The relationship between volatile sulphur compounds, tongue coating and periodontal disease

Self-perceived halitosis and its social impact on females: A cross-sectional study

Halitosis refers to socially unacceptable levels of breath odors. This affects the social life and psychological well-being of individuals. The purpose of this study was to evaluate the prevalence of self-perceived halitosis (SPH) among females and its effect on social life. This was a cross-sectional study. A previously validated questionnaire was distributed electronically through a secure link. The questionnaire consisted of 5 different parts that collected information on sociodemographic, medical history, oral hygiene and other health habits. It also included questions related to participant's knowledge and perception of halitosis and its social impact. All females who were at least 18 years were invited to participate. Data were transferred for analysis using the Statistical Package for Social Sciences program for Windows (IBM SPSS Statistics Version 26, Chicago, IL). Simple descriptive statistics such as frequency distributions and percentages were calculated for the study variables. The relationship between the variables and SPH was also evaluated using the chi-squared test of independence at 95% confidence (P ≤ .05). In total, 1089 subjects completed the questionnaire. The SPH prevalence was 62% among females. The correlation between SPH and sinusitis, gastrointestinal tract disorders, periodontal diseases were significant (P < .05). In addition, subjects with good tooth brushing habits reported no halitosis (91.6%) compared to subjects with poor tooth brushing habits who reported no halitosis (8.9%), and the difference was statistically significant (P < .001). Not using floss and tounge cleaners daily was significantly related to self-reported halitosis (P < .001). Females who reported SPH indicated that they were hesitant to talk to others (68.1%), uncomfortable around others (80.5%), did not like meeting others (44.2%), avoided by others (15%), and that halitosis affected their personal life (31.9%). This association was statistically significant for all variables of social life (P < .001). The prevalence of SPH is high and can have an incapacitating effect on females social lives. The management of halitosis includes active involvement of dental professionals and the incorporation of psychological support.

Non-Surgical Periodontal Treatment Impact on Subgingival Microbiome and Intra-Oral Halitosis

The purpose of this study was to characterize and compare subgingival microbiome before and after periodontal treatment to learn if any changes of the subgingival microbiome were reflected in intra-oral halitosis. We tested the hypothesis that intra-oral halitosis (Volatile sulfur compounds levels) correlates with corresponding subgingival bacterial levels before and after periodontal treatment. Twenty patients with generalized periodontitis completed the study. Subgingival plaque samples were collected at baseline and 6-8 weeks after nonsurgical periodontal therapy. Full-mouth periodontal status assessed probing depth (PD), clinical attachment loss (CAL), gingival recession (REC), bleeding on probing (BoP), PISA and PESA. Halitosis assessment was made using a volatile sulfur compounds (VSC) detector device. Periodontal measures were regressed across VSC values using adjusted multivariate linear analysis. The subgingival microbiome was characterized by sequencing on an Illumina platform. From a sample of 20 patients referred to periodontal treatment, 70% were females (n = 14), with a mean age of 56.6 (±10.3) years; full-mouth records of PD, CAL, BOP (%) allowed to classify the stage and grade of periodontitis, with 45% (n = 9) of the sample having Periodontitis Stage IV grade C and 95% (n = 19) had generalized periodontitis. The correlation of bacterial variation with VSCs measured in the periodontal diagnosis and in the reassessment after treatment were evaluated. Fusobacterium nucleatum, Capnocytophaga gingivalis and Campylobacter showaei showed correlation with the reduction of VSC after periodontal treatment (p-value = 0.044; 0.047 and 0.004, respectively). Capnocytophaga sputigena had a significant reverse correlation between VSCs variation from diagnosis (baseline) and after treatment. Microbial diversity was high in the subgingival plaque on periodontitis and intra-oral halitosis participants of the study. Furthermore, there were correlations between subgingival plaque composition and VSC counting after periodontal treatment. The subgingival microbiome can offer important clues in the investigation of the pathogenesis and treatment of halitosis.

Revisiting Standard and Novel Therapeutic Approaches in Halitosis: A Review

Halitosis, or bad breath, is an oral health problem characterized by an unpleasant malodor emanating from the oral cavity. This condition can have different origins and causes a negative burden in social interactions, communication and quality of life, and can in uncommon cases be indicative of underlying non-oral non-communicable diseases. Most cases of halitosis are due to inadequate oral hygiene, periodontitis and tongue coating, yet the remaining proportion of cases are due to ear-nose-throat-associated (10%) or gastrointestinal/endocrine (5%) disorders. For this reason, the diagnosis, treatment and clinical management of halitosis often require a multidisciplinary team approach. This comprehensive review revisits the etiology of halitosis as well as standard and novel treatment that may contribute to higher clinical success.

