Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
    Users Online: 194
Home Print this page Email this page Small font size Default font size Increase font size


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 3  |  Issue : 2  |  Page : 80-84

Non surgical management of periodontitis related halitosis among adults


Department of Oral Medicine, Oral Diagnosis and Periodontology, Faculty of Dentistry, Suez Canal University, Ismailia, Egypt; Department of Preventive Dental Sciences, Division of Periodontics, College of Dentistry, King Khalid University, Abha, Kingdom of Saudi Arabia

Date of Web Publication20-Jun-2014

Correspondence Address:
Hossam A Eid
Department of Preventive Dental Sciences, College of Dentistry, King Khalid University, Grager Campus, Post Box: 3263, Abha 61471, Kingdom of Saudi Arabia

Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0521.134855

Rights and Permissions
  Abstract 

Introduction: Management of periodontitis-related oral malodor may include simple measures such as scaling and root planning (SRP) and oral hygiene instructions. Aim: A prospective cross-sectional study was conducted to evaluate the effect of non-surgical management of periodontitis on controlling halitosis (oral malodor) measured by Halimeter. Methodology: Clinical data were recorded from 60 participants who were attended the out-patient periodontics clinic at the College of Dentistry of King Khalid University, Abha city, Saudi Arabia. The participants were grouped as periodontitis (case), non-surgically treated periodontitis and healthy (control). Volatile sulfur compounds were measured in parts per billion (ppb) as a caliber for halitosis for each group using a Halimeter ® . Data were statistically analyzed utilizing the Chi-square distribution test (P < 0.05). Results: In the average, case group showed strong halitosis 230.00 ± 54.29 ppb that was reduced to weak halitosis 124.25 ± 26.43 ppb following non-surgical (SRP) management of chronic periodontitis, with the deeper pockets, increased halitosis was measured as mean halitosis of periodontitis and treated cases 188.90 ± 14.22 ppb and 114.70 ± 20.75 ppb, 240.25 ± 58.08 ppb and 128.25 ± 39.31 ppb and 294.33 ± 19.64 ppb and 137.50 ± 23.36 ppb, respectively, in 5-6, 6.1-7 and 7.1-8 mm groups respectively. Conclusion: Based on study results, halitosis is directly related to periodontitis and periodontal pocket depth among the adults, which can be successfully controlled by SRP.

Keywords: Halimeter ® , halitosis, non-surgical therapy, periodontitis


How to cite this article:
Eid HA. Non surgical management of periodontitis related halitosis among adults. Saudi J Health Sci 2014;3:80-4

How to cite this URL:
Eid HA. Non surgical management of periodontitis related halitosis among adults. Saudi J Health Sci [serial online] 2014 [cited 2021 Jul 24];3:80-4. Available from: https://www.saudijhealthsci.org/text.asp?2014/3/2/80/134855


  Introduction Top


Halitosis can be referred to as bad or foul breath, breath malodor, oral malodor, and fetor oris. Halitosis is often caused by periodontal diseases and/or tongue coating and patients with periodontitis were at higher risk for halitosis detection than healthy individuals . [1],[2],[3] Halitosis associated with periodontitis negatively affected quality-of-life among Japanese population. [4] Conventional non-surgical periodontal therapy has a potential to ameliorate patient perceptions of oral health. Halitosis is considered the third reason, after caries and periodontal disease, for patients to seek dental care. [5] The prevalence of halitosis in the general population was reported to a range from 23% to 50%, respectively. [6] On an average, 80-90% of subjects suffering from halitosis, the condition was attributed to oral factors, hence the term oral malodor. [7],[8]

Several factors play a role in oral halitosis including periodontal diseases, tongue coating, peri-implant diseases, deep carious lesions, exposed necrotic tooth pulp, pericoronitis, mucosal ulcerations, healing wounds, impacted food or debris, unclean dentures, and factors causing decrease salivary flow rate. [9],[10] Halitosis arises from microbial degradation of organic substrates present in saliva, gingival crevicular fluids, oral soft-tissues, and retained debris, or may originate from the bacterial metabolism on the tongue dorsum, and in the periodontal pockets. [11],[12],[13]

