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Bad breath

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"Halitosis" redirects here. For the genus of molluscs, seeHaliotis.
Bad breath
Other namesHalitosis, fetor oris, oral malodour, putrid breath
SpecialtyGastroenterology,otorhinolaryngology,dentistry
SymptomsUnpleasantsmellpresent onbreath[1]
ComplicationsAnxiety,depression,obsessive compulsive disorder[1]
TypesGenuine, non-genuine[2]
CausesUsually from inside the mouth[1]
TreatmentDepends on cause,tongue cleaning,mouthwash,flossing[1]
MedicationMouthwash containingchlorhexidineorcetylpyridinium chloride[1]
Frequency~30% of people[1]

Bad breath,also known ashalitosis,is asymptomin which a noticeably unpleasantbreathodouris present.[1]It can result inanxietyamong those affected.[1]It is also associated withdepressionand symptoms ofobsessive compulsive disorder.[1]

The concerns of bad breath may be divided into genuine and non-genuine cases.[2]Of those who have genuine bad breath, about 85% of cases come from inside the mouth.[1]The remaining cases are believed to be due to disorders in thenose,sinuses,throat,lungs,esophagus,orstomach.[3]Rarely, bad breath can be due to an underlying medical condition such asliver failureorketoacidosis.[2]Non-genuine cases occur when someone complains of having bad breath but other people cannot detect it.[2]This is estimated to make up between 5% and 72% of cases.[2]

The treatment depends on the underlying cause.[1]Initial efforts may includetongue cleaning,mouthwash,andflossing.[1]Tentative evidence supports the use of mouthwash containingchlorhexidineorcetylpyridinium chloride.[1]While there is tentative evidence of benefit from the use of a tongue cleaner it is insufficient to draw clear conclusions.[4]Treating underlying disease such asgum disease,tooth decay,tonsil stones,orgastroesophageal reflux diseasemay help.[1]Counsellingmay be useful in those who falsely believe that they have bad breath.[1]

Estimated rates of bad breath vary from 6% to 50% of the population.[1]Concern about bad breath is the third most common reason people seekdental care,after tooth decay and gum disease.[2][3]It is believed to become more common as people age.[1]Bad breath is viewed as a socialtabooand those affected may bestigmatized.[1][2]People in the United States spend more than $1 billion per year on mouthwash to treat it.[3]

Signs and symptoms[edit]

Bad breath is when a noticeably unpleasantodouris believed to be present on thebreath.It can result inanxietyamong those affected. It is also associated withdepressionand symptoms ofobsessive compulsive disorder.[1]

Causes[edit]

Mouth[edit]

In about 90% of genuine halitosis cases, the origin of the odour is in the mouth itself.[5]This is known as intra-oral halitosis, oral malodour or oral halitosis.

The most common causes are odour producingbiofilmon thebackof the tongue or other areas of the mouth due to poor oral hygiene. This biofilm results in the production of high levels of foul odours. The odours are produced mainly due to the breakdown ofproteinsinto individualamino acids,followed by the further breakdown of certain amino acids to produce detectable foulgases.Volatile sulfur compounds are associated with oral malodour levels, and usually decrease following successful treatment.[6]Other parts of the mouth may also contribute to the overall odour, but are not as common as the back of the tongue. These locations are, in order of descending prevalence, inter-dental and sub-gingival niches, faultydentalwork, food-impaction areas in between the teeth,abscesses,and uncleandentures.[7]Oral based lesions caused by viral infections likeherpes simplexandHPVmay also contribute to bad breath.

The intensity of bad breath may differ during the day, due to eating certain foods (such asgarlic,onions,meat,fish,andcheese),smoking,[8]andalcohol consumption.Since the mouth is exposed to less oxygen[medical citation needed]and is inactive during the night, the odour is usually worse upon awakening ( "morning breath"). Bad breath may be transient, often disappearing following eating, drinking,tooth brushing,flossing,or rinsing with specializedmouthwash.Bad breath may also be persistent (chronic bad breath), which affects some 25% of the population in varying degrees.[9]

Tongue[edit]

Normal appearance of the tongue, showing a degree of visible white coating and normal irregular surface on the posterior dorsum.

