Foetor ex ore R19.6

Foetor ex ore refers to an unpleasant odor emitted from the oral cavity (Wu 2019).

In the case of foetor ex ore, also known as "halitosis", a distinction is made between

- True halitosis: This can be physiological or pathological. In this case, the intensity of the foetor exceeds the socially acceptable level (Wu 2019).

• - Physiological halitosis is caused by putrefaction processes in the oral cavity and is primarily caused by the dorsoposterior region of the tongue (Wu 2019). It is found, for example, in morning halitosis (Hampelska 2020).
• - Pathological halitosis is divided into:

- oral pathologic halitosis caused by oral diseases.

- extra-oral patholog. Halitosis from nose, sinus and larynx, lungs, upper digestive tract (Wu 2019).

- Pseudo- Halitosis: This is perceived solely by the patient and can be improved by simple oral hygiene measures (Wu 2019).

- Halitophobia: This is when patients continue to believe they have bad breath without physical or social evidence after treatment for true or pseudo-halitosis (Wu 2019).

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Foetor ex ore can be primary (originating in expiration) or secondary (originating in the oral cavity or upper respiratory tract). It can be distinguished by comparing oral and nasal breathing (Wu 2019).

In addition, foetor is divided into:

- Intraoral Halitosis (IOH): This is found in approximately 80-90% of affected individuals (Hampelska 2020).

- Extraoral Halitosis (EOH): This can be transmitted through the blood in diabetes, liver and kidney diseases (approx. 5 - 10 %) and through the respiratory tract or gastrointestinal tract (Hampelska 2020).

Another classification comes from Aydin and Harvey- Woodworth from 2014:

- Type 0: physiological halitosis

- Type 1: oral halitosis

- Type 2: transmitted through the respiratory tract

- Type 3: from the gastroesophageal area

- Type 4: transmitted by blood

- Type 5: subjectively perceived halitosis (Hampelska 2020)

Foetor ex ore is found in approximately 35% of all adults (Herold 2022).

Foetor ex ore is caused in 80-90% of cases by local processes (Herold 2022) in the mouth, nose, and throat (primarily by tongue coating and periodontitis [Mogilnicka 2020]), in 2nd place are chronic diseases of the liver (Wu 2019), followed by pulmonary diseases. Only after that, metabolic diseases, intoxications, and odor-intensive foods come into question as causes (Messmann 2012).

Halitophobia exists in approximately 5% of the population worldwide (Wu 2019), and no specific cause for foetor ex ore is found in approximately 40% (Scully 2014). In these cases, halitosis originates predominantly from the dorsoposterior parts of the tongue or from gingival pockets (Rosien 2021).

Foetor ex ore is primarily caused by putrefactive bacteria (especially methyl mercaptan [Wu 2019]) on the back of the tongue and volatile sulfur compounds from food waste (Wu 2019).

- 1. foul odor in the mouth, nose, throat caused by:

- dental diseases

- gingival diseases

- poor hygiene of interdental spaces and gingival pockets

- bacterial plaques

- food residues

- bacterial infections, such as in diphtheria (a sweet smell of rotten apples), angina plaut- Vincenti (foul-smelling, not infrequently unilateral odor), rhinitis atrophicans (Herold 2022), which causes a fetid odor, but which cannot be perceived by the patient himself (Boenninghaus 2005).

- Onions, garlic, tobacco use.

- ulcerations due to agranulocytosis

- mucositis existing after chemotherapy

- disintegrated tumors

- xerostomia

- diseases of salivary glands in e.g. Sjögren's syndrome

- elderly people

- fasting (Herold 2022)

- Biofilm of the tongue (Ortiz 2020)

- 2. unpleasant odor of exhaled air due to:

- digestive tract diseases in case of achalasia, esophageal cancer, esophageal diveticulum, HP- infection, stenosis of gastric outlet, foreign body in upper digestive tract, ileus (Herold 2022)

- pulmonary diseases such as bronchiectasis, purulent bronchitis, lung abscess, pneumonia (Herold 2022)

- metabolic disorders with e.g. acetone odor in coma diabeticum, odor of raw liver in foetor hepaticus, urinary odor in foetor uraemicus (Herold 2022)

- absorption of the odorous substances in the intestine by e.g. consumption of onions, garlic or intoxication with arsenic, melathion, phosphorus, tellurium, organic phosphoric acid esters, selenium

- in case of unknown cause, so called essential foetor

- after ingestion of drugs from the group of acid reducers, aminothiols, anticholinergics, antidepressants, antifungals, antihistamines, steroids, antispasmodics, chemotherapeutics, food supplements and organosulfur substances (Hampelska 2020).

- 3. hallucinatory olfactory sensations in:

- psychiatric or

- neurological disorders (Herold 2022).

