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Halitosis: Problem Solved!

Personal space is defined as the region surrounding a person which they regard as psychologically theirs.  Nothing can expand this space quicker than someone with bad breath.  We have all experienced it.  The smell can hit you like a load of bricks.  Your body involuntarily responds by backing up, and you pretend nothing is wrong.  I don’t care how good looking he or she may be, all you want to do is end the conversation and get out of there!

As a dentist, sometimes it is even difficult for me to let my patients know they have bad breath.  I detect it usually through organoleptics or the art of using ones nose to smell the smells.  This technique can be quite accurate.  It can distinguish between cigarettes, coffee, periodontal disease, stomach content, sinus infection, kidney disease, liver disease, diabetes mellitus, garlic, kimchi and gram negative anaerobes.

The human body is a most fascinating specimen of creation.  It is basically a hollow tube with bacteria, fungi and viruses living all over it.  It is of course sterile inside the tissue, but inside in the gut and on the skin it is teaming with trillions of microbes.  There are many different types of bacteria.  Some eat proteins, some eat fats, some eat carbohydrates, and some eat a combination of all nutrients in the human diet.  Some use oxygen in their respiration like we do, and others use sulfur in their respiration.  Sulfur is the oxidative element right under the periodic table from oxygen.  Bacteria that use sulfur instead of oxygen for respiration are called anaerobes (or without oxygen).  Different parts of the body support populations of microbes of different kinds. They are called the normal flora.  The mouth has some 500+ different normal flora.  Each individual bacteria are normally found infecting a certain percentage of the total amount of normal flora, and when they grow to a larger percentage usually found in the normal flora, they are considered a super-infection.

Gram negative anaerobes of the mouth are part of this normal flora.  They live out of sight in the dark crevasses of the mouth where oxygen has a hard time penetrating.   There they live on sulfur containing amino acids like cysteine, and methionine.  On their outer cellular membrane are special receptor sites that detect, attach to, and then pull in sulfur containing amino acids to be digested.  As the bacteria uses the sulfur to digest the amino acids, hydrogen sulfide gas is formed, and releases as a by-product of respiration just as we release carbon dioxide from our lungs with our oxygen respirations.  Hydrogen sulfide gas is a very volatile and potent smelling gas.  It is the compound that gas companies put into propane and natural gas so we can detect even the tiniest leak in their pipe lines.  Other volatile sulfur gases are cadaverine, and putrazine that are formed from anaerobic bacteria in decomposing animal carcasses.

When for whatever reason gram negative anaerobes erupt into a super-infection in our mouths, others can detect the volatile sulfur compounds in our breath through organoleptics well outside of their personal space.  This can be a devastating effect.  Humans are basically social animals (Facebook) and crave others attention.  When they have halitosis this personal social network breaks down and in some case even is turned-off.  Lets face it, bad breath is bad!

 

Killing Bacteria by the Millions!

How many of us have heard that claim from a mouthwash?  This, believe it or not, is true! There are millions upon millions of bacteria inside the normal mouth at any one time. Remember, they are called the normal flora.  They are setup in a hierarchy of good to bad.  The good ones are the most populated one in the mouth, and the bad ones are the least.  Unless you are counting the over fed Streptococcus mutans in some people’s mouths, which is fodder for another blog on bacterial plaque.  So when you use a bactericidal mouthwash you indeed wipe out a very large portion (millions) of the good bacteria and not necessarily the bad one which are hiding in the oxygen poor regions of the mouth. The heavy flavoring oils inside the mouthwashes then effectively mask the smell after that.  You also do not kill yeasts, that have a plant-like cell wall to protect themselves from the mouthwashes toxic effects.  One of the functions of a large population of good bacteria is to subdue, and inhibit the overgrowth of bad bacteria such as gram negative anaerobes. Continually “knocking-off” the good bacteria often leaves room for those lower percentage “bad” bacteria, and yeasts to overgrow into a super-infection, thus creating an imbalance in the normal flora of the mouth.  Chronic bacterial and yeast imbalances in the mouth’s normal flora can cause halitosis.

