Research
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These articles linked below provide a comprehensive overview of the causes, diagnosis, and treatment of halitosis, as well as associated factors and updated information on its etiology and management.
Our founder Doctor Liza Klein has participated in this scientific paper: ASSOCIATION OF HELICOBACTER PYLORI WITH BURNING MOUTH, LINGUAL PAPILLARY HYPERTROPHY AND HALITOSIS Valeria Denninghoff; Isabel Adler, Andrea Muirto; Mariana dos Santos; Juan Manuel Muiño; Liza Marina Marigo Klein; Alejandra Avagnina; Alejandro García
Burning, Lingual Papillary Hypertrophy and Halitosis (AHH) together have not been described so far as a clinical entity. However, patients who present this condition did not find an effective response to their demand. In some cases, a therapeutic diagnosis of Chronic Candidiasis was made in relation to Lingual Papillary Hypertrophy and they were referred to Periodontics services for their Chronic Halitosis for evaluation and treatment.
Many of these patients, when they attended their subsequent check-ups, had not resolved their clinical condition. The burning in his mouth was diagnosed as Stomatodynia or Burning Mouth Syndrome. A considerable percentage (60%) of these patients in the History of their Current Illness, reported suffering from chronic gastric discomfort, without treatment since when treated when they consulted with the clinical doctor or with the gastroenterology specialist, their symptoms were relativized to their nervous state.
Warren and Marshall described that 98% of patients with chronic active gastritis and 80% with gastric ulcer had helical microorganisms on the surface of the gastric mucosa (Marshall BJ et al., 1984). Gastric infection by Helicobacter pyfori (HP) is treated with systemic antibiotic therapy. The eradication percentage is between 80% and 90% with triple therapy (Lanzoprazole, Amoxicillin and Clarithromycin), administered for a period of at least 7 to 10 days (Gabryelewicz A, 1996). However, bacterial reinfection is observed in a considerable number of patients and annual reinfection rates in the world range between 0 and 30% (Della Libera E et al., 2001).
The questions that arise are how this bacterial infection is transmitted and what causes the reinfection process. Some researchers found HP in plaque and saliva, and have suggested that oral dissemination would be the main route of transmission. Both dental plaque and saliva could act as a reservoir and have implications for reinfection once the bacteria have been eradicated from the gastric tract. The discrepancies regarding the diagnosis of patients who consult for AAH with chronic gastric discomfort made us think about the action of HP on both the tongue and the stomach.
We reported in 2001 its association with AHH, in a male patient who suffered from chronic gastritis. Both the oral and gastric symptoms were related to the action of this bacteria. The diagnostic methods used were oral and gastric biopsy. The samples were evaluated with the Giemsa and Molecular Biology technique with positive results (Adier I et al., 2001; Adier I et al., 2005). Early diagnosis is essential for early treatment and cure of these individuals who consult with AHH regarding HP and its possible gastric involvement. For this reason, it is necessary to develop research designs that allow demonstrating the association between the clinical picture described and the bacterial infection. As well as establishing the sensitivity and specificity of the different diagnostic tests implemented to determine infection in the oral cavity. The objective of the study is to estimate the risk of infection due to the action of Helicobacter pylori in the mouth, in patients who present burning, lingual papillary hypertrophy and halitosis, and to evaluate the diagnostic efficacy of halimetry in relation to CRP.
• Patients with dental and gingivoperiodontal pathologies. •Patients with a diagnosis of: hepatitis C, HIV, kidney disease.
• Individuals with altered values in the coagulogram.
• Patients who received local-general antibiotic medication in the last eight months, or had undergone some prophylactic antibiotic treatment, or who were undergoing gastroenterological treatment with a diagnosis of HP infection.
• Smoking patients.
• Patients who did not sign the informed consent.
In all cases the investigation procedure was as follows: A-Stomatological Diagnosis. A protocolized clinical history was taken for all patients. Burning was assessed by self-report. Hypertrophy of the papillae of the lingual dorsum was considered with clinical inspection (Figure 1).
insert figure 1
Halitosis was evaluated with the Halimeter® Interscan model RH-17D. designed to monitor an individual's breath, measuring CSV concentration at parts per billion (ppb) levels. (Figure 2). A disposable mouthpiece was used in each determination. The patient was instructed to insert the mouthpiece into the mouth (approximately 4 centimeters). Each individual participating in the study was given an information sheet with the instructions they had to follow to carry out the determination. From the night before, avoid eating any type of food with known effects on breath (garlic, onion, etc.) or strong or spicy foods, and do not drink alcohol. Two hours before the treatment, do not eat any type of food or liquid (except water), avoid brushing your teeth or flossing, do not use rinses of any kind, do not chew gum or candy, and do not use perfume or lipstick.
