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Assessment and management of halitosis

Article  in  Dental Update · May 2015

DOI: 10.12968/denu.2015.42.4.346 · Source: PubMed

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 Periodontics

Vijendra P Singh

Neeraj Malhotra, Abhishek Apratim and Madhu Verma

Assessment and Management of

Halitosis
Abstract: Halitosis is an unpleasant condition that may be the origin of concern not only for a possible health condition but also for
frequent psychological alterations which may lead to social and personal isolation. The most frequent sources of halitosis that exist in
the oral cavity include bacterial reservoirs such as the dorsum of the tongue, saliva and periodontal pockets. Volatile sulphur compounds
(VSCs) are the prominent elements of oral malodour. Genuine halitosis and pseudo-halitosis should be in the treatment realm of dental
practitioners.
Clinical Relevance: Halitosis can be a symptom of underlying systemic disease, therefore the exact diagnosis and its source (oral or non-
oral) is important in the proper approach to its management.
Dent Update 2015; 42: 346–353

The word halitosis is derived from the Latin condition but also for frequent psychological Methyl mercaptan (CH3SH) is believed to
word halitus, which means exhalation. alterations leading to social and personal be the most malodorous component.3
Halitosis is a term used to refer to offensive isolation. The importance of oral malodour Sulphur-containing amino acids [cysteine]
or bad breath. Fetor exore, fetor oris and goes beyond the knowledge of its cause, are broken down by the anaerobic bacteria to
stomatodysodia (dysodia in Greek refers to diagnosis and therapy because it interacts release volatile sulphur compounds. Certain
stench) are other terms that have been used with other sociological issues such as culture, non-sulphur-containing substances like
in literature to describe halitosis. Oral halitosis religion, race, sex and social taboos. diamines [cadaverine4 (cadaver smell) and
is the specific term used to describe halitosis However, this condition was not putrescine5 (rotting meat smell)], acetone
that originates within the oral cavity.1,2 Breath studied scientifically until the 1940s and 1950s and acetaldehyde also contribute to halitosis
malodour may be an important factor in social when Fosnick et al developed an instrument emanating from the oral cavity. Other
communication and, therefore, may be the called the osmoscopy, which measures the potentially odour-producing substances
origin of concern not only for a possible health sources of malodour. They demonstrated that include indole (used in small quantities in
this problem could be either physiologic or perfumes, however, large quantities can
pathologic, and the source of bad breath could produce an offensive odour), skatole (faecal
Vijendra P Singh, MDS, Assistant originate from the mouth, the nasopharynx, or odour), short-chain carboxylic acids such as
Professor, Department of Periodontics, various other parts of the body. butyric and valeric acids (sweaty feet odour)
Faculty of Dentistry, Melaka Manipal The ratio between female and and ammonia. The activity of bacteria is at its
Medical College, Melaka, Malaysia, male patients with oral malodour is almost the peak at a pH of 7.2 and inhibited at a pH of
Neeraj Malhotra, MDS, PGDHHM, same; no gender-based differences have been 6.5.6
Reader, Department of Conservative found with regard to prevalence and severity
Dentistry and Endodontics, ITS Dental
College, Hospital and Research Centre,
of halitosis. However, it has been observed that Micro-organisms
women seek treatment more often than men.
Greater Noida, UP, India, Abhishek Volatile sulphur compounds
Apratim, MDS, Assistant Professor, (VSCs) are believed to be produced by
Department of Prothodontics, Faculty
Aetiology Gram-negative proteolytic anaerobes. These
of Dentistry, Melaka Manipal Medical The primary cause of halitosis is microbes are located in the stagnant areas of
College, Melaka, Malaysia and Madhu the release of volatile sulphur compounds the mouth, such as the periodontal pockets,
Verma, BDS, General Dental Practice, (VSCs), which include hydrogen sulphide, tongue surface, interproximal areas between
Lucknow, India. dimethyl sulphide and methyl mercaptan. the teeth and in the dental caries. The principal