As a side note:  Most of the manufacturers of mouthwash say on their websites that it is gingivitis and periodontal disease that causes bad breath.  Some want you to scrape your tongue as well (which is good to do, but generally not as effective as you would like against halitosis).  This unfortunately is what most dentists think, too.  The patient asks, “Geez doctor, I think I have bad breath.  What should I do for that?”.  The doctors answer, “Schedule yourself for a prophy cleaning and check-up regularly, and you will not have that problem”.  If this is true, then how come we have patients with no gingivitis or periodontal disease with very bad halitosis?

Alcohol Containing Mouthwashes:

There are many products on the market today that claim to prevent bad breath, but do they?  Most of the mouthwashes on the market today that have become a household name through millions of dollars in advertising, contain some kind of alcohol.  Alcohols are a  dehydrating,  oxidative,  soluble chemical that when placed in the mouth, essentially dries out the mucous membranes of the cheeks, gums, throat and tongue causing them to eventually slough off their outer layer of epithelium. Similar to when our skin peels from a sunburn.  This in effect cause more sulfur containing amino acids that are found in the epithelial tissues to be available for the anaerobic bacteria to eat, and digest, thus causing a rebound halitosis, or a return customer for the mouthwash industry.  It can become a mad cycle where the customer (you) can consume literally gallons of mouthwash per year.

I am happy to say that manufacturing companies are seeing the writing on the wall, and listening to dentists who are telling our patients to only use non-alcoholic fluoride containing mouthwashes.  Even Listerine has followed suit by marketing a non-alcoholic mouthwash.  It still doesn’t contain fluoride though, so I wouldn’t recommend it to my paitents.

Fluoride Containing Mouthwashes:

It simply makes no sense to me why a mouthwash would be manufactured today without fluoride.  I find there are just not enough anti-fluoride people in the market to cater to.   Even these non-alcoholic mouthwashes also indiscriminately kill off the normal flora of the mouth as well. Interfering with the normal flora can cause significant rebound halitosis.

 

Zinc Containing Dental Health Products:

There are many new and old products that have proprietary zinc compounds in their formula that have been proven to prevent halitosis caused by anaerobic bacterial respiration of sulfur containing amino acids in the mouth.  They are designed to usually NOT kill bacteria by the millions or disrupt the normal flora of the mouth.  Instead, the zinc containing compounds block the receptor sites on the outside of the bacterial membranes, thus blocking the uptake of sulfur containing amino acids in the first place.  If the bacteria cannot get the sulfur into their cells, then they cannot produce hydrogen sulfide gas. No gas, no halitosis.  It’s really that simple!  Over time, using these zinc containing products, the normal flora percentages are re-established and the patient may possibly be weaned off of mouthwashes altogether.

Products:

  • Smart Mouth (this is the one I recommend) has a patented zinc-ion technology that was settled in a lawsuit by their competitor Oxyfresh.  It is sold as a pair of pump bottles.  One pump bottle contains a minty fresh bluish-green liquid that contains all the zinc-ion technology (proprietary zinc chloride compound), and flavorings, and the other contains a nearly tasteless activator.  You simply pump a small amount of each bottle into a medicine cup, swish for about 30 seconds and expectorate.  I find this product to be very inexpensive and last a very long time because only a small amount is needed for the effect.  The results are immediate and long lasting fresh breath.  You can literally use it in the morning and prevent anaerobic bacterial halitosis for up to 12 hours.  If you use it before bedtime, you can prevent the dreaded morning breath.  And the mouthwash is sodium lauryl sulfate free!  Too bad the Smart Mouth toothpaste isn’t.
  • TheraBreath PLUS Mouthwash zinc gluconate
  • Tom’s Wicked Fresh mouthwash with zinc chloride
  • Oxyfresh zinc acetate

Who should use these products? Of course, this answer in simple: Anyone who thinks they may have halitosis. Why even ask this question?  There are really only three types of patients when it comes to halitosis.

