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Oral Medicine - Update For The Dental Practitioner
Oral Medicine - Update For The Dental Practitioner
PRACTICE
4
IN BRIEF
• Most oral malodour is related to diet, habits or inadequate oral hygiene.
• However cancer and some systemic and psychogenic diseases may present with malodour
This series provides an overview of current thinking in the more relevant areas of oral medicine for primary care practitioners,
written by the authors while they were holding the Presidencies of the European Association for Oral Medicine and the British
Society for Oral Medicine, respectively. A book containing additional material will be published. The series gives the detail
necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental
practice. Space precludes inclusion of illustrations of uncommon or rare disorders, or discussion of disorders affecting the hard
tissues. Approaching the subject mainly by the symptomatic approach — as it largely relates to the presenting complaint — was
considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the
relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis
is made. Guidance on management and when to refer is also provided, along with relevant websites which offer further detail.
ORAL MEDICINE ORAL MALODOUR Oral malodour at other times is often the con-
1. Aphthous and other Oral malodour, or halitosis, is a common com- sequence of eating various foods such as garlic,
common ulcers plaint in adults, though few mention it. Mal- onion or spices, foods such as cabbage, Brussel
2. Mouth ulcers of more odour can have a range of causes (Table 1). With sprouts, cauliflower and radish, or of habits such
serious connotation oral malodour from any cause, the patient may as smoking, or drinking alcohol. Durian is a
3. Dry mouth and disorders also complain of a bad taste. tropical fruit which is particularly malodourous.
of salivation The cause of malodour in such cases is usual-
4. Oral malodour Table 1 Main causes of oral malodour ly obvious and avoidance of the offending sub-
Oral sepsis
stance is the best prevention.
5. Oral white patches
6. Oral red and Dry mouth
Less common causes of oral malodour
hyperpigmented patches Starvation
Oral infections can be responsible for oral mal-
7. Orofacial sensation and Some foods odour. The micro—organisms implicated in oral
movement Habits: smoking, alcohol and some drugs malodour are predominantly Gram-negative
8. Orofacial swellings and Systemic disease anaerobes, and include:
lumps Diabetic ketosis • Porphyromonas gingivalis
9. Oral cancer Gastrointestinal disease • Prevotella intermedia
10. Orofacial pain Hepatic failure • Fusobacterium nucleatum
Renal failure • Bacteroides (Tannerella) forsythensis and
Respiratory disease • Treponema denticola.
1*Professor, Consultant, Dean, Eastman
Trimethylaminuria
Dental Institute for Oral Health Care
Sciences, 256 Gray’s Inn Road, UCL, Psychogenic factors Gram-positive bacteria have also been impli-
University of London, London WC1X 8LD; cated since they can denude the available glyco-
2Consultant, Senior Lecturer, Glasgow
proteins of their sugar chains, enabling the
Dental Hospital and School, 378 Common causes of oral malodour anaerobic Gram-negative proteolytic bacteria to
Sauchiehall Street, Glasgow G2 3JZ /
Associate Dean for Postgraduate Dental Oral malodour is common on awakening (morn- break down the proteins. Gram negative bacteria
Education, NHS Education for Scotland, ing breath) and then often has no special signifi- can produce chemicals that produce malodour,
2nd Floor, Hanover Buildings, 66 Rose cance — usually being a consequence of low sali- which include in many instances
Street, Edinburgh EH2 2NN
*Correspondence to: Professor Crispian
vary flow and lack of oral cleansing during sleep • volatile sulphur compounds (VSCs), mainly
Scully CBE as well as mouthbreathing. methyl mercaptan, hydrogen sulphide, and
Email: c.scully@eastman.ucl.ac.uk This rarely has any special significance, and dimethyl sulphide
can be readily rectified by eating, tongue brushing, • diamines (putrescine and cadaverine) and
Refereed Paper
© British Dental Journal 2005; 199: and rinsing the mouth with fresh water. Hydrogen • short chain fatty acids (butyric, valeric and
498–500 peroxide rinses may also help abolish this odour. propionic).
PRACTICE
The evidence for the implication of other micro- tomatic hypochondriasis (self-oral malodour;
organisms, such as Helicobacter pylori, is scant. halitophobia).
