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Halitosis
Professional Reference articles are written by UK doctors and are based on research evidence, UK and European
Guidelines. They are designed for health professionals to use, so you may find the language more technical than
the condition leaflets.

Seealso:BadBreath(Halitosis)writtenforpatients

Synonym: bad breath

Halitosis is an unpleasant odour emitted from the mouth.

Aetiology
Breath smells when certain aromatic chemicals are found within it these include hydrogen sulfide, methyl
mercaptan and dimethyl sulfide.

Occasionally, patients may confuse bad breath with bad taste in the mouth.

The most common causes of occasional halitosis include:

Smokingcigarettesorcigars.
Drymouth.
Drinkingalcohol.
Artificiallyinducedhalitosisaftereatingaparticularlyaromaticmealeg,garlic,onions,highlyspicedfood.

Othercauses
Crash dieting, or proteinonly diets

Afterafewhoursthebodybeginstobreakdownitsfatstoresandketonesarereleased.Thesegivethebreatha
distinctivesweetandsicklysmell.

Originating from the mouth

Alteredbloodaroundthegumcanbeanimportantcauseandmaybefoundwithdebrisorpusduetogingivitisand
periodontalpockets.[1]
Acuteulcerativegingivitisisassociatedwithatypicalformofhalitosis.
Acutenecrotisingulcerativegingivitis(Vincent'sdisease,trenchmouth)causesthemostnotablehalitosis.
Badmorningbreath:
Duringsleeptheflowofsalivaisdrasticallyreducedandthetongueandcheeksmoveverylittle.Thisallows
foodresiduestostagnateinthemouthanddeadcellsthatarenormallyshedfromthesurfaceofthetongue
andgumsandfromtheinsideofthecheekstoaccumulate.Asbacteriastarttoworkonthemanddigestthem,
anunpleasantsmellisgenerated.
Althoughnormal,anyonesufferingfromnasalcongestionwhomouthbreathesismorelikelytosufferfrom
theseactionstoagreaterextent.

Bacteriacolonisingthetongueandperiodontalpocketsplayanimportantroleintheproductionofvolatilesulfur
compoundswhichcancausehalitosis.Regularbrushingofthetongueishelpful.[2]Notethatplaqueontheteethis
notamajorcauseofhalitosisbutpatientsshouldbeadvisedtoexercisecarefultoothcare.
Fixeddenturesintensifythedevelopmentofhalitosis,astheymakedifficult,orevencompletelyimpede,the
complexoforalcavityhygienemeasures.[3]
Tonsilloliths(tonsilstones)Theseareclustersofcalcifiedmaterialthatforminthetonsillarcrypts,orcrevicesof
thetonsils.Theyaremadeupmostlyofcalciumbutcancontainotheringredientssuchasmagnesiumand
phosphorus,andcanfeellikeasmalllumpinthetonsils.Rarelyharmful,theycanbeanuisanceandhardto
removeandcanoftencausebadbreath.[4]

Originating from the nasopharynx

Chronicsinusitisandpostnasaldriparecommoncauses.

Foreignbodiesinthenosecanproduceastrikingodourtothebreath. [5]
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Foreignbodiesinthenosecanproduceastrikingodourtothebreath.[5]
Occasionally,chronictonsillitisandatrophicrhinitiscanbecauses.

Respiratory tract infections

Theseinclude,forexample,bronchiectasisandotherlunginfections.

Gastrointestinal disorders

Acidrefluxthisiscommonlybelievedtobeacause,althoughthereislittleevidence.Inonepostalsurveyof160
GPs,1%ofalltheprotonpumpinhibitorprescriptionswereforsymptomsofhalitosisand/orbittertaste(94%
responserate).[6]
Helicobacterpylorihasbeenfoundinupto87%ofpatientswithhalitosis,acidtasteandburningsensationsinthe
mouth.[7]

Systemic disorders

Diabetes,renalorliverdisease.

Fish odour syndrome (trimethylaminuria)[8]

Thisisisararedisorder,characterisedbylongstandingoralandbodymalodour.
Itiscausedbyanexcessoftrimethylamineduetoametabolicoxidationdefectthatproducesapungent
ammoniacalodoursimilartothatofrottenfish.

Hypermethioninaemia

Thisisanotherraremetabolicdisorderthatcanleadtooralmalodour:[9]

Pseudohalitosis

Thisisaconditionwherepeoplefalselybelievetheyhavebadbreath.[10]

Often, all these can be excluded and still no cause found.

Drugs
The following may also cause halitosis:[5]

Solventmisuse
Betel
Chloralhydrate
Nitritesandnitrates
Dimethylsulfoxide
Disulfiram
Somecytotoxicagents
Phenothiazines
Amfetamines

Epidemiology
There are no reliable estimates of prevalence, although several studies report the population prevalence of halitosis
(physiological or because of underlying disease) to be about 50%.[11]

Diagnosis
The clinical assessment of halitosis is usually subjective and is based on smelling air from the mouth and nose
and comparing the two organoleptic assessment.

