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Halitosis is a frequent or persistent unpleasant odor to the breath.
About 85% of cases result from oral conditions. A variety of systemic and extra-oral conditions account for the remainder.
Halitosis most often results from fermentation of food particles by anaerobic gram-negative bacteria in the mouth, producing such volatile sulfur compounds as hydrogen sulfide and methyl mercaptan. Causative bacteria may be present in areas of gingival or periodontal disease, particularly when ulceration or necrosis is present. In patients with healthy periodontal tissue, these bacteria deposit on the dorsal posterior tongue. Factors contributing to the overgrowth of causative bacteria include decreased salivary flow (eg, due to parotid disease or Sjögren's syndrome), salivary stagnation, and increased salivary pH.
Necrotic oral or nasopharyngeal cancer is a rare cause of halitosis.
Certain ingested substances (tobacco, alcohol) and foods (onions, garlic, some spices) contain volatile compounds that are released into exhaled air after systemic absorption.
Rarely, sinus or pulmonary infection produces malodor of exhaled breath. This is more common if infection is caused by a nasal or pulmonary foreign body or with bronchiectasis or anaerobic lung abscess. Food trapped in a Zenker's diverticulum also causes halitosis.
Several systemic diseases produce volatile substances detectable on the breath, although not the particularly foul, pungent odors typically considered halitosis. Diabetic ketoacidosis produces a sweet or fruity odor of acetone; liver failure, a “mousy” or sometimes faintly sulfurous odor; and renal failure, an odor of urine or ammonia. GI disorders do not generally cause halitosis because the esophagus is normally collapsed. It is a fallacy that breath odor reflects the state of digestion and bowel function.
Psychogenic halitosis is a patient's belief that he has bad breath despite the fact that others do not perceive it. This occurs in various mental disorders and may be reported by the hypochondriacal patient who commonly amplifies normal body sensations.
Evaluation
and Treatment
While obtaining the history, the physician should particularly seek symptoms of focal infection or systemic illness.
During the physical examination, the nose and oropharynx are examined for signs of infection, foreign body, or gingival disease. A sniff test of exhaled air is conducted. In general, oral causes result in the most putrefying, pungent smell, whereas systemic conditions result in a more subtle, abnormal odor. Ideally, for 48 h before the examination, the patient avoids eating garlic or onions, and for 2 h before, the patient abstains from eating, chewing, drinking, gargling, rinsing, or smoking. During the test, the patient exhales 10 cm from the examiner's nose, first through the mouth and then with the mouth closed. A worse odor through the mouth suggests an oral etiology. A worse odor through the nose suggests nasal or sinus etiology. Similar odor through both nose and mouth suggests a systemic or pulmonary cause. If site of origin is unclear, the posterior tongue is scraped with a plastic spoon. After 5 sec, the spoon is sniffed 5 cm from the examiner's nose.
Extensive diagnostic evaluation should not be undertaken unless the history and physical examination suggest an underlying disease. Portable sulfur monitors, gas chromatography, and chemical tests of tongue scrapings are best left to research protocols.
Underlying diseases are treated. If the cause is oral, the patient should see a dentist for professional cleaning and treatment of gingival disease and caries. Home treatment involves enhanced oral hygiene, including thorough flossing, tooth brushing, and brushing of the tongue with the toothbrush. Mouthwashes are of little benefit except to mask odor for about 20 min. Psychogenic halitosis may require psychiatric consultation.
Last full review/revision November 2005
Content last modified November 2005
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