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{{Infobox_Disease
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| Name          = Halitosis
| Image          =
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| DiseasesDB    = 5603
| ICD10          = {{ICD10|R|19|6|r|10}}
| ICD9          = {{ICD9|784.9}}
| ICDO          =
| OMIM          =
| MedlinePlus    =
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| MeshID        =
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{{SI}}
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'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''


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'''Halitosis''', '''oral malodor''' (scientific term), '''breath odor''', '''foul breath''', '''fetor oris''', '''fetor ex ore''', or most commonly '''bad breath''' are terms used to describe noticeably unpleasant odors exhaled in [[Breath|breathing]] – whether the [[olfaction|smell]] is from an oral source or not.


Halitosis has a significant impact &mdash; personally and socially &mdash; 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>
{{SK}} oral malodor; breath odor; foul breath; fetor oris; fetor ex ore; bad breath


==General==
==Overview==
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"). Bad breath may be '''transient''', often disappearing following eating, [[brushing]] one's [[teeth]], [[flossing]], and rinsing with specialised [[mouthwash]].
The word halitosis is derived from the Latin word ‘halitus’, meaning more than a socially acceptable degree of bad [[breath]] from the [[mouth]]. The majority of the time, it is due to poor dental, [[tongue]] hygiene, and gum [[infection]]s. It can be physiological due to decreased [[saliva]] flow or an underlying [[disease]]. The [[patient]] can perceive the bad [[breath]], or others might complain about it. It adversely affects the patient’s social and professional life.<ref name="pmid18460398">{{cite journal| author=Hughes FJ, McNab R| title=Oral malodour--a review. | journal=Arch Oral Biol | year= 2008 | volume= 53 Suppl 1 | issue=  | pages= S1-7 | pmid=18460398 | doi=10.1016/S0003-9969(08)70002-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18460398  }} </ref>


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]].
==Classification==


==Differential Diagnosis of Causes==
*[[Halitosis]] can be classified into physiologic, pathologic, or subjective:
**Physiologic [[halitosis]] occurs due to decreased [[saliva]] production. It occurs in the morning when the [[mouth]] is dry, and there is an overgrowth of oral [[bacteria]]. [[Tobacco]] [[smoking]] and certain food items like garlic and onion also cause bad [[breath]] due to aromatic compounds. Physiological [[halitosis]] improves significantly by [[flossing]], tooth brushing, rinsing with mouthwash, and drinking water.<ref name="pmid8655868">{{cite journal| author=Rosenberg M| title=Clinical assessment of bad breath: current concepts. | journal=J Am Dent Assoc | year= 1996 | volume= 127 | issue= 4 | pages= 475-82 | pmid=8655868 | doi=10.14219/jada.archive.1996.0239 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8655868  }} </ref>
**Pathological [[halitosis]] occurs due to an underlying [[disease]]. The common causes include postnasal drip, [[sinusitis]], [[gingivitis]], and [[caries]]. The tonsillar inflammation and peri-tonsillar abscesses can also result in bad breath.<ref name="pmid8655868" />
**Subjective [[halitosis]] is also called psychogenic [[halitosis]]. The [[patient]] thinks that they have bad [[breath]], while the diagnostic tests are negative for [[halitosis]].<ref name="pmid23633830">{{cite journal| author=Aylıkcı BU, Colak H| title=Halitosis: From diagnosis to management. | journal=J Nat Sci Biol Med | year= 2013 | volume= 4 | issue= 1 | pages= 14-23 | pmid=23633830 | doi=10.4103/0976-9668.107255 | pmc=3633265 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23633830  }} </ref>