Relationship Between Halitosis and Periodontitis: a Pilot Study

Objective

Halitosis, or oral malodour, is an unpleasant smell emanating from the oral cavity. It is a common complaint among patients with periodontitis, however, their relationship is not fully elucidated. This study aimed to evaluate the association between halitosis measures, clinical indicators of periodontitis and tongue coating, as well as a novel measure, periodontal inflamed surface area (PISA).

Material and methods

Data of 10 patients with periodontitis and halitosis were included in this study. Halitosis was assessed by the organoleptic method and the portable sulphide monitor, measuring volatiles sulphur compounds. A comprehensive periodontal examination was conducted, and the parameters of probing depth, gingival recession, clinical attachment level, bleeding on probing, plaque and tongue coating were registered. The PISA was calculated using clinical attachment level, gingival recession and bleeding on probing.

Results

A correlation between organoleptic score and tongue coating (r=0.554) and plaque (r=0.614) could be observed. No correlation between measures of halitosis and probing depth or the PISA could be detected. A significant correlation was found between organoleptic scores and volatiles sulphur compounds values (r=0.931).

Conclusion

This pilot study has shown and further reiterated a complex interplay between different factors causative to halitosis in patients affected by periodontitis. The results suggest that tongue coating and oral hygiene may have an important role in halitosis in patients with periodontitis.

The Relationship between Volatile Sulfur Compounds and the Severity of Chronic Periodontitis: A Cross-sectional Study

Background:

Halitosis is a problem that is often ignored or undervalued. It is not considered a major clinical issue; thus, little is carried out to eradicate it. Little is known about the relationship of malodorous breath with the severity of periodontitis. Hence, the study aimed to investigate the relationship between volatile sulfur compounds (VSCs) and chronic periodontitis.

Materials and Methods:

According to the severity of chronic periodontitis, 80 patients were categorized into four groups (mild, moderate, severe, and control). Probing depth and clinical attachment level were measured. Portable sulfide monitor (Halimeter) is used to assess VSCs. Statistical analyses were conducted using R studio (Northern Ave, Boston).

Results:

The differences in the VSC levels among the four groups were found to be statistically significant. The greater the severity of periodontitis, the higher the VSC levels found (P < 0.001). Male had higher levels of VSCs than female (225 and 180.53 parts per billion [ppb], respectively). The lowest mean level of VSCs was found in the subjects aged 15–29 years (161.79 ppb); the mean values increased with the age, reaching 282.89 ppb in subjects aged >59 years.

Conclusion:

Highly significant differences were found in the VSC levels among different severities of chronic periodontitis. Moreover, an age-related increase in the VSC levels was determined. In addition, male had higher concentration of VSCs than female.

Etiology and characteristics of halitosis in patients of a halitosis center in Northern Italy

BACKGROUND

As there are few studies in Europe describing characteristics of breath malodor for large groups of patients, this retrospective study was designed to analyse the etiology of halitosis among patients attending a breath malodor center in Northern Italy.

METHODS

Clinical records of 547 consecutive patients were reviewed and data on self-perceived halitosis, organoleptic scores, volatile sulphur compound (VSC) levels, and oral health condition were extracted and analysed.

RESULTS

The prevalence of intra-oral halitosis was 90.7%. In 21 patients no objective signs of breath malodor could be found. Periodontitis and gingivitis were the main cause of bad breath in 33.9% of subjects and in combination with tongue coating in 55.2%. Only eight subjects have tongue coating as the only cause of halitosis. Ear, nose and throat (ENT)/extra-oral causes were found in 5.2% of the patients. VSC concentrations were lower in the psychogenic halitosis group, whereas no statistically significant differences were detected when comparing intra-oral and extra-oral halitosis except for (CH3)2S.

CONCLUSIONS

Psychogenic halitosis is a rare condition among subjects complaining of suffering from bad breath. The most prevalent cause of halitosis is intra-oral, in particular a combination of tongue coating and periodontal disease. Tongue coating is rarely the primary cause of oral malodor.

Halitosis: prevalence, risk factors, sources, measurement and treatment - a review of the literature

Halitosis, an offensive breath odour, has multiple sources and negative impacts on people's social interactions and quality of life. It is important for health care professionals, including general physicians and dental professionals, to understand its aetiology and risk factors in order to diagnose and treat patients appropriately. In this study, we have reviewed the current literature on halitosis regarding its prevalence, classification, risk factors, sources, measurement and treatment.

