Halitosis
Encyclopedia
Halitosis is a term used to describe noticeably unpleasant odors exhaled in breathing. Halitosis is estimated to be the third most frequent reason for seeking dental
aid, following tooth decay and periodontal disease
.
itself. The intensity of bad breath differs during the day, due to eating certain foods (such as garlic
, onion
s, meat
, fish
, and cheese
), obesity
, smoking
, and alcohol consumption
. Since the mouth is exposed to less oxygen and is inactive during the night, the odor is usually worse upon awakening ("morning breath"). Bad breath may be transient, often disappearing following eating, brushing
one's teeth, flossing, or rinsing with specialized mouthwash
.
Bad breath may also be persistent (chronic bad breath), which is a more serious condition, affecting some 25% of the population in varying degrees.
Contrary to the popular legend that Listerine coined the term halitosis, it actually dates from the 1870s, combining the Latin halitus, meaning 'breath', with the Greek suffix osis often used to describe a medical condition, e.g., "cirrhosis of the liver". Bad breath is not, however, a modern affliction. Records mentioning bad breath have been discovered dating to 1550 B.C. A mouthwash of wine and herbs was one recommended way of solving the problem.
. Tongue bacteria produce malodorous compounds and fatty acids, and account for 80 to 90% of all cases of mouth-related bad breath. Large quantities of naturally-occurring bacteria are often found on the posterior dorsum
of the tongue, where they are relatively undisturbed by normal activity. This part of the tongue is relatively dry and poorly cleansed, and bacterial populations can thrive on remnants of food
deposits, dead epithelial cells
, and postnasal drip. The convoluted microbial structure of the tongue dorsum provides an ideal habitat
for anaerobic bacteria, which flourish under a continually-forming tongue coating of food debris, dead cells, postnasal drip and overlying bacteria, living and dead. When left on the tongue, the anaerobic respiration
of such bacteria can yield either the putrescent
smell of indole
, skatole
, polyamine
s, or the "rotten egg" smell of volatile sulfur compounds
(VSCs) such as hydrogen sulfide
, methyl mercaptan, Allyl methyl sulfide
, and dimethyl sulfide
.
is for the control of bad breath. Methods used against bad breath, such as mints, mouth sprays, mouthwash or gum, may only temporarily mask the odors created by the bacteria on the tongue, but cannot cure bad breath because they do not remove the source of the bad breath. In order to prevent the production of the sulfur-containing compounds mentioned above, the bacteria on the tongue must be removed, as must the decaying food debris present on the rear areas of the tongue. Most people who clean their tongue use a tongue cleaner
(tongue scraper), or a toothbrush.
. The odors are produced mainly due to the breakdown of protein
s into individual amino acid
s, followed by the further breakdown of certain amino acids to produce detectable foul gas
es. For example, the breakdown of cysteine
and methionine
produce hydrogen sulfide
and methyl mercaptan, respectively. Volatile sulfur compounds have been shown to be statistically associated with oral malodor levels, and usually decrease following successful treatment.
Other parts of the mouth may also contribute to the overall odor, 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, faulty dental
work, food-impaction areas in between the teeth, abscess
es, and unclean dentures
. Oral based lesions caused by viral infections like Herpes Simplex and HPV may also contribute to bad breath.
s has a pungent odor that differs from the oral odor. Nasal odor may be due to sinus infections or foreign bodies.
from the tonsil
s is considered a minor cause of bad breath, contributing to some 3–5% of cases. Approximately 7% of the population suffer from small bits of calcified
matter in tonsillar crypts called tonsillolith
s that smell extremely foul when released and can cause bad breath.
, which is the valve between the stomach
and the esophagus
, may not close properly due to a Hiatal Hernia or GERD
, allowing acid to enter the esophagus and gases escape to the mouth. A Zenker's diverticulum
may also result in halitosis due to aging food retained in the esophagus.
is considered by most researchers as a very uncommon source of bad breath (except in belching). The esophagus
is a closed and collapsed tube, and continuous flow (as opposed to a simple burp) of gas or putrid substances from the stomach
indicates a health problem—such as reflux serious enough to be bringing up stomach contents or a fistula
between the stomach and the esophagus—which will demonstrate more serious manifestations than just foul odor.
