containing amino acids such as methionine,
cysteine and cystine. The resulting volatile
reported complaint. Whether in the form of
occasional morning breath, which nearly
every otherwise healthy adult encounters,
dimethyl sulphide and dimethyl disulphide)
or rarer and more serious problems ranging
from metabolic disorders to chest tumours,
putrescine, foul-smelling diamines) are at
halitosis is said to affect nearly 50% of the
least partially responsible for the odours of
adult population. To judge from the size of
VSC concentrations associated withhalitosis, with over 80 species from
VSCs are found in higher concentrations in
particles, cells, blood and some chemical
components of saliva. Thus 90% of causes of
halitosis arise in the mouth1. As proteins
that subjects complaining of oral malodour
and other chemicals in these materials are
had significantly more bleeding sites and
as amino acids and peptides, many volatile
bacteria than subjects who did not report
compounds) related to their decomposition
implicated in a feedback loop which begins
(smelling of rancid butter or rotting meat),
inflammation, creating oxygen-poor pockets
in the mouth (e.g. between the gingiva and
anaerobic bacteria in them. These bacteria
then begin the proteolysis of salivary and
This is particularly true of the sulphur-
odour, these VSCs increase the permeability
of the oral mucosa, speed the degradation of
wounds, and also affect gingival and other
periodontal cell function1,4. All of these
which led to the growth conditions of the
halitotic anaerobes in the first place.
while the dorsal third of thetongue, the spaces between
implicated in halitosis are also encountered
chemical, mechanical, and even biological
flux. While salivary proteins are suitable
mechanical interaction with the hard palate
for bacterial proteolysis, saliva also contains
and the teeth (in contrast to the anterior
two-thirds of the tongue). This area is also
mouthwashes and antibacterial rinses either
because it triggers a gag reflex or helps to
fluid motion. Saliva also contains immune
close off the nasal cavity to the liquid with
factors like specific immunoglobulins.
which the patient gargles. The tongue is an
because of its large, continuous surface area
which features taste and filiform papillae
two-thirds of the tongue into contact with
and crevices related to mucous glands and
lingual tonsils1. Bacterial flourishing on the
scrape this portion of the tongue clean.
tongue is not unlike dust accumulation on a
large, wrinkled shag carpet; this is why, even
though periodontitis is linked with halitosis
in one-third of patients (and some studies
suggest this is a weak association at best5),
pathogens create. For example, sugar in the
than to periodontitis1 (particularly, one
systems pH below the range at which the
relief for those patients whose gag reflex is
with the normal circadian rhythms of sleep
is responsible for the morning breath with
It is important to note that, while poor oral
hygiene and poor oral health may often be
sufficient conditions for the development of
associated with either xerostomia or sleep
halitosis, they are not necessary conditions.
chewing or other oral-mechanical activity)
abnormal) metabolites from non-oral bodily
indicates the critical role saliva plays in the
processes and functions; this is the case with
control of halitosis. Bacterial putrefaction of
chemicals in the mouth is largely responsi-
Syndrome, which results from the bodys
ble for halitosis. Saliva contains proteins,
inability to completely break down choline
patients blood and other bodily fluids of
bacterial adherence to oral surfaces, and
which in some cases are actually bactericidal
for the fishy odour of the patients breath,
Moreover, salivas role as a solvent in the
urine and sweat. People are probably more
oral chemical environment carries over to
familiar with the acetone-smell of diabetic
its role in controlling mouth odour: Volatile
patients breath, and the ketone smell of
compounds dissolved in saliva dont smell
anorexics (and some dieters) breath.
until theyre evaporated into mouth air and
Problems with the renal system leading to
smell, while gall bladder problems and liver
decreasing their concentrations in saliva by
disorders like cirrhosis give the breath a
stimulating salivary flow makes it more difficult
disorders have associated effects as well.