BAX Gene Overexpression in the Tongue Could Warn of Infection Risk due to Periodontal Pathogens

Background:

Different host proteins play a central role in cell response during bacterial infections, the Bcl-2-Associated X protein (BAX) and Vascular Cell Adhesion Protein 1 (VCAM-1) are often reported in infective primary events during cell injury.

Objective:

The aim of this study is to evaluate the predictive value of these two proteins as biomarkers of oral bacterial infection, with particular emphasis on the tongue, which plays an important role in microbial homeostasis in the mouth.

Methods:

Twenty-nine patients were recruited and divided according to the Periodontal Index (CPI), 4 of them were severely compromised periodontal patients. Oral hygiene, gingival tissues and plaque presence were evaluated clinically. The laboratory analysis carried out on tongue tissue included: total bacterial genomes, proportion of specific periopathogens and BAX -VCAM-1 expression rate, while Reactive Oxygen Species (ROS) were measured in saliva.

Results:

Neither tongue microbiological status nor salivary ROS level corresponded with the state of disease. VCAM-1 mRNA expression rate was comparable in all patients but, on the contrary, BAX expression resulted high in periodontally-compromised patients and appears related to periodontal status in the analyzed subjects.

Conclusion:

This preliminary work suggests that the BAX protein is a possible candidate in a prognostic marker study for oral diseases started by periodontal bacteria. For example, none of the evaluated clinical and microbiological parameters could predict the presence, prognosis or recurrence of periodontal diseases. This biomarker could be a valuable tool in determining the risk, diagnosis and prognosis of this human illness.

Reliability, Accuracy, and Use Frequency of Evaluation Methods for Amount of Tongue Coating

OBJECTIVE

To classify the evaluation methods for amount of tongue coating (TC) and investigate their reliability, accuracy, and frequency of use.

METHODS

Articles published from 1985 to 2015 were searched for evaluation methods for the amount of TC in PubMed and the Cochrane Library. Only clinical researches were included except protocol articles. The methods were classified according to their characteristics.

RESULTS

Finally, 113 articles were selected. The evaluation method for the amount of TC from the articles was classified into 4 types: intuitive, specificative, computerized, and weighing TC. The reliability in the intuitive and specificative methods (κ =0.33-0.92) showed varying levels among the studies. In general, the amount of TC calculated by the specificative method (Spearman's r=0.68-0.80) was more strongly related to the directly measured value than to the value estimated by the computerized method (Pearson's r=0.442). The number of articles published on this topic has increased consistently, and the specificative method was the most frequently used. Despite the higher reliability of the computerized method, it has not been widely used.

CONCLUSIONS

The high prevalence of the specificative method would continue in clinical practice because of its convenience and accuracy. However, to establish higher reliability, the limitation of the subjectivity of the assessors should be overcome through calibration training. In the computerized method, novel algorithms are needed to obtain a higher accuracy so that it can help the practitioners confidently estimate the amount of TC.

Association of tongue brushing with the number of fungiform taste buds and taste perception: A preliminary study using confocal laser scanning microscopy in combination with a filter-paper disc method

OBJECTIVE

The aim of this study was to investigate the association of tongue brushing with the number of fungiform taste buds and taste perception using a confocal laser scanning microscopy in combination with a filter-paper disc method (FPDM).

METHODS

Twenty-four subjects with or without a habit of tongue brushing (11 males and 13 females, 20-46 years old) participated in this study. Nine of the 24 subjects had no habit of tongue brushing (Group 1, n=9). Fifteen subjects had a habit of tongue brushing, and the brushing regions of the tongue were as follows: central region (Group 2, n=7), or entire region (Group 3, n=8) of the tongue dorsum. Using confocal laser scanning microscopy, the average number of taste buds per fungiform papilla (FP) was counted. Taste perception was evaluated using an FPDM. These observations were performed in the midlateral region of the tongue since the distribution of fungiform papillae is large in the midlateral region compared to that in the central region.

RESULTS

The subjects in Group 3 showed a significantly decreased number of fungiform taste buds compared to Group 1 and Group 2. Group 3 also showed significantly higher FPDM scores than the other two groups.

CONCLUSIONS

Excessive tongue brushing of the entire tongue dorsum, including the midlateral region, may have an association with the decreased number of FP and taste buds and decreased taste sensation. To avoid these conditions, instituting proper tongue brushing methods, such as limiting it to the central region of the tongue and using a light touch, is suggested and is important for the subjects who are eager to participate in tongue brushing.