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>
==Pathophysiology==


* [[Allergic Rhinitis]]
*It is thought that [[halitosis]] is produced by bacterial overgrowth in the oral cavity.
* [[Atrophic Rhinitis]]
*Poor oral hygiene, dental caries, or gum infection results in the growth of gram-negative anaerobes in the mouth.<ref name="pmid27045438">{{cite journal| author=De Geest S, Laleman I, Teughels W, Dekeyser C, Quirynen M| title=Periodontal diseases as a source of halitosis: a review of the evidence and treatment approaches for dentists and dental hygienists. | journal=Periodontol 2000 | year= 2016 | volume= 71 | issue= 1 | pages= 213-27 | pmid=27045438 | doi=10.1111/prd.12111 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27045438  }} </ref>
* [[Botulism]]
*These bacteria thrive on debris material entrapped between teeth and gums. Lysosomal enzymes secreted by the bacteria break down the glycoproteins in the food particles. It results in volatile compounds like hydrogen sulfide, dimethyl sulfide, and methyl mercaptan, resulting in [[halitosis]].<ref name="pmid264535">{{cite journal| author=Tonzetich J| title=Production and origin of oral malodor: a review of mechanisms and methods of analysis. | journal=J Periodontol | year= 1977 | volume= 48 | issue= 1 | pages= 13-20 | pmid=264535 | doi=10.1902/jop.1977.48.1.13 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=264535  }} </ref>
* [[Bronchiectasis]]
*The Bacteroides, Prevotella, and Fusobacterium species are mainly responsible for [[halitosis]].<ref name="pmid12090458">{{cite journal| author=Sterer N, Rosenberg M| title=Effect of deglycosylation of salivary glycoproteins on oral malodour production. | journal=Int Dent J | year= 2002 | volume= 52 Suppl 3 | issue=  | pages= 229-32 | pmid=12090458 | doi=10.1002/j.1875-595x.2002.tb00930.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12090458  }} </ref>
* [[Chronic Bronchitis]]
* [[Chronic Sinusitis]]
* [[Constipation]]
* [[Cyanide]]
* [[Dental caries]]
* [[Diabetes Mellitus]] (with [[ketoacidosis]])
* [[Drugs]]
* [[Esophageal Diverticulum]]
* [[Esophagitis]]
* [[Fasting]]
* Foods
* [[Gastric carcinoma]]
* [[Gastritis]]
* [[Gastrocolic fistula]]
* [[Gastroesophageal Reflux Disease]] ([[GERD]])
* [[Hiatus hernia]]
* [[Hyperemesis Gravidarum]]
* [[Ileus]]
* [[Kidney Disease]]
* [[Liver Disease]]
* [[Liver failure]]
* [[Lung abscess]]
* [[Menstruation]] (may exacerbate halitosis)
* [[Parodontosis]]
* [[Pharyngitis]]
* [[Pneumonia]]
* [[Poor dental hygiene]]
* [[Postnasal drip]]
* [[Psychiatric]] ("pseudohalitosis")
* [[Pulmonary]] disorders
* [[Salivary gland disorder]]
* [[Sinus infection]]s
* [[Stomaticitis]]
* [[Thrush]]
* [[Tobacco]] or [[alcohol]] use
* [[Tonsillar Disease]]
* [[Trimethylaminuria]]
* [[Tumor]] exulceration (in the mouth)
* [[Ulcer Disease]]
* [[Uremia]]
* [[Xerostomia]] ([[dry mouth]])
* [[Zenker's Diverticulum|Zenker's (pharyngoesophageal) diverticulum]]


==Origins==
==Causes==
===Mouth===
Common causes of [[halitosis]] include:<ref name="pmid18460398">{{cite journal| author=Hughes FJ, McNab R| title=Oral malodour--a review. | journal=Arch Oral Biol | year= 2008 | volume= 53 Suppl 1 | issue=  | pages= S1-7 | pmid=18460398 | doi=10.1016/S0003-9969(08)70002-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18460398  }} </ref>


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]].
*[[Gingivitis]]
*[[Dental plaqe|Plaques]] on the [[tongue]]
*Inflammation of the gum around the impacted [[Wisdom teeth|wisdom tooth]]
*Ucerative gingival infection
*[[Stomatitis|Herepes stomatitis]]
*Chronic [[sinusitis]]
*[[Allergies]]
*Post-nasal drip
*Foreign objects in the [[nasal cavity]]
*[[Tonsillitis]] and peri-tonsillar abcsess
*Chronic [[bronchitis]]
*[[Bronchial carcinoma]]
*[[Gastroesophageal reflux disease]]
*Food containing onion, garlic and spices
*Caffeine intake
*[[Smoking]]
*Psycogenic [[halitosis]]


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]].
==Differntiating Halitosis from other Diseases==
[[Halitosis]] must be differentiated whether it has a physiological cause, some underlying disease, or psychogenic cause.


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>
==Epidemiology and Demographics==


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>
*The prevalence of [[halitosis]] is approximately 32,000 per 100,000 individuals worldwide.<ref name="pmid28676903">{{cite journal| author=Silva MF, Leite FRM, Ferreira LB, Pola NM, Scannapieco FA, Demarco FF | display-authors=etal| title=Estimated prevalence of halitosis: a systematic review and meta-regression analysis. | journal=Clin Oral Investig | year= 2018 | volume= 22 | issue= 1 | pages= 47-55 | pmid=28676903 | doi=10.1007/s00784-017-2164-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28676903  }} </ref>
*[[Halitosis]] affects men and women equally.<ref name="pmid1960254">{{cite journal| author=Rosenberg M, Kulkarni GV, Bosy A, McCulloch CA| title=Reproducibility and sensitivity of oral malodor measurements with a portable sulphide monitor. | journal=J Dent Res | year= 1991 | volume= 70 | issue= 11 | pages= 1436-40 | pmid=1960254 | doi=10.1177/00220345910700110801 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1960254  }} </ref>
*It is more common in middle and lower socioeconomic classes.<ref name="pmid28676903">{{cite journal| author=Silva MF, Leite FRM, Ferreira LB, Pola NM, Scannapieco FA, Demarco FF | display-authors=etal| title=Estimated prevalence of halitosis: a systematic review and meta-regression analysis. | journal=Clin Oral Investig | year= 2018 | volume= 22 | issue= 1 | pages= 47-55 | pmid=28676903 | doi=10.1007/s00784-017-2164-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28676903  }} </ref>
*The prevalence of [[halitosis]] is increasing with time.