Anaerobic bacteria such as Porphyromonas gingivalis (P.g.), Treponema denticola (T.d.) and Tannrella forsythia (T.f.) or bacteria that live normally within the surface of the tongue and deep periodontal pockets, reproduce in places without oxygen, digest proteins found in food, dead cells, blood and mucous. Proteins that contain amino acids, such as cysteine and methionine are rich in sulfur. [15],[16],[17] Volatile sulfur compounds (VSCs) are frequently encountered in the exhaled air and ultimately make breath smell like rotten eggs or dirty socks with feeling embarrassed. In over 85% of halitosis cases, the cause of the bad breath was the result of poor oral hygiene, 43% was found on tongue coating, 11% from gingivitis and/or periodontitis and 18% originated from the combination of the two. Pseudo-halitosis or halitophobia were diagnosed in 16% of the cases. [16],[17] This degradation lead to produce of VSCs, particularly hydrogen sulfide (H 2 S), methyl mercaptan (CH 3 SH), and dimethyl sulfide [(CH 3 ) 2 S]. [13],[14] H 2 S and CH 3 SH mainly contributed to intra oral halitosis, while (CH 3 ) 2 S was mainly found in extra-oral halitosis. [18] It has been reported that the VSCs level in mouth breath of patients with periodontal disease was found 8-times greater than that of the control patients. [19] Halitosis can be a mirror reflection of systemic diseases such as the upper and lower respiratory tract infections, metabolic diseases, medications, carcinoma, and other systemic diseases such as diabetes mellitus that gives rise to ketone bodies (ketoacidosis) in the breath. [20],[21]

In the past, it was difficult to measure halitosis. Recently, halitosis is measurable by the aid of Halimeter® device. [22] The Halimeter® is a gas analysis machine designed to measure the amount of sulfur bonds in a volume of gas. With the Halimeter®, it is possible to directly measure the quantitative amounts of offending VSCs present in parts per billion (ppb). [22] The normal range of normal breath ranging from 80 to 160 ppb, the bad breath is expected upon Halimeter® readings exceeded 160 ppb. Many trials had been done to control and manage oral malodor as treatment with the antibiotic rinse, which had a positive change in the periodontal status and breath odor of these patients. These data indicate that there is a considerable advantage to the use of topical antibiotic rinses. A substantial decrease in both halitosis and periodontal disease markers can be achieved without the risk of the systemic effects of an oral antibiotic. [22],[23] This advancement in measuring and controlling halitosis encouraged us to conduct this study to investigate the effect of non-surgical management on controlling periodontitis-related halitosis among adults.


  Methodology Top


Individuals recruited for this study were selected from the outpatient periodontics clinics of the College of Dentistry at King Khalid University, Abha city of Saudi Arabia. Written consents of the periodontitis patients were obtained on the forms that complied with the approved ethical form of the college ethical committee. Individuals aged 31.35 ± 3.25 (25-35) years, selected for this study were free from any systemic diseases or intra oral causes that may affect the oral breath negatively except periodontitis. Patients taken antibiotics within last 6 weeks were also excluded. 60 adult participants equally distributed according to gender, were selected for this study, and divided into three groups where each group contained 20 participants (10 males and 10 females):

  • Group I: Patients with chronic periodontitis, probing pocket depth (PPD) ≥5 mm, as case group
  • Group II: Patients of Group II were measured the halitosis following 2 weeks of non-surgical periodontal therapy i.e., thorough scaling and root planning (SRP)
  • Group III: Individuals free from any oral diseases, as a control group.


Halitosis values were divided into four categories and classified as: Normal (values from 0 to 100 ppb), weak (101-150 ppb), strong (151-300 ppb), or very strong (>300 ppb). [22] Each participant kept the mouth closed for 60 s before sampling. A plastic straw was inserted and positioned above the posterior portion of tongue dorsum, not touching the oral mucosa or the tongue. Breathing was not allowed during sampling. The mouth was kept open by approximately 1.5 cm, and the peak value was recorded. The measurements were duplicated, and the mean value was calculated.

