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| ==Overview== | | ==Overview== |
| Halitosis, oral malodor, or bad breath are all names for the same pathophysiology. It is defined as noticeably unpleasant odors exhaled in [[Breath|breathing]] – whether the [[olfaction|smell]] is from an oral source or not. Common causes include poor oral hygiene, dental or oral infections, or the ingestion of certain foods. Halitosis has a substantial economic and social influence. Most of the patients suffering from bad breath cause embarrassment and distress their social life and communication. Furthermore, halitosis can be suggestive of underlying diseases.
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| ==Pathophysiology==
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| In most cases (85-90%), bad breath originates in the [[mouth]] itself.<ref name=rosenberg0>Rosenberg M. The science of bad breath. ''Sci Am''. 2002 Apr;286(4):72-9. PMID 11905111.</ref> The intensity of bad breath differs during the day, as a function of [[dry mouth|oral dryness]], (which may be due to [[stress (medicine)|stress]] or [[fasting]]), eating certain foods (such as garlic, onions, meat, fish and cheese), [[obesity]]<ref>Rosenberg M, Knaan T, Cohen D. Association among bad breath, body mass index, and alcohol intake. ''J Dent Res''. 2007 Oct;86(10):997-1000. PMID 17890678.</ref>, [[tobacco smoking|smoking]] and [[alcohol consumption and health|alcohol consumption]].<ref>Knaan T, Cohen D, Rosenberg M. Predicting bad breath in the non-complaining population. ''Oral Dis''. 2005;11 Suppl 1:105-6.</ref> Because the mouth is dry and inactive during the night, the odor is usually worse upon awakening ("morning breath").
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| ===Mouth===
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| Though the causes of breath odor are not entirely understood, most unpleasant [[odor]]s are known to arise from [[protein]]s trapped in the mouth which are processed by oral bacteria. There are over 600 types of bacteria found in the average mouth. Several dozens of these can produce high levels of foul odors when incubated in the [[laboratory]].
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| The most common location for mouth-related halitosis is the [[tongue]]. Large quantities of naturally-occurring bacteria are often found on the posterior dorsum of the tongue, where they are relatively undisturbed by normal activity. This part of the tongue is relatively dry and poorly cleansed, and bacterial populations can thrive on remnants of [[food]] deposits, [[epithelium|dead epithelial cells]] and [[postnasal drip]]. The convoluted microbial structure of the tongue dorsum provides an ideal [[habitat]] for [[anaerobic bacteria]], which flourish under a continually-forming tongue coating of food debris, dead cells, postnasal drip and overlying bacteria, living and dead. When left on the tongue, the [[anaerobic respiration]] of such bacteria can yield either the [[putrefaction|putrescent]] smell of [[indole]], [[skatole]], [[polyamine]]s, or the "rotten egg" smell of volatile sulfur compounds (VSCs) such as [[hydrogen sulfide]], [[methyl mercaptan]] and [[dimethyl sulfide]].