Prevalence estimation of halitosis and its association with oral health-related parameters in an adult population of a city in North Italy

AIM

No epidemiological data on halitosis are available from Italy. Thus, the aim of this population-based cross-sectional study was to estimate the prevalence of halitosis in an urban adult population from North Italy and to explore related oral risk indicators.

MATERIALS AND METHODS

The survey used a two-stage probability sampling method to collect a representative sample of inhabitants, aged between 20 and 75 years, in the city of Turin. Seven hundred and forty-four adults were clinically examined (47% of sampled subjects) for oral malodor and periodontal conditions. Using a standardized questionnaire social, health and halitosis-related parameters were collected. Logistic models with interaction terms between tongue coating scores (TCS) and periodontal status were used to explore halitosis risk indicators.

RESULTS

The prevalence estimate of halitosis according to the organoleptic assessment was 53.51% (95% CI: 48.55-58.50). A statistically significant correlation was found between organoleptic and gas chromatography measurements (p < 0.0001). Stronger associations between halitosis and periodontitis were observed in people having higher TCS: adjusted odds ratio considering low and high TCS in individuals with severe periodontitis were 2.95 and 20.77 (p ≤ 0.003).

CONCLUSIONS

Due to the high prevalence of halitosis in the Turin population, its diagnosis and management should be incorporated in comprehensive dental care.

Association between viral hepatitis B infection and halitosis

OBJECTIVE

Oral malodor can be increased in breath of liver patients. However, no study has been performed for the association between volatile sulfur compounds (VSCs) and viral hepatitis. The aim of the present study was to determine the relationship between viral hepatitis and VSCs.

METHODS

This study analyzed 182 subjects and measured hydrogen sulfide (H2S), methyl mercaptan (CH3SH) and dimethyl sulfide [(CH3)2S] using the OralChroma(®). Hepatitis type B was evaluated. Periodontal health was assessed using the Community Periodontal Index (CPI) and bleeding on probing (BOP). Tongue coating score (TCS) was evaluated. Multiple logistic regression analyses were conducted to evaluate the relationship.

RESULTS

Viral hepatitis had an elevated odds of dimethyl sulfide defined halitosis (OR = 9.22, 95% CI = 2.08-40.95) after controlling for age, gender, alcohol consumption, current smoking, periodontitis, BOP, TCS and tongue brushing habit. The magnitude of the association between viral hepatitis and VSCs defined halitosis attenuated with adjustment of mediators (alcohol consumption, periodontitis, BOP, TCS and tongue brushing habit for hydrogen sulfide defined halitosis; periodontitis, TCS and tongue brushing habit for methyl mercaptan defined halitosis; tongue brushing habit for dimethyl sulfide defined halitosis).

CONCLUSIONS

Findings of this study suggest that viral hepatitis may be associated with methyl mercaptan defined halitosis.

Oral prophylaxis and its effects on halitosis-associated and inflammatory parameters in patients with chronic periodontitis

OBJECTIVE

A controlled clinical trial was conducted to evaluate the effects of oral prophylaxis on halitosis-associated, immunological and microbiological parameters.

METHODS

Thirty subjects were included in this controlled clinical trial (patients with generalized chronic periodontitis and controls without clinical attachment loss; each n = 15). Before oral prophylaxis and 14 days after (including tongue cleaning) volatile sulphur compounds (VSC), organoleptic scores and a tongue coating index were evaluated. The levels of IL-1β, IL-8, IL-10 and MMP-8 were measured in GCF, and also major periodontal pathogens were detected. Data were statistically analysed using anova and paired t-test.

RESULTS

Supragingival plaque and calculus removal with combined tongue cleaning was able to reduce significantly (P < 0.05) the VSC values in both groups (no significant differences between both groups). Two weeks after periodontal debridement, the VSC values were observed in the periodontitis group, but not in the control group, similar to the baseline values. The difference between the groups was statistically significant (P < 0.05). Only a repeated prophylaxis session in the periodontitis group was able to reduce VSC values significantly in comparison with baseline (P < 0.05). Organoleptic scores (10 and 30 cm) were significantly different (P < 0.05) between both groups before and after the treatment. Periodontal pathogens and host-derived markers were not significantly affected by a single prophylaxis session.

CONCLUSIONS

Oral prophylaxis may result in a significant decrease in VSC values. However, in periodontal diseases, a more complex treatment seems to be necessary.

