Halitosis, also known as fetor oris/oral malodor/morning breath/stomato dysodia/fetor ex-ore or bad breath, is a universal medico-social problem in all communities. The incidence of oral malodor ranges from 22% to 50% with highest in 18–29 years’ age group (47.8%) with males outshining females (55% vs. 45%).[1,2] People residing in high-altitude areas (HAAs) have more incidence of halitosis as compared to people residing in plains. Extreme low temperatures, low oxygen content, scarcity of nutritious diet, less availability of drinking water, low fluoride content (<0.02 parts per ml/l) in drinking water, poor socioeconomic conditions with low literacy rate, and minimal presence of dental treatment centers, are some of the common causes for halitosis in HAAs.
We present a rare cause of halitosis seen commonly in people of Nubra Valley of Ladakh region. Miyazaki et al. broadly divided halitosis into genuine halitosis, pseudo-halitosis, and halitophobia. Genuine halitosis is pathological or physiological. Physiological halitosis is also called morning halitosis. Pathological halitosis is due to intraoral (87%) and extraoral (13%) causes. Intraoral causes include tongue coating (most common cause of halitosis, 80%–90%), poor oral hygiene, oral infections, and dental and periodontal conditions. Extraoral causes include sinusitis, tonsillitis, rhinitis, foreign bodies, tobacco and betel nut chewing, smoking, alcohol, and gastrointestinal problems. Pseudo-halitosis is a complaint of halitosis without its actual existence. Halitophobia is just fear of halitosis without its actual existence and is attributable to a form of delusion or monosymptomatic hypochondriasis.
The primary mechanism for halitosis is presence of the volatile sulfide compounds (hydrogen sulfide, dimethyl sulfide, and methyl mercaptan), diamines (putrescine and cadaverine), and short-chain fatty acids (butyric acid, valeric acid, and propionic acid) resulting from the proteolytic degradation by anaerobic Gram-negative oral microorganisms of various sulfur-containing substrates in food debris, saliva, blood, and epithelial cells.
Out of all the patients examined and treated in Nubra Valley for dental ailments, around 80% were found to have halitosis with organoleptic scoring (sniff test) of 4–5 whereas the global incidence of severe halitosis is only 5%. The most common cause of halitosis in these people was found to be a local made smokeless chewable tobacco called “SUVIDHA” which is mixed with dried cow dung before consumption. This “SUVIDHA” packet contains tobacco, ash, oil, coloring agent, and flavored water. The contents of SUVIDHA are mixed with cow dung, which has been dried in summers for 4–5 days till it loses all the water content and then stocked. The tobacco and cow dung are mixed in 3:1 ratio, then rolled into a ball, and placed under the tongue/mucosa and are routinely sucked for 15–20 min [Figure 1]. There is a belief in local population that this tobacco keeps their mouth moist and helps in pain relief. Therefore, people are encouraged to start consuming it from very young age of around 15 years. This chewable tobacco adversely affects the oral cavity, and the presence of cow dung leads to peculiar pungent and decay smell. Tobacco and cow dung act as nidus for the growth of bacteria whereas hypoxia of HAAs stimulates the growth of anaerobic microorganisms.[3,6] The bacterial colonies lead to periodontal pathologies, increased caries, tooth staining, erosion of teeth, and halitosis.
To improve the overall dental hygiene and limiting the incidence of halitosis, dental and medical officers can play an important role by teaching people how to maintain oral hygiene and educating them about the ill effects of tobacco and cow dung, by conducting various oral health awareness programs, dental camps and counselling sessions. Reinforcement of oral health awareness programs, teaching how to maintain oral hygiene, and its importance will help in limiting the halitosis and improving the overall dental hygiene.
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