The tests were carried out in the morning between ten and twelve o'clock. Three consecutive determinations were made, which were averaged and if the value found in the patients exceeded 100 ppb, they were considered to have halitosis. The laboratory routine was requested and scraping of the affected lingual area was performed.
B-Serological Diagnosis: The anti-HP IgG titer (Triniti EIA-G) was determined from the patient's serum. A positive titer was considered when the sample presented values equal to or greater than 1.1. C-Diagnosis by Molecular Biology. DNA was extracted from the fresh scraping material. It was centrifuged at 15,000 rpm for 30 min. and the pellet was recovered from the tube by inversion.
The sample was digested in Buffer-PK (100mM Tris CIH-ph=8, 25mM EDTA, 0.5% SDS, 0.01% PK) at 42 °C ON. The lipoprotein fractions were extracted with Phenol-Chloroform-Isoamyl (CAR-LO ERBA, Italy). The purified DNA was precipitated with CINa/isopropanol and resuspended in T10E1 (Tris-EDTA). The purity and yield of the obtained DNA were measured by spectroscopy. The presence of the Helicobacter pylori genome was analyzed by Polymerase Chain Reaction (PCR) with primers homologous to a region that codes for the species-specific antigen, whose nucleotide sequence was the following: primer HP3: (5-TGGCGTGTCTATTGACAGCGAGC-3") and primer HP4: (5--CCTGCT-GGGCATACTTCACCATG-3) that are identified with residues 474 to 496 and 776 to 754 respectively.
The amplification was carried out in a reaction volume of 50 ul using between 500-1000 ng of total DNA. Each reaction tube contained 50 pmol of each primer, 200 uM of each dNTP. 10 mM Tris-HCI (pH 8.3), 50 mM KCl, 2 mM MgC12 and 1 U of Taq polymerase (Prome-ga. WI, USA). After an initial denaturation step at 95 °C for 5 min., 40 cycles of amplification were performed (denaturation at 95 °C for 1 min., annealing at 58 °C for 1 min. min. and elongation at 72 °C for 1 min.) with a final elongation at 72 °C for 5 min. On the other hand, a PCR was performed under similar conditions for a 110 bp fragment of the human beta-globin gene as amplification control (Saiki R et al., 1985).
All PCRs were evaluated by electrophoresis in 9% polyacrylamide gels in 1X TBE buffer (Tris-Boric-EDTA), visualized with ethidium bromide under ultraviolet light (Figure 3). On the other hand, the HP genome was identified through a second PCR. Primers homologous to a region that codes for the 16S rRNA gene were used, whose nucleotide sequences were the following: primer 165-880fw (5 -ATAGACGGGGACCCGCACAAG-3). and first 16S-999rv (5 -TGGCAAGCCAGACACTCCA-3) which are identified with residues 1030 to 1050 and 1131 to 1149 respectively (Glocker E et al., 2005). The specificity of the amplified fragment was analyzed using the BLAST sequence alignment program. This program allows identifying similarities between the amplicon obtained and the program's DNA databases (Altschul SF et al., 1997).
To verify the correct specificity of the amplicon, the fragments obtained by PCR were sequenced. Sequencing was performed with a commercial DYEnamic ET Terminator Cycle Sequencing Kit (Amersham Bios-ciences, Little Chalfont, Buckinghamshire, England). The sequence was separated by capillary electrophoresis (ABI PRISMTM 310 Genetic Analyzer, Applied Biosystem-Perkin Elmer Corporation, Foster City, CA, USA). The sequence obtained was analyzed with the ABI PRISMO DNA Sequencing Analysis Software (Applied Biosystem-Perkin Elmer Corporation, Foster City, CA, USA).
insert table 1
Many of these patients, when they attended their subsequent check-ups, had not resolved their clinical condition. The burning in his mouth was diagnosed as Stomatodynia or Burning Mouth Syndrome. A considerable percentage (60%) of these patients in the History of their Current Illness, reported suffering from chronic gastric discomfort, without treatment since when treated when they consulted with the clinical doctor or with the gastroenterology specialist, their symptoms were relativized to their nervous state.
