Halitosis: prevalence,risk factors,sources, measurement and treatment – a review of the literature

Halitosis, an offensive breath odour, has multiple sources and negative impacts on people’s social interactions and quality of life. It is important for health care professionals, including general physicians and dental professionals, to understand its aetiology and risk factors in order to diagnose and treat patients appropriately. In this study, we have reviewed the current literature on halitosis regarding its prevalence, classification, risk factors, sources, measurement and treatment.     

Activation of the coagulation cascade after infusion of a factor XI concentrate in congenitally deficient patients

Virally inactivated, high-purity factor XI concentrates are available for treatment of patients with factor XI deficiency. However, preliminary experience indicates that some preparations may be thrombogenic. We evaluated whether a highly purified concentrate produced signs of activation of the coagulation cascade in two patients with severe factor XI deficiency infused before and after surgery. Signs of heightened enzymatic activity of the common pathway of coagulation (elevated plasma levels of prothrombin fragment 1 + 2 and fibrinopeptide A) developed in the early post-infusion period, accompanied by more delayed signs of fibrin formation with secondary hyperfibrinolysis (elevated D-dimer and plasmin-antiplasmin complex). These changes occurred in both patients, but were more severe in the older patient with breast cancer when she underwent surgery, being accompanied by fibrinogen and platelet consumption. There were no concomitant signs of heightened activity of the factor VII-tissue factor mechanism on the factor Xase complex (plasma levels of activated factor VII and of factor IX and X activation peptides did not increase). The observed changes in biochemical markers of coagulation activation indicate that concentrate infusions increased thrombin generation and activity and that such changes were magnified by malignancy and surgery. Because some factor XI concentrates may be thrombogenic, they should be used with caution, especially in patients with other risk factors for thrombosis.     

Nutrition and bone health in children and adolescents

Bone accretion during childhood is proportional to the rate of growth. During this time, interval height velocity is relatively slow for both boys and girls. As a direct consequence of this, calcium retention in the body of an average child is lower than the calcium retention in an adolescent. Bone size, bone mass, and bone mineral areal density of the regional skeletal sites increase on average by about 4%/yr from childhood to late adolescence and young adulthood, when most of the bone mass is accumulated. Calcium needs are greater during adolescence (pubertal growth spurt) than in childhood or adulthood. According to calcium balance studies, the threshold in take for adolescents is about 1500 mg/d. Inadequate calcium intake during growth may increase the risk of childhood fractures and predispose certain individuals to a lower peak bone mass.     

From the Cover: A global carbon and nitrogen isotope perspective on modern and ancient human diet

Stable carbon and nitrogen isotope analyses are widely used to infer diet and mobility in ancient and modern human populations, potentially providing a means to situate humans in global food webs. We collated 13,666 globally distributed analyses of ancient and modern human collagen and keratin samples. We converted all data to a common “Modern Diet Equivalent” reference frame to enable direct comparison among modern human diets, human diets prior to the advent of industrial agriculture, and the natural environment. This approach reveals a broad diet prior to industrialized agriculture and continued in modern subsistence populations, consistent with the human ability to consume opportunistically as extreme omnivores within complex natural food webs and across multiple trophic levels in every terrestrial and many marine ecosystems on the planet. In stark contrast, isotope dietary breadth across modern nonsubsistence populations has compressed by two-thirds as a result of the rise of industrialized agriculture and animal husbandry practices and the globalization of food distribution networks.

