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Bad breath causes, diagnosis and treatment methods

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Bad breath; It is a serious problem that affects almost a large part of society. It is not a life-threatening condition. However, it causes social and psychological problems and harms interpersonal communication. Halitosis is mainly associated with oral factors. The fact that adolescents are in a critical period in terms of psychological development and that the source of this problem affects the nutritional factor necessary for growth and development reveals the seriousness of the issue. It is a social duty for dentists serving the society to have sufficient knowledge about bad breath in order to raise healthy generations.
It can be analyzed in two parts.
1- Mouth odors originating from the mouth
2- Mouth odors originating from the mouth
1 A ğ inline welded a ğ trace smell:
Halitosis originating from the oral cavity is defined as halitosis originating from the mouth. The factors contributing to this situation are:
a) Plugins on the language surface
b) Factors related to saliva
c) Condition of periodontal tissues and diseases
d) Oral carcinoma and cancers
e) Existing caries on teeth
f) Poor oral hygiene
g) Impaired restorations and prostheses
In clinical studies, most of the individuals complaining of bad breath have found that the problem is from the inside of the mouth.
It has been found to originate.
Plugins on the language surface : It is one of the most common causes of oral odour. The dorsal surface of the tongue is a favorable site for the growth of proteolytic, anaerobic bacteria responsible for halitosis. The papillae on the back of the tongue create an ecological area by creating a large surface area that facilitates the accumulation of oral bacteria. Proteolytic, located between the tongue papillae, anaerobic bacteria even volatile sulfur s Create your own (VSB) s is sitting. most frequent snow s Ila s advert VSB; hydrogen sulfide, methylmercaptan and dimethylsulfiteThese compounds are bad-smelling volatile gases produced by bacteria as a result of putrefaction. A ğ of trace smell (false a ğ it smelled like s in) source ğ i, usually this is VSB . Apart from these, by layers of saliva or tongue; sulfur compounds (H2S, CH3SH), short chain fatty acids (propionic, butyric, valeric), polyamines (cadaverine putrescine), alcohols (1-propoxy-2-propanol), phenyl compounds (indole, skatole, pyridine), alkanines(2 -methy-propane), ketones, nitrogen-containing compounds (urea, ammonia) such as volatile organic compounds are produced. It has been reported that the layer in the tongue plays the most important role in VSB production, followed by the periodontal condition. With this; It has been determined that yasDMFT (rotten, missing, filled tooth), smoking, socioeconomic status, oral hygiene and other social factors do not contribute to the incidence of halitosis. At the highest average VSB ğ between 10:00-12:00 and the lowest s at low average VSB ğ and it was between 13:00-15:00. ğ is u highlighted s Truck.
It has been reported that fissural tongue, the most common developmental defect of the tongue, with a prevalence of 5-11% in studies, also causes halitosis.
Factors related to saliva: Saliva is an important element in the formation of bad breath.
a-spitğ fame inğ I:It contains sulfur, which is in the structure of some amino acids and used in the formation of VSB.
b-Saliva flux s speed:Decreased salivary flow rate and stagnation can lead to bacterial exchange and oral
It has been shown that it contributes to the formation of odor.
c- Saliva pH: Slightly alkaline saliva has been found to produce the typical odor, while slightly acid saliva has been found to have the opposite effect. An acid pH prevents the formation of odorous metabolic end products through the inactivation of enzymes necessary for the putrefaction of amino acids, and while the pH is acidic, a few amino acids act in the basic direction. Oral activities reduce the number of VSB-producing bacteria in the mouth by stimulating saliva flow. VSB values ​​decrease significantly after oral activities such as eating and drinking, as food provides a decrease in oral pH, which has been defined as a factor preventing the production of halitosis.
d- Oxygen consumption in saliva/plaque: It has been reported that oxygen consumption plays a complex but important role in halitosis formation. In the studies, it was found that the VSB level, salivary flow rate and pH are lower in individuals with Down syndrome, and accordingly, bad breath is less intense.