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| The odors are produced mainly due to the anaerobic breakdown of [[protein]]s into individual [[amino acid]]s, followed by the further breakdown of certain amino acids to produce detectable foul [[gas]]es. For example, the breakdown of [[cysteine]] and [[methionine]] produce hydrogen sulfide and methyl mercaptan respectively. Volatile sulfur compounds have been shown to be statistically associated with oral malodor levels, and usually decrease following successful treatment.<ref name=rosenberg1>Rosenberg M. Clinical assessment of bad breath: current concepts. ''J Am Dent Assoc''. 1996 Apr;127(4):475-82. PMID 8655868.</ref>
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| Other parts of the mouth may also contribute to the overall odor, but are not as common as the back of the tongue. These locations are, in descending prevalence order: inter-dental and sub-gingival niches, faulty [[dentistry|dental]] work, food-impaction areas in-between the teeth, [[abscess]]es and unclean [[dentures]].<ref name=scully>Scully C, Rosenberg M. Halitosis. ''Dent Update''. 2003 May;30(4):205-10. PMID 12830698.</ref>
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| ===Gum disease===
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| There is some controversy over the role of [[periodontitis|periodontal diseases]] in causing bad breath. Whereas bacteria growing below the gumline (subgingival [[dental plaque]]) have a foul smell upon removal, several studies reported no statistical correlation between malodor and periodontal parameters.<ref>Stamou E, Kozlovsky A, Rosenberg M. Association between oral malodour and periodontal disease-related parameters in a population of 71 Israelis. ''Oral Dis''. 2005;11 Suppl 1:72-4. PMID 15752105.</ref><ref>Bosy A, Kulkarni GV, Rosenberg M, McCulloch CA. Relationship of oral malodor to periodontitis: evidence of independence in discrete subpopulations. ''J Periodontol''. 1994 Jan;65(1):37-46. PMID 8133414.</ref>
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| ===Nose===
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| The second major source of bad breath is the [[nose]]. In this instance, the odor exiting the [[nostril]]s has a pungent odor which differs from the oral odor. Nasal odor may be due to [[sinus infection]]s or [[foreign bodies]].<ref name=rosenberg1/><ref name=scully/>
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| ===Tonsils===
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| [[Putrefaction]] from the [[tonsil]]s is generally considered a minor cause of bad breath, contributing to some 3-5% of cases. Although approximately 5% of the population suffer from small bits of [[calcium|calcified]] matter in tonsillar crypts called [[tonsillolith]]s, which smell extremely foul when released, they do not necessarily cause bad breath.<ref name=rosenberg1/><ref>Finkelstein Y, Talmi YP, Ophir D, Berger G. Laser cryptolysis for the treatment of halitosis. ''Otolaryngol Head Neck Surg''. 2004 Oct; 131(4):372-7. PMID 15467602.</ref>
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| ===Systemic diseases===
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| There are a few systemic (non-oral) medical conditions which may cause foul breath odor, but these are extremely infrequent in the general population. Such conditions are: <ref>Tangerman A. Halitosis in medicine: a review. ''Int Dent J''. 2002 Jun;52 Suppl 3:201-6. PMID 12090453.</ref><ref name=tonzetich>Tonzetich J. Production and origin of oral malodor: a review of mechanisms and methods of analysis. ''J Periodontol''. 1977 Jan;48(1):13-20. PMID 264535.</ref>
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| # [[Fetor hepaticus]]: an example of a rare type of bad breath caused by chronic [[liver failure]].
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| # [[Lower respiratory tract infection]]s (Bronchial and lung infections).
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| # [[nephritis|Renal infections]] and [[renal failure]].
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| # [[Carcinoma]].
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| # [[Trimethylaminuria]] ("fish odor syndrome").
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| # [[Diabetes mellitus]].
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| # [[metabolism|Metabolic]] dysfunction.<ref>Tangerman A, Winkel EG. Intra- and extra-oral halitosis: finding of a new form of extra-oral blood-borne halitosis caused by dimethyl sulphide. ''J Clin Periodontol''. 2007 Sep;34(9):748-55. PMID 17716310.</ref>
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| Because these conditions are rare, may not display bad breath at all, and will most likely show additional characters (which are more conclusive, diagnostically, than the breath odor), people suffering from halitosis should not immediately conclude that they suffer from these conditions or diseases just by deducing from the breath odor alone.
