people who have halitophobia, it must be proven coating can be an important source of halitosis. The tongue that he/she has no measurable halitosis by measuring dorsum can be a shelter for these bacteria. If a patient has devices. If persons are obsessed with the idea of having bad geographic or fissure tongue, the coating will be more. Due breath, consultation with a hyua psychologist is required. to these reasons, cleaning of tongue dorsum by brushing, tongue scraper or tongue cleaner is important. One of the studies showed the importance of tongue cleaning; REFERENCES reduction of VSC levels was found with the toothbrush 1. Hine KH. Halitosis. 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