Surgeons carry out world’s first face,
jaw and tongue transplant
Brave dad has face rebuilt with bones
from own body following cancer
An Austrian Jewish dentist gives his
account of being in a Nazi camp following his escape-
Daily Telegraph, Sept 16, 1939.
The business of dentistry @ private practice level goes hand in
hand with the technicality and skills. From next issue we bring a
series of issues on the business aspect of dentistry. For the moment
on I hope you enjoy this issue of news and review articles.
welcome more and more of you to send your cases or articles for
Dental Follicle .
Its always amazing to hear of crash victims so badly mutilated
that they have to be identified by their dental records.What't tough
to understand it.. if they dont know who the dead fellow is, how
they know who the dentist of the dead man is???
Halitosis -Breath Malodor - A review-Part II
By Dr.Ghazala Danish MDS
Oral Diagnostitian & Radiologist
There is a saying "Listen to the patient and
he will tell you the diagnosis". This is very true for
patients with breath odor complaints. Besides what is
spontaneously told, the clinician should question about the
frequency of odor (e.g. does it happen only some weeks), the
time of appearance within the day (e.g. after meals, which
can indicate a hernia), whether others (non-confidants) have
identified the problem (imaginary breath odour?), what kind
of medications are taken, whether dryness of the mouth is
the points retrieved from this case history, which because
of the emotional character of the matter cannot be obtained
by a written questionnaire, must be used in the
(differential) diagnosis of the problem.
diagnostic approach to a malodor patient starts with a
thorough questioning about the medical history. Asking about
all the relevant pathologies for breath.
causes within the dentition are deep carious lesions with
food impaction and putrefaction, extraction wounds filled
with a blood clot, and purulent discharge leading to
important putrefaction. Interdental food impaction in large
interdental areas and crowding of teeth favor food
entrapment and accumulation of debris. Acrylic dentures,
especially when kept in the mouth at night or not regularly
cleaned, can also produce a typical smell associated with
candidiasis. The denture surface facing the gingiva is
porous and retentive for bacteria yeasts, debris, and all'
factors that cause putrefaction.
associated with gingivitis and periodontitis are almost all
Gram negative and are known to produce VSCs (Volatile
Sulfide Compounds). It is thus understandable that the VSC
levels in the mouth correlate positively with the depth of
periodontal pockets (the deeper the pocket, the more
bacteria, particularly anaerobic species) and that the
amount of VSCs in breath increases with the number, depth,
and bleeding tendency of the periodontal pockets. The low
oxygen tension in deep periodontal pockets also results in a
low pH and an activation of the decarboxylation of the amino
acids (e.g., lysine, ornithine) to cadavenne and putrescine,
two malodorous diamines. Thus, in the presence of gingivitis
or periodontitis, besides the prominent role of VSCs other
molecules might play a significant role.
themselves aggravate the periodontitis process; they
increase the permeability of the pocket and mucosal
epithelium and therefore expose the underlying connective
tissues of the periodontium to bacterial metabolites.
relevant malodorous pathologic manifestations of the
periodontium are pericoronitis, major recurrent oral
ulcerations, herpetic gingivitis, and necrotizing gingivitis
and periodontitis. Microbiologic observations indicate that
ulcers infected with gram-negative anerobes are
significantly more malodorous than non infected ulcer.
xerostomia often present with large amounts of plaque on
teeth, prostheses, and tongue dorsum. The increased
microbial load and the escape of VSCs as gases when saliva
is drying up explain the strong breath malodor.
tongue mucosa with an area of 25 cm2, shows a
very irregular surface topography. The anterior part is even
rougher because of the high number of papillae: the filiform
papillae with a core of 0.5 mm in length, a central crater,
and uplifted borders; the fungiform papillae, 0.5 to 0.8 mm
in length; the foliate papillae, located at the edge of the
tongue, separated by deep folds; and the vallate papillae, 1
mm in height and 2 to 3 mm in diameter. These innumerable
depressions in the tongue surface are ideal niches for
bacterial adhesion and growth, sheltered from cleaning
actions. Also, however, desquamated cells and food remnants
remain trapped in these retention sites and consequently can
be putrefied by the bacteria. A fissurated tongue (deep
fissures on dorsum, also called scrotal tongue or lingua
plicata) and a hairy tongue (lingua villosa) have an even
accumulation of food remnants Intermingled with exfoliated
cells and bacteria causes a coating on the tongue dorsum.