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| Most researchers consider the [[stomach]] as a very uncommon source of bad breath (except in [[belching]]). The [[esophagus]] is a closed and collapsed tube, and continuous flow (as opposed to a simple burp) of gas or putrid substances from the [[stomach]] indicates a health problem - such as [[gastroesophageal reflux|reflux]] or a [[fistula]] between the stomach and the esophagus - which will demonstrate more serious manifestations than just foul odor.<ref name=rosenberg0/>
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| ==Causes==
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| ===Common Causes===
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| * Poor [[dental hygiene]]
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| * [[Periodontitis]]
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| * [[Tooth abscess]]
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| * [[Liver failure]]
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| * [[GERD]]
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| * [[Zenker diverticulum]]
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| * [[Sinusitis]]
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| * [[Postnasal drip]]
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| ===Causes by Organ System===
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| {|style="width:80%; height:100px" border="1"
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| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
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| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning'''
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| |bgcolor="Beige"| [[Arsenic trioxide]], [[Botulism]], [[Cyanide]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| [[Antihistamines]], [[Aztreonam]],[[Cysteamine]], [[Disulfiram]], [[Emedastine Difumarate]], [[Tiagabine]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| [[Adenoiditis]], [[Allergic Rhinitis]], [[Atrophic rhinitis]], [[Carcinoma larynx ]], [[Catarrh]], [[Chronic sinusitis]], [[Chronic tonsillitis]], [[Postnasal drip]], [[Rhinitis]], [[Sinusitis]], [[Sphenoid sinusitis ]], [[Tonsillitis]], [[Vincent's angina]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| [[Diabetes]], [[Diabetic ketoacidosis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| [[Achalasia]], [[Acute necrotizing ulcerative gingivitis]], [[Appendicitis ]], [[Constipation]], [[Dry mouth]], [[Esophageal diverticulum ]], [[Esophageal pouch]], [[Esophageal stricture]], [[Gastrocolic fistula]], [[Gastroesophageal reflux]], [[GERD]], [[Hepatitis]], [[High protein diets]], [[Ileus]], [[Liver failure]], [[Oral cancer]], [[Parotiditis]], [[Stomatitis ]], [[Thrush]], [[Zenker's diverticulum]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| [[Cystic fibrosis]], [[Immotile cilia syndrome]], [[Primary ciliary dyskinesia]], [[Trimethylaminuria]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| [[Chronic sinusitis]], [[Chronic tonsillitis]], [[Vincent's angina]], [[Acute necrotizing ulcerative gingivitis]], [[Appendicitis ]], [[Paraotiditis]], [[Thrush]], [[Tuberculosis]], [[Alveolar osteitis]], [[Dental abscess]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| [[Acidosis]], [[Dehydration]], [[Fasting]], [[Uremia]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Obstetric/Gynecologic'''
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| |bgcolor="Beige"| [[Hyperemesis Gravidarum]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| [[Carcinoma larynx ]], [[Tumor]] exulceration of mouth, [[Oral cancer]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| [[Psychogenic halitosis]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| [[Tuberculosis]], [[Bronchiectasis]], [[Bronchitis]], [[Emphysema]], [[Lung abscess]], [[Pneumonia]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| [[Kidney failure]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Sexual'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Urologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dental'''
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| |bgcolor="Beige"| [[Alveolar osteitis]], [[Dental abscess]], [[Dental caries]], [[Dental plaque]], [[Dental sepsis]], [[Dentures]], [[Gingivitis]], [[Gum disease]], [[Periodontitis]], [[Poor dental health]], [[Poor dental hygiene]], [[Pyorrhea alveolaris]], [[Tooth abscess]], [[Tooth decay]]
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| [[Alcoholism]], [[Garlic]], inadequate [[saliva]], [[Mouth breathing]], [[Smoking]]
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| |-
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| |}
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|
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| ===Causes In Alphabetical Order <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>===
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| {{col-begin}} {{col-break}}
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| * [[Achalasia]]
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| * [[Acidosis]]
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| * [[Acute necrotizing ulcerative gingivitis]]
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| * [[Adenoiditis]]
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| * [[Alcoholism]]
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| * [[Allergic Rhinitis]]
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| * [[Alveolar osteitis]]
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| * [[Antihistamines]]
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| * [[Appendicitis ]]
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| * [[Arsenic trioxide]]
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| * [[Atrophic rhinitis]]
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| * [[Aztreonam]]
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| * [[Botulism]]
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| * [[Bronchiectasis]]
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| * [[Bronchitis]]
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| * [[Carcinoma larynx ]]
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| * [[Catarrh]]
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| * [[Chronic sinusitis]]
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| * [[Chronic tonsillitis]]
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| * [[Constipation]]
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| * [[Cyanide]]
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| * [[Cysteamine]]
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| * [[Cystic fibrosis]]
