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From Trisha's Desk Trisha E. O’Hehir, RDH, MS Editorial Director, Hygienetown

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The Link Between Bad Breath and Periodontitis
– by Trisha E. O’Hehir, RDH, BS, Hygienetown Editorial Director

Have you diagnosed periodontal disease while standing in line at the grocery store, in church or perhaps sitting next to someone on a plane? That's the smell of volatile sulphur compounds (VSCs). The three VSCs associated with oral malodor are hydrogen sulfide, methyl mercaptan and dimethyl sulfide and each has a particular odor. Hydrogen sulfide smells like rotten eggs, methyl mercaptan smells of feces and dimethyl sulfide is a combination of cabbage, sulfur and gasoline. Add a minty cover-up candy or rinse and you have the smell of minty perio breath.
VSCs are released with the breakdown of food, protein, cells, blood and saliva. In periodontal disease, dead and dying epithelial cells release VSCs. The turn-over rate of junctional and sulcular epithelial cells in health is two to four days; increasing eight fold in disease, which could mean replacement of epithelium every six hours. This leads to a level of VSCs that becomes clinically, as well as socially, significant. Thus your ability to diagnose periodontitis with your nose! Another source of VSCs is the breakdown of methionine, which is found in the gingival crevicular fluid in higher levels during periodontal disease.

Besides acting as the cause of bad breath, VSCs have a significant role in the initiation of periodontal disease and in the healing of both connective tissue and bone. Work published in the 1970s by Dr. Joseph Tonzetich, at the University of British Colombia, provided the first evidence of VSCs making junctional epithelial cells more permeable. Permeability of mucosa was measured in the presence of 95 percent air and 5 percent carbon dioxide as a control. Volatile sulfur compounds were added to the control atmosphere in varying concentrations, resulting in significant increases in permeability of the mucosa. Therefore, the volatile sulfur compounds of bad breath are not only a result of disease, but seem to contribute to the initiation and progression of disease by allowing bacterial antigens and toxins to easily penetrate the crevicular epithelial barrier.

More recent research confirms these early findings, demonstrating how VSCs can trigger epithelial cell death or apoptosis, thus increasing permeability of the junctional epithelium. With increased permeability, bacterial antigens and toxins are able to penetrate the junctional epithelium and move to the underlying connective tissue. This triggers a cascade of immune responses that leads first to gingivitis and eventually to the destruction of supporting periodontal structures.

To maintain bone levels and to repair damage associated with periodontitis, osteoblasts are needed. In the presence of VSCs, the DNA of osteoblasts is damaged, leading to fewer osteoblasts and increased proliferation of osteoclasts. With the balance now swaying to osteoclasts, bone loss occurs. Fibroblasts exposed to VSCs show compromised maturation due to lack of protein synthesis. This action will prevent connective tissue from healing adequately and repairing the damage associated with periodontitis.

Not everyone with bad breath has periodontitis. Even young children suffer with bad breath caused by VSCs. The greatest source of VSCs for those without periodontal disease is a coating on the dorsum of the tongue. Since research suggests bad breath is actually a precursor to periodontal infection, as well as a result, addressing bad breath in all patients, even very young ones, may be an important step in preventing future bone and connective tissue loss due to periodontitis.

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