Halitosis

Halitosis, or bad breath, may be acute or chronic, depending on the underlying cause. It may indicate the need for improved dental hygiene or may be a symptom of an underlying infection or chronic disease. Oral causes constitute about 90% of the etiologies of halitosis, whereas nasal causes constitute nearly 10%; thus, other etiologies are relatively uncommon.

Differential Diagnosis

• Head and neck etiologies
  –Foods (e.g., onion, garlic)
  –Dental conditions (periodontal disease, gingivitis, denture odor, dental abscesses, food particles not cleaned from teeth)
  –Postnasal drip
  –Dry mouth (xerostomia): Mouth breathing, side effect of medications, salivary gland disease, dehydration
  –Nasal foreign body
  –Gastroesophageal reflux disease
  –Chronic sinusitis
  –Allergic rhinitis
  –Tonsillar disease (e.g., streptococcal pharyngitis)
  –Zenker's (pharyngoesophageal) diverticulum: Presents as dysphagia, regurgitation, cough, and extreme halitosis
  –Tobacco or alcohol use

• Systemic etiologies
  –Diabetes mellitus, especially with ketoacidosis
  –Uremia
  –Pulmonary disorders (e.g., bronchiectasis, pneumonia, neoplasms, tuberculosis)
  –Trimethylaminuria (fishy breath odor)
  –Liver failure (fetor hepaticus)
  –Menstruation may exacerbate halitosis

Workup and Diagnosis

• Careful dental and medical history, including dental hygiene habits and dietary history
  –Note associated symptoms that suggest systemic etiology (e.g., cough, nasal congestion)
  –Odor after sleeping, dieting, or exercising suggests xerostomia
  –Odor upon talking suggests postnasal drip
  –Bleeding gums suggests periodontal disease
• Dental examination to rule out treatable dental causes (e.g., periodontal disease)
• Physical examination should include careful oral, nasal, sinus, neck, pulmonary, and abdominal examinations
  –Assess odor from mouth and nose separately
  –Small malodorous whitish stones on tongue suggest tonsilloliths
  –Place dentures into plastic bag for several minutes and then smell to evaluate for denture odor
  –Spoon test involves scooping mucous/saliva from back of tongue and evaluating for malodor; if present, suggests postnasal drip
  –Nasolaryngoscopy if nasal cause is suspected but specific cause cannot be identified
• Zenker's diverticulum is diagnosed by contrast barium swallow

Treatment

• Maintain good oral hygiene (e.g., brush teeth at least twice per day, floss daily, treat underlying periodontal disease)
• Avoid exacerbating medications or foods
• Tongue cleaning with toothbrush
• Gargle with chlorhexidine mouthwash twice a day for a week to assess improvement
• Treat postnasal drip (e.g., antihistamines, nasal steroids, polyp removal)
• Treat sinusitis with appropriate antibiotics
• Decrease or eliminate alcohol and tobacco use
• Zenker's diverticulum may require surgical resection if symptomatic
• Treat other underlying medical diseases (e.g., diabetic ketoacidosis, uremia, GERD)

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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