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| * [[Dehydration]]
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| * [[Dental abscess]]
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| * [[Dental caries]]
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| * [[Dental plaque]]
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| * [[Dental sepsis]]
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| * [[Dentures]]
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| * [[Diabetes]]
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| * [[Diabetic ketoacidosis]]
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| * [[Disulfiram]]
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| * [[Dry mouth]]
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| * [[Emphysema]]
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| * [[Esophageal diverticulum ]]
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| * [[Esophageal pouch]]
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| * [[Esophageal stricture]]
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| * [[Fasting]]
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| * [[Garlic]]
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| * [[Gastrocolic fistula]]
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| {{col-break}}
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| * [[Gastroesophageal reflux]]
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| * [[GERD]]
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| * [[Gingivitis]]
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| * [[Gum disease]]
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| * [[Hepatitis]]
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| * [[High protein diets]]
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| * [[Hyperemesis Gravidarum]]
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| * [[Ileus]]
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| * [[Immotile cilia syndrome]]
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| * Inadequate [[saliva]]
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| * [[Kidney failure]]
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| * [[Liver failure]]
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| * [[Lung abscess]]
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| * [[Mouth breathing]]
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| * [[Oral cancer]]
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| * [[Parotiditis]]
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| * [[Periodontitis]]
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| * [[Pneumonia]]
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| * [[Poor dental health]]
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| * [[Poor dental hygiene]]
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| * [[Postnasal drip]]
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| * [[Primary ciliary dyskinesia]]
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| * [[Psychogenic halitosis]]
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| * [[Pyorrhea alveolaris]]
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| * [[Rhinitis]]
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| * [[Sinusitis]]
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| * [[Smoking]]
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| * [[Sphenoid sinusitis ]]
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| * [[Stomatitis ]]
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| * [[Thrush]]
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| * [[Tonsillitis]]
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| * [[Tooth abscess]]
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| * [[Tooth decay]]
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| * [[Trimethylaminuria]] <ref> http://www.ncbi.nlm.nih.gov/books/NBK1103/</ref>
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| * [[Tuberculosis]]
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| * [[Tumor]] exulceration of mouth
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| * [[Uremia]]
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| * [[Vincent's angina]]
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| * [[Zenker's diverticulum]]
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| |}
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| ==Differentiating Halitosis from other Disorders==
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| ===Halitophobia (delusion halitosis)===
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| Some one quarter of the patients seeking professional advice on bad breath suffer from a highly exaggerated concern of having bad breath, known as ''[[halitophobia]]'', [[delusion|delusional]] halitosis, or as a manifestation of [[Olfactory Reference Syndrome]]. These patients are sure that they have bad breath, although many have not asked anyone for an objective opinion. Halitophobia may severely affect the lives of some 0.5-1.0% of the adult population.<ref>Lochner C, Stein DJ. Olfactory reference syndrome: diagnostic criteria and differential diagnosis. ''J Postgrad Med''. 2003 Oct-Dec;49(4):328-31. PMID 14699232.</ref> Only few psychologists and health professionals have tried to come to terms with this debilitating and difficult-to-treat emotional problem.<ref>Seemann R, Bizhang M, Djamchidi C, Kage A, Nachnani S. The proportion of pseudo-halitosis patients in a multidisciplinary breath malodour consultation. ''Int Dent J''. 2006 Apr; 56(2):77-81. PMID 16620035.</ref><ref>Eli I, Baht R, Kozlovsky A, Rosenberg M. The complaint of oral malodor: possible psychopathological aspects. ''Psychosom Med''. 1996 Mar-Apr; 58(2):156-9. PMID 8849633.</ref>
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| ==Epidemiology and Demographics==
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| Halitosis has a significant impact — personally and socially — on those who suffer from it or believe they do (halitophobia), and is estimated to be the 3rd most frequent reason for seeking [[dentistry|dental]] aid, following [[tooth decay]] and [[periodontal disease]].<ref name=loesche>Loesche WJ, Kazor C. Microbiology and treatment of halitosis. ''Periodontology 2000''. 2002;28:256-79. PMID 12013345.</ref>
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| ==Natural History, Complications and Prognosis==
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| ===Transient Bad Breath===
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| Bad breath may be '''transient''', often disappearing following eating, [[brushing]] one's [[teeth]], [[flossing]], and rinsing with specialised [[mouthwash]].
