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Halitosis

(Fetor Oris; Bad Breath; Oral Malodor)

By

Bernard J. Hennessy

, DDS, Texas A&M University, College of Dentistry

Medically Reviewed Feb 2022 | Modified Sep 2022
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Halitosis is a frequent or persistent unpleasant breath odor.

Pathophysiology of Halitosis

Halitosis most often results from fermentation of food particles by anaerobic gram-negative bacteria in the mouth, producing volatile sulfur compounds such as hydrogen sulfide and methyl mercaptan. Causative bacteria may be present in areas of periodontal disease Periodontitis Periodontitis is a chronic inflammatory oral disease that progressively destroys the tooth-supporting apparatus. It usually manifests as a worsening of gingivitis and then, if untreated, with... read more Periodontitis , particularly when ulceration or necrosis is present. The causative organisms reside deep in periodontal pockets around teeth. In patients with healthy periodontal tissue, these bacteria may proliferate on the dorsal posterior tongue.

Certain foods or spices, after digestion, release the odor of that substance to the lungs; the exhaled odor may be unpleasant to others. For example, the odor of garlic is noted on the breath by others 2 or 3 hours after consumption, long after it is gone from the mouth.

Etiology of Halitosis

About 85% of cases result from oral conditions. A variety of systemic and extraoral conditions account for the remainder (see table Some Causes of Halitosis Some Causes of Halitosis Some Causes of Halitosis ).

The most common causes overall are the following:

Gastrointestinal disorders rarely cause halitosis, because the esophagus is normally collapsed. However, certain disorders (eg, gastroesophageal reflux disease Gastroesophageal Reflux Disease (GERD) Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia... read more Gastroesophageal Reflux Disease (GERD) (GERD), esophageal diverticula, stomach cancer) may cause halitosis. It is a fallacy that breath odor reflects a state of digestion and bowel function.

Other breath odors

Table

Evaluation of Halitosis

History

History of present illness should ascertain duration and severity of halitosis (including whether other people have noticed or complained), adequacy of the patient’s oral hygiene, and the relationship of halitosis to ingestion of causative foods (see table Some Causes of Halitosis Some Causes of Halitosis Some Causes of Halitosis ).

Past medical history should ask about duration and amount of use of alcohol and tobacco. Drug history should specifically ask about use of drugs that can cause dry mouth (eg, those with anticholinergic effects—see table Some Causes of Xerostomia Some Causes of Xerostomia Some Causes of Xerostomia ).

Physical examination

Vital signs are reviewed, particularly for presence of fever.

The nose is examined for discharge and foreign body.

The pharynx is examined for signs of infection and cancer.

Sniff test

A sniff test of exhaled air is conducted. In general, oral causes of halitosis result in a putrefying, pungent smell, whereas systemic conditions result in a more subtle, abnormal odor. Ideally, for 48 hours before the examination, the patient avoids eating garlic or onions, and for 2 hours before, the patient abstains from eating, chewing, drinking, gargling, rinsing, or smoking. During the test, the patient exhales 10 cm away from the examiner’s nose, first through the mouth and then with the mouth closed. Malodor that is perceived as worse through the mouth suggests an oral etiology; malodor that is perceived as worse through the nose suggests a nasal or sinus etiology. Similar malodor through both nose and mouth may suggest a systemic or pulmonary cause.

If site of origin is unclear, the posterior tongue is scraped with a plastic spoon. After 5 seconds, the spoon is sniffed 5 cm from the examiner’s nose; a bad odor suggests the malodor is caused by bacteria on the tongue.

Red flags

The following findings are of particular concern:

  • Fever

  • Purulent nasal discharge or sputum

  • Visible or palpable oral lesions

Interpretation of findings

Because oral causes are by far the most common, any visible oral disease may be presumed to be the cause of halitosis in patients with no extraoral symptoms or signs, and a dentist should be consulted. When other disorders may be involved, clinical findings often suggest a diagnosis (see table Some Causes of Halitosis Some Causes of Halitosis Some Causes of Halitosis ).

In patients whose symptoms seem to be related to intake of certain food or drink and who have no other findings, a trial of avoidance (followed by a sniff test) may clarify the diagnosis.

Testing

Extensive diagnostic evaluation should not be undertaken unless the history and physical examination suggest an underlying disease (see table Some Causes of Halitosis Some Causes of Halitosis Some Causes of Halitosis ). Portable sulfur monitors, gas chromatography, and chemical tests of tongue scrapings are available but best left to research protocols or to specific dental offices that focus on halitosis evaluation and treatment.

Treatment of Halitosis

  • Regular oral hygiene and dental care

  • Cause treated

Underlying diseases are treated.

If the cause is oral, the patient should see a dentist for professional cleaning and treatment of gingival disease Gingivitis Gingivitis is a type of periodontal disease characterized by inflammation of the gums (gingivae), causing bleeding with swelling, redness, exudate, a change of normal contours, and, occasionally... read more Gingivitis and caries Caries Caries is tooth decay, commonly called cavities. The symptoms—tender, painful teeth—appear late. Diagnosis is based on inspection, probing of the enamel surface with a fine metal instrument... read more Caries . Home treatment involves enhanced oral hygiene, including thorough flossing, toothbrushing, and brushing of the tongue with the toothbrush or a scraper. Mouthwashes are of limited benefit, but some with oxidant formulations (typically containing chlorine dioxide) have shown greater short-term success. If the patient has a history of alcohol abuse, nonalcoholic mouthwashes should be used. Psychogenic halitosis may require psychiatric consultation.

Geriatrics Essentials

Older patients are more likely to take drugs that cause dry mouth, which leads to difficulties with oral hygiene (as do limited manual dexterity and conditions such as rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more Rheumatoid Arthritis (RA) and Parkinson disease Parkinson Disease Parkinson disease is a slowly progressive, degenerative disorder characterized by resting tremor, stiffness (rigidity), slow and decreased movement (bradykinesia), and eventually gait and/or... read more ) and hence to halitosis, but they are otherwise not more likely to have halitosis. Also, oral cancers are more common with aging and are more of a concern among older than younger patients.

Key Points

  • Most halitosis results from fermentation of food particles by anaerobic gram-negative bacteria that reside around the teeth and on the dorsum of the tongue.

  • Extraoral disorders may cause halitosis and are often accompanied by suggestive findings.

  • Home treatment includes enhanced toothbrushing, flossing, and tongue brushing or scraping.

  • Mouthwashes provide only brief benefit.

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