Risk factors for foetor ex ore are:

- Dry mouth:

This favors anaerobic bacterial putrefaction of food debris while leading to an increased gram-negative bacterial load, which in turn increases the production of sulfur compounds (Wu 2019).

- Smoking:

Smoking is associated with a detrimental effect on the periodontium on the one hand, and high levels of sulfur compounds are found in smokers (especially in gingival pockets) on the other hand, because the microbial balance is altered by smoking and the smoke itself contains sulfur compounds (Wu 2019).

- Dietary habits:

There are foods such as garlic, onions, some spices that cause temporary bad breath (Wu 2019).

- Alcohol:

Alcohol consumption (chronic) is also a potential risk factor, for the odorous by-products such as acetaldehyde likely produced during oxidation of alcohol in the mouth and liver (Wu 2019).

- Diabetes mellitus

- Obesity

- Dehydration

- Starvation state

- Stress(catecholamines and cortisol increase the production of hydrogen sulfide)

- advanced age (Hampelska 2020)

It is primarily volatile sulfur compounds such as hydrogen sulfide, dimethyl disulfide, diethyl disulfide, ethantiol, etc. that cause bad breath in exhaled air. In addition, gram-negative bacteria such as Actinobacillus actinomycetemcomitans, Bacteroides forsythus, Prevotella intermedia, Porphyromonas gingivalis may also play a role, as well as indole, skatole, acetone, ammonia, and other odorous compounds (Mogilnicka 2020).

Lack of cleaning of teeth and dental pockets results mainly in accumulation of:

- Degradation products of anaerobes such as amines, butyric acid and volatile sulfur compounds (Herold 2022). In particular, hydrogen sulfide, for which even low concentrations are sufficient, gives rise to the smell of rotten eggs (Mogilnicka 2020).

- Indoles: Indoles that can cause foetor ex ore include indole and skatole. They are produced by intraoral anaerobic Gram-negative bacteria of the oral cavity and cause a fecal odor (Mogilnicka 2020).

- Putrescine and cadaverine: They belong to diamines and are suspected to cause foetor ex ore by dental plaque. They are produced in saliva. Their odor is similar to that of spoiled fish or meat (Mogilnicka 2020).

- Acetone: Acetone is a volatile ketone produced from acetoacetate. It forms an odor of rotten apples. Elevated concentrations of acetone are found in exhaled air during fasting, high-fat or ketogenic diets, and especially in diabetic ketoacidosis (Mogilnicka 2020).

- Ammonia: Ammonia is found in the body in breath, saliva, blood, urine, and sweat. Ammonia, a breakdown product of protein metabolism, is transferred to urea metabolism via the liver (Schmuck 2008). In patients with end-stage renal failure, saliva contains high doses of urea, which makes the breath smell uremic, as do the high levels of ammonia in patients with chronic liver disease (Mogilnicka 2020).

Most commonly, secondary foetor es ore originates from the dorsum of the tongue, as this is a reservoir for anaerobic bacteria. Periodontal disease, devitalized teeth, free dental pulps, fixed orthodontic appliances, wounds, etc., also play a role (Wu 2019).

The diagnosis is usually made by an interdisciplinary team, e.g. dentist, ENT physician, internist (Herold 2022).

Foetor can be objectified by different methods such as organoleptic measurement (gold standard), electrochemical measurements, gas chromatography, test strips (Wu 2019), halimeter, etc. (Hähnel 2020). Salivary flow rate can be determined using sialometry (Hähnel 2020).

- Psychological problems

A chronic foul odor puts a lot of stress on the patient and can lead to psychological problems such as anxiety, lowered self-esteem, social withdrawal, etc. (Mogilnicka 2020). In a 2005 study by McKeown, the number of patients with psychological problems who visited a clinic specializing in foetor ex ore was 75%.

There is no generally valid therapy for foetor ex ore. Rather, an individual treatment plan must be created for each patient (Wu 2019).

- Halitosis caused by dental problems:

Therapy is through regular dental hygiene, including tongue scraper, regular dental visits with scaling, root planing, plaque removal, therapy of pericoronitis, etc. (Wu 2019).

Using a zinc toothpaste (Scully 2014).

In addition, peppermint rinses or antiseptic solutions such as chlorhexidine can be administered regularly (Wu 2019).

Probiotics:

Administration of the probiotics Lactobacillus salivarius or Streptococcus salivarius has also been shown to be helpful. However, studies on any long-term effects are lacking here to date (Wu 2019).

- Extraoral Halitosis:

Treatment of the respective cause of foetor ex ore (Herold 2022).

Patients in whom no cause for foetor ex ore can be found despite extensive investigations should also be assigned to this group and referred to appropriate specialists (Wu 2019).

- Patients with pseudomouth odor:

The examination results should be explained to them in detail (Wu 2019).

In a study published by Scully (2014), no evidence was found on prognosis.

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