Bad breath or halitosis is one of the most common complaints patients have. In fact, about ¼ of people suffer from halitosis. Whether it is a transient or a chronic condition, halitosis usually has some underlying pathology associated with it. The main compounds that actually cause the bad odor are volatile sulphur compounds, created by bacterial breakdown of amino acids. Halitosis can cause severe psychosocial hurdles for patients, which can lead to personal discomfort, social embarrassment and isolation.

Types of Halitosis

  • Physiological Halitosis: This form of bad breath is caused by putrefactive processes in the oral cavity, usually associated with the dorsoposterior region of the tongue.
  • Pathological Halitosis: Caused by pathology stemming from oral or extra-oral regions such as the upper digestive tract, pulmonary tract, nasal or para-nasal areas.
  • Pseudo-halitosis: Bad breath that only the patient can notice. This condition is usually solved by oral hygiene improvements.
  • Halitophobia: The constant fear and worrying of bad breath, despite no evidence of halitosis by the patient or others.

Sources of Halitosis:

  • Extra-oral Sites: Only about 10% of halitosis cases stem from extra-oral sites.
    • Liver infection, hepatitis and liver failure can cause a sweet, musty, fecal breath. This is caused by methyl mercaptan production- a volatile sulphur compound.
    • Respiratory tract, endocrine disorders, GI disease: The main culprit of halitosis from these sites is dimethyl sulphoxide – another volatile sulphur compound.
  • Intra-oral Sites (90% of cases):
    • Tongue: The dorsum of the tongue, due to its deep grooves, is a great place for Gram-negative and anaerobic bacteria to flourish. These bacteria use epithelial cell debris and food remnants to produce volatile sulphur compounds. There is a positive correlation between the severity of halitosis and the amount of coating on the tongue. Posterior of the circumvallate papillae has been shown to be particularly troublesome, as it is less accessible for hygiene.
    • Periodontal Disease: There is a significant positive correlation between halitosis and periodontal disease. During periodontal disease, as deeper gingival pockets with decreased pH and oxygen tensions form, the creation of volatile sulphur compounds is increased. Moreover, these sulphur compounds induce inflammation and further increase bacterial infiltration by their toxic effects on epithelial cells, hindering cell growth and proliferation.
    • Exposed tooth pulps, non-vital teeth, healing wounds, and fixed appliances: All these areas can harbor food and plaque, which further increases the production of volatile sulphur compounds by bacteria.
    • Intra-oral pathologies: Pericoronal infections, oral ulceration, and acute necrotizing ulcerative gingivitis are other conditions that can increase the bacterial load in the oral cavity, creating volatile sulphur compounds.

Treatment

The main method of action in most treatments combatting halitosis is reducing the bacterial load that is causing the production of the volatile sulphur compounds.

  • The etiology of halitosis should be pinpointed through a detailed medical history, nutritional history and oral hygiene habits.
  • Any food and bacterial traps should be eliminated. This can include the coating on the tongue, faulty restorations, and fixed oral appliances. Any pathology such as infections and caries should be treated.
  • Hygiene:
    • Home tongue scraping has shown significant effect in reducing bacterial loads on the dorsum of the tongue. Tongue scraping has shown more benefit than tongue brushing alone.
    • The zinc compounds in mouth rinses has shown to inhibit the bacterial breakdown of proteins, and thus reducing the formation of volatile sulphur compounds.
    • Chlorhexidine inhibits a wide spectrum of microbes in the mouth, and has shown to reduce halitosis significantly. Side effects of chlorhexidine can include short-term taste abnormalities and reversible staining of teeth.
    • Chlorhexidine and cetylpyridinium mouthwashes have shown the best results in reducing the amount of volatile sulphur compounds in expelled air and saliva.
    • High fiber foods, such as fruits and vegetables promote gastric emptying and reduce bacteria that can produce volatile sulphur compounds.
    • Green tea has been shown to be associated with lower volatile sulphur compounds. Although its mechanism of action is not fully known.  
  • Patient with halitosis with no oral sources of casue should be evaluate for extra-oral causes, such as GI tract infection or liver malfunction. Referral to their primary care physician or medical specialist is indicated.
  • If no evidence of halitosis is seen, halitophobia should be considered. Patient counseling, through showing examination results can aid in reducing this fear and constant anxiety.
Category: General