The most common location for mouth-related halitosis is thetongue.[10]Tongue bacteria produce malodourous compounds and fatty acids, and account for 80 to 90% of all cases of mouth-related bad breath.[11]Large quantities of naturally occurring bacteria are often found on the posteriordorsumof the tongue, where they are relatively undisturbed by normal activity. This part of the tongue is relatively dry and poorly cleansed, and the convoluted microbial structure of the tongue dorsum provides an idealhabitatforanaerobic bacteria,which flourish under a continually-forming tongue coating offooddebris,dead epithelial cells,postnasal dripand overlying bacteria, living and dead. When left on the tongue, theanaerobic respirationof such bacteria can yield either theputrescentsmell ofindole,skatole,polyamines,or the "rotten egg" smell ofvolatile sulfur compounds(VSCs) such ashydrogen sulfide,methyl mercaptan,allyl methyl sulfide,anddimethyl sulfide.The presence of halitosis-producing bacteria on the back of the tongue is not to be confused with tongue coating. Bacteria are invisible to the naked eye, and degrees of white tongue coating are present in most people with and without halitosis. A visible white tongue coating does not always equal the back of the tongue as an origin of halitosis, however a "white tongue"is thought to be a sign of halitosis. Inoral medicinegenerally, a white tongue is considered a sign of several medical conditions. Patients with periodontal disease were shown to have sixfold prevalence of tongue coating compared with normal subjects. Halitosis patients were also shown to have significantly higher bacterial loads in this region compared to individuals without halitosis.

Gums[edit]

Gingival crevices are the small grooves between teeth and gums, and they are present in health, although they may become inflamed whengingivitisis present. The difference between a gingival crevice andperiodontal pocketis that former is <3mm in depth and the latter is >3mm. Periodontal pockets usually accompanyperiodontal disease(gum disease). There is some controversy over the role ofperiodontal diseasesin causing bad breath. However, advanced periodontal disease is a common cause of severe halitosis. People with uncontrolled diabetes are more prone to have multiple gingival and periodontal abscess. Their gums are evident with large pockets, where pus accumulation occurs. This nidus of infection can be a potential source for bad breath. Removal of the subgingival calculus (i.e. tartar or hard plaque) and friable tissue has been shown to improve mouth odour considerably. This is accomplished by subgingival scaling and root planing and irrigation with an antibiotic mouth rinse. The bacteria that cause gingivitis and periodontal disease (periodontopathogens) are invariablygram negativeand capable of producing VSC.Methyl mercaptanis known to be the greatest contributing VSC in halitosis that is caused by periodontal disease and gingivitis. The level of VSC on breath has been shown to positively correlate with the depth of periodontal pocketing, the number of pockets, and whether the pockets bleed when examined with adental probe.Indeed, VSC may themselves have been shown to contribute to the inflammation and tissue damage that is characteristic of periodontal disease. However, not all patients with periodontal disease have halitosis, and not all patients with halitosis have periodontal disease. Although patients with periodontal disease are more likely to develop halitosis than the general population, the halitosis symptom was shown to be more strongly associated with degree of tongue coating than with the severity of periodontal disease. Another possible symptom of periodontal disease is a bad taste, which does not necessarily accompany a malodour that is detectable by others.

Other causes[edit]

Other less common reported causes from within the mouth include:[12][13][14]