===Gum disease===
==Risk Factors==
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>
Common risk factors in the development of [[halitosis]] include:<ref name="pmid12622277">{{cite journal| author=Messadi DV, Younai FS| title=Halitosis. | journal=Dermatol Clin | year= 2003 | volume= 21 | issue= 1 | pages= 147-55, viii | pmid=12622277 | doi=10.1016/s0733-8635(02)00060-8 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12622277  }} </ref>


===Nose===
*[[Hepatic cirrhosis]] and [[hepatic failure]]
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/>
*[[Chronic kidney disease]]
*[[Diabetic ketoacidosis]]
*[[Xerostomia]]
*[[Gastritis]] due to [[Helicobacter pylori]] [[infection]]


===Tonsils===
==Screening==
[[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>
There is insufficient evidence to recommend routine screening for [[halitosis]].


===Systemic diseases===
==Natual History, Complications, and Prognosis==
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>
Common complications of untreated [[halitosis]] include mood disorders like [[depression]], [[anxiety]], [[paranoia]], [[phobia]], and [[obsessive-compulsive disorder]].<ref name="pmid8849633">{{cite journal| author=Eli I, Baht R, Kozlovsky A, Rosenberg M| title=The complaint of oral malodor: possible psychopathological aspects. | journal=Psychosom Med | year= 1996 | volume= 58 | issue= 2 | pages= 156-9 | pmid=8849633 | doi=10.1097/00006842-199603000-00010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8849633  }} </ref>
# [[Fetor hepaticus]]: an example of a rare type of bad breath caused by chronic [[liver failure]].
# [[Lower respiratory tract infection]]s (Bronchial and lung infections).
# [[nephritis|Renal infections]] and [[renal failure]].
# [[Carcinoma]].
# [[Trimethylaminuria]] ("fish odor syndrome").
# [[Diabetes mellitus]].
# [[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>
 
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.  
 
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/>


==Diagnosis==
==Diagnosis==
===Self diagnosis and home diagnosis===
===Diagnostic Study of Choice===
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>
Organoleptic measurement is the gold standard test for the diagnosis of [[halitosis]].<ref name="pmid18602293">{{cite journal| author=Nalçaci R, Sönmez IS| title=Evaluation of oral malodor in children. | journal=Oral Surg Oral Med Oral Pathol Oral Radiol Endod | year= 2008 | volume= 106 | issue= 3 | pages= 384-8 | pmid=18602293 | doi=10.1016/j.tripleo.2008.03.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18602293  }} </ref>
====Organoleptic Measurement====


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>
*It is one of the oldest techniques to detect a bad smell.
*The air expelled from both [[nose]] and [[mouth]] is smelled to detect a foul odor.
*The [[patient]] inspires from the [[nose]] with [[mouth]] close and then expires from the [[mouth]], while the examiner detects it from a distance of 20 cm through a pipette.<ref name="pmid23633830">{{cite journal| author=Aylıkcı BU, Colak H| title=Halitosis: From diagnosis to management. | journal=J Nat Sci Biol Med | year= 2013 | volume= 4 | issue= 1 | pages= 14-23 | pmid=23633830 | doi=10.4103/0976-9668.107255 | pmc=3633265 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23633830  }} </ref>
*This diagnostic test is highly subjective, and the examiner grades the smell from a grade of 0 to 5, with zero being no smell and five being severe pungent smell.<ref name="pmid10833869">{{cite journal| author=Yaegaki K, Coil JM| title=Examination, classification, and treatment of halitosis; clinical perspectives. | journal=J Can Dent Assoc | year= 2000 | volume= 66 | issue= 5 | pages= 257-61 | pmid=10833869 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10833869  }} </ref>


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.
===History and Symptoms===