Homo sapiens are the most widely distributed terrestrial mammal on the planet. Over the course of the Holocene, modern human range has extended to all continents, to the farthest islands of every ocean, and above the polar circles. The ability to rapidly adapt to newly encountered environments via technological and cultural innovation, that manifested ultimately in changes to our own genome, enabled this breath-taking range of expansion (1). Our capacity for successful innovation is tightly coupled to our ability to consume as “extreme opportunistic omnivores,” that is, across multiple trophic levels, from the base of a food web to filling the niche of apex predator (2–4). The development of agriculture, animal husbandry, urbanized societies, and commercial trade progressively allowed us to engage in niche construction of increasing complexity and extent (5, 6). As we permanently extended our range to above the Antarctic Circle in the 20th century, we progressively extended our capacity for advanced ecosystem engineering, thereby achieving a high degree of control over the production and distribution of our food supply across the globe (6, 7).The archaeological record documents our expansion into new habitats, our technological and social innovations, changing cultural practices, and the food that sustained us (8). While the physical remains of our diets, such as bones and charred plant remains, provide direct evidence of diet, not all foodstuffs are well-preserved. Moreover, such direct evidence does not indicate the proportion of different components that were consumed. A challenge in recreating past dietary components lies in accounting for taphonomic processes that may impact different dietary items at different rates, leading to underrepresentation of some important taxa (2). In contrast, the stable carbon and nitrogen isotope composition of human tissue (mostly collagen and keratin) has been investigated over the last several decades as a proxy for the proportions of different potential dietary components enabling an accounting for taphonomy (9). Carbon isotope composition (δ¹³C value) provides an indication of relative contributions of aquatic and/or terrestrial sources of carbon in the diet. Nitrogen isotope composition (δ¹⁵N value) is used to draw inferences regarding both the protein source and trophic level of an individual in the months or years before their death (10).To date, studies involving patterns in the stable isotope composition of ancient human remains (mostly bone collagen that can be well-preserved) have tended to focus on regional-scale variations during the Holocene, with the intent of determining wholesale changes in subsistence strategies (e.g., agriculture and pastoralism) and changing technological innovation, as well as social practices and structures (11–13). Although interpretation can sometimes be straightforward when observed differences are large, smaller differences are complicated by the complexities associated with disentangling the ecosystem processes driving C and N isotope fractionation within the food webs supporting human diet (13, 14).A parallel body of research has been conducted on the stable isotope composition of the tissues of contemporary humans (15–18). This research has mostly focused on noninvasive nail and hair keratin to examine the physiological processes in the human body, to deduce the recent movements of individuals (19), or to identify locations for repatriation of human remains (20). Substantial effort has been directed toward developing a spatial understanding of the controls on the stable isotope composition of modern human tissues, mostly as a consequence of the potential forensic application of this type of research (18, 21).Archaeological and modern stable isotope results on human tissues are not readily comparable for multiple reasons (Materials and Methods), hence there has been no attempt to interrogate the full record of dietary breadth and change for a globally distributed, omnivorous species, from the prehistoric to recent times. To address this gap, we collated isotope compositions of collagen as well as hair and nail keratin from three worldwide populations: modern urban (dates AD 1910 to 2020; Materials and Methods), modern subsistence (dates AD 1910 to 2020), and material dating to before the manufacture of industrial fertilizer (before AD 1910; pre-Haber–Bosch; hereafter, PHB). We calibrated all isotope compositions to their modern diet equivalent in order to directly compare modern and PHB distributions on a common scale. We show that the industrialized food system is vastly compressed in niche space and vastly less resilient compared with modern subsistence and PHB diets that are underpinned by complex food webs.We systematically collated (n = 6,879) globally distributed analyses of PHB archaeological bone collagen (pre-1910), with the majority of the data derived from samples of mid-Holocene or later age. We further collated analyses from studies of modern (post-1910) hair and nail keratin from populations of subsistence foragers, fishers, agriculturalists and pastoralists (n = 1,167), and urban populations (n = 5,610). In order to compare populations, we adjusted all measured values onto a common frame of reference; this being the equivalent δ¹³C and δ¹⁵N values of hair keratin in 2010 or modern keratin equivalent. We then used the accepted fractionations between human hair keratin and diet to calculate the modern diet equivalent (δ¹³C_MDE value) and (δ¹⁵N_MDE) values for all samples in 2010 (Materials and Methods).This approach has the advantage of allowing direct comparison of all results against the framework of our much more detailed contemporary understanding of stable isotope systematics in the modern biosphere. Exploiting this link between PHB and modern samples requires the assumption that the environmental conditions that drive the food webs that humans rely upon, wherever they are, have remained stable and that the past can be mapped onto the present. While there have been changes in climate and environment during the Holocene, these have been relatively muted, with most larger-scale landscape change resulting from human intervention beginning at varying times across the world in the Holocene and accelerating rapidly with the rise of industrial agriculture in the 20th Century (22).     