  • Deep carious lesions (dental decay) – which cause localized food impaction and stagnation
  • Recent dental extraction sockets – fill with blood clot, and provide an ideal habitat for bacterial proliferation
  • Interdental food packing – (food getting pushed down between teeth) – this can be caused by missing teeth, tilted, spaced or crowded teeth, or poorly contoured approximaldental fillings.Food debris becomes trapped, undergoes slow bacterial putrefaction and release of malodourous volatiles. Food packing can also cause a localized periodontal reaction, characterized by dental pain that is relieved by cleaning the area of food packing with interdental brush or floss.
  • Acrylic dentures (plastic false teeth) – inadequate denture hygiene practises such as failing to clean and remove the prosthesis each night, may cause a malodour from the plastic itself or from the mouth as microbiota responds to the altered environment. The plastic is actually porous, and the fitting surface is usually irregular, sculpted to fit the edentulous oral anatomy. These factors predispose to bacterial and yeast retention, which is accompanied by a typical smell.
  • Oral infections
  • Oral ulceration
  • Fasting
  • Stressoranxiety
  • Menstrual cycle– At mid cycle and duringmenstruation,increased breath VSC were reported in women.
  • Smoking – Smoking is linked with periodontal disease, which is the second most common cause of oral malodour. Smoking also has many other negative effects on the mouth, from increased rates of dental decay topremalignant lesionsand evenoral cancer.
  • Alcohol
  • Volatile foods – e.g. onion,garlic,durian, cabbage, cauliflower and radish. Volatile foodstuffs may leave malodourous residues in the mouth, which are the subject to bacterial putrefaction and VSC release. However, volatile foodstuffs may also cause halitosis via the blood borne halitosis mechanism.
  • Medication – often medications can causexerostomia(dry mouth) which results in increased microbial growth in the mouth.

Nose and sinuses[edit]

In this occurrence, the air exiting thenostrilshas a pungent odour that differs from the oral odour. Nasal odour may be due tosinus infectionsorforeign bodies.[6][7]

Halitosis is often stated to be a symptom ofchronic rhinosinusitis,however gold standard breath analysis techniques have not been applied. Theoretically, there are several possible mechanisms of both objective and subjective halitosis that may be involved.[15]

Tonsils[edit]

There is disagreement as to the proportion of halitosis cases that are caused by conditions of the tonsils.[16]Some claim that the tonsils are the most significant cause of halitosis after the mouth.[16]According to one report, approximately 3% of halitosis cases were related to the tonsils.[16]Conditions of the tonsils that may be associated with halitosis include chronic caseoustonsillitis(cheese-like material can be exuded from thetonsillar crypt orifi),tonsillolithiasis(tonsil stones), and less commonlyperitonsillar abscess,actinomycosis,fungatingmalignancies,chondroidchoristoma,andinflammatory myofibroblastic tumor.[16]

Esophagus[edit]

Thelower esophageal sphincter,which is the valve between thestomachand theesophagus,may not close properly due to ahiatal herniaorGERD,allowing acid to enter the esophagus and gases to escape to the mouth. AZenker's diverticulummay also result in halitosis due to aging food retained in the esophagus.

Stomach[edit]

Thestomachis considered by most researchers as a very uncommon source of bad breath. The esophagus is a closed and collapsed tube, and continuous flow of gas or putrid substances from thestomachindicates a health problem—such asrefluxserious enough to be bringing up stomach contents or afistulabetween the stomach and the esophagus—which will demonstrate more serious manifestations than just foul odour.[5]

In the case ofallyl methyl sulfide(the byproduct ofgarlic's digestion), odour does not come from the stomach, since it does not get metabolized there.

Systemic diseases[edit]

There are a few systemic (non-oral) medical conditions that may cause foul breath odour, but these are infrequent in the general population. Such conditions are:[17][18]

  1. Fetor hepaticus:an example of a rare type of bad breath caused by chronicliver failure.
  2. Lower respiratory tract infections(bronchial and lung infections).
  3. Kidney infectionsandkidney failure.
  4. Carcinoma.
  5. Trimethylaminuria( "fish odour syndrome" ).
  6. Diabetes mellitus.
  7. Metabolicconditions, e.g. resulting in elevated blooddimethyl sulfide.[19]

Individuals affected by the above conditions often show additional, more diagnostically conclusive symptoms than bad breath alone.