===Professional diagnosis===
*The hallmark of [[halitosis]] is a bad odor from the [[mouth]].
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:
*A detailed history should be taken from the [[patient]] to rule out physiological and pseudo-halitosis. The frequency, onset, time, duration, exacerbating and relieving factors should be asked. A detailed medication history, Alchohol consumption and [[smoking]] should also be inquired .<ref name="pmid10833869">{{cite journal| author=Yaegaki K, Coil JM| title=Examination, classification, and treatment of halitosis; clinical perspectives. | journal=J Can Dent Assoc | year= 2000 | volume= 66 | issue= 5 | pages= 257-61 | pmid=10833869 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10833869  }} </ref>
# '''[[Halimeter]]'''&trade;: 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>
# '''[[Gas chromatography]]''': portable machines, such as the OralChroma&trade;, 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>
# '''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>
# '''[[beta-galactosidase|&beta;-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>


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>
===Physical Examination===


==Home care and treatment==
*Physical examination of patients with [[halitosis]] is usually remarkable for [[dental caries]], [[gingivitis]], [[post-nasal drip]] and [[sinusitis]].<ref name="pmid27095913">{{cite journal| author=Kapoor U, Sharma G, Juneja M, Nagpal A| title=Halitosis: Current concepts on etiology, diagnosis and management. | journal=Eur J Dent | year= 2016 | volume= 10 | issue= 2 | pages= 292-300 | pmid=27095913 | doi=10.4103/1305-7456.178294 | pmc=4813452 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27095913  }} </ref>
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:
*A detailed oral examination should be carried out to rule out any dental or gum disease.
# '''Eating a healthy breakfast''' with rough foods helps clean the very back of the tongue <ref name=tonzetich/>.
*Upper Respiratory tract examination should be done to rule out [[nasal polyps]], [[adenoids]], [[post-nasal drip]], and tonsillar hypertrophy. A detailed [[chest]] examination should be done to rule out [[chest]] infection.
# '''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/>
# '''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]].
# '''[[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>
# '''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/>
# '''Maintain [[water]] levels''' in the body by drinking several glasses of water a day.<ref name=rosenberg0/>


===Mouthwashes===
===Laboratory Findings===
[[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&trade; and [[Listerine]]&trade;.


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&trade;, Closys&trade; and others.  
*An elevated level of the volatile sulfur compound in exhaled air from the mouth is diagnostic of [[halitosis]].
*Volatile Sulfur compound monitors can measure the levels of volatile sulfur compounds content in exhaled air from the [[mouth]].
*[[Patient]]s are asked to close their [[mouth]]s and hold their breath for two to three minutes.
*Air is then collected from the [[mouth]] through a particular instrument, and the level of volatile sulfur compound is measured in parts per billion (ppb).
*Patients with halitosis have greater than 100 ppb levels of volatile sulfur compounds.<ref name="pmid14733469">{{cite journal| author=Lin MI, Flaitz CM, Moretti AJ, Seybold SV, Chen JW| title=Evaluation of halitosis in children and mothers. | journal=Pediatr Dent | year= 2003 | volume= 25 | issue= 6 | pages= 553-8 | pmid=14733469 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14733469  }} </ref><ref name="pmid21392690">{{cite journal| author=Babacan H, Sokucu O, Marakoglu I, Ozdemir H, Nalcaci R| title=Effect of fixed appliances on oral malodor. | journal=Am J Orthod Dentofacial Orthop | year= 2011 | volume= 139 | issue= 3 | pages= 351-5 | pmid=21392690 | doi=10.1016/j.ajodo.2009.03.055 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21392690  }} </ref>
*BANA is a test by which chemicals that cause halitosis are detected by strip.
*The main substrate on the test strip is benzoyl-DL-arginine-a-naphthylamide. Obligate [[anaerobes]] in the [[mouth]] hydrolyze BANA and release volatile compounds that cause halitosis.
*In addition, it also detects [[bacteria]] responsible for dental and gingival [[disease]]s.<ref name="pmid2212216">{{cite journal| author=Loesche WJ, Giordano J, Hujoel PP| title=The utility of the BANA test for monitoring anaerobic infections due to spirochetes (Treponema denticola) in periodontal disease. | journal=J Dent Res | year= 1990 | volume= 69 | issue= 10 | pages= 1696-702 | pmid=2212216 | doi=10.1177/00220345900690101301 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2212216  }} </ref><ref name="pmid23633830" />


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.
===Electrocardiogram===
There are no ECG findings associated with [[halitosis]].


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>
===X ray===
There are no x-ray findings associated with [[halitosis]].


==Halitophobia (delusion halitosis)==
===Echocardiography or Ultrasound===
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>
There are no echocardiography/ultrasound findings associated with [[halitosis]].


