HALITOSIS and MOUTHWASHES

halitosis

unpleasant noxious odour eminating from the oral cavity

definitive diagnosis can be difficult and requires a thorough dental and medical history .

examination of nose tonsils mucosal surfaces of the pharynx and oral cavity and teeth is required

common causes of halitosis

SELF LIMITING

• dry mouth from mouth breathing/ snoring

• odor causing foods garlic /onion/spices

• smoking and alcoholic beverages

INTRA ORAL CAUSES

• poor oral hygiene (food particles between the teeth , on tongue , around the gums )

• intraoral bacteria (tongue colonisation / dental caries/ periodontitis )

• acute infections within the mouth ( dental abscess / oral candidiasis / necrotising gingvitis )

SALIVARY GLAND HYPOFUNCTION

TONSILLAR PATHOLOGY

• chronic caseous tonsillitis

• peritonsiller abscess

ORAL CANCER

EXTRA ORAL CAUSES

• Acute pharyngeal infections (streptococcal pharyngitis , glandular fever )

• respiratory (post nasal drip /sinusitis/intranasal foriegn bodies /bronchitis/bronchiectasis/lung abscess / respiratory tract cancer )

• gastrointestinal ( Zenker diverticulum pouch like outpouching of mucosa or submucosa of pharynx , gastrocolic fistulae , helicobacter pylori infection , GERD )

• advanced kidney disease

• advanced liver disease

• trimethylaminuria (metabolic disorder causing fishy breath in skin , sweat , urine )

• ketoacidosis (starvation , protien only diet , diabetes )

what is percieved halitosis ? and how is it managed

this is a psychogenic halitosis without detectable malodour may reflect a psychological illness

other peoples behaviour such as covering the nose or averting the face is typically misinterpreted by these patients as their breath is offensive

this presents as a diagnostic and treatment challenge and despite reassurance may require psychological assessment

devices that measure volatile sulfur compounds are recommended for an accurate diagnosis (true/false)

FALSE (they give variable results and are costly so not recommended)

management of halitosis

for SELF LIMITING CAUSES

• improving oral hygiene including tongue cleaning

• avoiding odour causing foods , smoking and alcoholic beverages

• addressing cause of mouth breathing if identified

• considering a trial of non specific measures ( chewing sugarfree gum , ensuring adequate hydration, reducing caffiene intake )

INTRAORAL CAUSES depends on the origin of the malodour

• promote oral hygiene for transient or intraoral causes of halitosis

• if this doesnt resolve REFER TO A MEDICAL PRACTITIONER for appropriate investigation into extraoral causes

patients with recurrent or persistent halitosis should be reffered to a specialist (periodontist or oral medicine ) TRUE/FALSE

TRUE

TYPES OF MOUTHWASHES USED IN DENTISTRY

• antiseptic - periodontal disease , dental caries and pre and post procedural mouth rinsing

• fluoride mouthwashes :- high risk of dental caries

• anti inflammatory / analgesic :- symptomatic relief in inflammatory mucosal conditions (benzydamine )

• lubricating :- sodium bicarbonate / artificial salivary products temporary symptomatic relief in dry mouth

• alcohol containing :- may be associated with oral cancer and should be avoided

antiseptic mouthwashes indicatons and limitations

• can reduce plaque formation but do not reduce existing plaque

• existing plaque must be removed by mechanical cleaning

• antiseptic mouthwash in periodontal disease is controversial as they are only effective against supragingival plaque and are not effective beyond gingival crevice or periodontal pocket

• pts should be informed principal treatment of chronic periodontal disease is professional intervention with debridement involving affected teeth and meticulous oral hygiene

• can be benificial in some short term use in case of gingivitis or necrotising gingivitis when inflammation restricts normal tooth brushing

chlorhexidine is bactericidal andfungicidaland has no activity against viruses (true/false)

FALSE it has activity against some viruses

chlorhexidine mouthwash is inactivated by the detergent sodium lauryl sulfate used in standard toothpaste

false earlier it was thought that happens but now research proved it wrong

chx prevents plaque formation on a clean tooth surface and also reduces existing plaque (true/false)

false chx has no effect on existing plaque and adsorbs onto the oral surfaces so it remains effective for a longer period of time

cx formulations and delivery methods available in the market

• mouthwash chlorhexidine gluconate (0.12% and 0.2% ) gel

• slow realise formulation for local delivery into periodontal pockets

adverse effects of chx and the duration it is generally recommended for

• extraoral effects -

  • irritate mucosal surfaces

  • interrupt wound healing

• intraoral effects -

  burning sensation altered taste

  increased calculus formation

  brown discoloration of the tongue , buccal cavity , teeth and margins of dental restorations

RECOMMENDED FOR SHORT DURATION OF 2 WEEKS TO MINIMISE ADVERSE EFFECTS

chx is hypoallergenic and it doesnt cause allergies (true/false)

false causes allergies as severe as life threatning if pts reports allergy it should be avoided via all routes of administeration including topical

mouthwashes are essential for routine daily hygiene and should be included in the daily oral hygiene routine for as long as required (true/false)

false not required for optimal daily hygiene and prescribed for only short period of time

mouthwash is usually not required as part of standard oral hygiene routine provided mechanical cleaning (toothbrushing , interdental cleaning ) is performed properly .

MOUTHWASH SHOULD NOT BE USED AS A SUBSTITUTE FOR PROPER MECHANICAL TEETH CLEANING

different types of mouthwashes and their names

hydrogen peroxide

cetylpyridinium chloride

povodine - iodine

benzydamine

cetylpyridium chloride

ammonium compound with surfactant detergent and antibacterial properties

intraoral formulations include mouthwash gargles and lozenges

some formulations combine it with la for antiinflammatory effect

mouthwashes with essential oils are herbal medicines not proven to have any scientific basis (t/f)

false eucalyptol , menthol , thymol , methyl salicylate containing essential oils have been found to have antiseptic properties and reduce plaque formation ,but there is limited evidence of benifit

chorhexidine helps prevent dental caries by reducing plaque formation (t/f)

false

chx has limited role in prevention of dental caries in high risk pts.

chx reduces the level of cariogenic bacteria and prevents plaque formation on cleaned tooth surface further evidence is needed to assess whether this prevents dental caries

recommended prescription of chx

chlorhexidine + fluoride 0.2% + 0.0033% (15ppm) gel pea sized amount brushed onto teeth daily or weekly

or

chlorhexidine 0.5 % gel pea sized brushed onto teeth daily/weekly

for dental caries management chx is not preffered in gel format thn mouthwash because mouhwash helps in effective distribution of product (T/f)

false for dental caries management chlorhexidine gel is preffered to mouthwash

alcohol containing mouthwashes may increase the risk of oral cancer in children younger than 12 yrs

alcohol free chx mouthwashes have short expiry after opening

benzydamine

is a nsaid with analgesic properties used for temporary relief of painful inflammatory oral mucosal conditions

formulation includes -

intraoral gel

spray

in concentrations from 0.15-1%

some formulations combine benzydamine with an antiseptic

local adverse effects of benzydamine

numbness

burning

erythema

rash

FLUORIDE containing mouthwashes can be used as an additionzl source of fluoride for people at high risk of dental caries on the recommendation of a dentist (t/f)

• true