The latter cannot be easily removed because of the retention
offered by the irregular surface of the tongue dorsum. As
such, the two factors essential for putrefaction are united.
The dorsum of the tongue has therefore long been considered
as a primary; source of oral malodor. Indeed, high
correlations; have been reported between tongue coating and
odor formation. The prevalence of tongue coating is six
times higher in patients with periodontitis.
causes. With increased progesterone levels during the
menstrual cycle, a typical breath odor can develop; partners
are often well aware of this odor. Evidence also indicate
that VSC levels in the expired air are increased twofold to
four fold about the day of ovulation and in the
perimenstrual period. Increases in VSC are smaller in
Clinical and laboratory examination
It can be
worthwhile to involve the patient in monitoring the results
of therapy by self-examination, especially when an intraoral
cause has been identified. For example this can motivate the
patient to continue the oral hygiene instructions. The
following self-testing can be used:
metallic or non odorous plastic spoon after scraping the
back of the tongue
toothpick after introducing it in an interdental area
spit in a small cup or spoon.(especially when allowed to dry
for a few seconds so that putrefaction odors can escape from
?Licking the wrist and allowing
it to dry (reflects the saliva contribution to malodor
Specific Character of
?A "rotten eggs"
smell is indicative of VSCs
?A sweet odor,
which some describe as that of "dead mice," has been
associated with liver insufficiency; besides VSCs, aliphatic
?The smell of
"rotten apples" has been associated with unbalanced
insulin-dependant diabetes, which leads, to the accumulation
?A "fish odor" can suggest
kidney insufficiency characterized by uremia and
accumulation of dimethylamine and trimethylamine
some instruments are now available, the best method in the
examination of breath malodor is still the organoleptic
assessment made by a judge, who has been tested and
calibrated for his/her smelling acuity. This testing is done
by determining the threshold level for detecting a series of
dilutions of a malodorous compound such as isovaleric acid.
The discrimination power of the judge is evaluated by
presenting to him/her a series of odors for identification.
The use of
any fragrance, shampoo or body lotion, and smoking, alcohol
consumption or garlic intake is strictly forbidden 12 hours
before the assessment is made. This involves both the
patient and the judge. The judge will not wear rubber
gloves, the odor of which may interfere with the
organoleptic assessments. Assessments should be performed at
several appointments on different days, since breath odor
fluctuates dramatically from one day to the next. The
patient should be encouraged to bring a confidant to the
consultations to help him/her identify the odor causing the
problem. The judge will smell a series of different air
Oral cavity odor:
the subject opens his/her mouth and refrains from breathing;
the judge places his nose close to the mouth opening.
the subject breathes out through the mouth; the judge smells
both the beginning (determined by the oral cavity and
systemic factors) and the end (originating from the bronchi
and lungs) of the expired air.
Tongue coating scraping:
the judge smells the tongue scraping and also presents it to
the patient or the accompanying confidant to evaluate
whether they associate the smell from the scraping with the
Breath odor when breathing out through the
when the air expired through the nose is malodorous, but the
air expired through the mouth is not a nasal/paranasal
etiology should be suspected.
oro-pharyngeal examination, the clinician must look for
inflammation of the gingiva, or in the mucosa under
prosthesis. Fresh extraction wounds or interdental food
entrapment can cause bre.1th malodor. The pharynx should be
thoroughly inspected for the presence of inflamed tonsils.