==Scientific research==
===CT scan===
In 1996, an international scientific organization (The International Society for Breath Odor Research, [http://www.isbor.org ISBOR]) was formed to promote multidisciplinary research on all aspects of breath odors. [http://www.suntimes.com/lifestyles/health/524642,CST-NWS-breath24.article The seventh international conference on breath odor] took place in August, 2007 in Chicago, and the next conference is expected to take place in 2009 in Dortmund, Germany.
There are no CT scan findings associated with [[halitosis]].


==See also==
===MRI===
* [[Periodontitis]]
There are no MRI findings associated with [[halitosis]].
* [[Dental caries]]
* [[Tooth abscess]]
* [[Postnasal drip]]
* [[Oral hygiene]]
*  [[Toothbrush]]
* [[Tongue scraper]]
* [[Mouthwash]]
* [[Toothpaste]]


==References==
===Other Diagnostic Studies===
{{reflist|2}}
Other diagnostic studies for [[halitosis]] include gas chromatography, which demonstrates elevated levels of volatile sulfur compounds, including hydrogen sulfide, and methyl mercaptan. The pros of gas chromatography are that it has higher sensitivity than organoleptic measurements and can even detect low levels of volatile sulfur compounds. The drawbacks are this test is expensive and requires a skilled person to perform it.<ref name="pmid21462620">{{cite journal| author=Nachnani S| title=Oral malodor: causes, assessment, and treatment. | journal=Compend Contin Educ Dent | year= 2011 | volume= 32 | issue= 1 | pages= 22-4, 26-8, 30-1; quiz 32, 34 | pmid=21462620 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21462620  }} </ref><ref name="pmid18602310">{{cite journal| author=Suzuki N, Yoneda M, Naito T, Iwamoto T, Hirofuji T| title=Relationship between halitosis and psychologic status. | journal=Oral Surg Oral Med Oral Pathol Oral Radiol Endod | year= 2008 | volume= 106 | issue= 4 | pages= 542-7 | pmid=18602310 | doi=10.1016/j.tripleo.2008.03.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18602310  }} </ref><ref name="pmid18715357">{{cite journal| author=Scully C, Greenman J| title=Halitosis (breath odor). | journal=Periodontol 2000 | year= 2008 | volume= 48 | issue=  | pages= 66-75 | pmid=18715357 | doi=10.1111/j.1600-0757.2008.00266.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18715357  }} </ref>


==External links==
==Treatment==
*[http://www.tauac.org/site/News2?page=NewsArticle&id=6123 New study links bad breath to obesity]
===Medical Therapy===
* [http://www.perio.org American Academy of Periodontology].
Supportive therapy for [[halitosis]] includes:<ref name="pmid31825092">{{cite journal| author=Kumbargere Nagraj S, Eachempati P, Uma E, Singh VP, Ismail NM, Varghese E| title=Interventions for managing halitosis. | journal=Cochrane Database Syst Rev | year= 2019 | volume= 12 | issue=  | pages= CD012213 | pmid=31825092 | doi=10.1002/14651858.CD012213.pub2 | pmc=6905014 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31825092  }} </ref>
* [http://www.tau.ac.il/~melros/bda/ Halitosis – fact file] – of the British Dental Association.
* [http://www.mayoclinic.com/health/bad-breath/DS00025 Bad Breath] – by Mayo Clinic.
* [http://www.cnn.com/HEALTH/9702/24/nfm/bad.breath/ Article on Bad Breath prevention] – from CNN.com.
* [http://www.msnbc.msn.com/id/17011346/ Article on Bad-Breath Prevention Products] – from MSNBC.
* [http://www.isbor.org ISBOR] – International society for breath odor research.
* [http://www.badbreathhalitosis.com/ Halitosis Sufferers Forum]


{{Symptoms and signs}}
*Adequate hydration to keep the oral cavity moist.
{{SIB}}
*Regular brushing and [[flossing]] with proper technique to avoid the buildup of food residue, [[dental plaques]], and [[carries]].
*Proper cleaning of the [[tongue]] to remove [[plaque]] and coating.
*Dietary modification with decreased intake of food products releases aromatic compounds, i.e., onion, garlic, alcohol, and caffeine.
*Quit [[smoking]]
*During the daytime, [[patient]]s should chew sugar-free gums, as gums stimulate [[saliva]] production and keep the [[oral cavity]] moist.
*Rinse and gargle with mouthwash at least once a day, preferably at bedtime.
*Underlying dental and gum [[disease]]s should be appropriately treated as this will significantly reduce the [[oral]] [[bacteria]]l flora.<ref name="pmid17014537">{{cite journal| author=Kara C, Tezel A, Orbak R| title=Effect of oral hygiene instruction and scaling on oral malodour in a population of Turkish children with gingival inflammation. | journal=Int J Paediatr Dent | year= 2006 | volume= 16 | issue= 6 | pages= 399-404 | pmid=17014537 | doi=10.1111/j.1365-263X.2006.00769.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17014537  }} </ref>
*If an underlying medical [[disease]] is the cause of the halitosis, the [[patient]] needs to be referred to a particular specialty consultant.<ref name="pmid23633830">{{cite journal| author=Aylıkcı BU, Colak H| title=Halitosis: From diagnosis to management. | journal=J Nat Sci Biol Med | year= 2013 | volume= 4 | issue= 1 | pages= 14-23 | pmid=23633830 | doi=10.4103/0976-9668.107255 | pmc=3633265 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23633830  }} </ref>
*In [[patient]]s with psychogenic halitosis, the physician should give the [[patient]]s an appropriate assurance.  The [[patient]]s might need to be referred for psychiatric consultation for proper treatment.<ref name="pmid23633830">{{cite journal| author=Aylıkcı BU, Colak H| title=Halitosis: From diagnosis to management. | journal=J Nat Sci Biol Med | year= 2013 | volume= 4 | issue= 1 | pages= 14-23 | pmid=23633830 | doi=10.4103/0976-9668.107255 | pmc=3633265 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23633830  }} </ref>