The following periodontal indices were used on periodontally affected and control individuals at four sites: Mesiobuccal, midbuccal, distobuccal and midpalatal (midlingual). The plaque index, a modification of Silness and Loe, [24] was scored as:

  • 0 = No plaque was detected on the gingival or crown margin or the area in between
  • 1 = Plaque was visible following probing of either gingival margin of the crown or gingival area of the tooth
  • 2 = Plaque was visible on a portion of both gingival and crown margins without the need to probing
  • 3 = Plaque was visibly continuous on both gingival or crown margins and/or calculus was visible.


The gingival index by Loe and Silness [25] was modified and used to evaluate the degree of gingival inflammation on the abutment teeth at the defined sites as follows:

  • 0 = Absence of inflammation
  • 1 = Mild inflammation of the gingiva; slight change in color, slight edema and no bleeding
  • 2 = Moderate inflammation of the gingiva; redness, edema and glazed appearance and bleeding on probing
  • 3 = Severe inflammation of the gingiva; marked redness, edema and tendency to spontaneous bleeding.


PPD was measured as described by Ramfjord [26] from the free gingival crest to the level of attachment of the periodontium at the four previously mentioned sites. All the measurements were made with calibrated probes graduated in millimeters (University of Michigan "O" probe with William's markings; Hu-Friedy, Chicago, USA) under a standard dental light with patient seated in a semi-supine position in a standard dental chair.

Statistical analysis

Statistical analysis was performed with the IBM mainframe version of Statistical Analysis System, a powerful, time sharing and automatized method of a comprehensive data analysis, utilizing the Chi-square test P value for the effect of demographic characteristics (sex, educational background, location) and the significance value was set at <0.05.


  Results Top


[Figure 1] shows the presence of average halitosis among the study groups. Patients having periodontitis (case) had halitosis 230.00 ± 54.29 ppb and 102.35 ± 21.35 ppb in patients without periodontitis (control). Whereas, patients received non-surgical therapy for periodontitis, i.e. SRP showed improvement of halitosis condition (124.25 ± 26.43 ppb).
Figure 1: Case-control groups halitosis (ppb). Ppb-Parts per billion

Click here to view


[Figure 2] presents the data of average halitosis conditions among the male and female participants. Male participants in case group showed halitosis 240.38 ± 52.89 ppb that was higher (213.00 ± 56.30 ppb) than the female case group. In the control groups, male participants had a little higher halitosis (103.55 ± 24.23 ppb) than the female participants (100.89 ± 18.56 ppb). The halitosis conditions among the periodontitis-treated groups showed nearly the same in males and females 124.43 ± 19.97 ppb and 124.15 ± 30.11 ppb, respectively.
Figure 2: Gender-wise case-control groups halitosis (ppb). M-Male, F-Female, ppb-Parts per billion

Click here to view


[Figure 3] shows the average PPD 6.58 ± 1.03 mm among all periodontitis patients in which average PPD among males and females were 6.69 ± 1.03 mm and 6.36 ± 1.07 mm, respectively.
Figure 3: Average and gender-wise pocket depth (PPD). M-Male, F-Female, PPD-Probing pocket depth