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| ===Chronic Bad Breath===
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| Bad breath may also be '''persistent''' (chronic bad breath), which is a more serious condition, affecting some 25% of the population in varying degrees.<ref>Bosy A, Oral malodor: philosophical and practical aspects. ''J Can Dent Assoc''. 1997 Mar;63(3):196-201 PMID 9086681.</ref> It can negatively affect the individual's personal, social and business relationships, leading to poor [[self-esteem]] and increased [[Stress (medicine)|stress]]. This condition is usually caused by the [[metabolism|metabolic]] activity of certain types of oral [[bacteria]].
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| ==Diagnosis==
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| ===Self diagnosis and home diagnosis===
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| Scientists have long thought that smelling one's own breath odor is often difficult due to habituation, although many people with bad breath are able to detect it in others. Research has suggested that self-evaluation of halitosis isn't easy because of preconceived notions of how bad we think it should be. Some people assume that they have bad breath because of bad [[taste]] (metallic, sour, fecal, etc), however bad taste is considered a poor indicator.<ref>Tanaka M, Anguri H, Nishida N, Ojima M, Nagata H, Shizukuishi S. Reliability of clinical parameters for predicting the outcome of oral malodor treatment. ''J Dent Res''. 2003 Jul; 82(7):518-22. PMID 12821711.</ref><ref name=rosenberg2>Rosenberg M, Kozlovsky A, Gelernter I, Cherniak O, Gabbay J, Baht R. and Eli I. Self-estimation of oral malodor. ''J Dent Res''. 1995 Sep; 74(9):1577-82. PMID 7560419.</ref>
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| For these reasons, the simplest and most effective way to know whether one has bad breath is to ask a trusted adult family member or very close friend ("confidant"). If the confidant confirms that there is a breath problem, he or she can help determine whether it is coming from the mouth or the nose, and whether a particular treatment is effective or not.<ref name=eli1>Eli I, Baht R, Koriat H, Rosenberg M. Self-perception of breath odor. ''J Am Dent Assoc''. 2001 May; 132(5):621-6. PMID 11367966.</ref>
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| One popular home method to determine the presence of bad breath is to lick the back of the [[wrist]], let the [[saliva]] dry for a minute or two, and smell the result. This test results in overestimation, as concluded from research,<ref name=rosenberg0/> and should be avoided. A better way would be to lightly scrape the posterior back of the tongue with a plastic disposable spoon and to smell the drying residue. A spouse, family member, or close friend may be willing to smell one's breath and provide honest [[feedback]]. Home tests are now available which use a chemical reaction to test for the presence of [[polyamines]] and sulfur compounds on tongue swabs, but there are few studies showing how well they actually detect the odor. Furthermore, since breath odor changes in intensity throughout the day depending on many factors, multiple testing may be necessary.
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| ===Professional diagnosis===
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| If bad breath is persistent, and all other medical and dental factors have been ruled out, specialised testing and treatment is required. Hundreds of dental offices and commercial breath clinics now claim to diagnose and treat bad breath. They often use some of several laboratorial methods for diagnosis of bad breath:
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| # '''[[Halimeter]]'''™: a portable sulfide monitor used to test for levels of sulfur emissions (specifically, [[hydrogen sulfide]]) in the mouth air. When used properly this device can be very effective at determining levels of certain VSC-producing bacteria. However, it has drawbacks in clinical applications. For example, other common sulfides (such as [[mercaptan]]) are not recorded as easily and can be misrepresented in test results. Certain foods such as garlic and onions produce sulfur in the breath for as long as 48 hours and can result in false readings. The Halimeter is also very sensitive to alcohol, so one should avoid drinking alcohol or using alcohol-containing mouthwashes for at least 12 hours prior to being tested. This analog machine loses sensitivity over time and requires periodic recalibration to remain accurate.<ref>Rosenberg M, McCulloch CA. Measurement of oral malodor: current methods and future prospects. ''J Periodontol''. 1992 Sep;63(9):776-82. PMID 1474479.</ref>