[[cs:Zápach z úst]]
===Surgery===
[[de:Mundgeruch]]
Surgical intervention is not recommended for the management of [[halitosis]].
[[es:Halitosis]]
[[fr:Halitose]]
[[it:Alitosi]]
[[he:באשת]]
[[nl:Foetor ex ore]]
[[ja:口臭]]
[[pl:Cuchnący oddech]]
[[pt:Halitose]]
[[ru:Галитоз]]
[[sv:Dålig andedräkt]]
[[te:నోటి దుర్వాసన]]


===Primary Prevention===
There are no established measures for the primary prevention of [[halitosis]].


===Secondary Prevention===
There are no established measures for the secondary prevention of [[halitosis]].


==References==
{{Reflist|2}}


[[Category:Oral hygiene]]
[[Category:Up-To-Date]]
[[Category:Signs and symptoms]]
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Mydah Sajid, M.B.B.S.

Synonyms and keywords: oral malodor; breath odor; foul breath; fetor oris; fetor ex ore; bad breath

Overview

The word halitosis is derived from the Latin word ‘halitus’, meaning more than a socially acceptable degree of bad breath from the mouth. The majority of the time, it is due to poor dental, tongue hygiene, and gum infections. It can be physiological due to decreased saliva flow or an underlying disease. The patient can perceive the bad breath, or others might complain about it. It adversely affects the patient’s social and professional life.[1]

Classification

  • Halitosis can be classified into physiologic, pathologic, or subjective:
    • Physiologic halitosis occurs due to decreased saliva production. It occurs in the morning when the mouth is dry, and there is an overgrowth of oral bacteria. Tobacco smoking and certain food items like garlic and onion also cause bad breath due to aromatic compounds. Physiological halitosis improves significantly by flossing, tooth brushing, rinsing with mouthwash, and drinking water.[2]
    • Pathological halitosis occurs due to an underlying disease. The common causes include postnasal drip, sinusitis, gingivitis, and caries. The tonsillar inflammation and peri-tonsillar abscesses can also result in bad breath.[2]
    • Subjective halitosis is also called psychogenic halitosis. The patient thinks that they have bad breath, while the diagnostic tests are negative for halitosis.[3]

Pathophysiology

  • It is thought that halitosis is produced by bacterial overgrowth in the oral cavity.
  • Poor oral hygiene, dental caries, or gum infection results in the growth of gram-negative anaerobes in the mouth.[4]
  • These bacteria thrive on debris material entrapped between teeth and gums. Lysosomal enzymes secreted by the bacteria break down the glycoproteins in the food particles. It results in volatile compounds like hydrogen sulfide, dimethyl sulfide, and methyl mercaptan, resulting in halitosis.[5]
  • The Bacteroides, Prevotella, and Fusobacterium species are mainly responsible for halitosis.[6]

Causes

Common causes of halitosis include:[1]

Differntiating Halitosis from other Diseases

Halitosis must be differentiated whether it has a physiological cause, some underlying disease, or psychogenic cause.

Epidemiology and Demographics

  • The prevalence of halitosis is approximately 32,000 per 100,000 individuals worldwide.[7]
  • Halitosis affects men and women equally.[8]
  • It is more common in middle and lower socioeconomic classes.[7]
  • The prevalence of halitosis is increasing with time.

Risk Factors

Common risk factors in the development of halitosis include:[9]

Screening

There is insufficient evidence to recommend routine screening for halitosis.