Warren and Marshall described that 98% of patients with chronic active gastritis and 80% with gastric ulcer had helical microorganisms on the surface of the gastric mucosa (Marshall BJ et al., 1984). Gastric infection by Helicobacter pyfori (HP) is treated with systemic antibiotic therapy. The eradication percentage is between 80% and 90% with triple therapy (Lanzoprazole, Amoxicillin and Clarithromycin), administered for a period of at least 7 to 10 days (Gabryelewicz A, 1996). However, bacterial reinfection is observed in a considerable number of patients and annual reinfection rates in the world range between 0 and 30% (Della Libera E et al., 2001).
The questions that arise are how this bacterial infection is transmitted and what causes the reinfection process. Some researchers found HP in plaque and saliva, and have suggested that oral dissemination would be the main route of transmission. Both dental plaque and saliva could act as a reservoir and have implications for reinfection once the bacteria have been eradicated from the gastric tract. The discrepancies regarding the diagnosis of patients who consult for AAH with chronic gastric discomfort made us think about the action of HP on both the tongue and the stomach.
We reported in 2001 its association with AHH, in a male patient who suffered from chronic gastritis. Both the oral and gastric symptoms were related to the action of this bacteria. The diagnostic methods used were oral and gastric biopsy. The samples were evaluated with the Giemsa and Molecular Biology technique with positive results (Adier I et al., 2001; Adier I et al., 2005). Early diagnosis is essential for early treatment and cure of these individuals who consult with AHH regarding HP and its possible gastric involvement. For this reason, it is necessary to develop research designs that allow demonstrating the association between the clinical picture described and the bacterial infection. As well as establishing the sensitivity and specificity of the different diagnostic tests implemented to determine infection in the oral cavity. The objective of the study is to estimate the risk of infection due to the action of Helicobacter pylori in the mouth, in patients who present burning, lingual papillary hypertrophy and halitosis, and to evaluate the diagnostic efficacy of halimetry in relation to CRP.
MATERIALS AND METHODS
Between June 2009 and March 2010, patients with AHH symptoms who reported gastric discomfort were prospectively studied.They were excluded:
• Patients under 21 years of age.• Patients with dental and gingivoperiodontal pathologies. •Patients with a diagnosis of: hepatitis C, HIV, kidney disease.
• Individuals with altered values in the coagulogram.
• Patients who received local-general antibiotic medication in the last eight months, or had undergone some prophylactic antibiotic treatment, or who were undergoing gastroenterological treatment with a diagnosis of HP infection.
• Smoking patients.
• Patients who did not sign the informed consent.
In all cases the investigation procedure was as follows: A-Stomatological Diagnosis. A protocolized clinical history was taken for all patients. Burning was assessed by self-report. Hypertrophy of the papillae of the lingual dorsum was considered with clinical inspection (Figure 1).
insert figure 1
Halitosis was evaluated with the Halimeter® Interscan model RH-17D. designed to monitor an individual's breath, measuring CSV concentration at parts per billion (ppb) levels. (Figure 2). A disposable mouthpiece was used in each determination. The patient was instructed to insert the mouthpiece into the mouth (approximately 4 centimeters). Each individual participating in the study was given an information sheet with the instructions they had to follow to carry out the determination. From the night before, avoid eating any type of food with known effects on breath (garlic, onion, etc.) or strong or spicy foods, and do not drink alcohol. Two hours before the treatment, do not eat any type of food or liquid (except water), avoid brushing your teeth or flossing, do not use rinses of any kind, do not chew gum or candy, and do not use perfume or lipstick.
The tests were carried out in the morning between ten and twelve o'clock. Three consecutive determinations were made, which were averaged and if the value found in the patients exceeded 100 ppb, they were considered to have halitosis. The laboratory routine was requested and scraping of the affected lingual area was performed.
B-Serological Diagnosis: The anti-HP IgG titer (Triniti EIA-G) was determined from the patient's serum. A positive titer was considered when the sample presented values equal to or greater than 1.1. C-Diagnosis by Molecular Biology. DNA was extracted from the fresh scraping material. It was centrifuged at 15,000 rpm for 30 min. and the pellet was recovered from the tube by inversion.
The sample was digested in Buffer-PK (100mM Tris CIH-ph=8, 25mM EDTA, 0.5% SDS, 0.01% PK) at 42 °C ON. The lipoprotein fractions were extracted with Phenol-Chloroform-Isoamyl (CAR-LO ERBA, Italy). The purified DNA was precipitated with CINa/isopropanol and resuspended in T10E1 (Tris-EDTA). The purity and yield of the obtained DNA were measured by spectroscopy. The presence of the Helicobacter pylori genome was analyzed by Polymerase Chain Reaction (PCR) with primers homologous to a region that codes for the species-specific antigen, whose nucleotide sequence was the following: primer HP3: (5-TGGCGTGTCTATTGACAGCGAGC-3") and primer HP4: (5--CCTGCT-GGGCATACTTCACCATG-3) that are identified with residues 474 to 496 and 776 to 754 respectively.