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| # '''[[Gas chromatography]]''': portable machines, such as the OralChroma™, are currently being introduced.<ref>van den Velde S, Quirynen M, van Hee P, van Steenberghe D. Halitosis associated volatiles in breath of healthy subjects. ''J Chromatogr B Analyt Technol Biomed Life Sci''. 2007 Jun 15;853(1-2):54-61. PMID 17416556.</ref> This technology is specifically designed to digitally measure molecular levels of the three major VSCs in a sample of mouth air ([[hydrogen sulfide]], [[methyl mercaptan]], and [[dimethyl sulfide]]). It is accurate in measuring the sulfur components of the breath and produces visual results in graph form via computer interface.<ref>Murata T, Rahardjo A, Fujiyama Y, Yamaga T, Hanada M, Yaegaki K, Miyazaki H. Development of a compact and simple gas chromatography for oral malodor measurement. ''J Periodontol''. 2006 Jul;77(7):1142-7. PMID 16805675.</ref>
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| # '''BANA test''': this test is directed to find the salivary levels of an [[enzyme]] indicating the presence of certain halitosis-related bacteria.<ref>Kozlovsky A, Gordon D, Gelernter I, Loesche WJ, Rosenberg M. Correlation between the BANA test and oral malodor parameters. ''J Dent Res''. 1994 May; 73(5):1036-42. PMID 8006229.</ref>
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| # '''[[beta-galactosidase|β-galactosidase]] test''': salivary levels of this enzyme were found to be correlated with oral malodor.<ref>Sterer N, Greenstein RB, Rosenberg M. Beta-galactosidase activity in saliva is associated with oral malodor. ''J Dent Res''. 2002 Mar;81(3):182-5. PMID 11876272.</ref>
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| Although such instrumentation and examinations are widely used in breath clinics, the most important measurement of bad breath (the gold standard) is the actual [[inhalation|sniffing]] and scoring of the level and type of the odor carried out by trained experts ("organoleptic measurements"). The level of odor is usually assessed on a six point intensity scale.<ref name=loesche/><ref name=rosenberg1/><ref> Greenman J, Duffield J, Spencer P, Rosenberg M, Corry D, Saad S, Lenton P, Majerus G, Nachnani S, El-Maaytah M. Study on the Organoleptic Intensity Scale for Measuring Oral Malodor. ''J Dent Res''. 83(1): 81-85, 2004. PMID 14691119.</ref>
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| ==Treatment==
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| ===Lifestyle Changes and Home Care===
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| Currently, '''chronic halitosis''' is not very well understood by most [[physician]]s and [[dentist]]s, so effective treatment is not always easy to find. Six strategies may be suggested:
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| # '''Eating a healthy breakfast''' with rough foods helps clean the very back of the tongue <ref name=tonzetich/>.
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| # '''Gently cleaning the tongue surface''' twice daily with a tongue brush, [[tongue scraper]] or tongue cleaner to wipe off the bacterial [[biofilm]], debris and mucus. An inverted [[teaspoon]] is also effective; a [[toothbrush]] should be avoided, as the bristles will grip the tongue, causing a gagging reflex. Scraping or otherwise damaging the tongue should be avoided, and scraping of the V-shaped row of [[taste bud]]s found at the extreme back of the tongue should also be avoided. Brushing a small amount of [[antibacterial]] mouth rinse or tongue gel onto the tongue surface will further inhibit bacterial action.<ref name=rosenberg0/>
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| # '''Chewing gum''': Since dry mouth can increase bacterial buildup and cause or worsen bad breath, chewing sugarless gum can help with the production of [[saliva]], and thereby help to reduce bad breath. Chewing may help particularly when the mouth is dry, or when one cannot perform [[oral hygiene]] procedures after meals (especially those meals rich in [[protein]]). This aids in provision of saliva, which washes away oral bacteria, has antibacterial properties and promotes mechanical activity which helps cleanse the mouth. Some chewing gums contain special anti-odor ingredients. Chewing on fennel seeds, [[cinnamon]] sticks, [[mastic]] gum or fresh parsley are common [[folk remedies]].