Natual History, Complications, and Prognosis

Common complications of untreated halitosis include mood disorders like depression, anxiety, paranoia, phobia, and obsessive-compulsive disorder.[10]

Diagnosis

Diagnostic Study of Choice

Organoleptic measurement is the gold standard test for the diagnosis of halitosis.[11]

Organoleptic Measurement

  • It is one of the oldest techniques to detect a bad smell.
  • The air expelled from both nose and mouth is smelled to detect a foul odor.
  • The patient inspires from the nose with mouth close and then expires from the mouth, while the examiner detects it from a distance of 20 cm through a pipette.[3]
  • This diagnostic test is highly subjective, and the examiner grades the smell from a grade of 0 to 5, with zero being no smell and five being severe pungent smell.[12]

History and Symptoms

  • The hallmark of halitosis is a bad odor from the mouth.
  • A detailed history should be taken from the patient to rule out physiological and pseudo-halitosis. The frequency, onset, time, duration, exacerbating and relieving factors should be asked. A detailed medication history, Alchohol consumption and smoking should also be inquired .[12]

Physical Examination

Laboratory Findings

  • An elevated level of the volatile sulfur compound in exhaled air from the mouth is diagnostic of halitosis.
  • Volatile Sulfur compound monitors can measure the levels of volatile sulfur compounds content in exhaled air from the mouth.
  • Patients are asked to close their mouths and hold their breath for two to three minutes.
  • Air is then collected from the mouth through a particular instrument, and the level of volatile sulfur compound is measured in parts per billion (ppb).
  • Patients with halitosis have greater than 100 ppb levels of volatile sulfur compounds.[14][15]
  • BANA is a test by which chemicals that cause halitosis are detected by strip.
  • The main substrate on the test strip is benzoyl-DL-arginine-a-naphthylamide. Obligate anaerobes in the mouth hydrolyze BANA and release volatile compounds that cause halitosis.
  • In addition, it also detects bacteria responsible for dental and gingival diseases.[16][3]

Electrocardiogram

There are no ECG findings associated with halitosis.

X ray

There are no x-ray findings associated with halitosis.

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with halitosis.

CT scan

There are no CT scan findings associated with halitosis.

MRI

There are no MRI findings associated with halitosis.

Other Diagnostic Studies

Other diagnostic studies for halitosis include gas chromatography, which demonstrates elevated levels of volatile sulfur compounds, including hydrogen sulfide, and methyl mercaptan. The pros of gas chromatography are that it has higher sensitivity than organoleptic measurements and can even detect low levels of volatile sulfur compounds. The drawbacks are this test is expensive and requires a skilled person to perform it.[17][18][19]

Treatment

Medical Therapy

Supportive therapy for halitosis includes:[20]

  • Adequate hydration to keep the oral cavity moist.
  • Regular brushing and flossing with proper technique to avoid the buildup of food residue, dental plaques, and carries.
  • Proper cleaning of the tongue to remove plaque and coating.
  • Dietary modification with decreased intake of food products releases aromatic compounds, i.e., onion, garlic, alcohol, and caffeine.
  • Quit smoking
  • During the daytime, patients should chew sugar-free gums, as gums stimulate saliva production and keep the oral cavity moist.
  • Rinse and gargle with mouthwash at least once a day, preferably at bedtime.
  • Underlying dental and gum diseases should be appropriately treated as this will significantly reduce the oral bacterial flora.[21]
  • If an underlying medical disease is the cause of the halitosis, the patient needs to be referred to a particular specialty consultant.[3]
  • In patients with psychogenic halitosis, the physician should give the patients an appropriate assurance. The patients might need to be referred for psychiatric consultation for proper treatment.[3]

Surgery

Surgical intervention is not recommended for the management of halitosis.

Primary Prevention

There are no established measures for the primary prevention of halitosis.

Secondary Prevention

There are no established measures for the secondary prevention of halitosis.