Condition of periodontal tissues and diseases :
It has been shown that many periodontal pathogenic bacteria can produce VSB, and even members of the normal flora produce VSB. It has been determined that during periodontal disease, bacterial colonization in the periodontal pocket increases further and has an important role in the formation of VSB. A positive correlation was found between increased VSB level and bleeding index. Porphyromonas gingivalisIt has been emphasized that hemoglobin is required for the growth of blood, and blood decomposition products reveal sulfur-containing peptides and amino acids, which are sources of VSB. Tannerella forsythia, P. gingivalisand Prevotella intermedia showed that periodontal pathogenic bacteria such as In periodontally healthy or edentulous individuals, halitosis can occur due to the destruction of the proteins on the tongue surface, tonsils and saliva, and sulfur-containing organic compounds. In many people with a healthy oral condition; Halitosis can occur with the transfer of sulfur and protein-rich secretions from the postnasal drip into the exhaled air.
Ağ with the smell of traces clay microflora:
More than 300 types of bacteria that cause bad breath have been isolated from the mouth. Fusobacterium Veillonella, T. denticola, P. gingivalis Bacteroidesand Peptostreptococcus Putrefaction occurs under anaerobic conditions by bacteria such as bacteria. Studies have shown that almost all odor production is the result of gram-negative bacterial metabolism, and that gram-positive bacteria contribute very little to it. Fusobacterium nucleatum is an important microorganism in gingivitis and periodontitis and produces high levels of VSB. Necessary nutrients for bacteria; oral fluids, tissues and food debris. Methionine, a sulfurous amino acid, is reduced to methylmercaptan and cysteine. Cysteine ​​is degraded to cystine and, to a greater extent, to hydrogen sulfide in the presence of sulfidase-positive microorganisms. This activity; It is supported at pH 7.2 and suppressed at pH 6.5. In-vitroisolated as klebsiellaand Enterobacter ‘of; In dental prostheses, it has been stated that it emits an odor similar to the malodor produced by the production of VSB and cadaverine. It has been reported that in patients with periodontal infection, the VSB and methylmercaptan/hydrogen sulfide ratio in the oral air is 8 times higher than the individuals in the control group. Bacteria that cause bad breath naturally colonize the mouth. The possibility of transmission of these bacteria from pets to humans is a topic of interest. In a study aimed at determining the possible correlation between bad breath and regular contact between pets and dental patients, it was found that pets (dogs, cats) in childhood or current ownership can transmit bacteria that cause bad breath.
2 Ağ out of sights I Sourced Ağ Trace Scent:
Fragrances originate from within the body and are transferred to the lungs through the circulatory system. If it is sufficiently volatile, it comes out with the exhaled air and a bad odor occurs in the breath. Systemic disorders and conditions that cause bad breath of extra-oral origin; nasal, sinus, bronchial and lung infections (rotten odor), gastrointestinal diseases, diabetes mellitus, liver failure, kidney failure (fishy odor), metabolism disorders (trimethylaminuria uremia), consumption of foods such as garlic, onions and alcohol, and smoking. Hunger and wrong diet can initiate the dissolution of fat and protein in the body, and the resulting by-products can cause bad breath. A certain part of the cases of halitosis originating from extra-oral origin fall into the category of ‘blood origin halitosis’. Aliphatic tertiary amine; Trimethylamine is a volatile compound found in excess in patients with a metabolic disorder known as trimethylaminuria (fish-odour syndrome). Helicobacter pylori is a curved microaerophile gram-negative bacterium that has been considered a risk factor for gastric cancer. In the study, pyloriwith tongue burning hyperplasia and a ğ a city among the scent of traces s which happened ğ u specified s , oral-oral transmission s should not be forgotten ğ Is i highlighted? s Truck.