The tonsils often present with crypts, which may harbor
anaerobic bacteria, pus and even calculus (tonsilloliths).
for a dentist is the examination of the nostrils, although
this is essential if the breath malodor is noticed more
clearly when the subject breathes out through the nostrils.
analyse air or incubated saliva or crevicular fluid for any
volatile component. Some hundred components were isolated,
and mostly identified, from saliva and or tongue coating,
from ketones to alkanes and from sulfur-containing compounds
to phenyl compounds.
chromatography is only available in specialized centers and
for identifying non-oral causes such as intestinal or
Portable Volatile Sulfide Monitor
electronic device (Halimeter, Interscan, Chatsworth, Calif)
analyzes the concentration of hydrogen sulfide and
methyl-mercaptan, but without discriminating them.
examination should preferably be done after atleast 4 hours
of fasting and after keeping the mouth closed for 3 minutes.
The mouth air is aspirated by inserting a drinking straw
fixed on the flexible tube of the instrument. The straw is
kept about 2 cm behind the lips without touching any surface
and while the subject keeps the mouth slightly open and
breathes normally. The sulfide meter uses a voltametric
sensor that generates signal when exposed to
sulfur-containing gases, especially, hydrogen sulfide.
Absence of breath malodor lead to readings of 100 ppb or
lower. Patients with elevated concentrations of VSCs easily
reach 300 to 400 ppb. This device can only reveal
sulfur-containing gases, which explains the poor correlation
with organoleptic measurements. Even if a large extent of
the breath malodor originating from the oral cavity is
dominated by VSCs, gases such as putresdne and cadaverine,
which call also have an intraoral origin, will remain
unnoticed by this device. The monitor needs regular
calibration and replacement of the sensors biannually.
field or Phase-contrast Microscopy
and periodontitis are typically associated with a higher
incidence of motile organisms and spirochetes. So shifts in
these proportions allow monitoring of therapeutic progress.
Another advantage of direct microscopy is that the patient
becomes aware of bacteria being present in plaque, tongue
practice, 0.5 ml of unstimulated saliva is collected in a
glass tube (diameter 1.5 cm), and the tube is flushed with
carbon dioxide (CO2) and sealed. The sealing
prevents inflow from outside air, and the glass prevents the
smell of the hardware. It is incubated at 37° C in an
anaerobic chamber under an atmosphere of 80% nitrogen, 10%
carbon dioxide, and 10% hydrogen over 3 hours. The
organoleptic ratings highly correlate With VSC and
organoleptic rating of the patient’s breath. The
discrimination power for the effect of oral rinses even
appears superior to intraoral registrations. It was
calculated that for discriminating between different oral
therapies, applying the saliva incubation test instead of
organoleptic ratings can reduce the number of patients
needed to reach statistical significance of 50%.
clinicians have the responsibility to diagnose and treat
malodor. At least 85% of breath malodors have an oral
treatment is to be preferred. The treatment of oral malodor
consists of the elimination of the pathology present, such
as deepened and inflamed periodontal pockets and/ or tongue
coating. If another underlying disease is suspected, or if
clinical experts in the different disciplines (internal
medicine, periodontology; ENT, psychology, etc.) are not
available, it is possible to rapidly (within 1-2 weeks) make
a differential diagnosis by performing a full-mouth one
stage disinfection of the oro-pharynx, including the use of
chlorhexidine spray to deal with the pharynx. Since all oral
diseases which cause malodor relate to microorganisms, this
one stage professional approach reinforced by stringent home
care will dramatically reduce the oro-pharyngeal microbiota
and the putrefraction they cause and thus the malodour. If
the symptoms do not disappear, the patient should be
referred to a specialized multidisciplinary center where gas
chromatography can help in the differential diagnosis.
breath malodor should be distinguished from etiological
treatment. It is well established that zinc-containing mouth
rinses have tI1e property to complex the divalent sulfur
radicals, reducing this important cause of malodor. Thus it
appears that the application of zincchloride
triclosan-containing toothpaste on the tongue dorsum reduces
the oral malodor for some 4 hours. Baking soda
containing dentifrices (> 20%) confers a significant
odor-reducing benefit for up to 3 hours. The use of
hydrogen peroxide rinse also offers positive perspectives.