In the case of allyl methyl sulfide
(the byproduct of garlic
's digestion), odor does not come from the stomach, since it does not get metabolized there.
Individuals afflicted by the above conditions often show additional, more diagnostically conclusive symptoms than bad breath.
al halitosis, or as a manifestation of Olfactory Reference Syndrome
. These patients are sure that they have bad breath, although many have not asked anyone for an objective opinion. Halitophobia may severely affect the lives of some 0.5–1.0% of the adult population.
, 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 bad taste
(metallic, sour, fecal, etc.), however bad taste is considered a poor indicator.
For these reasons, the simplest and most effective way to know whether one has bad breath is to ask a trusted adult family member or very close friend ("confidant
"). If the confidant confirms that there is a breath problem, he or she can help determine whether it is coming from the mouth or the nose, and whether a particular treatment is effective or not.
One popular home method to determine the presence of bad breath is to lick
the back of the wrist
, let the saliva
dry for a minute or two, and smell the result. This test results in overestimation, as concluded from research, and should be avoided. 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 of polyamine
s and sulfur compounds on tongue swabs are now available, but there are few studies showing how well they actually detect the odor. Furthermore, since breath odor changes in intensity throughout the day depending on many factors, multiple testing sessions may be necessary.
Although such instrumentation and examinations are widely used in breath clinics, the most important measurement of bad breath (the gold standard) is the actual sniffing
and scoring of the level and type of the odor carried out by trained experts ("organoleptic measurements"). The level of odor is usually assessed on a six-point intensity scale.
s and dentist
s, so effective treatment is not always easy to find. The following strategies may be suggested:
es often contain antibacterial agents including cetylpyridinium chloride
, chlorhexidine (which can cause temporary staining of the teeth), zinc gluconate
, essential oil
s, and chlorine dioxide
. Zinc and chlorhexidine provide strong synergistic effect. They may also contain alcohol
, which is a drying agent.
Other solutions rely on odor eliminators, such as oxidizers
, to eliminate existing bad breath on a short-term basis.
A new approach for home treatment of bad breath is the use of oil-containing mouthwashes and two-phase (oil:water) mouthwashes. Essential oils have been found effective in reducing halitosis, and are being used in several commercial mouthwashes.
leaf is an excellent remedy against bad breath. 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 cause tooth decay and dye one's teeth bright red when chewed. Both areca nut and the betel leaf chewing however are recognised risk factors for squamous cell carcinoma (i.e., oral cancer). Their use is not recommended.
Dentistry
Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...
aid, following tooth decay and periodontal disease
Periodontal disease
Periodontitis is a set of inflammatory diseases affecting the periodontium, i.e., the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth...
.
General
In most cases (85–90%), bad breath originates in the mouthMouth
The mouth is the first portion of the alimentary canal that receives food andsaliva. The oral mucosa is the mucous membrane epithelium lining the inside of the mouth....
itself. The intensity of bad breath differs during the day, due to eating certain foods (such as garlic
Garlic
Allium sativum, commonly known as garlic, is a species in the onion genus, Allium. Its close relatives include the onion, shallot, leek, chive, and rakkyo. Dating back over 6,000 years, garlic is native to central Asia, and has long been a staple in the Mediterranean region, as well as a frequent...
, onion
Onion
The onion , also known as the bulb onion, common onion and garden onion, is the most widely cultivated species of the genus Allium. The genus Allium also contains a number of other species variously referred to as onions and cultivated for food, such as the Japanese bunching onion The onion...
s, meat
Meat
Meat is animal flesh that is used as food. Most often, this means the skeletal muscle and associated fat and other tissues, but it may also describe other edible tissues such as organs and offal...
, fish
Fish
Fish are a paraphyletic group of organisms that consist of all gill-bearing aquatic vertebrate animals that lack limbs with digits. Included in this definition are the living hagfish, lampreys, and cartilaginous and bony fish, as well as various extinct related groups...
, and cheese
Cheese
Cheese is a generic term for a diverse group of milk-based food products. Cheese is produced throughout the world in wide-ranging flavors, textures, and forms....