Click here to view


[Figure 4] shows the relationship of all study parameters among periodontitis and periodontitis-treated groups. In 5-6 mm PPD group [Figure 4]a, mean halitosis of periodontitis and treated cases showed halitosis 188.90 ± 14.22 ppb and 114.70 ± 20.75 ppb, respectively. Among male and female case groups had halitosis 193.17 ± 14.76 ppb and 182.50 ± 12.34 ppb, respectively, whereas, in the treated cases, halitosis 110.83 ± 20.80 ppb and 120.50 ± 22.28 ppb were evident in males and female patients, respectively. As shown in [Figure 4]b (6.1-7 mm PPD group), mean halitosis of periodontitis and treated cases were found 240.25 ± 58.08 ppb and 128.25 ± 39.31 ppb, respectively. Halitosis conditions among male and female periodontitis patients and treated cases were higher than 5-6 mm PPD group with values of 260.33 ± 51.38 ppb and 180.00 ± 00.00 ppb; 134.33 ± 45.79 ppb and 110.00 ± 00.00 ppb, respectively. In 7.1-8 mm PPD group [Figure 4]c, halitosis conditions in average of periodontitis and treated cases were found 294.33 ± 19.64 ppb and 137.50 ± 23.36 ppb, respectively. Among males and females in both periodontitis and treated cases, halitosis were found highest among all PPD groups and that were 296.25 ± 6.95 ppb and 290.50 ± 41.72 ppb, but readings of treated cases were 136.50 ± 29.08 ppb and 139.50 ± 13.44 ppb, respectively.
Figure 4: (a) Is presenting the gender-wise relationship of PPD and halitosis conditions among periodontitis and periodontitis-treated groups. In 5~6 mm PPD group, (b) (6.1~7 mm PPD group), mean halitosis of periodontitis and treated cases, (c) halitosis conditions in average of periodontitis and treated cases. M-Male, F-Female, PPD-Probing pocket depth, ppb-Parts per Billion

Click here to view



  Discussion Top


The inflammation of gingival and periodontal tissues creates typical sources for oral malodors and plaque-related periodontal disease can increase the severity of halitosis. [4],[27],[28],[29] However, the other forms of periodontal disease, especially acute and aggressive forms such as acute necrotizing ulcerative gingivitis, pericoronitis, Vincent's disease or aggressive forms of periodontitis, can increase unpleasant breath odor. [4] Subjects with periodontitis reported substantial functional, physical, psychological, and social oral health-related quality of life impacts. [29] Halitosis or bad breath is frequently associated with chronic periodontitis which has health and social implications, which may lead to a significant social or psychological handicap. [2] Different conditions have been implicated, such as, periodontal pockets, stomatitis, rhinitis, pharyngitis and local factors, e.g. lack of self-clearing agents, smoking and food debris. [1],[2],[3] This study was performed with the participants having ≥5 mm PPD. Halitosis is a common feature of periodontitis in spite of age and genders [1],[2],[3],[4],[8] and that was clearly evident in this study. Periodontitis is related to increased pocket depth (PPD > 3 mm). [23],[24],[25] The case study group had average PPD 6.58 ± 1.03 mm. The progression of periodontitis was also related to the range of PPD. Study results showed the evidences of PPD ranges where the patients having deeper PPD had more halitosis conditions. Anaerobic bacteria (e.g. P.g., T.d. and T.f.) that live normally in the deep periodontal pockets, digest proteins (e.g. cysteine and methionine) found in food, dead cells, blood and mucous, that are rich in sulfur to produce VSCs. [15],[16],[17] Strong halitosis were evident with the pocket deepening that expressed presence of increased numbers of such bacteria that produced VSCs. Halitosis can be a mirror reflection of systemic diseases such as the upper and lower respiratory tract infections, metabolic diseases, medications, carcinoma, and other systemic diseases such as diabetes mellitus that gives rise to ketone bodies in the breath. [20],[21],[29] All participants were selected for this study who were free from any systemic diseases even not taken antibiotics within the last 6 weeks nor received any sorts of periodontal therapies. Therefore, the research was conducted solely with the patients who were suffering from periodontitis. The case group received non-surgical therapy (SRP) at their initial visits and measured halitosis after 2 weeks. The present study may also prove that the management of periodontitis by non-surgical therapy (SRP) could reduce the strong halitosis (230.00 ± 54.29 ppb) to weak halitosis (124.25 ± 26.43 ppb) conditions even may lead to normal conditions (3 cases had <100 ppb after SRP). The results of this study supports that the oral microflora specially anaerobic periodontopathic bacteria which is a source of production of VSCs can be reduced in the short-term with conservative therapy as SRP with the positive effect on decreasing oral malodor intensity in periodontitis patients.