Delusional halitosis[edit]

One quarter of the people seeking professional advice on bad breath have an exaggerated concern of having bad breath, known ashalitophobia,delusionalhalitosis,or as a manifestation of theolfactory reference syndrome.They are sure that they have bad breath, although many have not asked anyone for an objective opinion. Bad breath may severely affect the lives of some 0.5–1.0% of the adult population.[20]

Diagnosis[edit]

Self diagnosis[edit]

Scientists have long thought that smelling one's own breath odour is often difficult due toacclimatization,although many people with bad breath are able to detect it in others. Research has suggested that self-evaluation of halitosis is not easy because of preconceived notions of how bad we think it should be. Some people assume that they have bad breath because of badtaste(metallic, sour, fecal, etc.), however bad taste is considered a poor indicator.

Patients often self-diagnose by asking a close friend.[21]

One popular home method to determine the presence of bad breath is tolickthe back of thewrist,let thesalivadry for a minute or two, and smell the result. This test results inoverestimation,as concluded from research, and should be avoided.[5]A better way would be to lightly scrape the posterior back of the tongue with a plastic disposable spoon and to smell the drying residue. Home tests that use a chemical reaction to test for the presence ofpolyaminesand sulfur compounds on tongue swabs are now available, but there are few studies showing how well they actually detect the odour. Furthermore, since breath odour changes in intensity throughout the day depending on many factors, multiple testing sessions may be necessary.

Testing[edit]

If bad breath is persistent, and all other medical and dental factors have been ruled out, specialized testing and treatment is required. Hundreds of dental offices and commercial breath clinics now claim to diagnose and treat bad breath.[citation needed]They often use some of several laboratory methods for diagnosis of bad breath:

  • Halimeter:a portable sulfide monitor used to test for levels of sulfur emissions (to be specific,hydrogen sulfide) in the mouth air. When used properly, this device can be very effective at determining levels of certain VSC-producing bacteria. However, it has drawbacks in clinical applications. For example, other common sulfides (such asmercaptan) are not recorded as easily and can be misrepresented in test results. Certain foods such as garlic and onions produce sulfur in the breath for as long as 48 hours and can result in false readings. The Halimeter is also very sensitive to alcohol, so one should avoid drinking alcohol or using alcohol-containing mouthwashes for at least 12 hours prior to being tested. This analog machine loses sensitivity over time and requires periodic recalibration to remain accurate.[22]
  • Gas chromatography:portable machines are being studied.[23]This technology is designed to digitally measure molecular levels of major VSCs in a sample of mouth air (such ashydrogen sulfide,methyl mercaptan,anddimethyl sulfide). It is accurate in measuring the sulfur components of the breath and produces visual results in graph form via computer interface.
  • BANA test:this test is directed to find the salivary levels of anenzymeindicating the presence of certain halitosis-related bacteria.
  • β-galactosidasetest: salivary levels of this enzyme were found to be correlated with oral malodour.

Although such instrumentation and examinations are widely used in breath clinics, the most important measurement of bad breath (the gold standard) is the actualsniffingand scoring of the level and type of the odour carried out by trained experts ( "organoleptic measurements" ). The level of odour is usually assessed on a six-point intensity scale.[3][6]

Classification[edit]

Several classification schemes have been proposed to define halitosis.[24]

Miyazakiet al.[edit]

The Miyazakiet al.classification was originally described in 1999 in a Japanese scientific publication,[25]and has since been adapted to reflect North American society, especially with regards halitophobia.[26]The classification assumes three primary divisions of the halitosis symptom, namely genuine halitosis, pseudohalitosis and halitophobia.

  • Genuine halitosis
    • A. Physiologic halitosis
    • B. Pathologic halitosis
      • (i) Oral
      • (ii) Extra-oral
  • Pseudohalitosis
  • Halitophobia

This classification has been criticized for being inflexible, and that the pseudohalitosis and halitophbia categories contain psychopathologic connotations.[24]

Tangerman and Winkel[edit]

The Tangerman and Winkel classification was suggested in Europe in 2002.[27][19]This classification focuses only on those cases where there is genuine halitosis, and has therefore been criticized for being less clinically useful for dentistry when compared to the Miyazakiet al.classification.

