ORIGINAL PAPERS Adv Clin Exp Med 2007, 16, 3, 411 416 ISSN 1230 025X Copyright by Silesian Piasts University of Medicine in Wrocław ZBIGNIEW KOZŁOWSKI 1, BARBARA BRUZIEWICZ MIKŁASZEWSKA 2, TOMASZ KONOPKA 1, ZUZANNA DRULIS KAWA 3, EWA LEWCZYK 4 Using a Halitometer to Verify the Symptoms of Halitosis Wykorzystanie halimetru do weryfikacji objawów halitozy 1 Department of Parodontology Department of Oral Pathology Silesian Piasts University of Medicine in Wrocław, Poland 2 Department of Prosthodontics Silesian Piasts University of Medicine in Wrocław, Poland 3 Institute of Genetics and Microbiology University of Wrocław, Poland 4 Bacteriological Laboratory Korczak Lower Silesian Pediatric Center in Wrocław, Poland Abstract Background. Halitosis, or bad breath, is believed to be caused by the metabolism of microorganisms, mainly anaerobic bacteria, inhabiting the oral cavity which release volatile sulfur compounds (VSCs). The high incidence of this condition and the lack of effective treatment methods make it a significant problem of contemporary den tistry. Objectives. The aim was to objectivize halitosis symptoms using a halitometer and to determine the microbiolog ical spectrum from smears collected from the tongue root and periodontal pockets of patients with clinical symp toms of halitosis. Material and Methods. The study involved 67 patients of both sexes, divided into two groups: those with symp toms of halitosis (36 subjects, mean age: 38.0 years) and those without (31 subjects: mean age: 33.8 years). Subjects classified as generally healthy were qualified for the examinations. Halitosis symptoms were objectivized using a halitometer (RH 17 Halimeter, Interscan Corp., USA and Canada) in units of parts per billion (ppb). Mean halitometric readings (from three examinations) above 125 ppb were considered halitosis positive. Clinical exam ination evaluated oral hygiene (PIl index according to Loe and Silness, PI2 according to O Leary, and API accord ing to Lange et al.) and the condition of the periodontium (PBI index according to Saxer and Muhlemann and peri odontal pocket depth using a Periprobe electronic probe on four dental surfaces). Bacteriological evaluation involved smears from the back of the tongue and, in case of inflammation, also from the periodontal pockets. Statistical analysis was performed using the chi squared test and the non parametric Mann Whitneys U test assum ing a level of significance of p < 0.05. Results. The bacterial species Prevotella oralis, Prevotella dentalis, and Leptotrichia buccalis significantly affect ed the VSC levels. The highest halitometer values were observed in patients whose bacterial levels were high. The clinical parameters did not differ significantly between the groups. Conclusions. The use of a halitometer enables an objective, reproducible measurement of volatile sulfur com pounds in expired air. Halitometer readings increase with increased levels of some oral bacteria. Tests using a hal itometer confirm less objective organoleptic examinations; however, it should be remembered that the instrument does not evaluate other smells (Adv Clin Exp Med 2007, 16, 3, 411 416). Key words: halitometer, halitosis, volatile sulfur compounds, bacteria. Streszczenie Wprowadzenie. Halitosis określana także jako fetor ex ore, fetor oris, oral malodor lub bad breath oznacza nie świeży oddech. Za przyczynę halitozy uważa się metabolizm mikroorganizmów (głównie bakterii beztlenowych) w jamie ustnej, powodujący powstawanie lotnych związków siarki (VSC volatile sulfur compounds). Częste wy stępowanie tej dolegliwości i brak skutecznych metod jej leczenia powoduje, że jest to istotny problem współcze snej stomatologii. Cel pracy. Obiektywizacja objawów halitozy za pomocą halimetru RH 17 SERIES. Określano ponadto spektrum mikrobiologiczne z wymazów pobranych z nasady języka i kieszonek przyzębnych u pacjentów z klinicznymi ce chami halitosis. * This study was supported by grant No. 0341/P05/2002/23 from the Polish Committee for Scientific Research (KBN).