), obesity
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
, smoking
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
, and alcohol consumption
Alcohol consumption and health
The long term effects of alcohol range from possible health benefits for low levels of alcohol consumption to severe detrimental effects in cases of chronic alcohol abuse...
. Since the mouth is exposed to less oxygen and is inactive during the night, the odor is usually worse upon awakening ("morning breath"). Bad breath may be transient, often disappearing following eating, brushing
Tooth brushing
Tooth brushing is the act of cleaning teeth with a toothbrush.Modern medical research has shown that brushing teeth properly can prevent cavities, and periodontal, or gum disease, which causes at least one-third of adult tooth loss. If teeth are not brushed correctly and frequently, it could lead...
one's teeth, flossing, or rinsing with specialized mouthwash
Mouthwash
Mouthwash or mouth rinse is a product used to enhance oral hygiene. Some manufacturers of mouthwash claim that antiseptic and anti-plaque mouth rinse kill the bacterial plaque causing cavities, gingivitis, and bad breath. Anti-cavity mouth rinse uses fluoride to protect against tooth decay...
.
Bad breath may also be persistent (chronic bad breath), which is a more serious condition, affecting some 25% of the population in varying degrees.
Contrary to the popular legend that Listerine coined the term halitosis, it actually dates from the 1870s, combining the Latin halitus, meaning 'breath', with the Greek suffix osis often used to describe a medical condition, e.g., "cirrhosis of the liver". Bad breath is not, however, a modern affliction. Records mentioning bad breath have been discovered dating to 1550 B.C. A mouthwash of wine and herbs was one recommended way of solving the problem.
Tongue
The most common location for mouth-related halitosis is the tongueTongue
The tongue is a muscular hydrostat on the floors of the mouths of most vertebrates which manipulates food for mastication. It is the primary organ of taste , as much of the upper surface of the tongue is covered in papillae and taste buds. It is sensitive and kept moist by saliva, and is richly...
. Tongue bacteria produce malodorous compounds and fatty acids, and account for 80 to 90% of all cases of mouth-related bad breath. Large quantities of naturally-occurring bacteria are often found on the posterior dorsum
Dorsum (biology)
In anatomy, the dorsum is the upper side of animals that typically run, fly, or swim in a horizontal position, and the back side of animals that walk upright. In vertebrates the dorsum contains the backbone. The term dorsal refers to anatomical structures that are either situated toward or grow...
of the tongue, where they are relatively undisturbed by normal activity. This part of the tongue is relatively dry and poorly cleansed, and bacterial populations can thrive on remnants of food
Food
Food is any substance consumed to provide nutritional support for the body. It is usually of plant or animal origin, and contains essential nutrients, such as carbohydrates, fats, proteins, vitamins, or minerals...
deposits, dead epithelial cells
Epithelium
Epithelium is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. Epithelial tissues line the cavities and surfaces of structures throughout the body, and also form many glands. Functions of epithelial cells include secretion, selective...
, and postnasal drip. The convoluted microbial structure of the tongue dorsum provides an ideal habitat
Habitat
* Habitat , a place where a species lives and grows*Human habitat, a place where humans live, work or play** Space habitat, a space station intended as a permanent settlement...
for anaerobic bacteria, which flourish under a continually-forming tongue coating of food debris, dead cells, postnasal drip and overlying bacteria, living and dead. When left on the tongue, the anaerobic respiration
Anaerobic respiration
Anaerobic respiration is a form of respiration using electron acceptors other than oxygen. Although oxygen is not used as the final electron acceptor, the process still uses a respiratory electron transport chain; it is respiration without oxygen...
of such bacteria can yield either the putrescent
Putrefaction
Putrefaction is one of seven stages in the decomposition of the body of a dead animal. It can be viewed, in broad terms, as the decomposition of proteins, in a process that results in the eventual breakdown of cohesion between tissues and the liquefaction of most organs.-Description:In terms of...
smell of indole
Indole
Indole is an aromatic heterocyclic organic compound. It has a bicyclic structure, consisting of a six-membered benzene ring fused to a five-membered nitrogen-containing pyrrole ring. Indole is a popular component of fragrances and the precursor to many pharmaceuticals. Compounds that contain an...