  1. Those who have halitosis, and know it
  2. Those that don’t have halitosis, but think they do
  3. Those that have halitosis, and don’t think they do

The first category are the easiest to treat.  Just tell them about Smart Mouth and direct them to the nearest Walmart, Target or Walgreens.  Teachers, sales people, lawyers, doctors, speakers, politicians, actors, you name it, routinely use this product every morning before they encounter the public.

The second group are the ones who cannot be convinced their breath is okay.  For those people we can put them on a halimeter to measure the concentration of sulfur dioxide in their breath, and they still don’t believe it.  A halimeter is portable gas chromatograph calibrated to measure volatile sulfur compounds.  Again, the treatment for these patients is simple.  You put them on Smart Mouth mouthwash, and it will not hurt.

The third group is the one that is tricky to work with.  They are the ones who come in for a dental appointment, and you smell their bad breath.  This bad breath is even there after their very thorough cleaning.  What do you do as a dentist/hygienist?  Unfortunately, most dentists and hygienists don’t want to inform a paying patient that they have a bad breath problem. After all, how do you tell someone they have bad breath without offending them?  It is a really big problem as you can imagine.  Think about how you would feel if someone told you you had halitosis right after you spent money to get your teeth cleaned.  Not fun!

Halitosis.  If you think about it, who would be better to tell someone about their super-infection than a dental professional?  This is how I do it, and if you have a better way, then I’m all ears.  There are really two ways I can start off the conversation.  Sometimes I’ll say out loud to my hygienist, “Did you detect volatile sulfur compounds?”.  For which the hygienist is trained to say, “Yes”.  Then I go on with the exam.  If the patient doesn’t catch the bait by asking what are volatile sulfur compounds, then I’ll ask if they use a mouthwash.  If they say “Yes”, then I ask them why.  This can then launch into switching to a better more effective mouthwash.  If they say “No”, then you have to tell them you have detected volatile sulfur compound in their breath caused by a super-infection of gram negative anaerobes.  This usually gets a bovine stare back from the patient before I dive into normal flora, bad bacteria, sulfur containing amino acids and proprietary zinc compounds.  Then I tell them about Smart Mouth, and hope for the best.  This does take a lot of time to counsel the patient, and I understand there is a dental assistant tapping their foot wanting you somewhere else.  This is one of the main reasons why I, and other dentists/hygienists don’t spend the time needed to inform the patient of the treatment for halitosis.  There could even be a down side to this scenario where you may not have presented the message very well, and the patient gets upset, and decides to take their business elsewhere.  Bummer!  Fortunately, I don’t think I have insulted anyone to that extent, but I could have, especially in the beginning, which was at least 15 years ago when Smart Mouth use to be called TriOral, and was only sold to the patients by dental offices.  I am so glad we don’t have to do that anymore.  I am perfectly happy to refer them to the nearest big chain pharmacy, to not have to keep an inventory of this product myself, and be the products only salesman.

References:

1. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006701. Mouthrinses for the treatment of halitosis. Fedorowicz ZAljufairi HNasser MOuthouse TLPedrazzi V. UKCC (Bahrain Branch), Ministry of Health, Bahrain, Box 25438, Awali, Bahrain. zbysfedo@batelco.com.bh

2. Eur Arch Otorhinolaryngol. 2011 Feb 16. A New Tool Measuring Oral Malodor Quality of Life. Kizhner VXu DKrespi YP. Department of Otolaryngology Head and Neck Surgery, St. Luke’s-Roosevelt Hospital Center, University Hospital of Columbia University, 425W 59 street 10th floor, New York, NY, 10019, USA, vkizhner@gmail.com.

3. Curr Probl Dermatol. 2011;40:107-15. Epub 2011 Feb 10. Oral care. Hitz Lindenmüller ILambrecht JT. Clinic for Oral Surgery, Oral Radiology and Oral Medicine, School of Dentistry, Basel University, Basel, Switzerland.