mouth caused by inhalation or exhalation to
Halitosis is a common secondary complaint
of patients with xerostomia, or chronic dry
mouth, which is often a result of advanced
age or of the irradiation of the head and
neck which constitutes treatment for many
as antihistamines, antihypertensives, and
Parkinsons disease, can cause xerostomia as
a side effect. Xerostomic patients salivary
function is impaired, which either aggravates
or precipitates periodontitis or simply raises
the salivary concentration of the VSCs so
their concentration in exhaled mouth air is
increased. A drop in salivary flow associated
Other oral causes include ulceration from
basis with the recent development of H.
diabetes, herpes, or trauma; postoperative
complications from tonsillectomy8 or oral
reconstructive surgery9; oral cancers, dental
between H. pylori infection and halitosis
abscesses, candidiasis, impacted food, improp-
erly performed restorations to teeth, use of
tobacco products, and dirty dentures. Foods
the disappearance of halitosis (measured by
rich in sulphur compounds, such as garlic,
eradication double therapy that eliminated
other, established halitotic bacteria. The
study also found that in the presence of H.
dinitrate, ammonium trichlorotellurate10, even
completely effective against halitosis.
tetracycline11) can cause halitosis as a sideeffect.
judges assessment, through own sense of
smell, of the odour of the patients breath or
saliva. While experienced odour judges may
have developed a degree of acuity in sensing
sinus cavity, and simple sore throat. Possible
particular compounds (odour judges are still
gastrointestinal causes for halitosis are a
used in current research), the process was
highly subjective and now seems unfit as a
argue that because of the gastrointestinal
sensory processing also places a limit on the
respiratory pathway, and since the normal
ability of a judge to isolate a particular
state of the oesophagus is one of collapse,
breath odour should not necessarily indicate
linear relationship between the number of
Self-diagnosis seems particularly flawed, since
colonogastric fistula (a rare complication of
becomes desensitized to odours it encounters
fistula13, and with various diverticula14,15.
continually. Additionally, psychological factors
Other researchers (in work that has yet to
be widely reproduced) studied patterns of
obsessive-compulsive disorder may distort the
halitosis in couples and suggested a possible
patients own sense of his personal mouth
link between the bacterium Helicobacter pylori
odour, potentially leading to a form of hypo-
(implicated in stomach ulcers) and breath
chondria known as delusional halitosis18. A
1996 study found that self-ratings of mouth
odour were significantly higher than the ratings
associated with periodontal health. Complain-
the narrow but convenient to the expensive
ants had a relatively higher psychopathological
score on an SCL-90 profile than an age- and
research concerns itself with establishing
gender-matched reference group not reporting
markers for halitosis. Levels of substances
A recent Japanese clinical study is indicative
of the problems with self-diagnosis: It finds
microflora) are used as instruments for
that patients entering Japanese dental clinics
levels of chemicals implicated in halitosis
were significantly less likely (by a factor of
those patients who had a different primary
complaint (say, periodontitis or gingivitis)
and a secondary complaint of halitosis. The
researchers concluded that the majority of
patients with primary complaints of halitosis
zinc-oxide and nitrogen chemiluminescence
at the dental clinic did not actually have
detectors. The chemiluminescence detector,
halitosis, but suffered from an imaginary
for example, permits the precise measure-
others attitudes. Not surprisingly, the
indole and cadaverine) in organic matrices.
researchers found that the patients whose
unconfirmed by diagnosis at the clinic were
present in heretofore-undetectable concen-
more likely to be dissatisfied with the quality
A 1996 Japanese study utilising a zinc-oxide
Another study on self-assessment21 made use
thin film semiconductor shows that this sensor
of a new microbiological test to differentiate
technology may be fruitfully employed in the
between psychogenic and organic halitosis.