It has been reported that hormonal changes occurring during ovulation, menstruation, pregnancy and menopause cause bad breath. Oral airborne VSB has been found to be elevated in women during and around the mid-cycle of menstruation, as well as during the mid-proliferative and mid-luteal phases.
A Bad breath Classification:
one)real bad breath
a) Physiological halitosis
b) Pathological halitosis (Type-1, Type-2, Type-3 pathological halitosis)
2)fake mouth odor
1) Real Ağ trace odor
It is a clearly noticeable severe halitosis condition.
a) Physiological Ağ trace odor
It is a severe bad breath caused by bacteria in the mouth. VSB formed by bacteria that reproduce on the back of the tongue and gases accumulated in the digestive tract are the cause of bad breath in the morning hours. There is no systemic disease that may cause bad breath. Volatile aromatic compounds that pass into the blood after feeding are expelled with expiratory air.
and physiological halitosis. Measurements are between physiological limits.
b) Pathological Ağ trace odor
It is caused by intraoral and extraoral causes. Pathological halitosis is divided into 3 groups.
Type-1 pathological ağ trace smell: Halitosis is detected by the patient and the smell is generally accepted. An application to the dentist is made with a complaint other than bad breath. The treatment starts with the warning of the dentist.
Type-2 pathological ağ trace smell: The odor is detected by the patient’s relatives
Type-3 pathological ağ trace smell : The patient or his relatives have a suspicion of bad breath. From time to time, there are vague complaints.
2) Liar Ağ trace odor
Although the patient complains of bad breath, there is no real smell and it is not noticed by others.
3) Halitophobia
It occurs as a result of patients with bad breath problem believing that they still have bad breath after treatment. Some of the patients have a fear of smell, not smell.
A ğ Trace Smell Detection Methods
There are various methods of detecting bad breath:
one)Patient complaints
2)Spouse and friend feedback
3)groin test
4)At-home microbial tests
5)Microbial and fungal tests
6)Saliva incubation test
7)artificial nose
8)Organoleptic method (smell test
9)Measurement of volatile sulfur compounds [Gas chromatography Sulfite monitors ( Halimeter device)]
10)ME(N-benzoyl-DL-arginine-naphthylamide) test
11th)Ninhydrin method
12)olfactory agents
There is no equipment that can measure all the elements that cause bad breath.
Patient Complaints
Acknowledgment of bad breath often begins with the complaints of a person who believes or is told that they have bad breath. But surprisingly; Halitosis is not detected in 40-60% of individuals who apply to clinics and complain of bad breath. Therefore; the patient’s complaint of halitosis is the least reliable measure that can be used to document halitosis
kas Light Test
Scraping of the back of the tongue; Nasal odor and oral odor are distinguished by asking the individual to close their mouth and exhale through their nose.
Saliva I Incubation Test
Saliva incubation is an indirect way to score malodor. Due to its simplicity, it is useful as an alternative to direct organoleptic measurements in longitudinal studies.
Artificial (electronic) Nose
It is a handmade device developed to quickly classify unidentified gaseous chemicals. This device originates from sensor technology that can smell and generate unique profiles for different odors. states that this device can be used as a diagnostic tool to detect odors. This technology; It is expected to be inexpensive, small and adaptable to practically any odor detection method. If the electronic nose is to be an assessment technology that will revolutionize the field of smell in a measurable and reproducible way.
Organoleptic Method
Despite its lack of objectivity, the organoleptic score is the gold standard in the assessment of halitosis. Organoleptic scoring is considered to be less reliable due to limitations such as being affected by environmental conditions (measurer, temperature, time) and is rarely used in epidemiological studies. Before evaluating the organoleptic score of the individual; coffee,
Drinking tea, fruit juice, smoking and using scented cosmetics should be avoided. However, the main problem with organoleptic scoring is the problem for the examiner and the individual being studied.
It is an uncomfortable procedure.
