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Halitosis:it an offensive odor originated from oral cavity or air filled cavity

Oral malodor or bad breath can originate from physiologic or pathologic sources, and has been estimated to occur chronically in approximately half the population.
Odor-producing compounds are inspired into the lungs and then expired.
halitosis is derived from the Latin word "halitus," which means breath, and the Greek "osis " which means condition


This occurs when odors (from foods or tobacco) are ingested and inhaled or when pathologically produced odiferous compounds (intra oral or systemic) are introduced into the lungs.
Halitosis has been estimated to be from oral sources in (40 - 90) % of case;however, it can also arise from systemic diseases
cause

Transitory halitosis

Oral halitosis is a very common problem in dental patients, in fact, most adult subjects have socially unacceptable bad breath when waking up in the morning.
This problem is transitory and
attributed to physiologic causes such as reduced saliva flow during sleep.
Although these transitory problems are easily controlled, persistent bad breath may be indicative either of oral diseases (i.e. periodontal diseases the presence of
bacterial reservoirs in the mouth) or indicative of systemic diseases (i.e, hepatic cirrhosis or diabetes mellitus


when dealing with the problem of halitosis or with the halitosis patient: it is important to distinguish between "genuine halitosis" and "pseudo-halitosis. " Genuine halitosis" is where the breath malodor is a real problem that can be easily diagnosed either by organoleptic or by physic-chemical means.“Pseudo halitosis” is where the oral malodor dose not exist but the patient believes that he or she has it. if after successful treatment for either genuine halitosis or pseudo- halitosis the patient still believe that he or she has halitosis .then the diagnosis is termed “halitophobia”


physiologic halitosis also termed transient halitosis,, is self-limited, does not prevent the patient from carrying out a normal life, and usually does not need any therapy. This situation, also termed ( morning breath) is more a cosmetic problem than a health-related condition. happens when a patient eats certain aromatic foods such as herbs, spices,, onions, garlic

Classification of halitosis

Local:
Pathological.
Non pathological.
Systemic.
Pathological.
Non pathological.
Systemic drug administration.
Xerostomia.

Local(non pathoiogig)

(morning breath ) This occure Due to
Decrease salivary flow
decrease tongue movement
Lead to food stagnation

Denture:Poor maintenance & overnight use of dental prostheses can produce malodors as a result of poor oral hygiene or decrease night time salivary flow.
In children under 4 years. (fermentation of milk)
smoking : due to xerostomia and nicotin( substrate of mal odour).
food: spicy food,tea,coffe


Decay inside a tooth provides an anaerobic environment and is thus a great place to live if you are a sulfur metabolizing germ.

Local pathologic

Teeth condition: Although dental caries does not produce bad breath, it creates food traps as do overhanging, sub gingival and open restorations. Debris remaining in these areas decomposes and produces fetid odors


Gingival condition: the gingival sulcus are reservoirs for microbes that can produce VSCs. specifically gram-negative anaerobic bacteria (e.g., porphyromonas gingivitis. Prevotella intermedia , Fusobacterium nucleatum, and Treponema denticola


Several factors can result in a shift from gram-Positive to gram negative bacteria in the oral cavity:
diminished salivary flow, and inflammatory diseases (i.e., gingivitis, periodontitis, major aphthous stomatitis, and herpetic gingivostomatitis) P.A abscees,p.D disease,pericoronitis,cancer, R.c filling,pemphigus,pemphegoid,dentigerous cyst,E.multiform,healing trauma


Tongue:A fissured tongue provide' reservoirs for food, bacteria, and cellular debris, and stagnating saliva, conditions conducive to oral malodor .
Related structure: tonsillar crypts provide reservoirs for food bacteria &cellular debris & stagnating saliva, leading to malodor

Systemic pathological include:

. Respiratorv diseases:
are a common source of these odors. Infections involving gram-negative anaerobic bacteria (tuberculosis, pneumonia), obstructions (foreign bodies) tumors (lung cancer) and the production of pus (empyema. bronchiectasis) can all contribute to the emission of foul odors on the nasal cavity, sinuses, nasopharynx, pharynx, and lungs.
The postnasal drip associate with upper respiratory viral infections and allergic or infectious sinusitis-as a common source or halitosis.