4. Beijing Da Xue Xue Bao. 2011 Feb 18;43(1):22-25. [Effect of oral rinse with Turkish gall on the clinical periodontal parameters and halitosis.] [Article in Chinese] An YBHe LMeng HXLiu TTYan FH. Department of Periodontology, Peking University School and Hospital of Stomatology, Beijing 100081, China.

5. J Clin Dent. 2011;22(1):23-6. Short-term germ-killing effect of sugar-sweetened cinnamon chewing gum on salivary anaerobes associated with halitosis. Zhu MCarvalho RScher AWu CD. Department of Pediatric Dentistry, College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA.

6. Am J Dent. 2010 Sep;23 Spec No B:27B-31B. Breath malodor reduction with use of a stannous-containing sodium fluoride dentifrice: a meta-analysis of four randomized and controlled clinical trials. Feng XChen XCheng RSun LZhang YHe T. Department of Preventive and Pediatric Dentistry, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Basic Research Academic Discipline, China

7. J Clin Dent. 2010;21(4):96-100. Evaluation of the antimicrobial activity of dentifrices on human oral bacteria. Haraszthy VIZambon JJSreenivasan PK. School of Dental Medicine, University at Buffalo Buffalo, NY, USA.

8. Kathmandu Univ Med J (KUMJ). 2010 Apr-Jun;8(30):269-75. Halitosis: much beyond oral malodor. Ongole RShenoy N. Department of Oral Medicine &Radiology, Manipal College of Dental Sciences, Mangalore.

9. Srp Arh Celok Lek. 2010 Sep-Oct;138(9-10):564-9. [Oral lesions in patients with psychiatric disorders]. [Article in Serbian] Jovanovi? SGaji? IMandi? BMandi? JRadivojevi? V. Department of Public Health, School of Dentistry, University of Belgrade, Belgrade, Serbia. svetlanajr@ptt.rs

10. Can J Gastroenterol. 2010 Sep;24(9):552-6. The gastrointestinal aspects of halitosis. Kinberg SStein MZion NShaoul R. Pediatric Department, Bnai Zion Medical Center, Kiryat-Ata, Haifa, Israel.

11. Intern Emerg Med. 2010 Dec 8. [Epub ahead of print] Halitosis: could it be more than mere bad breath? Campisi GMusciotto ADi Fede ODi Marco VCraxì A. Sector of Oral Medicine, Department of Oral Sciences, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy, campisi@odonto.unipa.it.

12. J Orofac Orthop. 2010 Nov;71(6):430-41. Epub 2010 Nov 17. Halitosis, oral health and quality of life during treatment with Invisalign(®) and the effect of a low-dose chlorhexidine solution. [Article in English, German] Schaefer IBraumann B. Department of Orthodontics, University of Cologne, Cologne, Germany. isabelle.schaefer@uk-koeln.de

13. Gut Liver. 2010 Sep;4(3):320-5. Epub 2010 Sep 24. Halimeter ppb Levels as the Predictor of Erosive Gastroesophageal Reflux Disease. Kim JGKim YJYoo SHLee SJChung JWKim MHPark DKHahm KB. Department of Gastroenterology, Gachon Graduate School of Medicine, Incheon, Korea.

14. Int J Dent Hyg. 2010 Nov;8(4):258-68. doi: 10.1111/j.1601-5037.2010.00479.x. Epub 2010 Sep 6. Effectiveness of mechanical tongue cleaning on breath odour and tongue coating: a systematic review. Van der Sleen MISlot DEVan Trijffel EWinkel EGVan der Weijden GA. Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, The Netherlands.

15. Int J Dermatol. 2010 Oct;49(10):1165-8. doi: 10.1111/j.1365-4632.2009.04432.x. Tonsillar actinomycosis mimicking a tonsillolith: colonization of the palantine tonsil presenting as a foul-smelling, removable, unilateral, giant tonsillar concretion. Cohen PRTschen JA. The University of Houston Health Center, University of Houston, Houston, TX, USA. mitehead@aol.com

16. Psychother Psychosom. 2010;79(6):392-4. Epub 2010 Sep 9. The complaint of oral malodour: psychopathological and personality profiles. Rocca PAimetti MGiugiario MPigella ERomano FCrivelli BRocca GBogetto F.

