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| 32 | Smile Dental Journal | Volume 7, Issue 3 - 2012 ABSTRACT There are many causes for genuine halitosis. Here, we introduce several halitosis cases experienced in our clinic. The first case was caused by poorly placed restorations. The second case was caused by an endodontic lesion, while the third was caused by periodontitis associated with internal and external resorption. The last case was caused by severe periodontitis associated with a tooth fracture. These four patients received halitosis treatment in our clinic, which resolved these long-lasting problems or oral malodor. KEYWORDS Halitosis, Oral problems, Dental treatment. The Variable Etiology of Oral Pathologic Halitosis: A Case Series Masahiro Yoneda 1 , Nao Suzuki 2 , Sonia M. Macedo 3 , Akie Fujimoto 2 , Kosaku Iha 2 , Chihiro Koga 1 , Masaro Matsuura 1 , Takao Hirofuji 2 1 Center for Oral Diseases, Fukuoka Dental College, Fukuoka – Japan – [email protected] 2 Section of General Dentistry, Department of General Dentistry, Fukuoka Dental College, Fukuoka – Japan 3 Faculdade de Odontologia da Universidade de São Paulo, São Paulo – Brazil INTRODUCTION Most pathologic halitosis is caused by oral problems, 1 of which periodontitis is perhaps the most prevalent. 2 Therefore, periodontal treatment is useful in reducing oral malodor. However, some patients visit our halitosis clinic because periodontal treatment such as scaling and tooth brushing instruction had failed to resolve this halitosis. Following extensive examination, we identified several additional problems that caused oral malodor and were thus able to target treatment to resolve their oral malodor and increase their quality of life. Here, we introduce a case series illustrating the variable etiology of oral pathologic halitosis. CASE REPORTS ON THE VARIABLE ETIOLOGY OF ORAL PATHOLOGIC HALITOSIS Oral malodor caused by unfitted restorations A 54-year-old female patient visited the Fukuoka Dental College hospital complaining of oral malodor, 3 from which she had suffered for more than 20 years. Her previous dentist performed periodontal treatment (scaling and root planning) but this did not decrease her breath odor. She therefore visited our halitosis clinic. We examined her breath odor using an organoleptic test, halimeter test 4 (Interscan, USA) and a high-precision gas chromatograph 5 (Shimadzu, Japan). The organoleptic test result (score = 3) indicated strong oral malodor, and the gas chromatograph revealed that three major volatile sulfide compounds (VSCs; hydrogen sulfide, methylmercaptan, dimethylsulfide) were all above threshold. No severe periodontal problem was observed by visual or radiographic examination (Figs. 1,2) but many ill-fitting restorations were identified in her mouth (Fig. 2). Upon removal of these restorations, we discovered severe decay in the underlying tooth tissue (Fig. 3) that necessitated extraction of one tooth and flap surgery of another to remove caries and obtain sufficient clinical crown length. After periodontal and prosthodontic treatment, oral conditions were checked (Fig. 4) and breath odor was compared with that at the first visit (Fig. 5). The VSCs were completely absent and the patient was highly satisfied with the results. Oral malodor caused by an endodontic lesion A 72-year-old male attended our hospital with a chief complaint of oral malodor and severe tooth wear 6 (Fig. 6). His breath odor had worried him for about 20 years, and we detected strong breath odor. There was little inflammation in the periodontal tissues, but malodor was detected from a restoration margin in tooth 16. No periapical radiolucency was observed (Fig. 7A) but the tooth was tender to percussion. Upon removal of the metal crown, we found no root canal filling, and severe pus discharge with strong malodor was observed. After endodontic treatment (Fig. 7B), oral malodor was drastically decreased (data not shown). The patient had been using a hard toothbrush and drinking vinegar to reduce his breath odor. After identifying the cause of his halitosis, he was advised to adopt more conventional oral hygiene habits, which halted the progression of his tooth wear (Fig. 8).
Transcript of A Case Series
| 32 | Smile Dental Journal | Volume 7, Issue 3 - 2012
ABSTRACT
There are many causes for genuine halitosis. Here, we introduce several halitosis cases experienced in our clinic. The first case was caused by poorly placed restorations. The second case was caused by an endodontic lesion, while the third was caused by periodontitis associated with internal and external resorption. The last case was caused by severe periodontitis associated with a tooth fracture. These four patients received halitosis treatment in our clinic, which resolved these long-lasting problems or oral malodor.
KEYWORDS
Halitosis, Oral problems, Dental treatment.