412 Z. KOZŁOWSKI et al. Materiał i metody. Badaniem objęto 67 osób, obu płci, podzielonych na dwie grupy: I z objawami halitozy 36 osób (średnia wieku 38,0) oraz II bez objawów halitozy 31 osób (średnia wieku 33,8). Do badania kwalifikowa no osoby ogólnie zdrowe. Jako kryterium obiektywizacji objawu halitozy przyjęto wskazania halimetru RH 17 SE RIES produkcji Interscan Corporation (USA & Canada) w jednostkach ppb. Za wartość graniczną przyjęto średnie (uzyskane z 3 pomiarów) wskazanie halimetru powyżej 125 ppb. W badaniu klinicznym oceniano stan przyzębia i higieny jamy ustnej. Badanie kliniczne obejmowało ocenę higieny jamy ustnej wskaźniki PI1 wg Löe i Silnes sa, PI2 wg O Leary oraz API wg Lange et al.; stanu zapalnego tkanek przyzębia wskaźnik PBI wg Saxera i Mühle manna oraz pomiar głębokości kieszonek z użyciem sondy elektronicznej Periprobe przy 4 powierzchniach zębo wych (GK). Do badań bakteriologicznych używano wymazów pobranych z tylnej ściany języka, a w przypadku za palenia przyzębia również z kieszonek przyzębnych. Analizę statystyczną wyników dokonano z użyciem testu χ 2 oraz nieparametrycznego testu U Manna Whitneya, przyjmując poziom istotności p < 0,05. Wyniki. Na wzrost stężenia lotnych związków siarki, mierzonego w ppb, wyraźny wpływ wśród zbadanych bak terii mają: Prevotella oralis, Prevotella dentalis, Leptotrichia buccalis. Największe wartości ppb występowały u tych pacjentów, u których występowała duża liczba oznaczanych bakterii. Badane wskaźniki kliniczne nie róż niły się istotnie w obu grupach. Wnioski. Użycie halitometru pozwala na obiektywny i powtarzalny pomiar stężenia lotnych związków siarki w wydychanym powietrzu. Na podwyższanie wskazań halimetru wpływa wzrost liczby niektórych bakterii wystę pujących w jamie ustnej. Testy wykonane halimetrem potwierdzają mniej obiektywne badania organoleptyczne, należy jednak brać pod uwagę to, że halitometr nie ocenia innych czynników zapachowych (Adv Clin Exp Med 2007, 16, 3, 411 416). Słowa kluczowe: halitometr, halitoza, lotne związki siarki, bakterie. Halitosis, also referred to as fetor ex ore, fetor oralis, and maldolor, simply means bad breath. The condition affects about five million adult Ame ricans, 24% of Japanese, and about 1/8 of the investigated patients in the present authors obser vations [1, 2]. Halitosis is believed to be caused by by products of the metabolism of microorganisms (mainly anaerobic bacteria) inhabiting the oral cav ity. About 90% of the by products consist of volatile sulfur compounds (VSCs), mainly hydro gen sulfide and methyl mercaptan [3, 4]. The effect of other volatile substances formed by lysine and ornithine decarboxylation, such as cadaverine, has also been confirmed [5]. Dental and otolaryngolog ical causes of halitosis are found in about 87% of patients who seek advice for this problem. About 8% of cases are due to gastroenterological, pul monological, nephrological, and other causes, while in 5% of cases the cause remains unknown [1, 2]. The condition is influenced by diet, smok ing, xerostomia, and some drugs (mainly anti cholinergics and neuroleptics). Moreover, potential effects of bad oral hygiene and the condition of the marginal periodontium such as gingivitis and peri odontitis have been postulated [6]. Halitosis is a difficult therapeutic problem and permanent eradication of the condition is rarely achieved. It requires interdisciplinary cooperation of the dentist not only with a microbiologist, but also with other specialists, especially family doc tors, because of their knowledge of the somatic disorders of their patients. Bad breath is a subjec tive phenomenon reported by patients and their relatives, which is a reason for significant discom fort for the affected persons. Thus a dentist who is confronted with such a complaint has to face the difficult problem of objectivizing the reported symptoms and their eradication. There are several methods of evaluating the level of halitosis [3, 4, 7]. Organoleptic methods are inaccurate due to the different smell sensitivities of examiners. These problems can be overcome by using a halitometer. This instrument is used for the measurement of VSCs present in the air expired through the mouth, such as hydrogen sulfate (H 2 S), methyl mercaptane (CH 3 SH), and also, to a lesser degree, dimethyl sulfide (CH 3 ) 2 S. The examination involves all the components, and the result in ppb (parts per billion) reflects the total VSC content. However, it should be remembered that the final results may be affected by, among others, alcohol, smoking, aromatic oils, and oral hygiene fluids [3, 8 10]. Despite certain limitations, such as