Extra-oral Halitosis Research Articles

The portable gas chromatograph OralChroma™: a method of choice to detect oral and extra-oral halitosis

It is now generally accepted that the volatile sulfur compounds (VSCs) hydrogen sulfide, methyl mercaptan and dimethyl sulfide are the main contributors to halitosis when of oropharyngeal origin. Gas chromatography using a specific sulfur detector is the most appropriate method to detect halitosis of different origin (intra-oral and extra-oral halitosis) and should be considered as the gold standard. However, a gas chromatograph is an expensive apparatus and needs trained personnel. The less specific Halimeter is the most used apparatus in halitosis research. In this study a newly developed portable gas chromatograph, the OralChroma™ (Abilit Corporation, Japan), was evaluated for use in the field of halitosis. The results show that the OralChroma is a very sensitive apparatus for measuring VSCs. Just like standard gas chromatography, it can perfectly differentiate between intra-oral and extra-oral blood-borne halitosis, while the Halimeter can only detect intra-oral halitosis. The hardware of the OralChroma meets all the needs for becoming the apparatus of choice in the field of halitosis. However, the software needs a major revision. Sometimes, the concentrations given for the different VSCs are completely incorrect due to a wrong assignment of the place of the VSCs in the chromatogram.

Clinical evaluation of 222 Iranian patients with halitosis

The primary objectives of the study were to investigate the levels of volatile sulfur compounds (VSCs) in Iranian patients and to find the most prevalent class of halitosis among them. The secondary objective was to study the measures employed by the patients to reduce halitosis. 46.4% of the 222 patients were female (average 32.1 years) and 53.6% were male (average 32.1 years). Contrary to other reports, males were dominant in this study. All the subjects were evaluated through oral examination, gas chromatographic analysis, organoleptic assessment and mouth cleaning and rinsing test (MCART). Finally, each patient was classified according to current classification. The patients were also asked about the measures employed by them to reduce halitosis. The data were statistically analysed using SPSS software. Gas chromatographic analysis revealed that the median values for H2S, CH3SH and (CH3)2S levels were 214 ppb, 64 ppb and 2 ppb, respectively. Average values of H2S, CH3SH and (CH3)2S were 358.7 ppb, 143.0 ppb and 19.5 ppb, respectively. A correlation was demonstrated between organoleptic scores and the concentration of only H2S, CH3SH and the total of three gases. In 62.2% of the subjects, no oral pathologic condition was found, but tongue coating was observed. The patients were in only class I (genuine halitosis) and class II (pseudo-halitosis) halitosis. None of them was diagnosed as halitophobia. The percentages of classes I and II were 98.6% and 1.4%, respectively. The percentages of sub-classes of class I halitosis in total subjects were as follows: 60.8% physiologic halitosis, 37.8% oral pathologic halitosis and 0% extraoral pathologic halitosis. The mean value of organoleptic score for physiologic halitosis was 4.0 and those for oral pathologic halitosis and pseudo-halitosis were 4.3 and 1.6, respectively. MCART was a useful tool to distinguish oral halitosis from extraoral halitosis. Levels of VSCs were not as high as those measured in other countries. Although in most cases VSCs were a contributing factor to halitosis, VSCs levels were not useful diagnostic criteria for the minority of the patients. The most prevalent class and sub-class of halitosis in the patients were genuine halitosis and physiologic halitosis. Measures employed by the patients to reduce halitosis were mostly related to the oral cavity.

Appropriate sample bags and syringes for preserving breath samples in breath odor research: a technical note

It is now generally accepted that the volatile sulfur compounds (VSCs) hydrogen sulfide, methyl mercaptan and dimethyl sulfide are the main contributors to halitosis when of oropharyngeal origin. The VSCs hydrogen sulfide and methyl mercaptan are the major causes of bad breath in oral malodour whereas dimethyl sulfide is generally the major cause of bad breath in extra-oral halitosis. To facilitate research in the field of halitosis, it is highly advantageous to be able to preserve breath samples for longer periods of time before measurement of the VSCs, e.g. for sampling patients at home or when studying a large cohort of patients where an immediate measurement of the VSCs is not possible. After testing numerous sample bags, ultimately the foil balloons, coated inside with the synthetic polymer polyethylene, were the preferred ones. All the VSCs in breath remained quite stable for at least 3 days in these balloons. Besides the sampling bags, the use of an appropriate syringe for sampling mouth air and for injecting samples in e.g. a gas chromatograph is also of great importance. Usually, syringes with a rubber barrel seal are used. However, some rubbers quickly adsorb the VSCs in breath. When preserving breath samples for longer periods, the rubber also releases VSCs, especially methyl mercaptan. It was also found that these syringes release a compound which interferes with dimethyl sulfide, when using gas chromatographic measurements with the OralChroma. We now use all-plastic syringes (B/Braun Injekt), made of polypropylene and polyethylene, in which the VSCs in breath remain quite stable for at least 9 h.