The test involved observing lead sulphide
precipitation on an applicator tip imbedded
considerable power for classifying patients
halitosis) had previously been established by
ments, which significantly correlated with
Among more objective measures are the
9. Finkelstein, Y. et al. Endoscopic diagnosis and
Cost-effective and reliable management of
treatment of persistent halitosis after pharyngeal
flap surgery. Plastic and Reconstructive Surgery 92(6):
toothbrushing, flossing, and cleaning of the
10. Tichler, T., et al. Hair preservation and platelet/
tongues coat. These techniques aid in the
granulocyte sparing effect using AS101 with
chemotherapy: A randomized study (Meeting
control of the oral microflora that cause both
abstract). 18th International Congress of Chemotherapy.
halitosis and dental caries. Research has shown
that salivary concentrations of thiols (such as
11. Ogunwande, S.A. Halitosis and abuse of antibiotics.
Report of a case. Ceylon Medical Journal 34(3):131
mercaptans), which are precursors of foul
mouth odour, can be significantly reduced
12. Logio, T., et al. The management of Crohns colitis
with colonogastric fistula. Report of a case. Diseases
of the Colon and Rectum 30(9):699704.
solutions or hydrogen peroxide-containing
13. Mosimann, F. Faecaloid breath heralding secondary
toothpastes. Mouthwashes and mouth rinses
aorto-enteric fistula. Vasa 24(1):7778.
containing chlorhexidine gluconate have also
14. Tolliver, B.A. J.A. DiPalma. Zenkers Bezoar.
Southern Medical Journal 88(7):751752.
proven effective in controlling oral microbes,
15 .Cirillo, F., A. Scurelli, P. Alquati. Zenkers
but not without side effects such as tooth
diverticulum in the elderly. Description of a case
staining. More advanced treatments, such as
and surgical treatment. Minerva Chirurgica 47 (23
24):18131817. (Published in Italian).
the use of antibiotics, are rarely indicated,
16. Tiomny, E., et al. Halitosis and Helicobacter pylori.
A possible link?Journal of Clinical Gastroenterology
17. E. Ierardi et al. Halitosis and Helicobacter Pylori:
A Strong Relationship. University of Bari. Paper
presented at the Third International Conference
1. Spielman, A.I., P. Bivona, B.R. Rifkin,Halitosis: A
on Breath Odour, Vancouver, BC, 1997.
Common Oral Problem. New York State Dental
18. Iwu, C.O., O. Akpata. Delusional halitosis. Review
of the literature and analysis of 32 cases. British
2. Moss, S.J. Halitosis, Malodor. Report submitted to
the FDI Commission, October 1996, pp.16.
19. Eli, I., et al. The complaint of oral malodor. Possible
3. De Boever, E.H., M. De Uzeda, W.J. Loesche.
psychopathological aspects. Psychsomatic Medicine
Relationship between volatile sulfur compounds,
BANA-hydrolyzing bacteria and gingival health in
20. Iwakura, M., et al. Clinical characteristics of
patients with and without complaints of oral
halitosis: Differences in two patient groups with
malodor. Journal of Clinical Dentistry 4(4):114119.
primary and secondary complaints of halitosis.
4. Johnson, P.W., W. Ng, J. Tonzetich. Modulation of
Journal of Dental Research 73(9):15681574.
human gingival fibroblast cell metabolism by methyl
21. J.L. Richter. A comparison of the validity of four
mercaptan. Journal of Periodontal Research 27(5):
tests in differentiating between organic and psycho-
genic halitosis. Paper presented at the Third
5. Bosy, A., et al. Relationship of oral malodor to
International Conference on Breath Odour.
periodontitis: Evidence of independence in discrete
subpopulations. Journal of Periodontology 65(1):
22. Kozlovsky, A., et al.Correlation between the BANA
test and oral malodor parameters. Journal of Dental
6. Miyazaki, H., et al. Correlation between volatile
sulphur compounds and certain oral health
23. J. Tonzetich. Current Methods for the Detection
measurements in the general population. Journal of
and Quantification of Oral Malodour. University
of British Columbia. Paper presented at the Third
7. Kleinberg, I., G. Westbay. Salivary and metabolic
International Conference on Breath Odour,
factors involved in oral malodor formation. Journal
24. Shimura, M., et al. A new monitor with a zinc-oxide
8. Lee, W.C., J.F. Sharp. Complications of paediatric
tonsillectomy post-discharge. Journal of Laryngology
measurement of volatile sulfur compounds in
mouth air. Journal of Periodontology 67(4):396402.