The posterior area of the tongue dorsum is Other people’s behaviour, or perceived
often the location of the microbial activity associ- behaviour, such as apparently covering the nose
ated with bad breath. Debris, such as in patients or averting the face, is typically misinterpreted
with poor oral hygiene, or under a neglected or a by these patients as an indication that their
poorly designed dental bridge or appliance is breath is indeed offensive. Such patients may
another cause. Any patient with oral cancer or a have latent psychosomatic illness tendencies.
dry mouth can also develop oral malodour. Many of these patients will adopt behaviour
Defined infective processes that can cause to minimise their perceived problem, such as
malodour may include: • covering the mouth when talking
• Periodontal infections (especially necrotising • avoiding or keeping a distance from other
gingivitis or periodontitis) people
• Pericoronitis • avoiding social situations
• Other types of oral infections • using chewing gum, mints, mouthwashes or
• Infected extraction sockets sprays designed to reduce malodour
• Ulcers. • frequent toothbrushing
• cleaning their tongue.
Improvement of oral hygiene, prevention or
treatment of infective processes, and sometimes Thus the oral hygiene may be superb in such
the use of antimicrobials can usually manage patients. Medical help may be required to man-
this type of oral malodour. age these patients.
Such patients unfortunately fail to recognise
Rare causes of oral malodour their own psychological condition, never doubt
Systemic causes of oral malodour are rare but they have oral malodour and thus are often
important and range from drugs to sepsis in the reluctant to visit a psychologic specialist.
respiratory tract to metabolic disorders (Table 2).
Summary
The complaint of oral malodour in the absence Oral malodour can have a range of causes,
of malodour though most cases of true malodour have an oral
The complaint of oral malodour may be made by cause, and many others are imagined (Fig. 1).
patients who do not have it but imagine it
because of psychogenic reasons. This can be a DIAGNOSIS OF ORAL MALODOUR
real clinical dilemma, since no evidence of oral Assessment of oral malodour is usually sub-
malodour can be detected even with objective jective by simply smelling exhaled air
testing, and the oral malodour may then be (organoleptic method) coming from the mouth
attributable to a form of delusion or monosymp- and nose and comparing the two. Odour origi-
nating in the mouth, but not detectable from
the nose is likely to be either oral or pharyn-
Table 2. Rare causes of oral malodour geal origin. Odour originating in the nose may
Drugs come from the sinuses or nasal passages. Chil-
Chloral hydrate dren sometimes place foreign bodies in the
Cytotoxic drugs nose, leading to sepsis and malodour! Only in
Dimethyl sulphoxide the rare cases in which similar odour is equal-
Nitrites and nitrates ly sensed coming from both the nose and
Solvent abuse
mouth can one of the many systemic causes be
inferred.
Respiratory problems
Specialist centres may have the apparatus
Nasal sepsis
for objectively measuring the responsible
Tonsillitis
volatile sulphur compounds (methyl mercap-
Sinusitis tan, hydrogen sulphide, dimethyl sulphide) – a
Lower respiratory tract infection halimeter. Microbiological investigations such
Systemic disease as the BANA (benzoyl-arginine-naphthyl-
Gastrointestinal disease: (some believe in an amide) test or darkfield microscopy can also
association with Helicobacter pylori infection) be helpful.
Hepatic failure
Renal failure Management of oral malodour
Diabetic ketosis; the breath may smell of acetone. The management includes first determining
Trimethylaminuria (fish-malodour syndrome); an which cases may have an extraoral aetiology.
autosomal dominant metabolic disorder. A full oral examination is indicated and if an
Trimethylamine (TMA) is produced by intestinal bacteria oral cause is likely or possible, management
on eating cholines (mainly in fish and eggs) and is
typically oxidised by a liver enzyme. Individuals with should include treatment of the cause, and other
trimethylaminuria lack this enzyme and thus secrete measures (see box).
TMA in various bodily fluids and via their breath. In cases of malodour which may have an
Psychogenic factors extraoral aetiology, the responsibility of the gen-
eral dental practitioner is to refer the patient for
PRACTICE