346 DentalUpdate May 2015

 Periodontics

bacteria that are implicated in the creation drinks can either dry the mouth, such as include:
alcohol-containing liquids (wine and some  Plaque-related gingival and periodontal
of oral malodour include Fusobacterium
mouthwashes) and cigarettes, or provide disease, such as gingivitis, periodontitis,
nucleatum, Prevotella intermedia and Tannerella
high concentrations of protein or sugar. Dairy necrotizing ulcerative gingivitis, pericoronitis,
forsythensis. Other bacteria that have been
products are known to break down in the abscesses;
implicated in the production of VSCs include
mouth and release amino acids that are rich  Ulceration caused by malignancy, local
Porphyromonas gingivalis, Porphyromonas
in sulphur. Onion and garlic contain high causes, apthae, drugs;
endodontalis, Treponema denticola,
concentrations of sulphur, which can pass  Hyposalivation caused by drugs,
Aggregatibacter actinomycetemcomitans, through the lining of the intestine into the radiotherapy, chemotherapy, Sjögren’s
Atopobium parvulum, Campylobacter rectus, bloodstream, and subsequently be released syndrome;
Desulfovibrio species, Eikenella corrodens, into the lungs and then exhaled.  Tongue coating resulting from poor oral
Eubacterium sulci, Fusobacterium species Smoking not only raises the hygiene;
and Peptostreptococcus micros. Helicobacter concentration of volatile compounds in the  Deposition of debris in dental appliances;
pylori can produce VSCs and should also be mouth and lungs, but also further aggravates  Bone disease such as osteomyelitis,
considered as a possible cause of halitosis.7 the situation because of its drying effect on
osteonecrosis, dry socket and malignancy.
Klebsiella and Enterobacter are reported the oral mucosa. Morning breath is related to
A study in the elderly found
to have emitted foul odours in vitro which the decreased saliva production and secretion
the accumulation of bacterial plaque on
resembled bad breath in denture wearers.8 resulting in the transient desiccation of the
the tongue, oral dryness, burning mouth,
mouth.
overnight denture wear, and lower educational
Exogenous (transient) causes of levels to be significantly related to oral
halitosis Intra-oral causes of halitosis malodour.9 Saliva seems to undergo chemical
The intake of food and Intra-oral causes of halitosis changes with ageing. As the amount of ptyalin

Classification Treatment Needs Description

I. Genuine halitosis 1. Obvious malodour, with intensity beyond socially acceptable level, is perceived.

A. Physiologic halitosis TN-1 1. Malodour arises through putrefactive process within the oral cavity. Neither
specific disease nor pathologic condition that could cause halitosis is found.
2. Origin is mainly the dorso-posterior region of the tongue.
3. Temporary halitosis due to dietary factors (eg garlic) should be excluded.

B. Pathologic halitosis
(i) Oral TN-1 and TN-2 1. Halitosis caused by disease, pathologic condition or malfunction of oral tissues.
2. Halitosis derived from tongue coating, modified by pathologic condition
(eg periodontal disease, xerostomia) is included in this subdivision.

(ii) Extra-oral TN-1 and TN-3 1. Malodour originates from nasal, paranasal and/or laryngeal regions.
2. Malodour originates from pulmonary tract or upper digestive tract.
3. Malodour originates from disorders anywhere in the body whereby the odour
is blood-borne and emitted via the lungs (eg diabetes mellitus, hepatic cirrhosis,
uremia, internal bleeding).

II. Pseudo-halitosis TN-1 and TN-4 1. Obvious malodour is not perceived by others, although the patient stubbornly
complains of its existence.
2. Condition is improved by counselling (using literature support, education and
explanation of examination results) and simple oral hygiene measures.

III. Halitophobia TN-1 and TN-5 1. After treatment for genuine halitosis or pseudo-halitosis, the patient persists in
believing that he/she has halitosis.
2. No physical or social evidence exists to suggest that halitosis is present.
Table 1. The classification of halitosis with corresponding treatment needs (TN).19

May 2015 DentalUpdate 347

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Category Description increased degradation of protein. Studies