DHL TIME DEFINITE - Value Added Services and Surcharges Time Definite International Value Added Service/Surcharge Description The handling and transportation of shipments containing Biological substances Category B (UN3373) Fee for change of billing instructions from Transport collect to an Import Express account numberA fee for the transport and handling of substances and commoditie
CHRONIC MEDICINE BENEFIT APPLICATION FORM APPLICATION INSTRUCTIONS (please complete this application as follows) The application must be completed in black ink. Please print clearly and legibly. One application form must be completed per patient. Kindly take note of the clinical entrance criteria for the various chronic conditions. These are detailed on pages 6 to 8. Certain entry
containing amino acids such as methionine,
cysteine and cystine. The resulting volatile
reported complaint. Whether in the form of
occasional morning breath, which nearly
every otherwise healthy adult encounters,
dimethyl sulphide and dimethyl disulphide)
or rarer and more serious problems ranging
from metabolic disorders to chest tumours,
putrescine, foul-smelling diamines) are at
halitosis is said to affect nearly 50% of the
least partially responsible for the odours of
adult population. To judge from the size of
VSC concentrations associated withhalitosis, with over 80 species from
VSCs are found in higher concentrations in
particles, cells, blood and some chemical
components of saliva. Thus 90% of causes of
halitosis arise in the mouth1. As proteins
that subjects complaining of oral malodour
and other chemicals in these materials are
had significantly more bleeding sites and
as amino acids and peptides, many volatile
bacteria than subjects who did not report
compounds) related to their decomposition
implicated in a feedback loop which begins
(smelling of rancid butter or rotting meat),
inflammation, creating oxygen-poor pockets
in the mouth (e.g. between the gingiva and
anaerobic bacteria in them. These bacteria
then begin the proteolysis of salivary and
This is particularly true of the sulphur-
odour, these VSCs increase the permeability
of the oral mucosa, speed the degradation of
wounds, and also affect gingival and other
periodontal cell function1,4. All of these
which led to the growth conditions of the
halitotic anaerobes in the first place.
with the normal circadian rhythms of sleep
is responsible for the morning breath with
It is important to note that, while poor oral
hygiene and poor oral health may often be
sufficient conditions for the development of
associated with either xerostomia or sleep
halitosis, they are not necessary conditions.
Other oral causes include ulceration from
basis with the recent development of H.
1996 study found that self-ratings of mouth
odour were significantly higher than the ratings
associated with periodontal health. Complain-
the narrow but convenient to the expensive
ants had a relatively higher psychopathological
score on an SCL-90 profile than an age- and
research concerns itself with establishing
gender-matched reference group not reporting
markers for halitosis. Levels of substances
A recent Japanese clinical study is indicative
of the problems with self-diagnosis: It finds
microflora) are used as instruments for
that patients entering Japanese dental clinics
levels of chemicals implicated in halitosis
were significantly less likely (by a factor of
those patients who had a different primary
complaint (say, periodontitis or gingivitis)
and a secondary complaint of halitosis. The
researchers concluded that the majority of
patients with primary complaints of halitosis
zinc-oxide and nitrogen chemiluminescence
at the dental clinic did not actually have
detectors. The chemiluminescence detector,
halitosis, but suffered from an imaginary
for example, permits the precise measure-
others attitudes. Not surprisingly, the
indole and cadaverine) in organic matrices.
9. Finkelstein, Y. et al. Endoscopic diagnosis and
Cost-effective and reliable management of
treatment of persistent halitosis after pharyngeal
flap surgery. Plastic and Reconstructive Surgery 92(6):
toothbrushing, flossing, and cleaning of the
10. Tichler, T., et al. Hair preservation and platelet/
tongues coat. These techniques aid in the
granulocyte sparing effect using AS101 with
chemotherapy: A randomized study (Meeting
control of the oral microflora that cause both
abstract). 18th International Congress of Chemotherapy.