D e n t a l    F o l l i c l e               

             The        Monthly     E-newsletter                   Vol - I V    Number-  I V   September 2009

In this Issue:

  • Editorial

  • News

  • DentistryUnited @ Rank 6 on GOOGLE

  • Laughter - The best Medicine


  • Surgeons carry out world’s first face, jaw and tongue transplant

  • Brave dad has face rebuilt with bones from own body following cancer fight                                          

  • An Austrian Jewish dentist gives his account of being in a Nazi camp following his escape-
    Daily Telegraph, Sept 16, 1939.



Editorial :

      Dear Fellow Dentist,

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.

I welcome more and more of you to send your cases or articles for Dental Follicle .

mailto: dentistryunited at gmail dot com

Click here to join DentistryUnited
Click to join DentistryUnited

Yours truly

Dr. Syed  Nabeel

Editor of Dental Follicle & WebMaster

News :


                        DentistryUnited Ranks 6 on Google  for key word "Dentistry"

Laughter - The Best Medicine :

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


Patient history

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 noticed, etc.

Several of 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.


Medical History

The proper diagnostic approach to a malodor patient starts with a thorough questioning about the medical history. Asking about all the relevant pathologies for breath.


Intra-oral causes

Possible 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.


Periodontal Infections

Bacteria 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.

VSCs 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.

Other 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.


Dry Mouth

Patients with 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.

The dorsal 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 rougher surface.

The 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.

Hormonal 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 mid-follicular phases.


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:

?  Smelling a metallic or non odorous plastic spoon after scraping the back of the tongue

?  Smelling a toothpick after introducing it in an interdental area

?  Smelling saliva spit in a small cup or spoon.(especially when allowed to dry for a few seconds so that putrefaction odors can escape from the liquid

?  Licking the wrist and allowing it to dry (reflects the saliva contribution to malodor


Specific Character of Breath Odor

?  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 acids accumulate

?  The smell of "rotten apples" has been associated with unbalanced insulin-dependant diabetes, which leads, to the accumulation of ketones.

?  A "fish odor" can suggest kidney insufficiency characterized by uremia and accumulation of dimethylamine and trimethylamine


Even though 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 samples.

?  Oral cavity odor: the subject opens his/her mouth and refrains from breathing; the judge places his nose close to the mouth opening.

?  Breath odor: 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 malodor complaint.

?  Breath odor when breathing out through the nose: 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.

In the 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).

Less obvious 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.


Gas chromatography

This can 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.

Gas chromatography is only available in specialized centers and for identifying non-oral causes such as intestinal or bronchial/pulmonary causes.


Portable Volatile Sulfide Monitor

This electronic device (Halimeter, Interscan, Chatsworth, Calif) analyzes the concentration of hydrogen sulfide and methyl-mercaptan, but without discriminating them.

The 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.



 Dark field or Phase-contrast Microscopy

Gingivitis 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 and saliva.


Saliva Incubation Test

For clinical 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%.

Dental clinicians have the responsibility to diagnose and treat malodor. At least 85% of breath malodors have an oral source.



An etiologic 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.

Masking of 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.

Hardly 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.

When dryness 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.

Chlorhexidine 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.

Essential oil- Listerine was found to be only relatively effective against oral malodor.

Chlorine 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.

Two-Phase 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.

Triciosan- 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.



Breath 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 consultation.


Surgeons carry out world’s first face, jaw and tongue transplant

Surgeons have successfully carried out the world’s first face, jaw and tongue transplant.

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.











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.”



An Austrian Jewish dentist gives his account of being in a Nazi camp following his escape-

Daily Telegraph, Sept 16, 1939.