Intra‐ and extra‐oral halitosis: finding of a new form of extra‐oral blood‐borne halitosis caused by dimethyl sulphide

The aim of this study was to unravel the origen and cause of intra-oral and extra-oral halitosis. We studied 58 patients complaining of halitosis, using gas chromatography of volatile sulphur compounds (VSCs) in mouth and nose breath, organoleptic scoring of mouth and nose breath, Halimeter readings of mouth air and tongue-coating inspection. Subjects had no precence or history of periodontitis. Of 58 patients, 47 patients had halitosis of oral origin, six had halitosis of extra-oral origin and five had no halitosis (halitophobia). A strong correlation was found between the degree of intra-oral halitosis as measured by organoleptic scoring of mouth breath and the concentration of the VSCs hydrogen sulphide (H(2)S) and methyl mercaptan (CH(3)SH) in mouth breath. Taking into account the much larger odour index of CH(3)SH, it was concluded that CH(3)SH is the main contributor to intra-oral halitosis. In all six cases of extra-oral halitosis, halitosis was caused by the presence of elevated levels of dimethyl sulphide (CH(3)SCH(3)) in mouth and nose breath. Our study provides evidence that the VSC, CH(3)SH and to a lesser extent H(2)S are the main contributors to intra-oral halitosis and that CH(3)SCH(3) is the main contributor to extra-oral or blood-borne halitosis, due to a hitherto unknown metabolic disorder.

Classification and examination of halitosis

In this paper, the classification of halitosis and the examination procedures used in diagnosing halitosis are outlined. Halitosis is classified into categories of genuine halitosis, pseudo-halitosis and halitophobia. Genuine halitosis is subclassified into physiologic halitosis and pathologic halitosis. Pathologic halitosis itself is subdivided into oral and extraoral halitosis. Patients diagnosed with pseudo-halitosis and halitophobia usually complain about having oral malodour that does not really exist. Pseudohalitosis can be treated by dental practitioners, but halitophobic patients must be referred to psychological specialists. Oral malodour can be measured using an organoleptic measurement or a gas chromatography analysis. The organoleptic measurement is the most practical procedure with which one can evaluate oral malodour. Gas chromatography (GC) analysis using a flame photometric detector has been shown to be the gold standard for measuring oral malodour, owing its reputation to its objectivity and reproducibility. Moreover, GC is specific for volatile sulphur compounds (VSC), which are the main causes of oral malodour. It has been demonstrated that there is a high correlation between the intensity of oral malodour and the VSC concentration as measured by GC.

Halitosis in medicine: A review

This review deals with the different forms of halitosis. Halitosis can be subdivided according to its original location. At present, halitosis of oral origin is quite well understood and some excellent reviews have already appeared in the literature. Special attention is given here to extra-oral halitosis. Extra-oral halitosis can be subdivided into: halitosis from the upper respiratory tract including the nose; halitosis from the lower respiratory tract; blood-borne halitosis. In blood-borne halitosis, malodourant compounds in the bloodstream are carried to the lungs where they volatilise and enter the breath. Potential sources of blood-borne halitosis are some systemic diseases, metabolic disorders, medication and certain foods. The methods of analysis of halitosis are critically reviewed. Attention is also given to odour characterisation of various odourants.

Halitosis: a serious social problem

Halitosis means an unpleasant odor of the expired air, regardless of the source of this odor. The foul breath originating from the oral cavity itself is termed as oral malodor and it is usually the main contributor of unpleasant breath in an otherwise healthy individual. The most predominant causes of halitosis are gingivitis, periodontitis, and tongue coating. However, several non-oral pathologic conditions have also been related to halitosis, including infection of the upper and lower respiratory tracts, the gastrointestinal tract, and some metabolic diseases involving the kidneys and the liver, which should never be overlooked. Though this complaint of bad breath has existed from time immemorial, it has only recently come to scientific platforms of analysis and is being increasingly recognized as a social stigma in an ever-growing sensitive society. Breath malodor has important socio-economic consequences. Literature reveals almost $1 billion a year is spent in the United States on deodorant-type mouth rinses and mints which provide only short-term masking effects, instead of spending the money on a proper diagnosis and etiologic care to manage bad breath. Sulfur containing volatiles are the main constituent of oral malodor and that their levels correlate with the intensity as determined organoleptically. The treatment of intraoral halitosis consists of scaling/root planing and daily removal of tongue coating, and for extraoral halitosis, treatment of underlying systemic disease by a specialist. Keywords: halitosis; bad breath; oral malodour DOI: http://dx.doi.org/10.3126/hren.v9i2.4983 Health Renaissance 2011: Vol.9 (No.2): 106-111