Halitosis

Mark Douglas Andrews

Halitosis (fetor oris) is a common problem, usually thought to be merely a social handicap related to poor oral hygiene or disease of the oral cavity. However, it can represent a marker for a more serious systemic illness that requires diagnosis and treatment (1). In modern society, oral malodor has been continually stigmatized, giving rise to a commercial market for mouthwash and mouth fresheners exceeding $800 million annually (2). Despite this publicity, patients only occasionally present with a primary complaint of halitosis and generally are unaware of the problem, but at some time more than half the population will be affected. Unfortunately, physicians and dentists remain relatively indifferent and unconcerned about this health issue.

Approach

Persistent or abnormal halitosis (usually noted by persons around the patient) exceeds in severity the more common and benign morning halitosis. The important initial task is to categorize the halitosis as either localized to the oral cavity or originating systemically. In addition, causes of halitosis can be subcategorized into common pathologic and nonpathologic types. The cause of halitosis can be attributed to bacterial activity in disorders of the oral cavity in 80% to 90% of patients, with the remaining 10% to 20% of cases attributed to nonoral or systemic sources (2,3).

A. Nonpathologic causes

 1. Morning breath is caused by decreased salivary flow during sleep associated with increased fluid pH, and resulting elevated gram-negative bacterial growth and volatile sulfur compounds production (4).

 2. Xerostomia, regardless of cause (e.g., sleep, diseases, medication side effects, mouth breathing), can contribute to halitosis. Age-related changes in salivary gland physiology result in a gradual decline in saliva quantity and quality.

 3. Missed meals. Dieting or missed meals can lead to halitosis secondary to decreased salivary flow and absence of food’s mechanical action on the tongue surface to wear down filiform papillae.

4. Tobacco or alcohol use is usually considered to be a contributing cause of halitosis.

5. Food sources. Metabolites from ingested food are absorbed into the circulatory system and then excreted through the lungs, thereby contributing to halitosis. Onions, garlic, alcohol, pastrami, and other meats are common offenders.

6. Medications. Drugs with anticholinergic side effects can cause xerostomia, especially in the elderly. An assortment of other agents can have a role in the production of offensive breath by a diversity of mechanisms. These agents include amphetamines, anticholinergics, antidepressants, antihistamines, decongestants, antihypertensives, anti-Parkinsonian agents, antipsychotics, anxiolytics, chemotherapeutic agents, diuretics, narcotic analgesics, and radiation therapy.

B. Pathologic causes

 1. Local oropharynx. Chronic peridontal disease and gingivitis are the most common sources caused by the promotion of bacterial overgrowth. Stomatitis and glossitis caused by systemic disease, medication, or vitamin deficiencies can lead to trapped food particles and desquamated tissue. An improperly cleaned prosthetic appliance can be a local contributor as can primary pharyngeal cancer. Also important are conditions associated with parotid dysfunction (e.g., viral and bacterial infections, calculi, drug reactions, systemic conditions including Sjögren’s syndrome).

 2. Gastrointestinal tract. Important sources include gastroesophageal reflux disease (GERD), gastrointestinal bleeding associated with a decayed odor, gastric cancer, malabsorption syndromes, and enteric infections.

 3. Respiratory tract. Chronic sinusitis, nasal foreign bodies or tumors, postnasal drip, bronchitis, pneumonia, bronchiectasis, tuberculosis, and malignancies may be causative.

4. Psychiatric causes are less common, but a complaint of halitosis can represent a delusional syndrome associated with somatization, depression, organic brain syndrome, or schizophrenia. Halitophobia refers to imaginary halitosis (3).

5. Systemic sources include diabetic ketoacidosis (sweet, fruity, acetone breath), renal failure (ammonia or “fishy” odor), hepatic failure (“fetor hepaticus”—a sweet amine odor), high fever with dehydration, and vitamin or mineral deficiencies leading to dry mouth.

History

A focus on the characteristics of the bad breath is critical, although the patient is often unable to self-diagnosis or describe accurately because of olfactory desensitization. Is the odor transient or constant? A constant odor suggests chronic systemic disease or serious disorders of the oral cavity. What are the precipitating, aggravating, or relieving factors? What are the patient’s smoking habits, medications, dietary preferences, and brushing and flossing routines?

Physical examination

A. Physical examination should be undertaken with an emphasis on the evaluation of the oral cavity, particularly looking for ulceration, dryness, trauma, postnasal drainage, infections, cryptic tonsils, or neoplasms.

B. Techniques for localizing the odor source (systemic versus oral cavity).

1. Seal lips and blow air through the nose. If fetid odor is noted, this is suggestive of a systemic source.

2. Pinch nose with lips closed. Hold respiration and exhale gently through the mouth. Odors detected in this fashion, generally are local in origin.

Testing

For most patients with complaints of halitosis, clinical laboratory testing and diagnostic imaging are unnecessary and should only be pursued on the basis of specific findings indicated by the history and physical examination. The Schirmer’s test may be useful in identifying xerophthalmia and associated xerostomia seen with Sjögren’s syndrome and some other rheumatologic conditions (Chapter 12.1). If indicated, radiologic studies and imaging procedures of the sinuses, thorax, and abdomen may be used to identify infectious processes, neoplasms, and GERD with its complications.

Diagnostic assessment

The key to diagnosis and management of halitosis is a thorough history and focused physical examination with a particular emphasis on diseases and disorders of the oral cavity. Because 80% to 90% of all malodorous conditions can be traced to oral causes, simple examination maneuvers as described previously can be diagnostically helpful in excluding the likelihood of more distant or complex systemic sources. Salivation, mastication, and swallowing all lead to a decreased propensity to generate bad breath. Conversely, conditions or medications that reduce salivation or promote masticatory inactivity favor production of fetid breath. Because the key to treatment of halitosis of oral origin, beyond the limitation of aggravating factors, is proper oral hygiene, an evaluation of the patient’s toothbrushing and flossing regimens is imperative. Brushing should include gingival, tongue, and palatal surfaces because vigorous tongue brushing twice daily has been demonstrated in several studies to reduce the severity of malodorous morning breath (5).

References

1. Replogle WM, Keebe DK. Halitosis. Am Fam Physician 1996;53:1215–1223.

2. Spielman AI, Bivona P, Refkin BR. Halitosis: a common oral problem. N Y State Dent J 1996;62:36–42.

3. Ben-Aryeh H, Horowitz G, Nir D, Laufer D. Halitosis: an interdisciplinary approach. Am J Otolaryngol 1998;19:8–11.

4. Amir E, Shimonov R, Rosenberg M. Halitosis in children. J Pediatr 1999;134:
338–343.

5. Johnson BE. Halitosis, or the meaning of bad breath. J Gen Intern Med 1992;7:
649–656.

Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X