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| # '''[[Gargling]]''' right before bedtime with an effective mouthwash (see below). Several types of commercial [[#mouthwashes|mouthwashes]] have been shown to reduce malodor for hours in peer-reviewed scientific studies. Mouthwashes may contain active ingredients which are inactivated by the [[soap]] present in most [[toothpaste]]s. Thus it is recommended to refrain from using mouthwash directly after toothbrushing with paste (also see mouthwashes, below).<ref>Yaegaki K, Coil JM, Kamemizu T, Miyazaki H. Tongue brushing and mouth rinsing as basic treatment measures for halitosis. ''Int Dent J''. 2002 Jun;52 Suppl 3:192-6. PMID 12090451.</ref>
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| # '''Maintaining proper [[oral hygiene]]''', including [[brushing]], daily [[flossing]], and periodic visits to [[dentist]]s and [[hygienist]]s. Flossing is particularly important in removing rotting food debris and bacterial plaque from between the teeth, especially at the gumline. [[Dentures]] should be properly cleaned and soaked overnight in antibacterial solution (unless otherwise advised by your dentist).<ref name=scully/>
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| # '''Maintain [[water]] levels''' in the body by drinking several glasses of water a day.<ref name=rosenberg0/>
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| ===Mouthwashes===
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| [[Mouthwash]]es often contain antibacterial agents including [[cetylpyridinium chloride]], [[chlorhexidine]], [[zinc gluconate]], [[essential oil]]s, and [[chlorine dioxide]]. They may also contain [[alcohol]], which is a drying agent and may worsen the problem. Rinses in this category include Scope™ and [[Listerine]]™.
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| Other solutions rely on odor eliminators like [[oxidizing agent|oxidizers]] to eliminate existing bad breath on a short-term basis. Rinses in this category include TheraBreath™, Closys™ and others.
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| Bad breath may be temporarily reduced by using a [[hydrogen peroxide]] rinse. Hydrogen peroxide at a [[concentration]] of 1.5% can be taken as an oral [[antiseptic]] by gargling 10 ml, about two [[teaspoon]]s. Hydrogen peroxide is commonly available at a concentration of 3% and should be diluted to 1.5% by mixing it with an equal volume of water. Hydrogen peroxide is a powerful [[oxidizer]] which kills most bacteria, including useful aerobic bacteria. Prolonged use of hydrogen peroxide may be harmful. Concentrated hydrogen peroxide (>50%) is [[corrosion|corrosive]], and even domestic-strength solutions can cause irritation to the [[eye]]s, [[mucous membrane]]s and [[skin]]. Swallowing hydrogen peroxide solutions is particularly dangerous, as decomposition in the stomach releases large quantities of gas (10 times the volume of a 3% solution) leading to internal [[bleeding]]. Inhaling over 10% can cause severe [[lung|pulmonary]] irritation.
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| A relatively new approach for home-care of bad breath is by oil-containing mouthwashes. The use of essential oils has been studied,<ref>Carvalho MD, Tabchoury CM, Cury JA, Toledo S, Nogueira-Filho GR. Impact of mouthrinses on morning bad breath in healthy subjects. ''J Clin Periodontol''. 2004 Feb;31(2):85-90. PMID 15016031.</ref> was found effective and is being used in several commercial mouthwashes, as well as the use of two-phase (oil:water) mouthwashes, which have been found to be effective in reducing oral malodor.<ref>Rosenberg M, Gelernter I, Barki M, Bar-Ness R. Day-long reduction of oral malodor by a two-phase oil:water mouthrinse as compared to chlorhexidine and placebo rinses. ''J Periodontol''. 1992 Jan;63(1):39-43. PMID 1552460.</ref>
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| ==See also==
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| * [[Periodontitis]]
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| * [[Dental caries]]
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| * [[Tooth abscess]]
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| * [[Postnasal drip]]
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| * [[Oral hygiene]]
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| * [[Tongue scraper]]
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| * [[Mouthwash]]
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| * [[Toothpaste]]
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| ==References==
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| {{reflist|2}}
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| [[es:Halitosis]]
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| [[fr:Halitose]]
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| [[ja:口臭]]
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| [[pl:Cuchnący oddech]]
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| [[pt:Halitose]]
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| [[ru:Галитоз]]
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| [[Category:Oral hygiene]]
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| [[Category:Symptoms]]
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| [[Category:Signs and symptoms]]
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