Halitosis

Several systemic diseases produce volatile substances detectable on the breath, although not the particularly foul, pungent odors typically considered halitosis. Diabetic ketoacidosis Diabetic Ketoacidosis (DKA) Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with... read more (DKA) produces a sweet or fruity odor of acetone, liver failure Acute Liver Failure Acute liver failure is caused most often by drugs and hepatitis viruses. Cardinal manifestations are jaundice, coagulopathy, and encephalopathy. Diagnosis is clinical. Treatment is mainly supportive... read more produces a unique mousy odor (musty, sweet, and/or sulfurous), and renal failure Acute Kidney Injury (AKI) Acute kidney injury is a rapid decrease in renal function over days to weeks, causing an accumulation of nitrogenous products in the blood (azotemia) with or without reduction in amount of urine... read more produces an odor of urine or ammonia.

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 ).

Review of systems should seek symptoms of causative disorders, including nasal discharge and face or head pain (sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more , nasal foreign body Nasal Foreign Bodies Nasal foreign bodies are found occasionally in young children, the intellectually impaired, and psychiatric patients. Common objects pushed into the nose include cotton, paper, pebbles, beads... read more ), productive cough and fevers (pulmonary infection), and regurgitation of undigested food when lying down or bending over (Zenker diverticulum Esophageal Diverticula An esophageal diverticulum is an outpouching of mucosa through the muscular layer of the esophagus. It can be asymptomatic or cause dysphagia and regurgitation. Diagnosis is made by barium swallow... read more ). Predisposing factors such as dry mouth, dry eyes, or both (Sjögren syndrome Sjögren Syndrome Sjögren syndrome is a relatively common chronic, autoimmune, systemic, inflammatory disorder of unknown cause. It is characterized by dryness of the mouth, eyes, and other mucous membranes ... read more ) should be noted.

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 ).

Vital signs are reviewed, particularly for presence of fever.

The nose is examined for discharge and foreign body.

The mouth is examined for signs 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 , dental infection Toothache and Infection Pain in and around the teeth is a common problem, particularly among patients with poor oral hygiene. Pain may be constant, felt after stimulation (eg, heat, cold, sweet food or drink, chewing... read more , and cancer. Signs of apparent dryness are noted (eg, whether the mucosa is dry, sticky, or moist, and whether saliva is foamy, stringy, or normal in appearance).

The pharynx is examined for signs of infection and cancer.

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.

The following findings are of particular concern:

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 ).

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.

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 ). 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.