  Conclusion Top


Based on study results halitosis is directly related to periodontitis and periodontal pocket depth among the adults, which can be successfully controlled by simple procedures such as SRP besides, instructions for oral hygiene.

 
  References Top

1.Apatzidou AD, Bakirtzoglou E, Vouros I, Karagiannis V, Papa A, Konstantinidis A. Association between oral malodour and periodontal disease-related parameters in the general population. Acta Odontol Scand 2013;71:189-95.  Back to cited text no. 1
    
2.Zalewska A, Zatoñski M, Jab³onka-Strom A, Paradowska A, Kawala B, Litwin A. Halitosis: A common medical and social problem. A review on pathology, diagnosis and treatment. Acta Gastroenterol Belg 2012;75:300-9.  Back to cited text no. 2
    
3.Nachnani S. Oral malodor: Causes, assessment, and treatment. Compend Contin Educ Dent 2011;32:22-4, 26-8, 30-1.  Back to cited text no. 3
    
4.Takeuchi H, Machigashira M, Yamashita D, Kozono S, Nakajima Y, Miyamoto M, et al. The association of periodontal disease with oral malodour in a Japanese population. Oral Dis 2010;16:702-6.  Back to cited text no. 4
    
5.Saito A, Hosaka Y, Kikuchi M, Akamatsu M, Fukaya C, Matsumoto S, et al. Effect of initial periodontal therapy on oral health-related quality of life in patients with periodontitis in Japan. J Periodontol 2010;81:1001-9.  Back to cited text no. 5
    
6.Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6:2-7.  Back to cited text no. 6
    
7.Al-Ansari JM, Boodai H, Al-Sumait N, Al-Khabbaz AK, Al-Shammari KF, Salako N. Factors associated with self-reported halitosis in Kuwaiti patients. J Dent 2006;34:444-9.  Back to cited text no. 7
    
8.Gurbuz T, Tan H. Oral health status in epileptic children. Pediatr Int 2010;52:279-83.  Back to cited text no. 8
    
9.Kara C, Tezel A, Orbak R. Effect of oral hygiene instruction and scaling on oral malodour in a population of Turkish children with gingival inflammation. Int J Paediatr Dent 2006;16:399-404.  Back to cited text no. 9
    
10.Liu XN, Shinada K, Chen XC, Zhang BX, Yaegaki K, Kawaguchi Y. Oral malodor-related parameters in the Chinese general population. J Clin Periodontol 2006;33:31-6.  Back to cited text no. 10
    
11.Sinjari B, Murmura G, Caputi S, Ricci L, Varvara G, Scarano A. Use of Oral Chroma™ in the assessment of volatile sulfur compounds in patients with fixed protheses. Int J Immunopathol Pharmacol 2013;26:691-7.  Back to cited text no. 11
    
12.Donaldson AC, McKenzie D, Riggio MP, Hodge PJ, Rolph H, Flanagan A, et al. Microbiological culture analysis of the tongue anaerobic microflora in subjects with and without halitosis. Oral Dis 2005;11 Suppl 1:61-3.  Back to cited text no. 12
    
13.Riggio MP, Lennon A, Rolph HJ, Hodge PJ, Donaldson A, Maxwell AJ, et al. Molecular identification of bacteria on the tongue dorsum of subjects with and without halitosis. Oral Dis 2008;14:251-8.  Back to cited text no. 13
    
14.Cortelli JR, Barbosa MD, Westphal MA. Halitosis: A review of associated factors and therapeutic approach. Braz Oral Res 2008;22 Suppl 1:44-54.  Back to cited text no. 14
    
15.Campisi G, Musciotto A, Di Fede O, Di Marco V, Craxì A. Halitosis: Could it be more than mere bad breath? Intern Emerg Med 2011;6:315-9.  Back to cited text no. 15
    
16.Chomyszyn-Gajewska M, Skrzypek A. Halitosis: Diagnosis and treatment. Przegl Lek 2013;70:65-8.  Back to cited text no. 16
    