4. gastrointestinal diseases:

Individuals with gastrointestinal diseases suffer from halitosis.
gastro esophageal reflux and pyloric stenosis.
This is generally controlled using H2 blockers like Tagamet, Zantac or Pepsid.
Pyloric Stenosis--This is a developmental condition found in infants which causes vomiting, and is corrected surgically permit the release of gastric odors into the oral cavity

Achalasia:

It is a swallowing disorder in which there is a failure of the contents of the esophagus to empty into the stomach; these patients experience halitosis when food debris and saliva are trapped and decay in the esophagus. Gastric ulceration, infection, carcinoma, and malabsorption can also contribute to oral malodors.

3- Systemic drug administration:

medication radiotherapy and chemotherapy can directly affect the oral cavity, resulting in halitosis. The most common medications associated with halitosis are those that inhibit salivary output Chronic use of inhaled corticosteroids alters the respiratory tract flora and leads to malodors.
Cancer treatments (chemotherapy, head and neck radiation) have transient 'T persistent effects on the salivary system, oropharyngeal tissues, and oral flora, resulting in oral malodors


4- XerostomiaIt is due to:Electrolyte imbalance, such as diabetus insipidus.Severely dehydrated pt.Pt with cardiac failure, or uremia.Sjogren’s syndrome.Senile atrophy of salivary gl.Radiation of the head & neck.Salivery gl. diseases, such as: obstruction, ectopic gl. or tumor.

Certain medication that cause xerostomia:

Anti- hypertensive drugs.
TCA depressant.
Diuretics.
Lithium.
Chemotherapy.
anticholinergics (often used as decongestants as well as surgical drying agents like atropine


Salivary hypo function diminishes the self cleansing action of the oral cavity, and lower levels overnight frequently result in "morning breath." When saliva evaporates, non sulfur-containing gases (e.g., cadaverine. putrescine, butyic. indole) can be released in addition to the VSCs. contributing to halitosis in the patient with salivary hypo function.

Systemic non pathological:

G.I.T:as garlic,onion,alochol
Alcohol produce drying oral mucosa,sloughing of the mucosa,and in prescence of bacteria lead to halitosis
Halitophobia :fear of halitosis will cause halitosis

Diagnosis of halitosis:

Organoleptic measurement:
A subjective test scored on the basis of the examiner's perception of a subject's oral malodor. Different semi quantitative scales has been used; however, at the most recent International Workshop on Oral Halitosis (1999).
there was consensus on using a scale ranging from 0 to 5. Before the organoleptic assessment, both patients and examiner must follow some instructions in order to obtain a more reliable result. Patients are instructed to abstain from eating strong foods at least 48 hours before the assessment and to avoid using scented cosmetics for 24 hours before the assessment.
Patients must abstain from ingesting any food or drink, omit their usual oral hygiene practices, abstain from using oral rinse and breath fresheners, and abstain from smoking for 12 hours before the assessment.
The oral malodor examiner is required to refrain from drinking coffee, tea, or juice and to refrain from smoking and using scented cosmetics before the assessment.

Organoleptic Scores

Organoleptic Scale (0-5).
0- no appreciable odor.
1- barely noticeable odor.
2- slight but noticeable odor.
3- moderate odor.
4- strong odor
5- extremely foul odor
2- Gas chromatographv (GC):
GC is considered the gold standard for measuring oral malodour since it is specific for VSCs, the main cause of oral maloclour.
The GC equipment is expensive, bulky, and' the procedure requires a skillful operator. Therefore, this technology has been. confined to research and not to clinical use.

3-Sulphide monitoring:

Sulphide monitors analyze for total sulphur content of the subject's mouth air. Although compact sulphide monitors are inexpensive and easy to use.

The most reliable and practical procedure for evaluating a patient's level of oral malodor is still thorough Organoleptic assessment by : trained clinician.
Nevertheless, the use of a portable sulphide monitor is of interest. since we can quantify the changes and the patients are able to monitor their evolution through therapy.
This is an important factor, especially in those patients with pseudohalitosis or halitophobia.

TREATMENT OF HALITOSIS

History from patient
Clinical examination
Identify and management of underlying cause
O.H.I
Tooth brushing,dental floss,tongue brush
Oxidizing agents (dioxide, peroxide), zinc chloride, and triclosan rinses, and prescription antimicrobial rinses

Aviod smoking and alcohol

If the source of the malodor is suspected to arise from oral disorders, such as defective dental restorations and prostheses, periodontal diseases, or candidacies, definitive treatment diminishes the number of oral microbes salivary hypofunction contributes to halitosis; sugarless candies mints, or gums, artificial saliva, and pilocarpine(5 mg tid) can increase salivary output and may improve malodor




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