have shown that periodontal ligament (PDL)
TN-1 Explanation of halitosis and instructions for oral hygiene cells exposed to methyl mercaptan in culture
(support and reinforcement of a patient’s own self-care for alter their intracellular pH and become more
further improvement of his/her oral hygiene). acidic. In addition, they exhibit decreased
motility, lowered protein synthesis and
TN-2 Oral prophylaxis, professional cleaning and treatment for alterations in collagen metabolism. These
oral diseases, especially periodontal diseases. changes are predominantly detrimental
to the ability of these cells to maintain or
TN-3 Referral to a physician or medical specialist. regenerate mineralized tissues.18
TN-4 Explanation of examination data, further professional
instruction, education and reassurance. Classification of halitosis
Miyazaki et al19 proposed a simple
TN-5 Referral to a clinical psychologist, psychiatrist or other classification (Table 1) with corresponding
psychological specialist. treatment need (TN) of halitosis which
Table 2. Treatment needs (TN) for halitosis.19 Note: TN-1 is applicable to all cases requiring TN-2
includes the categories of genuine halitosis,
through TN-5. pseudo-halitosis and halitophobia. Five
classes (Table 2)19 of treatment need for
halitosis have been categorized to provide
guidelines for clinicians. Dental practitioners
decreases and mucin increases, saliva Hormonal
are responsible for the management of
becomes thick and viscous and presents With increased progesterone15
physiologic halitosis (TN-1), oral pathologic
problems for the elderly.10 levels during the menstrual cycle, a typical
halitosis (TN-1 and TN-2) and pseudo-
Patients with deep breath odour can develop. Evidence also
halitosis (TN-1 and TN-4), physician or
periodontal pockets are associated indicates that VSC levels in the expired air are
medical specialist would manage the extra-
with increased levels of VSCs.11 Deep increased two-fold to four-fold about the day
oral pathologic halitosis (TN-3), and
periodontal pockets are associated of ovulation and in the premenstrual period.
halitophobia (TN-5) would be managed by a
with low oxygen tension and low pH, physician, psychiatrist or psychological
which activates the decarboxylation of Effects of VSCs on gingivitis and specialist.
the amino acids (eg lysine, ornithine) to periodontitis
cadaverine and putrescine, which is a
malodorous diamine. The presence of
Volatile sulphur compounds (VSCs) Diagnosis
are potentially capable of altering permeability Oral malodour can be assessed
active periodontal inflammation has also
of the gingival tissues, inducing inflammatory by the following methods.
been suggested to be more important for
responses, and modulating functions of
the production of oral malodour than just
gingival fibroblasts. VSCs penetrate deeply into
these periodontal pockets.11 Patient history
the tissues where they can induce deleterious
changes in the non-keratinized epithelium, There is a saying ‘Listen to the
Other causes of halitosis basement membrane and underlying lamina patient and he will tell you the diagnosis’.
propria, which can be demonstrated in This is true for patients with breath odour
Drug-induced complaints.
histologic sections. VSCs are not only directly
Amphetamine, chloral Besides what is spontaneously
toxic to tissues, but they may also facilitate
hydrate, cytotoxic drug, dimethyl told, the clinician should also ask the
entry of other bacterial antigens, such as
sulphoxide, disulfiram, nitrate and nitrite, following questions:
lipopolysaccharides (LPS), into the underlying
phenothiazine and solvent abuse are  The frequency of odour (eg does it
lamina propria.16
some drugs associated with halitosis.12 happen only some weeks);
Gingivitis results from the
induction of an immune response  The time of appearance within the day (eg
Systemic accompanied by alterations in fibroblast after meals, which can indicate a hernia);
Nasal sepsis (eg sinusitis, function. CH3SH has been shown to induce  Whether others (non-confidants) have
postnasal drip), diabetic ketosis, gastro- secretion of IL-1ß from mononuclear cells in identified the problem (imaginary breath
intestinal disease, hepatic failure, renal culture.17 Methyl mercaptan has also been odour?);
failure, respiratory infection and sinusitis, shown to act synergistically with both LPS and  What kind of medications are taken;
hiatus hernia, trimethylaminuria, fish- IL-1ß to increase secretion of prostaglandin  Whether dryness of the mouth is noticed,
odour-syndrome (rare, smells of rotten fish E2 and collagenase (important mediators of etc.
due to insufficient enzyme to break down inflammation and tissue destruction). The
trimethylamine), post-irradiation therapy, effects of CH3SH on collagen metabolism are Medical history
Sjögren’s syndrome.13,14 a reflection of both decreased synthesis and A detailed history of the