The Variable Etiology of Oral Pathologic Halitosis: A Case Series
Masahiro Yoneda1, Nao Suzuki2, Sonia M. Macedo3, Akie Fujimoto2, Kosaku Iha2, Chihiro Koga1,
Masaro Matsuura1, Takao Hirofuji2
1Center for Oral Diseases, Fukuoka Dental College, Fukuoka – Japan – [email protected] of General Dentistry, Department of General Dentistry, Fukuoka Dental College, Fukuoka – Japan
3Faculdade de Odontologia da Universidade de São Paulo, São Paulo – Brazil
INTRODUCTION
Most pathologic halitosis is caused by oral problems,1 of which periodontitis is perhaps the most prevalent.2 Therefore, periodontal treatment is useful in reducing oral malodor. However, some patients visit our halitosis clinic because periodontal treatment such as scaling and tooth brushing instruction had failed to resolve this halitosis. Following extensive examination, we identified several additional problems that caused oral malodor and were thus able to target treatment to resolve their oral malodor and increase their quality of life. Here, we introduce a case series illustrating the variable etiology of oral pathologic halitosis.
CASEREPORTSONTHEVARIABLEETIOLOGYOFORALPATHOLOGICHALITOSIS
OralmalodorcausedbyunfittedrestorationsA 54-year-old female patient visited the Fukuoka Dental College hospital complaining of oral malodor,3 from which she had suffered for more than 20 years. Her previous dentist performed periodontal treatment (scaling and root planning) but this did not decrease her breath odor. She therefore visited our halitosis clinic. We examined her breath odor using an organoleptic test, halimeter test4 (Interscan, USA) and a high-precision gas chromatograph5 (Shimadzu, Japan). The organoleptic test result (score = 3) indicated strong oral malodor, and the gas chromatograph revealed that three major volatile sulfide compounds (VSCs; hydrogen sulfide, methylmercaptan, dimethylsulfide) were all above threshold. No severe periodontal problem was observed
by visual or radiographic examination (Figs.1,2) but many ill-fitting restorations were identified in her mouth (Fig.2). Upon removal of these restorations, we discovered severe decay in the underlying tooth tissue (Fig.3) that necessitated extraction of one tooth and flap surgery of another to remove caries and obtain sufficient clinical crown length. After periodontal and prosthodontic treatment, oral conditions were checked (Fig.4) and breath odor was compared with that at the first visit (Fig.5). The VSCs were completely absent and the patient was highly satisfied with the results.
OralmalodorcausedbyanendodonticlesionA 72-year-old male attended our hospital with a chief complaint of oral malodor and severe tooth wear6 (Fig.6). His breath odor had worried him for about 20 years, and we detected strong breath odor. There was little inflammation in the periodontal tissues, but malodor was detected from a restoration margin in tooth 16. No periapical radiolucency was observed (Fig.7A) but the tooth was tender to percussion. Upon removal of the metal crown, we found no root canal filling, and severe pus discharge with strong malodor was observed. After endodontic treatment (Fig.7B), oral malodor was drastically decreased (data not shown). The patient had been using a hard toothbrush and drinking vinegar to reduce his breath odor. After identifying the cause of his halitosis, he was advised to adopt more conventional oral hygiene habits, which halted the progression of his tooth wear (Fig.8).
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and external resorption (Fig.10), which may relate to a previous trauma. After extraction, breath odor was remarkably decreased (data not shown).
OralmalodorcausedbytoothfractureA 56-year-old female patient visited our breath clinic complaining of strong breath odor,8 which her family had alerted her to two years previously. She had received scaling at a dental clinic but her breath odor improved only temporarily, re-emerging after only a few days. She thus visited our oral malodor clinic. Her oral hygiene was poor and we observed swelling and periodontal pockets
OralmalodorcausedbyinternalandexternalresorptionofthetoothA 39-year-old male patient visited our breath clinic complaining of strong breath odor.7 Previous dentists had performed scaling and root planing, but his oral malodor did not decrease. We could detect relatively strong breath odor. His periodontal condition was not severe except around tooth 21, which had deep periodontal pockets (Fig.9A) and evidence of vertical bone resorption on X-ray examination (Fig.9B). We reflected the flap and confirmed multiple perforations on the tooth. The extracted tooth revealed internal
(Fig.1) Intra-oral view at initial visit. Moderate inflammation and unfitted margins were observed around the restorations
(Fig.2) Dental radiograph at initial visit. Unfitted margins were observed on some restorations
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in her mouth (Fig.11). Some teeth were fractured (Fig.12) and three were subsequently extracted. We took time to motivate her to improve her oral hygiene. Her general health prevented her from attending again for three years, but when she finally visited us for oral check-up, her motivation and oral condition were both good (Fig.13) and her breath odor was mild (data not shown).