Odourdetectablefromthemouth,butnotfromthenose,islikelytobeoforalorpharyngealorigin.
Odourfromthenosealoneislikelytobecomingfromthenoseorsinuses.
Inrareinstanceswhentheodourfromthenoseandmouthareofsimilarintensity,asystemiccauseofthe
malodourmaybelikely.
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There is no consensus regarding duration of bad breath for diagnosis of halitosis, although the standard
organoleptic test for bad breath involves smelling the breath on at least two or three different days.[11]

Management
Investigateandmanagepossiblesystemic(nonoral)sourceiftheorganolepticmethoddetectsmalodourfromboth
themouthandthenose.
Improveoralhygienebyprofessionalandpatientadministeredtoothcleaning.[1]
Regularatraumatictonguecleaning.[12]
Regularuseofantimicrobialtoothpastesandmouthwashes,suchas:
Chlorhexidinegluconate.
Triclosan/copolymer/sodiumfluoridetoothpaste.[13]

Tworandomisedcontrolledtrials(RCTs)havefoundthatregularuseofamouthwashreducesbreathodourattwo
tofourweekscomparedwithplacebo.[14,15]Peopleintheactivetreatmentgrouphadsignificantlymoretongue
discolourationthanpeopleusingplacebomouthwashaftertwoweeks.
Regulardentalreviewtoensuremaintenanceofeffectiveoralhygiene.
Halitophobia(fixatedwithteethcleaningandtonguecleaningandfrequentlyusingchewinggums,mints,
mouthwashes,andspraysinthehopeofreducingtheirdistress)warrantsreferraltoclinicalpsychologist.
EradicationofH.pyloriinpatientswithfunctionaldyspepsiaandhalitosisresultsinsustainedresolutionofhalitosis
duringlongtermfollowupinthemajorityofcases.

Furtherreading&references
HalitosisNICECKS,January2010
GingivitisandperiodonitisNICECKS,August2012
CoventryJ,GriffithsG,ScullyC,etalABCoforalhealth:periodontaldisease.BMJ.2000Jul1321(7252):369.
BritishDentalAssociationSmileWebsite
ScullyC,FelixDHOralmedicineupdateforthedentalpractitioner:oralmalodour.BrDentJ.2005Oct22
199(8):498500.

1.MoritaM,WangHLAssociationbetweenoralmalodorandadultperiodontitis:areview.JClinPeriodontol.2001
Sep28(9):8139.
2.DanserMM,GomezSM,VanderWeijdenGATonguecoatingandtonguebrushing:aliteraturereview.IntJDent
Hyg.2003Aug1(3):1518.
3.ZigursG,VidzisA,BrinkmaneAHalitosismanifestationandpreventionmeansforpatientswithfixedteeth
dentures.Stomatologija.20057(1):36.
4.RamS,SiarCH,IsmailSM,etalPseudobilateraltonsilloliths:acasereportandreviewoftheliterature.Oral
SurgOralMedOralPatholOralRadiolEndod.2004Jul98(1):1104.
5.PorterSR,ScullyCOralmalodour(halitosis).BMJ.2006Sep23333(7569):6325.
6.KarkosPD,ThomasL,TempleRH,etalAwarenessofgeneralpractitionerstowardstreatmentof
laryngopharyngealreflux:aBritishsurvey.OtolaryngolHeadNeckSurg.2005Oct133(4):5058.
7.HoshiK,YamanoY,MitsunagaA,etalGastrointestinaldiseasesandhalitosis:associationofgastricHelicobacter
pyloriinfection.IntDentJ.2002Jun52Suppl3:20711.
8.MitchellSTrimethylaminuria(fishodoursyndrome)andoralmalodour.OralDis.200511Suppl1:103.
9.Periodontology2000,Vol.48,2008,6675
10.UguruC,UmeanukaO,UguruNP,etalThedelusionofhalitosis:experienceataneasternNigeriantertiary
hospital.NigerJMed.2011AprJun20(2):23640.
11.YaegakiK,CoilJMExamination,classification,andtreatmentofhalitosisclinicalperspectives.JCanDent
Assoc.2000May
12.OuthouseTL,AlAlawiR,FedorowiczZ,KeenanJVTonguescrapingfortreatinghalitosis,CochraneDatabase
SystRev2006(2):CD005519.
13.HuD,ZhangY,PetroneM,etalClinicaleffectivenessofatriclosan/copolymer/sodiumfluoridedentifricein
controllingoralmalodor:a3weekclinicaltrial.OralDis.200511Suppl1:513.
14.AdlerI,DenninghoffVC,AlvarezMI,etalHelicobacterpyloriassociatedwithglossitisandhalitosis.Helicobacter.
2005Aug10(4):3127.
15.WinkelEG,RoldanS,VanWinkelhoffAJ,etalClinicaleffectsofanewmouthrinsecontainingchlorhexidine,
cetylpyridiniumchlorideandzinclactateonoralhalitosis.Adualcenter,doubleblindplacebocontrolledstudy.J
ClinPeriodontol.2003Apr30(4):3006.

OriginalAuthor: DocumentID:
DrHuwThomas 2226(v23)

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CurrentVersion: LastChecked:
DrRogerHenderson 14May2014

PeerReviewer: NextReview:
DrHelenHuins 13May2019

Disclaimer:This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its
accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For
details see our conditions.

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