348 DentalUpdate May 2015

 Periodontics

condition, duration, the severity, and the recorded on the organoleptic scale: sulphide and displays the concentrations on a
impact on the patient’s everyday life should be 0 = no appreciable odour; display panel.
taken, any predisposing and modifying factors 1 = barely noticeable odour;
investigated and concerns from the patient’s 2 = slight but noticeable odour; Sulphide monitoring22
family members also noted. 3 = moderate odour; Sulphide monitors analyse for
4 = strong odour, total sulphur content of the subject’s mouth
Clinical examination 5 = extremely foul odour. air. Although compact sulphide monitors are
A clinical examination should be inexpensive, portable and easy to use, most of
carried out checking the patient’s oral hygiene, Conditions for organoleptic measurement19 them are not able to distinguish between the
caries, periodontal status, tongue coating and Patients are given the following VSCs. For example, the Halimeter® analyses
also plaque retention; all these factors should instructions before the assessment: the total sulphur content of the individual’s
be recorded.  To abstain from taking antibiotics for three breath but cannot differentiate between
weeks; various sulphides. The instrument measures
Radiographical examination  To abstain from eating garlic, onion and parts per billion levels of hydrogen sulphide
A radiographical examination spicy foods for 48 hours; and, to a lesser extent, methyl mercaptan. A
could be used to look for evidence of dental  To abstain from ingesting any food or measurement is taken once a peak reading has
caries, alveolar bone defects and defective drink; been reached:23
restorations.  To omit their usual oral hygiene practices,  Less than 100 is normal;
using oral rinse and breath fresheners;  100−180 is minor halitosis;
Self examination  To abstain from smoking for 12 hours  Greater than 250 is chronic halitosis.
A self examination could involve before the assessment; There may be false positive results
the following:  To avoid using scented cosmetics for 24 due to other volatile vapours, such as acetone,
 Smelling a sterile metallic or non-odorous hours. ethanol and methanol that do not contribute
plastic spoon after scraping the posterior part The examiner, who should have to oral halitosis.
of the dorsum of the tongue.20 After about 5 a normal sense of smell, is required to refrain
seconds, the odour from the contents of the from drinking coffee, tea or juice, and to
BANA (Benzyl D L arginine α naphthylamide) test
spoon is assessed, holding the spoon about 5 refrain from smoking and using scented
A BANA test6 is a chairside
cm away from the nose. cosmetics before the assessment.
colorimetric assay that assesses the proteolytic
 Smelling a toothpick/dental floss after activity of anaerobic bacteria. It is a rapid
introducing it in an interdental area. The odour Gas chromatography (GC)21 chairside test for the evaluation of non-
is assessed by holding the toothpick/floss Gas chromatography is a sulphurous malodorous compounds. The
about 3 cm from the nose. highly sensitive technique to assess breath BANA test correlates significantly with the
 Smelling saliva spit in a small cup or spoon. malodour. This is considered the gold organoleptic score.
 Licking the wrist and allowing it to standard for measuring oral malodour since
dry (reflecting the saliva contribution to it is specific for VSCs, the main cause of Electronic nose
malodour). oral malodour. Traditional laboratory gas The FF-1 odour discrimination
chromatography or gas chromatography– analyser (Electronic nose, Shimadzu
Special tests mass spectrometry are cumbersome, need Corporation) was used by Tanaka et al.24
inert column carrier gas (gas cylinders of Electronic noses25 are chemical sensors
Organoleptic measurement19 nitrogen or helium) and require technicians that have been used in recent times for
A subjective test scored on or specialists with adequate training, the quantitative assessment of malodour
the basis of the examiner’s perception of and are thus clinically impractical.10 The associated with food and beverages. These
a subject’s oral malodour. This is carried GC equipment is expensive, bulky and electronic noses clinically assess oral malodour
out simply by sniffing the patient’s breath the procedure requires a skilful operator. and examine the association between oral
and scoring the level of oral malodour. A Therefore, this technology has been malodour strength and oral health status. The
translucent tube (2.5 cm D, 50−70 cm L) is confined to research and not to clinical use. set-up comprises a pre-concentrator, an array
placed through the privacy screen, inserted However, a newly developed portable gas of six metal oxide semiconductor sensors
into the patient’s mouth. The patient then chromatograph (Oral ChromaTM, Abimedical, selected for their different sensitivities and
exhales slowly and the breath, undiluted by Osaka) has now been described, which selectivities to fragrant substances, and a
room air, can be evaluated and assigned an does not use a special carrier gas (using pattern recognition software. The instrument
organoleptic score. The use of a privacy screen air instead) and is highly sensitive yet can be set to various modes such as the
allows the patient to believe that he/she has relatively low cost compared with a standard ‘allnote measurement mode’ which is the
undergone a specific malodour examination gas chromatograph.10 The Oral ChromaTM standard setting used for measuring all volatile
rather than the direct-sniffing procedure. analyses individual concentrations of volatile substances and the ‘topnote measurement
An organoleptic test19 should be sulphur compounds, such as hydrogen mode’, which primarily measures volatile
carried out on two or three different days and sulphide, methyl mercaptan and dimethyl substances with a low boiling point. The results