the fact that the halitometer only measures the levels of VSCs, with no regard for other smells such as cavaderin [5, 11, 12], the use of this instrument enables obtaining objective and reproducible results and seems to be the most reliable method for evalu ating halitosis intensity. The aim of the study was to objectivize halitosis by means of the RH 17 model Halimeter (Interscan Corporation, USA and Canada). Moreover, the microbiological profile was determined from smears collected from the root of the tongue and periodontal pockets of patients with clinical symptoms of halitosis and a control group. Material and Methods The study involved 67 patients of both sexes divided into two groups: group I with symptoms of halitosis (36 subjects, mean age: 38.0 years) and
Verifying the Symptoms of Halitosis 413 group II without (31 subjects, mean age: 33.8 years). Subjects classified as generally healthy were qualified for the examinations, while those with active dental caries, gangrenous teeth, or prosthetic restorations were excluded from the study. The subjects were advised not to use any oral fluids or pastes containing chlorhexidine prior to the examination due to their halitosis reducing effect [13]. The readings of the RH 17 Halimeter in units of ppb were assumed as the objectivization criterion for halitosis symptoms. Mean (from three readings) readings above 125 ppb were considered halitosis positive. The measurements were per formed in the morning before meals. The clinical examination included an evalua tion of oral hygiene: the PIl index according to Loe and Silness, the PI2 index according to O Leary, and the API index according to Lange and colleagues [14]. Evaluation of the periodon tium included the PBI index according to Saxer and Muhlemann [14] and the depth of the peri odontal pockets using a Periprobe electronic probe on four dental surfaces (GK). The bacteriological examinations involved smears from the posterior surface of the tongue and, in case of periodontitis, also from the peri odontal pockets, collected on Portagerm Amies transport medium manufactured by BioMerieux. The samples were delivered to the laboratory with in an hour from collection. For aerobic bacteria the material was cultured on Columbia agar plus 5% sheep blood (SB), MacConkey agar, and mannitol salt agar. Yeast like fungi were cultured on Sabouraud chloramphenicol agar. The plates were incubated in an oxygen atmosphere at 35 C for 24 48 h. For anaerobic bacteria, Schaedler agar plus 5% SB, Schaedler Neo Vanco agar plus 5% SB, and Columbia CAN agar plus 5% SB plates were used. The plates were incubated in an anaerobic atmosphere using the Genbox system manufac tured by BioMerieux at 35 C for 7 days. Statistical analysis of the results was per formed using the chi squared test and the non parametric Mann Whitney U test assuming the level of significance at p < 0.05. Results Mean halitometer values and the clinical para meters of both groups are presented in Table 1. No significant differences in the levels of halitosis as expressed in ppb and the condition of the oral cav ity as expressed by the periodontal and hygiene indices were found. Table 2 presents a list of the bacteria cultured in both groups of subjects, show Table 1. Mean halitometer values and the evaluated clinical parameters Tabela 1. Średnie wartości ppb oraz oceniane wskaźniki kliniczne Clinical parameter Group I: with halitosis Group II: without halitosis Significance (Wskaźnik kliniczny) (Grupa I z objawami halitozy) (Grupa II bez objawów halitozy) of differences (n = 36) (n = 31) (Istotność różnic) p < 0.05 X SD X SD Mean age years 38.00 33.78 NS (Średnia wieku lata) Halimeter value ppb 192.94 39.71 52.61 17.46 0.032* (Wskazanie helimetru ppb) Number of teeth 24.64 3.93 26.42 1.93 NS (Liczba zębów) PII 0.35 0.54 0.44 0.70 NS PI2 (%) 25.3 37.5 26.4 36.7 NS API (%) 33.2 42.2 29.2 36.9 NS PBI 0.74 1.06 0.89 1.32 NS GK 1.81 2.69 1.63 2.17 NS The clinical examination included an evaluation of oral hygiene: PIl index according to Löe and Silness, PI2 according to O Leary, and API according to Lange et al., and evaluation of periodontal tissue: PBI index according to Saxer and Mühlemann, and the depth of periodontal pockets using a Periprobe electronic probe on four dental surfaces (GK) and ppb above 125 units. Badanie kliniczne obejmowało ocenę higieny jamy ustnej: wskaźniki PI1 wg Löe i Silnessa, PI2 wg O Leary oraz API wg Lange et al.; stanu zapalnego tkanek przyzębia: wskaźnik PBI wg Saxera i Mühlemanna oraz pomiar głębokości kieszonek z użyciem sondy elektronicznej Periprobe przy 4 powierzchniach zębowych (GK) i ppb > 125 jednostek.