Establishing and managing a periodontal biobank for research: the sharing of experience

Periodontal bio‐repositories, which allow banking of clinically validated human data and biological samples, provide an opportunity to derive biomarkers for periodontal diagnosis, prognosis and therapeutic activities which are expected to improve patient management. This article presents the establishing of the Malaysian Periodontal Database and Biobank System (MPDBS) which was initiated in 2011 with the aim to facilitate periodontal research. Partnerships were established with collaborating centres. Policies on specimen access, authorship and acknowledgement policies were agreed upon by all participating centres before the initiation of the periodontal biobank. Ethical approval for the collection of samples and data were obtained from institutional ethics review boards. A broad‐based approach for informed consent was used, which covered areas related to quality of life impacts, genetics and molecular aspects of periodontal disease. Sample collection and processing was performed using a standardized protocol. Biobanking resources such as equipment and freezers were shared with the Malaysian Oral Cancer Database and Tissue Bank System (MOCDTBS). In the development of the MPDBS, challenges that were previously faced by the MOCDTBS were considered. Future challenges in terms of ethical and legal issues will be faced when international collaborations necessitate the transportation of specimens across borders.     

Effect of Intensive Salt‐Restriction Education on Clinic,Home, and Ambulatory Blood Pressure Levels in Treated Hypertensive Patients During a 3‐Month Education Period

The authors tested the hypothesis that low‐salt diet education by nutritionists would lower blood pressure (BP) levels in treated hypertensive patients. The amount of urinary salt excretion and clinic, home, and ambulatory BP values at baseline and at 3 months were measured in 95 patients with hypertension. After randomization to a nutritional education group (E group, n=51) or a control group (C group, n=44), the C group received conventional salt‐restriction education and the E group received intensive nutritional education aimed at salt restriction to 6 g/d by nutritionists. From baseline to the end of the study, 24‐hour urinary sodium excretion was significantly lowered in the E group compared with the C group (6.8±2.9 g/24 h vs 8.6±3.4 g/24 h, P<.01). Morning home systolic BP tended to be lowered in the E group (P=.051), and ambulatory 24‐hour systolic BP was significantly lowered in the E group (−4.5±1.3 mm Hg) compared with the C group (2.8±1.3 mm Hg, P<.001). Intensive nutritional education by nutritionists was shown to be effective in lowering BP in treated hypertensive patients.

The association between excessive salt intake and blood pressure (BP) elevation is well‐known, and some interventional studies such as the International Study of Electrolyte Excretion and Blood Pressure (INTERSALT) demonstrated that the amount of salt intake was associated with BP levels.¹ In an international study of 101,945 individuals from 17 countries, it was found that the estimated sodium intake of 3 g/d to 6 g/d was associated with lower incidences of cardiovascular events and death compared with higher or lower levels of salt intake.² In a study of a mildly hypertensive population, clinic and ambulatory BP levels were significantly lowered by low salt intake compared with those in the control group.³ In the same study, lower salt intake was associated with lower excretion of urinary albumin and a lower pulse wave velocity (a measure of arterial stiffness) compared with those in the control group. Taken together, these findings support the importance of salt restriction for the improved control of BP and protection from end‐organ damage, provided that the salt restriction is successfully performed.In the 2014 guidelines from the Japanese Society of Hypertension (JSH), salt restriction to <6 g/d is recommended for all hypertensive populations.⁴ However, this recommendation is mostly based on observational studies⁵ or interventional studies in which the diets of patients were completely controlled, sometimes under hospitalized conditions.⁶ For example, in the Dietary Approaches to Stop Hypertension (DASH) trial,⁷ a low‐salt diet was given to the patients during the study period. Few studies have examined whether intensive nutritional education in an outpatient clinic, especially education on dietary salt restriction, can lower not only clinic BP but also home and ambulatory BP levels. Thus, in the present study, we tested the hypothesis that intensive nutritional education focused on salt restriction and provided by nutritionists in an outpatient clinic lowers clinic, home, and ambulatory BP in treated hypertensive patients.