To deal with the tongue coating it appears that tongue
brushing with chlorhexidine, besides oral rinses with the
same antiseptic, reduces the organoleptic scores
significantly. Whether the beneficial effect of tongue
brushing is related to the removal of bacteria and/ or to
the reduction of their substratum, remains an open question.
efficient are mints and other short acting "anti-breath"
odor components. Most of them have not been properly tested
in a blind way against a placebo. A recent review compared
the efficiency of oral rinses, toothpastes and cosmetics for
breath odor therapy.
is at stake, any measure to increase the salivary flow may
be beneficial. This can mean a proper fluid intake or the
use of chewing gum to trigger the periodontal-parotid
reflex, which originates from the mechanoreceptors in the
periodontal ligament of molar teeth (lower) and has the
parotid gland as a target. The presence of these molars is
therefore crucial before advocating the use of chewing gum
to enhance salivary secretion. The pH of the saliva can also
be reduced to increase the solubility of malodorous
components. Evidence shows that the effect is short-lived.
is considered the most effective anti plaque and
antigingivitis agent because of its strong antibacterial
effects and superior substantivity in the oral cavity,
chlorhexidine rinsing provides significant reduction in VSC
levels and organoleptic ratings.
oil- Listerine was found to be only relatively effective
against oral malodor.
Dioxide (ClO2) is a powerful oxidizing agent that
can eliminate bad breath by oxidation of hydrogen sulfide,
methylmercaptan and the amino acids methionine and cysteine.
Oil-Water Rinse- the efficacy of oil-water-CPC formulation
is thought to result from the adhesion of a high proportion
of oral microorganisms to the oil droplets, which is further
enhanced by the CPC. A twice-daily rinse with this product
(before bedtime and in the morning) showed reductions in
both VSC levels and organoleptic ratings.
a broad-spectrum antibacterial agent, has been found to be
effective against most oral bacteria and has a good
compatibility with other compounds used for oral home care.
malodor has important socio-economic consequences. A proper
diagnosis and determination of the etiology allows the
proper etiological treatment to be instituted quickly.
Although gingivitis, periodontitis and tongue coating are by
far the most common causes, other more challenging diseases
should not be overlooked. This can be dealt with either by a
trial therapy to deal quickly with intra-oral causes (the
full month one-stage disinfection) or by a multidisciplinary
Surgeons carry out
world’s first face, jaw and tongue transplant
Surgeons have successfully carried out
the world’s first face, jaw and tongue
They spent 16 hours
operating on a man of 43 whose face had
been horribly disfigured by radiotherapy
for a tumour 11 years ago.
The patient will eventually be able
to eat, taste, swallow and speak again.
Pedro Cavadas, who led 30 Spanish
medics in Valencia in the day-long op,
said yesterday: “The patient’s seen
himself and is delighted.”
The case was marred by controversy
after authorities released details about
the donor against his family’s wishes.
French woman Isabelle Dinoire received
the first face transplant four years ago
after losing her nose, lips and chin
when a dog mauled her.
VIDEO OF THE MONTH
Brave dad has face rebuilt with
bones from own body following cancer fight
Dad Tim Gallego feels like a new man after having his face
rebuilt from different parts of his body. Financial adviser
Tim, 46, had 16 operations to reshape his face after he was
hit with disfiguring mouth cancer. Bones from his ribs and
hips were used to form a new nose and jaw. Arteries from his
legs were moved to his neck and skin from his wrists was
grafted on to his lower face.
Months of radiotherapy followed before
he started the long process of
rebuilding his face bit by bit. And
within a week of being diagnosed Katie
found out she was pregnant with their
first child, Imogen.
Tim, from Poundbury, Dorset, said: “I
looked like a monster but I’ve always
been positive and believed I’d get back
to normal. It’s just that normal has
ended up being a bit different.”