17. Arch Oral Biol. 2010 Nov;55(11):842-7. Levels of salivary stress markers in patients with anxiety about halitosis. Fukui MHinode DYokoyama MYoshioka MKataoka KIto HO. Department of Preventive Dentistry, Institute of Health Biosciences, The University of Tokushima Graduate School, Kuramotocho, Japan. fmakoto@dent.tokushima-u.ac.jp

18. J Miss State Med Assoc. 2009 Dec;50(12):422-5. Halitosis: hindrance or hint? Innocent-Ituah I. m,CidDepartment of family Medicine, University of Mississippi Medical Center. innocentituah@yahoo.com

19. J Food Sci. 2010 Aug 1;75(6):C549-58. Effect of milk on the deodorization of malodorous breath after garlic ingestion. Hansanugrum ABarringer SA. Dept. of Food Science and Technology, The Ohio State Univ., Columbus, OH 43210, USA.

20. Am J Dent. 2010 Jun;23(3):175-8. A randomized cross-over clinical trial to evaluate the effect of a 0.454% stannous fluoride dentifrice on the reduction of oral malodor. Chen XHe TSun LZhang YFeng X. Department of Preventive and Pediatric Dentistry, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, China.

21. Eur Arch Otorhinolaryngol. 2011 Feb;268(2):267-72. Epub 2010 Aug 5. Temperature-controlled radiofrequency tonsil ablation for the treatment of halitosis. Tanyeri HMPolat S. Department of Otorhinolaryngology, Acibadem University Faculty of Medicine, Acibadem Healthcare Group Maslak Hospital, Istanbul, Turkey.

22. J Am Dent Assoc. 2010 Aug;141(8):1008-9. Some evidence shows that certain mouthrinses can reduce halitosis. Kumar SKByrne G.

23. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Aug;110(2):201-8. Effects of probiotic Lactobacillus salivarius WB21 on halitosis and oral health: an open-label pilot trial. Iwamoto TSuzuki NTanabe KTakeshita THirofuji T. Section of General Dentistry, Department of General Dentistry, Fukuoka Dental College, Fukuoka, Japan.

24. J Dent. 2010 Jun;38 Suppl 1:S2-5. Listerine: past, present and future–a test of thyme. Fine DH. Department of Oral Biology, University of Medicine and Dentistry of New Jersey, New Jersey Dental School, Newark, New Jersey, USA. finedh@umdnj.edu

25. Rev Stomatol Chir Maxillofac. 2010 Jun;111(3):144-7. Epub 2010 Jun 4. [Mouthwash solutions containing microencapsulated natural extracts: Clinical results on dental plaque and gingivitis]. [Article in French] Mouhyi JDel Corso MHippolyte MPSammartino GDohan Ehrenfest DM. Department of Biomaterials, Institute for Clinical Sciences, the Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 8B, 41390 Gothenburg, Suède.

26. J Periodontol. 2010 Nov;81(11):1564-71. Epub 2010 Jul 1. Effect of eucalyptus-extract chewing gum on oral malodor: a double-masked, randomized trial. Tanaka MToe MNagata HOjima MKuboniwa MShimizu KOsawa KShizukuishi S. Department of Preventive Dentistry, Osaka University Graduate School of Dentistry, Osaka, Japan. tanakam@dent.osaka-u.ac.jp

27. J Sch Health. 2010 Jul;80(7):346-52. Oral malodor and related factors in Japanese senior high school students. Yokoyama SOhnuki MShinada KUeno MWright FAKawaguchi Y. Department of Oral Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan. yokoyama.ohp@tmd.ac.jp