  • Intra-oral halitosis
  • Extra-oral halitosis
    • A. Blood borne halitosis
      • (i) Systemic diseases
      • (ii) Metabolic diseases
      • (iii) Food
      • (iv) Medication
    • B. Non-blood borne halitosis
      • (i) Upper respiratory tract
      • (ii) Lower respiratory tract

The same authors also suggested that halitosis can be divided according to the character of the odour into 3 groups:[19]

Aydin and Harvey-Woodworth[edit]

Based on the strengths and weaknesses of previous attempts at classification, Aydin and Harvey-Woodworth proposed a cause-based classification.[24]

  • Type 0 (physiologic)
  • Type 1 (oral)
  • Type 2 (airway)
  • Type 3 (gastroesophageal)
  • Type 4 (blood-borne)
  • Type 5 (subjective)

Any halitosis symptom is potentially the sum of these types in any combination, superimposed on the physiologic odour present in all healthy individuals.[24]

Management[edit]

Approaches to improve bad breath may include physical or chemical means to decrease bacteria in the mouth, products to mask the smell, or chemicals to alter the odour creating molecules.[1]Many different interventions have been suggested and trialed such as toothpastes, mouthwashes, lasers, tongue scraping, and mouth rinses.[28]There is no strong evidence to indicate which interventions work and which are more effective.[28]It is recommended that in those who usetobacco productsstop.[1]Evidence does not support the benefit of dietary changes orchewing gum.[1]

Mechanical measures[edit]

Brushing the teeth may help.[29]While there is evidence of tentative benefit fromtongue cleaningit is insufficient to draw clear conclusions.[4]Flossingmay be useful.[1]

Mouthwashes[edit]

Mouthwashesoften contain antibacterial agents includingcetylpyridinium chloride,chlorhexidine,zinc gluconate,zinc chloride,zinc lactate,hydrogen peroxide,chlorine dioxide,amine fluorides,stannous fluoride,hinokitiol,[30]andessential oils.[31]Listerineis one of the well-known mouthwash products composed of different essential oils.[32]Other formulations containing herbal products and probiotics have also been proposed.[33]Cetylpyridinium chloride and chlorhexidine can temporarily stain teeth.

Underlying disease[edit]

Ifgum diseaseandcavitiesare present, it is recommended that these be treated.[1]

If diseases outside of the mouth are believed to be contributing to the problem, treatment may result in improvements.[1]

Counsellingmay be useful in those who falsely believe that they have bad breath.[1]

Epidemiology[edit]

It is difficult for researchers to make estimates of the prevalence of halitosis in the general population for several reasons. Firstly, halitosis is subject to societal taboo and stigma, which may impact individuals' willingness to take part in such studies or to report accurately their experience of the condition. Secondly, there is no universal agreement about what diagnostic criteria and what detection methods should be used to define which individuals have halitosis and which do not. Some studies rely on self reported estimation of halitosis, and there is contention as to whether this is a reliable predictor of actual halitosis or not. In reflection of these problems, reported epidemiological data are widely variable.[34]

History, society and culture[edit]

The earliest known mention of bad breath occurs in ancient Egypt, where detailed recipes for toothpaste are made before thePyramidsare built. The 1550 BCEbers Papyrusdescribes tablets to cure bad breath based onincense,cinnamon,myrrhandhoney.[35]Hippocratic medicineadvocated a mouthwash of red wine and spices to cure bad breath.[36]Alcohol-containing mouthwashes are now thought to exacerbate bad breath as they dry the mouth, leading to increased microbial growth. TheHippocratic Corpusalso describes a recipe based on marble powder for females with bad breath.[37]The Ancient Roman physicianPlinywrote about methods to sweeten the breath.[38]

Ancient Chinese emperors required visitors to chewclovebefore an audience.[35]TheTalmuddescribes bad breath as a disability, which could be grounds for legal breaking of a marriage license.[12]Early Islamic theology stressed that the teeth and tongue should be cleaned with asiwak,a stick from the plantSalvadora persicatree.[12]This traditional chewing stick is also called a Miswak, especially used inSaudi Arabia,an essentially is like a natural toothbrush made from twigs.[35]During theRenaissanceera,Laurent Joubert,doctor to KingHenry III of Francestated that bad breath is "caused by dangerousmiasmathat falls into the lungs and through the heart, causing severe damages ".[35]