References

  1. ↑ 1.0 1.1 Hughes FJ, McNab R (2008). "Oral malodour--a review". Arch Oral Biol. 53 Suppl 1: S1–7. doi:10.1016/S0003-9969(08)70002-5. PMID 18460398.
  2. ↑ 2.0 2.1 Rosenberg M (1996). "Clinical assessment of bad breath: current concepts". J Am Dent Assoc. 127 (4): 475–82. doi:10.14219/jada.archive.1996.0239. PMID 8655868.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Aylıkcı BU, Colak H (2013). "Halitosis: From diagnosis to management". J Nat Sci Biol Med. 4 (1): 14–23. doi:10.4103/0976-9668.107255. PMC 3633265. PMID 23633830.
  4. ↑ De Geest S, Laleman I, Teughels W, Dekeyser C, Quirynen M (2016). "Periodontal diseases as a source of halitosis: a review of the evidence and treatment approaches for dentists and dental hygienists". Periodontol 2000. 71 (1): 213–27. doi:10.1111/prd.12111. PMID 27045438.
  5. ↑ Tonzetich J (1977). "Production and origin of oral malodor: a review of mechanisms and methods of analysis". J Periodontol. 48 (1): 13–20. doi:10.1902/jop.1977.48.1.13. PMID 264535.
  6. ↑ Sterer N, Rosenberg M (2002). "Effect of deglycosylation of salivary glycoproteins on oral malodour production". Int Dent J. 52 Suppl 3: 229–32. doi:10.1002/j.1875-595x.2002.tb00930.x. PMID 12090458.
  7. ↑ 7.0 7.1 Silva MF, Leite FRM, Ferreira LB, Pola NM, Scannapieco FA, Demarco FF; et al. (2018). "Estimated prevalence of halitosis: a systematic review and meta-regression analysis". Clin Oral Investig. 22 (1): 47–55. doi:10.1007/s00784-017-2164-5. PMID 28676903.
  8. ↑ Rosenberg M, Kulkarni GV, Bosy A, McCulloch CA (1991). "Reproducibility and sensitivity of oral malodor measurements with a portable sulphide monitor". J Dent Res. 70 (11): 1436–40. doi:10.1177/00220345910700110801. PMID 1960254.
  9. ↑ Messadi DV, Younai FS (2003). "Halitosis". Dermatol Clin. 21 (1): 147–55, viii. doi:10.1016/s0733-8635(02)00060-8. PMID 12622277.
  10. ↑ Eli I, Baht R, Kozlovsky A, Rosenberg M (1996). "The complaint of oral malodor: possible psychopathological aspects". Psychosom Med. 58 (2): 156–9. doi:10.1097/00006842-199603000-00010. PMID 8849633.
  11. ↑ Nalçaci R, Sönmez IS (2008). "Evaluation of oral malodor in children". Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 106 (3): 384–8. doi:10.1016/j.tripleo.2008.03.001. PMID 18602293.
  12. ↑ 12.0 12.1 Yaegaki K, Coil JM (2000). "Examination, classification, and treatment of halitosis; clinical perspectives". J Can Dent Assoc. 66 (5): 257–61. PMID 10833869.
  13. ↑ Kapoor U, Sharma G, Juneja M, Nagpal A (2016). "Halitosis: Current concepts on etiology, diagnosis and management". Eur J Dent. 10 (2): 292–300. doi:10.4103/1305-7456.178294. PMC 4813452. PMID 27095913.
  14. ↑ Lin MI, Flaitz CM, Moretti AJ, Seybold SV, Chen JW (2003). "Evaluation of halitosis in children and mothers". Pediatr Dent. 25 (6): 553–8. PMID 14733469.
  15. ↑ Babacan H, Sokucu O, Marakoglu I, Ozdemir H, Nalcaci R (2011). "Effect of fixed appliances on oral malodor". Am J Orthod Dentofacial Orthop. 139 (3): 351–5. doi:10.1016/j.ajodo.2009.03.055. PMID 21392690.
  16. ↑ Loesche WJ, Giordano J, Hujoel PP (1990). "The utility of the BANA test for monitoring anaerobic infections due to spirochetes (Treponema denticola) in periodontal disease". J Dent Res. 69 (10): 1696–702. doi:10.1177/00220345900690101301. PMID 2212216.
  17. ↑ Nachnani S (2011). "Oral malodor: causes, assessment, and treatment". Compend Contin Educ Dent. 32 (1): 22–4, 26–8, 30–1, quiz 32, 34. PMID 21462620.
  18. ↑ Suzuki N, Yoneda M, Naito T, Iwamoto T, Hirofuji T (2008). "Relationship between halitosis and psychologic status". Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 106 (4): 542–7. doi:10.1016/j.tripleo.2008.03.009. PMID 18602310.
  19. ↑ Scully C, Greenman J (2008). "Halitosis (breath odor)". Periodontol 2000. 48: 66–75. doi:10.1111/j.1600-0757.2008.00266.x. PMID 18715357.
  20. ↑ Kumbargere Nagraj S, Eachempati P, Uma E, Singh VP, Ismail NM, Varghese E (2019). "Interventions for managing halitosis". Cochrane Database Syst Rev. 12: CD012213. doi:10.1002/14651858.CD012213.pub2. PMC 6905014 Check |pmc= value (help). PMID 31825092.
  21. ↑ Kara C, Tezel A, Orbak R (2006). "Effect of oral hygiene instruction and scaling on oral malodour in a population of Turkish children with gingival inflammation". Int J Paediatr Dent. 16 (6): 399–404. doi:10.1111/j.1365-263X.2006.00769.x. PMID 17014537.
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