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Halitosis is a general term applied to any offensive odor emanating from the breath, regardless of source. Although usually not associated with a serious underlying medical problem, its social consequences and implications can be far-reaching. Affected individuals frequently suffer intense embarrassment and discomfort, and offensive breath has halitosis, halatosis, haltosis, bad breath

Oral factors that enhance or relieve malodor change throughout the day. At any given time, a person's breath may contain up to 400 different sulfur compounds. But the incidence, intensity, and duration of halitosis vary considerably from individual to individual, and even within an individual. The intensity of the malodor determines its detection threshold and degree of offensiveness. Here are 

Halitosis is a dynamic condition that is influenced by the degree of salivation, mastication, and

Volatile sulfur compounds are permeable in soft tissues, and when the quantity of these compounds exceeds the capacity of saliva and soft tissues to adsorb them into solution, real-odor is the likely consequence.

Variations in oral flora, oral hygiene, eating habits, and salivary flow rates may (or may not) provide a favorable environment in which bacteria can thrive. The right temperature, humidity, substrate, nutrients, presence or absence of oxygen, and pH are necessary to cause bad breath.

The normal salivary pH of 6.5 suppresses the growth of gram-negative bacteria that activate certain enzymes and cause malodor. An acidic pH favors the growth of gram-positive organisms that produce little odor, and an alkaline pH (7.2) encourages growth of gram-negative organisms.

Oral sources for halitosis

Most causes of oral malodor--some 47-90%--can be localized to the oral cavity and associated hollow cavities that provide an excellent environment for bacterial growth. Retentive surfaces such as periodontal pockets, the interproximal dental surfaces, and the tongue are ideal sites for harboring bacteria, accumulating plaque, and

The intensity of breath odor tends to increase with age, probably because of regressive changes in salivary glands that affect the quantity and quality of salivary flow. Dentures are a common culprit, especially older ones made of vulcanite, a porous material that encourages the accumulation of food debris and

Periodontal disease is responsible for one third of halitosis cases. The saliva of persons with periodontal disease tends to putrefy more rapidly and produce a more disagreeable odor. Interdental pockets develop that can retain food. When the bacteria in and around the pocket decompose food particles, the consequent inflammatory process leads to a rise in the substrates and growth factors needed to promote the growth of  

Inflammatory processes of the oral cavity such as stomatitis, glossitis, gingivitis, and cryptic tonsils can lead to the development of fissures and ulcerations of the oral mucosa that trap food particles, bacteria, desquamated cells, and tissues. Contrary to widespread belief, dental caries do not cause oral malodor unless the pulp is

Nonoral sources of halitosis

About 10% of all cases of oral malodor have extraoral or systemic sources. Diseases of the nasopharyngeal passages predominate--sinusitis, tonsillitis, and nasal foreign bodies. Lower respiratory tract conditions such as bronchiectasis, necrotic tumors, and cavitary lesions tend to produce a putrid oral odor similar to that of rotten meat. The halitosis typically occurs late in the disease process after more obvious or urgent symptoms have already appeared. Halitosis of rapid onset that progressively intensifies may suggest an infective source such as one secondary to carcinoma or other localized airway disease.

Perhaps the best known example of a systemic source is the fruity, sweet breath odor of diabetes and diabetic ketoacidosis, caused by pulmonary expiration of acetone and ketones. Liver cirrhosis is associated with a musty breath odor (fetor hepaticus), that has been likened to a mix of rotten eggs and garlic. It arises from pulmonary expiration of dimethyl sulfides, methyl mercaptan, and

Halitosis: The diagnosis

The initial diagnostic challenge is determining whether the patient's complaint is well-founded or exaggerated. The patient should be instructed not to drink, eat, chew, rinse the mouth, gargle, or use breath fresheners for at least 2 hours before the evaluation; smoke for at least 6-12 hours beforehand; use scented cosmetics such as perfumed lipstick, aftershave lotions, or perfumes for 24 hours; eat onions, garlic, or spicy foods for 48 hours; or take antibiotics for 3 weeks. Because of the subjective nature of the condition, it

Treatment of halitosis

The goals of treatment are to correct the underlying cause and eliminate the odor. Most cases are caused by local factors, and a good oral hygiene regimen can reduce oral malodor by 29%-88%. Flossing reduces mouth and saliva odor, as well as salivary cadaverine levels. Rinsing the mouth with water is effective for up to 15 minutes; brushing with toothpaste for up to 

Bacteria harbored on the dorsum of the tongue may be controlled with daily tongue scraping One study found that brushing the tongue along with the teeth is most effective in reducing malodor from the tongue. Over-brushing may cause traumatic ulcers, however, which are good retentive sites. Thorough tooth and tongue brushing can reduce methyl mercaptan and hydrogen sulfide

Odors from extraoral sources may be mitigated by lifestyle modifications--quitting smoking, changing the diet by eating more fresh fruits and vegetables and decreasing fats to 40-60 g daily, drinking fluids, reducing caffeine intake, and stopping or changing medications that may be causing xerostomia. Significant xerostomia may require sialogogues to promote salivary flow--chewing gums, hard candies, and mints or artificial salivary substitutes such as carboxyl methyl cellulose and pilocarpine HCl (Salagen). Pilocarpine, 5-10 mg tid, (preferably taken before meals) increases salivary flow for up to 30 minutes.25 Side effects include

Substances such as oil of peppermint or wintergreen and most mouthwashes offer only a temporary masking effect. The latter are effective up to 30 minutes but no longer than 60 minutes. Alcohol-containing mouthwashes are less effective and can dry oral tissues,

The prescription-only chlorhexidine gluconate antibacterial oral rinse (Peridex, Perio-Gard) is more effective in reducing plaque and gingivitis than OTC formulations. Using the solution for 6 months has been shown to reduce counts of certain anaerobic bacteria by

Mouthwashes containing cetylpyridinium chloride, benzethonium chloride, phenolic-flavored oils, sodium bicarbonate, zinc chloride, and zinc with alpha-ionone have shown efficacy in reducing hydrogen sulfide and methyl mercaptan levels by 24%-59% for at least 3 hours when compared to placebo.

A new two-phase, oil-water mouthwash appears to be as effective as 0.2% chlorhexidine mouthwash, and 50% more effective than commercially available products. Most bacteria have a lipid coat, and the oil phase is effective in adsorbing and removing bacteria and cellular debris. This solution also contains cetyl-pyridinium chloride, a cationic surfactant that efficiently binds and desorbs

Halitophobia (psychogenic halitosis)

Psychogenic halitosis, an exaggerated fear of having bad breath, should be considered if no clinical findings support the patient's complaints. Affected individuals are acutely sensitive to their own odor and persistently complain about it, despite a lack of supportive evidence. They avoid social situations, and are preoccupied with concealing the perceived odor by frequently brushing