InB. G. JefferisandJ. L. Nichols'"Searchlights on Health"(1919), the following recipe is offered:" [One] teaspoonful of the following mixture after each meal: One ounce chloride of soda, one ounce liquor of potassa, one and one-half ounces phosphate of soda, and three ounces of water. "

In the present day, bad breath is one of the biggest social taboos. The general population places great importance on the avoidance of bad breath, illustrated by the annual $1 billion that consumers in the United States spend on deodorant-type mouth (oral) rinses, mints, and related over-the-counter products.[13]Many of these practices are merely short term attempts at masking the odour. Some authors have suggested that there is an evolutionary basis to concern over bad breath. An instinctive aversion to unpleasant odours may function to detect spoiled food sources and other potentially invective or harmful substances.[39]Body odours in general are thought to play an important role in mate selection in humans,[40]and unpleasant odour may signal disease, and hence a potentially unwise choice of mate. Although reports of bad breath are found in the earliest medical writings known, the social stigma has likely changed over time, possibly partly due to sociocultural factors involving advertising pressures. As a result, the negative psychosocial aspects of halitosis may have worsened, and psychiatric conditions such as halitophobia are probably more common than historically. There have been rare reports of people committing suicide because of halitosis, whether there is genuine halitosis or not.

Etymology[edit]

The word halitosis is derived from the Latin wordhalitus,meaning 'breath', and the Greek suffix-osismeaning 'diseased' or 'a condition of'.[41]With modernconsumerism,there has been a complex interplay of advertising pressures and the existing evolutionary aversion to malodour. Contrary to the popular belief thatListerinecoined the termhalitosis,its origins date to before the product's existence,[42]being coined by physician Joseph William Howe in his 1874 bookThe Breath, and the Diseases Which Give It a Fetid Odor,[43][44]although it only became commonly used in the 1920s when amarketing campaignpromoted Listerine as a solution for "chronic halitosis". The company was the first to manufacture mouth washes in the United States. According toFreakonomics:

Listerine "...was invented in the nineteenth century as powerful surgical antiseptic. It was later sold, in distilled form, as both a floor cleaner and a cure forgonorrhea.But it wasn't a runaway success until the 1920s, when it was pitched as a solution for "chronic halitosis" — a then obscure medical term for bad breath. Listerine's new ads featured forlorn young women and men, eager for marriage but turned off by their mate's rotten breath. "Can I be happy with him in spite ofthat?"one maiden asked herself. Until that time, bad breath was not conventionally considered such a catastrophe, but Listerine changed that. As the advertising scholar James B. Twitchell writes," Listerine did not make mouthwash as much as it made halitosis. "In just seven years, the company's revenues rose from $115,000 to more than $8 million."[45]

Alternative medicine[edit]

According to traditionalAyurvedicmedicine, chewingareca nutandbetelleaf is a remedy for bad breath.[46]In South Asia, it was a custom to chew areca or betel nut and betel leaf among lovers because of the breath-freshening and stimulant drug properties of the mixture. Both the nut and the leaf are mild stimulants and can be addictive with repeated use. The betel nut will also causedental decayand red or black staining of teeth when chewed.[47]Both areca nut and betel leaf chewing, however, can causepremalignant lesionssuch asleukoplakiaandsubmucous fibrosis,and are recognized risk factors for oral andoropharyngealsquamous cell carcinoma(oral cancer).[48]

Practitioners and purveyors ofalternative medicinesell a vast range of products that claim to be beneficial in treating halitosis, including dietary supplements, vitamins, and oral probiotics. Halitosis is often claimed to be a symptom of "candida hypersensitivity syndrome"or related diseases, and is claimed to be treatable withantifungal medicationsor alternative medications to treat fungal infections.

Research[edit]

In 1996, the International Society for Breath Odor Research (ISBOR) was formed to promote multidisciplinary research on all aspects of breath odours.

References[edit]

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External links[edit]

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