28. J Periodontal Res. 2010 Oct;45(5):681-7. Epub 2010 Jun 20. Relationship between oral malodor and the menstrual cycle. Kawamoto ASugano NMotohashi MMatsumoto SIto K. Dental Hygienist Section, Nihon University Dental Hospital, Tokyo, Japan. imanaga@dent.nihon-u.ac.jp

29. Oral Dis. 2010 Oct;16(7):702-6. doi: 10.1111/j.1601-0825.2010.01685.x. The association of periodontal disease with oral malodour in a Japanese population. Takeuchi HMachigashira MYamashita DKozono SNakajima YMiyamoto MTakeuchi NSetoguchi TNoguchi K. Department of Periodontology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan. take777@dent.kagoshima-u.ac.jp

30. Rev Belge Med Dent (1984). 2010;65(1):12-38. [Mouthwashes: the supply in Belgium reviewed on the basis of recent literature]. [Article in French] Marcelis KDekeyser CDeclerck DQuirynen M. Katholieke Universiteit Leuven, Ecole de Médecine Dentaire, de Stomatologie et de Chirurgie Maxillo-faciale, Service de Parodontologie, Kapucijnenvoer 7 blok a – bus 7001, 3000 Louvain, Belgique. marceliskoen@hotmail.com

31. Schweiz Monatsschr Zahnmed. 2010;120(5):402-5. The correlation of organoleptic and instrumental halitosis measurements. Brunner FKurmann MFilippi A. Department of Prosthodontics, Albert-Ludwigs-University, Freiburg, Germany.

32. J Hist Dent. 2010 Spring;58(1):43-7. John Peter Zenger’s fight for freedom of the press: halitosis exposed. Christen AG. Department of Oral Biology, Indiana University School of Dentistry, USA. achriste@iupui.edu

33. J Med Dent Sci. 2010 Mar;57(1):25-33. Relationship between oral malodor and glycosylated salivary proteins. Takehara SYanagishita MPodyma-Inoue KAUeno MShinada KKawaguchi Y. Department of International Health Development, Division of Public Health, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan. takehara.ohp@tmd.ac.jp

34. Med Oral Patol Oral Cir Bucal. 2010 Nov 1;15(6):e850-4. Evaluation of halitosis and sialometry in patients submitted to head and neck radiotherapy. Albuquerque DFde Souza Tolentino EAmado FMArakawa CChinellato LE. Bauru Dental School, University of São Paulo, Manoel de Abreu Hospital, Bauru, Brazil.

35.   J Dent Hyg. 2010;84(2):65-74. Epub 2010 Mar 19. Halitosis: a review of current literature. Armstrong BLSensat MLStoltenberg JL. University of Minnesota School of Dentistry, Minneapolis, Minnesota, USA.

36. Health Qual Life Outcomes. 2010 Mar 26;8:34. Self-reported halitosis and emotional state: impact on oral conditions and treatments. Settineri SMento CGugliotta SCSaitta ATerranova ATrimarchi GMallamace D. Department of Neuroscience, Psychiatry and Anaesthesiology, University of Messina, Via Consolare Valeria 1, 98100 Messina, Italy. salvatore.settineri@unime.it

37.  Health Qual Life Outcomes. 2010 Mar 26;8:34. Self-reported halitosis and emotional state: impact on oral conditions and treatments. Settineri SMento CGugliotta SCSaitta ATerranova ATrimarchi GMallamace D. Department of Neuroscience, Psychiatry and Anaesthesiology, University of Messina, Via Consolare Valeria 1, 98100 Messina, Italy. salvatore.settineri@unime.it

38. Perit Dial Int. 2010 Mar 25. [Epub ahead of print] DOES PERITONEAL DIALYSIS AFFECT HALITOSIS IN PATIENTS WITHEND-STAGE RENAL DISEASE? Keles MTozoglu UUyanik AEltas ABayindir YZCetinkaya RBilge OM. Nephrology, Atatürk University Medical Faculty, Erzurum, Turkey.