Even Volatile Sulfurs Measurement of the two:
a) Gas chromatography
It is applied with the help of a photometric detector, which allows to distinguish individual gases and detect sulfur in the mouth. The necessary equipment can be used by qualified personnel and it takes time to analyze the results. As a result; gas chromatography cannot be used in dentistry and halitosis examinations.
b) Sulfite monitors
ta s descending sulphitemeter (Halimeter ® , Interscan Corp., Chatsworth, US&Canada ), in the last few years a ğ common in detecting trace odor s used in cultivation. 10 It is an electrochemical, voltmetric sensor; snow with sulfide and mercaptan gases s Ila s ti ğ It gives a signal and measures the hydrogen sulfide concentration. No specialized personnel are required for the application. Perfume, hairspray, deodorant di ğ against fragrant products s Disadvantages of the device are its sensitivity and the need for periodic recalibration.
Test me
It is not a surprising observation that volatile sulfur compound monitors detect 18-67% of odors as measured by the organoleptic score. Because the nose smells; due to volatile fatty acids (butyrate propionate, etc.), diamines (cadaverine putrescine) and other malodorous products of bacterial metabolism. Often these compounds can only be measured by laboratory-based experiments; For this reason, they cannot be detected in the patient chair. In the studies carried out, the BANA test; It was found to correlate significantly with organoleptic scores and cadaverine levels from whole mouth, tongue, and saliva, but not with volatile sulfur compounds.
Ninhydrin Method
The ninhydrin colorimetric reaction is a simple, fast and inexpensive method that can be used to study amino acids and low molecular weight amines by means of a conventional amine analyzer.
The ninhydrin method for detecting salivary amines can be an alternative or additional method for diagnosing halitosis; It can also be used to evaluate treatment efficacy.
A ğ trace odor; gram-negative bacteria, ba s high energy source ğ on protein amino acids with s It is a result of excessive activity. Therefore, even volatile sulfur s (VSB) and lower s low molecular a ğ There was a statistical correlation between the concentrations of various amines ğ u du s is famous.
There are no standard and accepted protocols for the treatment of bad breath. However, possible protocols; It includes the basic elements covering standard dental and periodontal treatment and focuses on the treatment of halitosis. If the patient does not respond, the diagnostic phase should be restarted.
Objective measurement of VSB using an instrument is an essential part of diagnosis. The treatment algorithm for halitosis is a step-by-step problem-solving procedure and should be done according to the case. It is possible to mask the existing odor with various products for a while.
The main treatment s It should be gathered around three headings:
1- To eliminate bacterial colonization on the back of the tongue
2-Blocking the existing VSB,
3- e the patient ğ push.
The treatment of patients with halitosis should be done according to the classification mentioned above.
Physiological Ağ Trace Smell Treatment
The first thing to do is to identify the source of the bad smell. Followed by; diet should be regulated, oral hygiene education should be given and tongue cleaning should be emphasized. Patients should be reminded that the back of the tongue is the least accessible but usually the most smelly area. Specially produced tongue brushes or tongue combs are available for tongue cleaning. A hard toothbrush may also be sufficient and economical for this process. It has been reported that the concentration of hydrogen sulfide and methyl mercaptan in the mouth air decreases by 25-75% after cleaning the teeth and tongue. The biggest problem that occurs during tongue brushing is the nausea and vomiting reflex. To prevent or alleviate this situation; Brushing should not be done in front of a mirror, short, small brushing should be done to develop vagal tolerance and the tongue should be brushed at short intervals during exhalation. If patients still complain of bad breath after good oral hygiene is maintained, rinsing with an effective mouthwash may be recommended. Mouthwashes have become a common hygiene tool in patients suffering from oral halitosis. Antimicrobial agents in mouthwashes temporarily reduce the number of microorganisms in the oral cavity. Most commercial products claim to effectively eliminate bad breath. However, the use of alcohol-based strongly sweetened solutions only masks bad breath. Therefore, they often take on the role of providing temporary relief rather than a permanent cure. These mouthwash products can actually accelerate bad breath due to the drying effect caused by their high alcohol content.