May 2015 DentalUpdate 351

 Periodontics

of a preliminary study showed that the Masking products halitosis by reducing conditions necessary for
main compounds related to oral malodour The usage of masking products metabolizing sulphur-containing amino acids
were volatile substances with a low boiling only is never an effective management of to volatile sulphur-containing compounds.
point.26 halitosis. Nevertheless, some commercially
available products, such as mints, toothpastes, Probiotics
Newer developments in diagnosis22 mouthrinses, sprays and chewing gums, The objective of probiotics10 is to
There are many other portable attempt to control halitosis with pleasant prevent the re-establishment of non-desirable
VSC monitors that are compact and flavours and fragrances. A short-term masking bacteria and thereby limit the re-occurrence
relatively inexpensive, eg Tanita breath effect can be gained with menthol-containing of oral malodour over a prolonged period.
alert, Osmoscope, Halimeter and diamond gum and may be the result of the menthol.31 Recently, several studies were performed to
probe. Another chairside test kit (Halitox replace bacteria responsible for halitosis with
reagent kit) measures halitosis-linked probiotics such as Streptococcus salivarius
Mechanical reduction of micro-organisms and
toxins. It is a quick, simple colorimetric (K12), Lactobacillus salivarius or Weissella
their substrates
test that detects both volatile sulphur cibaria. Several studies conclude that probiotic
Mechanical reduction of micro-
compounds, as well as polyamines.27 A bacterial strains, originally sourced from
organisms and their substrates can be
recent study using Tanita breath alert, the indigenous oral microbiotas of healthy
achieved by taking a solid breakfast, improving
BANA and a Halitox reagent kit, has shown humans, may have potential application as
hyposalivation, using chewing gum, brushing
that Tanita breath alert can be a useful adjuncts for the prevention and treatment
the teeth, flossing, using toothpicks, tongue
tool in self assessment of malodour, but of halitosis.32 The oral administration of the
cleaning and professional oral healthcare.
it is currently not available in India.28 The probiotic lactobacilli not only seemed to
The passage of solid food over the surface
diamond probe/Perio 2000 system is a improve the physiologic halitosis, but also
of the tongue may remove the tongue
dental device designed to detect sulphide showed beneficial effects on bleeding on
coating.3 Extreme hyposalivation increases
concentration of various forms (S, HS, H2S probing from the periodontal pockets.33
the production of volatile sulphur-containing
and CH3SH) in gingival sulci. The micro-
compounds.30 Salivary stimulation by eating
sulphide sensor responds to sulphide
breakfast, chewing or consuming acid food
ions and measures metabolic products of
and saliva substitutes diminishes the effect
Conclusion
many anaerobic bacteria and, indirectly, Malodour should not be
of hyposalivation.22 Levels of VSCs could be
bacterial activity. The reaction of the considered as just cosmetic therapy, since the
reduced for at least 1 hour by brushing the
sulphide ions with the sensor generates a available evidence indicates that many VSCs
teeth and the tongue, and then rinsing the
measurable voltage that is proportional to are toxic to periodontal tissues, even when
mouth with water.27
the sulphide concentration. Since sulphides present at extremely low concentrations.
are continually cleared from the pockets Periodontal tissues, unlike the tongue and
by crevicular fluid flow, the presence of Chemical reduction of micro-organisms alveolar mucosa, are not protected by a
high sulphide levels indicates a higher Toothpastes and mouthrinses keratinized layer and may be particularly
level of anaerobic bacterial activity.29 If the with antimicrobial properties can reduce susceptible in injury. Traditional procedures
presence of sulphide was indicated above oral malodour by reducing the number of of scaling, root planing and the practice of
threshold (>0.5), the light on the front of micro-organisms chemically.28 Often used oral hygiene, combined with tongue-scraping,
the display panel would change colour, active ingredients in these product are are effective at reducing levels of these
depending on the sulphide concentration, chlorhexidine,29 triclosan,24 essential oils15 compounds in mouth air and are satisfactory
and an audible tone would sound.29 and cetylpyridinium chloride.9 Other effective as cosmetic treatment. Underlying systemic
chemical agents are allylpyrocatechol, disease should also be considered as a
The management of halitosis L-trifluoromethionine and dehydroascorbic possible source of aetiology and appropriately
acid. management accordingly.
The available methods30
leading to a lowering of oral malodour
level can be divided into: Chemical neutralization of odorous compounds
1. The usage of masking products; Toothpastes, mouthrinses, References
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