39. Appl Environ Microbiol. 2010 May;76(9):2806-14. Epub 2010 Mar 12. Relationship between oral malodor and the global composition of indigenous bacterial populations in saliva. Takeshita TSuzuki NNakano YShimazaki YYoneda MHirofuji TYamashita Y. Section of Preventive Dentistry, Division of Oral Health, Growth and Development, Kyushu University Faculty of Dental Science, Higashi-ku, Fukuoka, Japan.

40. Vaccine. 2010 Apr 26;28(19):3496-505. Epub 2010 Feb 26. Vaccination targeting surface FomA of Fusobacterium nucleatum against bacterial co-aggregation: Implication for treatment of periodontal infection and halitosis. Liu PFShi WZhu WSmith JWHsieh SLGallo RLHuang CM.Department of Medicine, Division of Dermatology, University of California, San Diego, CA 92161, USA.

41. Med Oral Patol Oral Cir Bucal. 2010 Sep 1;15(5):e677-80. Probiotic treatment in the oral cavity: an update. Flichy-Fernández AJAlegre-Domingo TPeñarrocha-Oltra DPeñarrocha-Diago M. Valencia University Medical and Dental School, Valencia.

42. Odontology. 2010 Feb;98(1):44-51. Epub 2010 Feb 16. The relationship between physiologic halitosis and periodontopathic bacteria of the tongue and gingival sulcus. Yasukawa TOhmori MSato S. Department of Periodontology, The Nippon Dental University School of Life Dentistry at Niigata, 1-8 Hamaura-cho, Chuo-ku, Niigata, 951-8580, Japan. yasu@ngt.ndu.ac.jp

43. Trials. 2010 Feb 12;11:14. Effects of a mouthwash with chlorine dioxide on oral malodor and salivary bacteria: a randomized placebo-controlled 7-day trial. Shinada KUeno MKonishi CTakehara SYokoyama SZaitsu TOhnuki MWright FAKawaguchi Y. Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan. shinada.ohp@tmd.ac.jp

44. Niger J Med. 2009 Jul-Sep;18(3):295-8. Tonsillectomy for the treatment of halitosis. Al-Abbasi AM. Basrah College of Medicine, Basrah-Iraq.mmalabbasi@yahoo.com

45.  Anal Chim Acta. 2010 Feb 19;661(1):97-102. Epub 2009 Dec 4. Novel colorimetric sensor for oral malodour. Alagirisamy NHardas SSJayaraman S. Hindustan Unilever Research Center, 64 Main Road, Whitefield, Bangalore 560066, India.

46. Int J Dent Hyg. 2010 Feb;8(1):41-6. Patients’ self-assessment of oral malodour and its relationship with organoleptic scores and oral conditions. Romano FPigella EGuzzi NAimetti M. Section of Periodontology, Department of Biomedical Sciences and Human Oncology, University of Torino, Torino, Italy.

47. J Periodontol. 2009 Dec;80(12):2028-34. Oral malodorous compound inhibits osteoblast proliferation. Imai TIi HYaegaki KMurata TSato TKamoda T. Department of Oral Health, School of Life Dentistry at Tokyo, Nippon Dental University, Tokyo, Japan. imai-109@tky.ndu.ac.jp

48. Minerva Stomatol. 2009 Sep;58(9):435-44. Halitosis: a stomatological and psychological issue. [Article in English, Italian] Nardi GMForabosco AForabosco GMusciotto ACampisi GGrandi T. La Sapienza University of Rome, Rome, Italy.

49. J Clin Periodontol. 2009 Nov;36(11):964-9. Clinical reliability of non-organoleptic oral malodour measurements. Vandekerckhove BVan den Velde SDe Smit MDadamio JTeughels WVan Tornout MQuirynen M. Department of Periodontology, Catholic University of Leuven, Leuven BE-3000, Belgium.

50. J Can Dent Assoc. 2009 Oct;75(8):585-90. Probiotics for oral health: myth or reality? Bonifait LChandad FGrenier D. Laval University, Quebec City, Quebec.

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