414 Z. KOZŁOWSKI et al. Table 2. Bacteria and fungi cultured in the individual study groups Tabela 2. Bakterie i grzyby wyhodowane w poszczególnych grupach Bacteria Group I: Group II: without Test chi squared with (Nazwa bakterii) with halitosis halitosis Yates correction (Grupa I z obja (Grupa II bez obja (Test χ 2 z poprawką wami halitozy) wów halitozy) Yatesa) N = 36 N = 31 Aerobic Streptococcus oralis 34 30 Ns (Tlenowe) Actinetobacter jonsonii 1 0 Ns Cedecea sp. 0 1 Ns Comamonas testosteroni 0 1 Ns Enterobacter cloacae 3 0 Ns Enterobacter amnigenus 1 0 Ns Hafnia alvei 1 0 Ns Serratia marcescens 1 0 Ns Serratia liquefaciens 1 0 Ns Pseudomonas putida 1 0 Ns Staphylococcus aureus 0 1 Ns Klebsiella pneumoniae 3 0 Ns Neisseria sp. 33 27 Ns Anaerobic Prevotella buccalis 2 3 Ns (Beztlenowe) Prevotella intermedia 1 0 Ns Prevotella oralis 21 4 0.003 Peptostreptococcus prevoti 2 0 Ns Eubacterium lentum 1 1 Ns Peptostreptococcus micr 1 0 Ns Peptostreptococcus sp 3 0 NS Prevotella denticola 13 2 0.0091 Leptotrichia buccalis 8 0 0.0156 Enterobacterium sp. 1 0 Ns Veillonella sp. 17 15 Ns Clostridium sp. 3 3 Ns Capnocytophaga sp. 4 3 Ns Actinomyces sp. 3 2 Ns Candida albicans 2 2 Ns ing a higher prevalence of Prevotella oralis (p = 0.003), Prevotella dentalis (p = 0.0091), and Leptotrichia buccalis (p = 0.0156) in the group of patients with halitosis than in the group without. The highest halitometer values were observed in those patients in whom the levels of the evaluated bacteria were high. Discussion The use of a halitometer enables an objective and reproducible measurement of the levels of volatile sulfur compounds in expired air. Tests per formed with this instrument confirm the less objective organometric evaluation; however, it should be considered that the halitometer does not measure other smells, such as cadaverin. In this study no difference was found between the levels of halitosis expressed in ppb and the condition of the oral cavity expressed by the periodontium and hygiene indices (Table 1). The effect of oral hygiene and the condition of the periodontium on the incidence of halitosis has been confirmed in other reports [13, 15 17]. However, the results seem to indicate that the inci dence and intensity of halitosis may not really be affected by oral hygiene, but rather by the compo sition of the oral bacterial flora. Other studies [18] have demonstrated increased levels of VSCs in patients with deep periodontal pockets (> 4 mm) in comparison with subjects with a clinically healthy periodontium. However, the authors suggest that the reason lies not in the condition of the peri odontium, but in the increased incidence of coated tongue in patients suffering from periodontopathy. On the other hand, Bosy et al. [19] indirectly asso ciate periodontal disease with halitosis by the pos sibility of the release of sulfur compounds and volatile fatty acids (such as butyric acid and propi onic acid) by bacteria inhabiting subgingival plaque. The lack of this association in the present study may result from the fact that the patients with periodontal disease were receiving periodon tal treatment at the time of halitosis measurement, which might have affected the final outcome.
Verifying the Symptoms of Halitosis 415 Iwanicka Grzegorek and colleagues [12] used a Halimeter to examine 295 patients, including 202 women, and obtained a similar outcome, i.e. 125 ppb. The studies demonstrated the highest incidence of halitosis in the age group of 25 34 years and confirmed an association between organoleptic evaluation and halitometric measure ments, consistent with the observations of the pre sent study. Patients reporting an unpleasant odor from the mouth that could be smelled by the exam iner during halitometric measurement always revealed values 125 ppb. Halitosis is strictly associated with the pres ence of bacteria which, in the course of their metabolism, release the volatile compounds responsible for bad breath. This problem has been addressed by many authors [4, 20 22]. Claus et al. [23] described about 85 chemical compounds which do not contain sulfur atoms but contribute to halitosis. The analysis of the culture findings (Table 2) allows drawing the hypothesis that the increase in the levels of VSCs as measured by the halitometer is significantly affected, among others, by Prevotella oralis (p = 0.003), Prevotella den talis (p = 0.0091), and Leptotrichia buccalis (p = 0.0156). The highest halitometer values were observed in those patients who had significant amounts of the evaluated bacteria (Tables 1 and 2). The studies by Kishi et al. [20] showed an associ ation between unpleasant odor from the mouth and such VSC producing bacteria as Porphyromonas gingivalis, Prevotella intermedia, Bacteroides forsythus, and Treponema denticola. Moreover, bad breath is also associated not only with coating of the tongue, but especially with the presence Porphyromonas gingivalis in the tongue coat. Gancarz et al. [21] showed evidence for an associ ation between halitosis and such Gram negative bacteria as Enterobacter cloacae, Enterobacter amnigenes, Pseudomonas Putida, Comomonas testosterone, and Cedeacea spp. On the other hand, Goldberg et al. [22] point to the role of Enterobacter and Klebsiella bacteria in the etiolo gy of halitosis. The problem of the incidence of halitosis is still current. A wider understanding of its etiology and new diagnostic possibilities should contribute to finding methods of prevention and effective management of this condition. The authors conclude that the use of the halit ometer enables an objective, reproducible mea surement of volatile sulfur compounds in expired air. Halitometer readings increase with increased levels of some oral bacteria. Tests with the use of the halitometer confirm the less objective organoleptic examinations; however, it should be remembered that the instrument does not evaluate other smells. 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