17.Quirynen M, Dadamio J, Van den Velde S, De Smit M, Dekeyser C, Van Tornout M, et al. Characteristics of 2000 patients who visited a halitosis clinic. J Clin Periodontol 2009;36:970-5.  Back to cited text no. 17
    
18.Tangerman A, Winkel EG. Intra- and extra-oral halitosis: Finding of a new form of extra-oral blood-borne halitosis caused by dimethyl sulphide. J Clin Periodontol 2007;34:748-55.  Back to cited text no. 18
    
19.Quirynen M, Dadamio J, Van den Velde S, De Smit M, Dekeyser C, Van Tornout M, et al. Characteristics of 2000 patients who visited a halitosis clinic. J Clin Periodontol 2009;36:970-5.  Back to cited text no. 19
    
20.Pratibha PK, Bhat KM, Bhat GS. Oral malodor: A review of the literature. J Dent Hyg 2006;80:8.  Back to cited text no. 20
    
21.Southward K, Bosy A. Treatment of oral malodor and periodontal disease using an antibiotic rinse. Gen Dent 2013;61:41-5.  Back to cited text no. 21
    
22.Salako NO, Philip L. Comparison of the use of the Halimeter and the Oral Chroma™ in the assessment of the ability of common cultivable oral anaerobic bacteria to produce malodorous volatile sulfur compounds from cysteine and methionine. Med Princ Pract 2011;20:75-9.  Back to cited text no. 22
    
23.Babacan H, Sokucu O, Marakoglu I, Ozdemir H, Nalcaci R. Effect of fixed appliances on oral malodor. Am J Orthod Dentofacial Orthop 2011;139:351-5.  Back to cited text no. 23
    
24.Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand 1964;22:121-35.  Back to cited text no. 24
    
25.Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 25
    
26.Ramfjord SP. The periodontal disease index (PDI). J Periodontol 1967;38 Suppl: 602-10.  Back to cited text no. 26
    
27.Field CA, Gidley MD, Preshaw PM, Jakubovics N. Investigation and quantification of key periodontal pathogens in patients with type 2 diabetes. J Periodontal Res 2012 47:470-8.  Back to cited text no. 27
    
28.Davies A, Epstein JD. Oral Complications of Cancer and its Management. Oxford: Oxford University Press; 2010. p. 230-40.  Back to cited text no. 28
    
29.Durham J, Fraser HM, McCracken GI, Stone KM, John MT, Preshaw PM. Impact of periodontitis on oral health-related quality of life. J Dent 2013;41:370-6.  Back to cited text no. 29
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
1 The relationship between volatile sulfur compounds and the severity of chronic periodontitis: A cross-sectional study
MAlrashidi Abdullah,Mohammed Alasqah,MShafshak Sanaa,Khalid Gufran
Journal of Pharmacy And Bioallied Sciences. 2020; 12(5): 268
[Pubmed] | [DOI]
2 Nylon-Supported Plasmonic Assay Based on the Aggregation of Silver Nanoparticles: In Situ Determination of Hydrogen Sulfide-like Compounds in Breath Samples as a Proof of Concept
Neus Jornet-Martínez,Lusine Hakobyan,Ana Isabel Argente-García,Carmen Molins-Legua,Pilar Campíns-Falcó
ACS Sensors. 2019;
[Pubmed] | [DOI]
3 The effect of professional tooth cleaning or non-surgical periodontal therapy on oral halitosis in patients with periodontal diseases. A systematic review
HCD Deutscher,SHM Derman,AG Barbe,R Seemann,MJ Noack
International Journal of Dental Hygiene. 2017;
[Pubmed] | [DOI]
4 Vikodak - A Modular Framework for Inferring Functional Potential of Microbial Communities from 16S Metagenomic Datasets
Sunil Nagpal,Mohammed Monzoorul Haque,Sharmila S. Mande,Niyaz Ahmed
PLOS ONE. 2016; 11(2): e0148347
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methodology
Results
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed4540    
    Printed189    
    Emailed1    
    PDF Downloaded350    
    Comments [Add]    
    Cited by others 4    

Recommend this journal