Tongue coating microbiome regulates the changes in tongue texture and coating in patients with post-menopausal osteoporosis of Gan-shen deficiency syndrome type

Tongue inspection is a unique and important method of diagnosis in traditional Chinese medicine (TCM). It is a diagnostic approach which involves observing the changes in the tongue proper and tongue coating in order to understand the physiological functions and pathological changes of the body. However, the biological basis of TCM tongue diagnosis remains to be poorly understood and lacks systematic investigation at the molecular level. In this study, we evaluated the effects of tongue coating microbiome on changes in the tongue texture and coating in patients with post-menopausal osteoporosis (PMO) of Gan‑shen deficiency syndrome type. Our aim was to delineate the mechanisms of tongue coating microbiome-induced changes in the tongue texture and coating by investigating the histomorphological changes and performing a bacterial analysis of the tongue coating. We found that the number of intermediate cells in the red tongue with a thin coating was higher, while the number of superficial cells in the red tongue with a thin coating was lower. The maturation value (MV) of tongue exfoliated cells in the red tongue with a thin coating decreased, compared with that in the pale red tongue with a thin white coating. Furthermore, the total bacterial count, oral streptococcus, Gram‑positive (G+) and Gram‑negative (G-) anaerobic bacteria in the red tongue with a thin coating was significantly decreased compared with the pale red tongue with a thin white coating. The results of ultrastructural examination demonstrated that the number of epithelial cells and bacteria in the red tongue with a thin coating decreased compared with that in the pale red tongue with a thin white coating. These observations indicate that the tongue coating microbiome may be an important factor contributing to changes in the tongue in patients with PMO of Gan‑shen deficiency syndrome type.

Relationship between halitosis and periodontal disease - associated oral bacteria in tongue coatings

AIM

The objective of our study was to investigate the relationship between halitosis and oral bacteria in tongue coating (TC) and saliva samples from patients with halitosis, and to evaluate the effect of tongue cleaning on halitosis.

METHODS

Ninety-four participants complaining of oral malodour were included in the study. Organoleptic (OR) values, volatile sulphur compound (VSC) concentrations determined by gas chromatography and TC scores were used as clinical parameters of halitosis. Quantitative real-time polymerase chain reactions were used to determine the numbers of periodontal disease-associated oral bacteria.

RESULTS

There was a significant correlation between TC scores and OR values, methylmercaptan (CH3 SH) concentrations and VSC concentrations (Spearman's rank-correlation coefficient test, P < 0.01). There was also a positive correlation between the clinical parameters of halitosis and total bacterial numbers and Prevotella intermedia, Fusobacterium nucleatum and Campylobacter rectus concentrations in the TC samples. However, there was no similar correlation with respect to the saliva samples. The participants were sub-divided into two groups based on whether they had the habit of tongue cleaning or not. The participants with the habit of tongue cleaning had significantly lower OR scores, VSC concentrations and P. intermedia, F. nucleatum and C. rectus levels than the other participants (Mann-Whitney U-test, P < 0.05).

CONCLUSION

These results suggested that periodontal disease-associated oral bacteria in TCs are closely related to halitosis and that tongue cleaning may be an effective method for improving halitosis.

Halitosis: the multidisciplinary approach

Halitosis, bad breath or oral malodour are all synonyms for the same pathology. Halitosis has a large social and economic impact. For the majority of patients suffering from bad breath, it causes embarrassment and affects their social communication and life. Moreover,halitosis can be indicative of underlying diseases. Only a limited number of scientific publications were presented in this field until 1995. Ever since, a large amount of research is published, often with lack of evidence. In general, intraoral conditions, like insufficient dental hygiene, periodontitis or tongue coating are considered to be the most important cause (85%) for halitosis. Therefore, dentists and periodontologists are the first-line professionals to be confronted with this problem. They should be well aware of the origin, the detection and especially of the treatment of this pathology. In addition, ear-nose-throat-associated (10%) or gastrointestinal/endocrinological (5%) disorders may contribute to the problem. In the case of halitophobia, psychiatrical or psychological problems may be present. Bad breath needs a multidisciplinary team approach: dentists, periodontologists, specialists in family medicine, ear-nose-throat surgeons, internal medicine and psychiatry need to be updated in this field, which still is surrounded by a large taboo.Multidisciplinary bad breath clinics offer the best environment to examine and treat this pathology that affects around 25% of the whole population. This article describes the origin, detection and treatment of halitosis, regarded from the different etiological origins.