SUMMARY&DISCUSSION
There are many types and causes of halitosis.
International classification of halitosis is widely used and genuine halitosis is divided into that of oral and extra-oral origin.9,10 Most oral malodor arises from the oral cavity, in which a variety of problems can cause oral malodor, most notably periodontitis.2 Hence, periodontal treatment is often the first-line therapy for halitosis patients and is often very effective. However, some cases remain that do not respond to such treatment, which can cause significant anxiety and lead to patients visiting many dental clinics to try to resolve their problem.
(Fig.3) Upper front teeth after removing restorations. A,B: Just after removal of crown C,D: After removal of metal cores.There were deep caries around the teeth
(Fig.4) Intra-oral view after treatment. Periodontal condition was improved after treatment
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Careful examination and proper diagnosis are thus imperative for halitosis treatment.
Our first case of oral malodor was caused by a poorly adapted restoration. If the unfitted margin is hidden, it may not be immediately obvious that it is associated with oral malodor. However, through radiographic examination and careful probing of the margin, the unfitted restorations can be detected. Application of compressed air to the margin is also effective in locating the cause of oral malodor. In the absence of other problems such as periodontal disease, breath odor can be drastically decreased by contouring an unfitted restoration.
The second case, of oral malodor caused by an endodontic lesion, is rather rare, and was confounded by the absence of any obvious endodontic pathology. The tooth was properly restored and there was no periapical radiolucency. However, having identified the
(Fig.6) Intra-oral view at initial visit. Severe tooth wear was observed
(Fig.7)A:Dental radiograph of tooth 16 at initial visit. B: Dental radiograph of tooth 16 after treatment. A: No root canal filling was observed at the initial visit. B: Root canals were properly filled after endodontic treatment
Before Treatment After Treatment
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(Fig.5) Change in oral malodor before and after treatment. Dottedbars: threshold levels of each volatile sulfur compounds. *below the measuring limit of the gas chromatogram column. A: Hydrogen sulfide B: Methylmercaptan C: Dimethylsulfide
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cause, our treatment resolved the halitosis and we were able to eliminate the patient’s erosive tooth care habits.The third and fourth cases were caused by periodontitis, but both were associated with complicating factors, namely internal/external resorption and tooth fracture, respectively.
Such complications must be rigorously explored when we encounter localized vertical bone loss. In the latter case, we also had to contend with low patient motivation, a relatively rare occurrence in halitosis patients. However,
through good communication and relationship building, we were able to explain the importance of oral hygiene and teach him the requisite skills, thus instilling long-lasting motivation that enabled this patient to maintain good oral hygiene and control his breath odor over a long period.
In dealing with halitosis, we must be aware of its diverse etiology and explore fully the alternative causes through careful examination to arrive at the proper diagnosis and deliver the most appropriate treatment.
(Fig.8) Intra-oral view after treatment. Tooth wear was restored with composite resin
(Fig.9) A: Facial view of tooth 21. B: Periodontal pockets around tooth 21. C: Radiograph of tooth 21. A: Inflammation was observed around the tooth 21. B: There was a bone resorption around the tooth 21. C: There were deep periodontal pockets around the tooth 21
(Fig.10) Photographs of extracted tooth 21. A: Just after extraction. B: After removal of granulation tissues. C: Dental radiograph. Multiple perforations associated with internal and external resorption were observed
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(Fig.11) Intra-oral view at initial visit. Oral hygiene was bad, and severe inflammation was observed
(Fig.12) Dental radiograph at initial visit. There were bone resorption and tooth fractures
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ACKNOWLEDGMENTS
This work was partly supported by a Grant-in-Aid for Scientific Research (No. 20592249) and Environmental Stress and Genome Response in Control of Aging and Diseases from the Japanese Ministry of Education, Culture, Sports, Science and Technology.
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9. Miyazaki H, Arao M, Okamura K, Kawaguchi Y, Toyofuku A, Hoshi K, and Yaegaki K. Tentative classification for halitosis patients and its treatment needs. Niigata. Dent. J. 1999;32:11-5.
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(Fig.13) Intra-oral view after treatment. Periodontal condition was improved after treatment
