Halitosis 

Halitosis, or oral malodour, is a common complaint among the general population. If severe or longstanding, it may decrease self-confidence and social interactions.

Classification of Halitosis

1. Genuine Halitosis
   • Physiological Halitosis
   • Pathological Halitosis
     • Oral Halitosis: Due to disease or pathological condition of the oral tissue.
     • Extraoral Halitosis: Malodour originating from outside the oral cavity (pulmonary or upper digestive tract).
2. Pseudo Halitosis
   • The patient believes that he/she has bad breath which is not perceived by others around them.
3. Halitophobia
   • Even after treatment for genuine halitosis or pseudo-halitosis, patients believe that they still have bad breath.
4. Psychosomatic Halitosis
   • Patients interpret other people’s reactions, such as covering the nose, averting the face, or stepping back, as signs of having bad breath. These patients may have psychological conditions such as social phobia (anxiety about other individuals’ behavior towards them). Clinicians should focus on identifying symptoms of social phobia rather than looking for halitosis.

Causes of Halitosis

Oral Causes:

• Poor Oral Hygiene:
  • Accumulation of food debris and dental bacterial plaque on teeth and the tongue.
  • Oral microbes such as Prevotella melaninogenica, Treponema denticola, Porphyromonas gingivalis, and other gram-negative bacteria break down food debris, resulting in the production of chemicals such as volatile sulfur compounds, diamines, and short-chain fatty acids responsible for oral malodour.
• Specific Conditions:
  • Acute necrotizing ulcerative gingivitis (Vincent’s disease, trench mouth)
  • Acute gingivitis
  • Adult and aggressive periodontitis
  • Pericoronitis
  • Dry socket
  • Xerostomia
  • Oral ulceration
  • Oral malignancy

Non-Oral Causes:

• Respiratory Disease:
  • Foreign body
  • Sinusitis, tonsillitis
  • Lung diseases: malignancy, bronchiectasis, lung abscesses, necrotizing pneumonia
• Gastrointestinal Tract:
  • Pharyngo-oesophageal diverticulum
  • Gastro-oesophageal reflux disease
  • Pyloric stenosis or duodenal obstruction
  • Helicobacter pylori infection
• Systemic Disease:
  • Hepatic failure (fetor hepaticus)
  • Renal failure (end stage)
  • Diabetic ketoacidosis
  • Leukaemias
  • Trimethylaminuria (“fish odour syndrome”)
• Drugs:
  • Solvent misuse
  • Chloral hydrate
  • Nitrites and nitrates
  • Dimethyl sulphoxide
  • Disulfiram
  • Some cytotoxic agents
  • Phenothiazines
  • Amphetamines
• Transient Halitosis:
  • Volatile foods such as garlic, onions, or spices (durian is reputed to be the worst)
  • Tobacco and alcohol
  • Betel nut products

Examination

• Intraoral Examination: To find out any oral diseases which may contribute to bad breath.
• Odour from the Mouth Alone: The cause is likely to be of oral or pharyngeal origin.
• Odour from the Nose Alone: The cause is likely from the nose or the sinuses.
• Odour from Both Nose and Mouth in Equal Intensity: A systemic cause is likely.

Management

• Good Oral Hygiene:
  • Brushing teeth, interdental flossing, tongue brushing.
  • Eating regularly and avoiding foods and drinks which may cause transient halitosis.
  • Use of antimicrobial toothpastes and mouthwashes (e.g., 0.2% aqueous chlorhexidine gluconate mouthwash, oil-water rinse, triclosan/co-polymer/sodium fluoride toothpaste, hydrogen peroxide mouthwash especially in cases of gingivitis).
• Antibiotics: Rarely used except in cases of post-operative halitosis.
• Psychological Evaluation and Treatment: May be necessary in patients with halitophobia.