The amplification was carried out in a reaction volume of 50 ul using between 500-1000 ng of total DNA. Each reaction tube contained 50 pmol of each primer, 200 uM of each dNTP. 10 mM Tris-HCI (pH 8.3), 50 mM KCl, 2 mM MgC12 and 1 U of Taq polymerase (Prome-ga. WI, USA). After an initial denaturation step at 95 °C for 5 min., 40 cycles of amplification were performed (denaturation at 95 °C for 1 min., annealing at 58 °C for 1 min. min. and elongation at 72 °C for 1 min.) with a final elongation at 72 °C for 5 min. On the other hand, a PCR was performed under similar conditions for a 110 bp fragment of the human beta-globin gene as amplification control (Saiki R et al., 1985).
All PCRs were evaluated by electrophoresis in 9% polyacrylamide gels in 1X TBE buffer (Tris-Boric-EDTA), visualized with ethidium bromide under ultraviolet light (Figure 3). On the other hand, the HP genome was identified through a second PCR. Primers homologous to a region that codes for the 16S rRNA gene were used, whose nucleotide sequences were the following: primer 165-880fw (5 -ATAGACGGGGACCCGCACAAG-3). and first 16S-999rv (5 -TGGCAAGCCAGACACTCCA-3) which are identified with residues 1030 to 1050 and 1131 to 1149 respectively (Glocker E et al., 2005). The specificity of the amplified fragment was analyzed using the BLAST sequence alignment program. This program allows identifying similarities between the amplicon obtained and the program's DNA databases (Altschul SF et al., 1997).
To verify the correct specificity of the amplicon, the fragments obtained by PCR were sequenced. Sequencing was performed with a commercial DYEnamic ET Terminator Cycle Sequencing Kit (Amersham Bios-ciences, Little Chalfont, Buckinghamshire, England). The sequence was separated by capillary electrophoresis (ABI PRISMTM 310 Genetic Analyzer, Applied Biosystem-Perkin Elmer Corporation, Foster City, CA, USA). The sequence obtained was analyzed with the ABI PRISMO DNA Sequencing Analysis Software (Applied Biosystem-Perkin Elmer Corporation, Foster City, CA, USA).
Statistical Analysis:
A database was created using the Data Entry of the SPSS statistical package, setting a range of admissible values for the dependent variables (AAH/other Pathologies) and the independent variables (HP: yes/no) for information processing. For the analysis of the descriptive data, the continuous variables were analyzed, with their mean, median, mode, range and standard error. Categorical variables were represented in percentages or relative frequencies. A factor analysis of all variables was carried out and a correlation coefficient was determined, with a level of significance of 5% (< 0.05). The X2 Mantel-Haenzel-OR-IC (0.95) was performed. Sensitivity was determined. specificity, Positive and Negative Predictive Value of the studies carried out in individuals with AHH, in which the presence of the was investigated through serology, histopathology (Giemsa), immunohistochemistry and molecular biology. The sample consisted of 27 patients, whose age range was 24-78 years with a median of 64, with 67% being female. (Table 1).insert table 1
RESULTS
The results of halimetry and PCR are shown in Table 2. and Figure 3 shows the electrophoretic run in a 9% polyacrylamide gel of the PCR amplification product of the region that codes for the HP 16S rRNA gene (120 bp). Lane 1-4: Positive samples in different concentrations. Lane 5: Ladder 100bp as PM marker. Lane 6: Positive control. Lane 7: Negative control.
Bad breath: What causes it and what to do about it
Almost everyone experiences bad breath once in a while. But for some people, bad breath is a daily problem, and they struggle to find a solution. Approximately 30% of the population complains of some sort of bad breath. Halitosis (Latin for "bad breath") often occurs after a garlicky meal or in the morning after waking. Other causes of temporary halitosis include some beverages (including alcoholic drinks or coffee) and tobacco smoking.
Some people may not be aware of their own halitosis and learn about it from a relative, friend, or coworker, causing some degree of discomfort and distress. In severe cases, bad breath (as well as bad body odor) may negatively impact personal relationships and a person's quality of life...
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