Patients should be instructed to stop using any alcohol-containing mouthwash offered as part of a treatment plan to eliminate bad breath. VSB has strong affinity for metals and combines with metals to form non-volatile metal sulfides.
These newly formed compounds are no longer the cause of odor. For this reason, mouthwashes containing metal compounds can be used in the treatment of bad breath. It has been reported that mouthwashes containing zinc bind more VSB. Mouthwashes containing essential oil; It has been shown to effectively kill bacteria in difficult-to-reach interface areas. Although the effectiveness of chlorhexidine mouthwash has been confirmed, many patients do not comply with long-term use of chlorhexidine because of changes in taste sensations, burning sensation and tooth discoloration. Hydrogen peroxide mouthwashes reduce the concentration of salivary thiols. It has been stated that these agents may be beneficial in the management of halitosis due to acute necrotizing ulcerative gingivitis. Various products such as biphasic oil-water mouthwashes, zinc chloride mouthwashes, and cetylpyridinium chloride mouthwash can effectively reduce bad breath for several hours. However, the long-term effects need to be determined. The copolymer in the formula tricloxan/copolymer/sodium fluoride; It has been shown that the antibacterial agent tricloxan increases its distribution and adhesion to oral surfaces. The tricloxan concentration in the plaque biofilm s 12 hours after brushing was sufficient to inhibit the growth of bacteria. ğ u, hence the return of bad breath s your reputation is late ğ i reported s Truck . In another study, the use of toothpaste containing tricloxan; It has been found that it is effective in removing bad breath in the morning, during the day and during the night, and this effect is increased by tongue cleaning. Chewing gum has also been found to be effective in eliminating bacterial colonization on the back of the tongue. Chewing gum creates a cleansing effect on the back of the tongue by increasing the flow and serosity of the saliva. It removes accumulated VSB and partially inhibits bacterial colonization. Sodium bicarbonate gums convert volatile sulfur compounds into non-volatile compounds. Thus, it is deodorant. Sugar-free gums increase methyl mercaptan, a compound responsible for bad breath. Peppermint and peppermint gums do not have such an effect. salivariusIt has been reported that the replacement of K12-producing bacteriocin and the bacteria that cause bad breath can provide an alternative treatment for the long-term reduction of bad breath.
Pathological Ağ Trace Smell Treatment
When it comes to pathological halitosis due to intraoral reasons, first of all, oral hygiene education should be given, periodontal diseases should be treated, caries should be restored, and restorations and prostheses with impaired harmony should be eliminated. For patients with complicating factors such as fixed and/or removable dentures, or for elderly patients, more advanced hygiene methods should be used, including oral irrigation and a sonic or ultrasonic toothbrush. Individuals who use floss daily have been found to have significantly lower levels of odor than those who do not. Therefore, the female; It is a good motivational tool when the patient is provided to smell after each use. In the case of pathological halitosis due to extraoral causes (systemic diseases), the patient should be referred to a specialist doctor.
Liar Ağ Trace Smell Treatment
The patient is asked to fill out a questionnaire containing guiding questions, and the patient is motivated by making a correct diagnosis in the light of the answers. In addition, oral hygiene education should be given.
Halitophobia Treatment
Patients diagnosed with halitophobia should be referred to a psychiatrist.
Bad breath is a distressing condition that affects the majority of society regardless of age. Patients presenting with this problem expect an accurate diagnosis and effective treatment from the dentist. Therefore, the clinician should know the steps to be taken when encountering patients suffering from bad breath and should be knowledgeable about systemic diseases with halitosis symptoms. Priority steps should be fulfilled in individuals suffering from bad breath, and if the patient’s complaint persists, the diagnostic phase should be restarted. Patients whose halitosis problem cannot be resolved after all attempts should be directed to the relevant physician.

Best regards
Dr. Suhan SUNGUR