, skatole
Skatole
Skatole or 3-methylindole is a mildly toxic white crystalline organic compound belonging to the indole family. It occurs naturally in feces and coal tar, and has a strong fecal odor...
, polyamine
Polyamine
A polyamine is an organic compound having two or more primary amino groups .This class of compounds includes several synthetic substances that are important feedstocks for the chemical industry, such as ethylene diamine , 1,3-diaminopropane , and hexamethylenediamine...
s, or the "rotten egg" smell of volatile sulfur compounds
Organosulfur compounds
Organosulfur compounds are organic compounds that contain sulfur. They are often associated with foul odours, but many of the sweetest compounds known are organosulfur derivatives. Nature abounds with organosulfur compounds—sulfur is essential for life. Two of the 20 common amino acids are...
(VSCs) such as hydrogen sulfide
Hydrogen sulfide
Hydrogen sulfide is the chemical compound with the formula . It is a colorless, very poisonous, flammable gas with the characteristic foul odor of expired eggs perceptible at concentrations as low as 0.00047 parts per million...
, methyl mercaptan, Allyl methyl sulfide
Allyl methyl sulfide
Allyl methyl sulfide is an organosulfur compound with the chemical formula CH2CHCH2SCH3. The molecule features two functional groups, an allyl and a sulfide. It is a colourless liquid with a strong odor characteristic of alkyl sulfides. It is a metabolite of garlic, and "garlic breath" is...
, and dimethyl sulfide
Dimethyl sulfide
Dimethyl sulfide or methylthiomethane is an organosulfur compound with the formula 2S. Dimethyl sulfide is a water-insoluble flammable liquid that boils at and has a characteristic disagreeable odor. It is a component of the smell produced from cooking of certain vegetables, notably maize,...
.
Cleaning the tongue
The most widely-known reason to clean the tongueTongue cleaner
A tongue cleaner is an oral hygiene device designed to clean the bacterial build-up, food debris, fungi, and dead cells from the surface of the tongue. The bacteria and fungi that grow on the tongue are related to many common oral care and general health problems...
is for the control of bad breath. Methods used against bad breath, such as mints, mouth sprays, mouthwash or gum, may only temporarily mask the odors created by the bacteria on the tongue, but cannot cure bad breath because they do not remove the source of the bad breath. In order to prevent the production of the sulfur-containing compounds mentioned above, the bacteria on the tongue must be removed, as must the decaying food debris present on the rear areas of the tongue. Most people who clean their tongue use a tongue cleaner
Tongue cleaner
A tongue cleaner is an oral hygiene device designed to clean the bacterial build-up, food debris, fungi, and dead cells from the surface of the tongue. The bacteria and fungi that grow on the tongue are related to many common oral care and general health problems...
(tongue scraper), or a toothbrush.
Mouth
There are over 600 types of bacteria found in the average mouth. Several dozen of these can produce high levels of foul odors when incubated in the laboratoryLaboratory
A laboratory is a facility that provides controlled conditions in which scientific research, experiments, and measurement may be performed. The title of laboratory is also used for certain other facilities where the processes or equipment used are similar to those in scientific laboratories...
. The odors are produced mainly due to the breakdown of protein
Protein
Proteins are biochemical compounds consisting of one or more polypeptides typically folded into a globular or fibrous form, facilitating a biological function. A polypeptide is a single linear polymer chain of amino acids bonded together by peptide bonds between the carboxyl and amino groups of...
s into individual amino acid
Amino acid
Amino acids are molecules containing an amine group, a carboxylic acid group and a side-chain that varies between different amino acids. The key elements of an amino acid are carbon, hydrogen, oxygen, and nitrogen...
s, followed by the further breakdown of certain amino acids to produce detectable foul gas
Gas
Gas is one of the three classical states of matter . Near absolute zero, a substance exists as a solid. As heat is added to this substance it melts into a liquid at its melting point , boils into a gas at its boiling point, and if heated high enough would enter a plasma state in which the electrons...
es. For example, the breakdown of cysteine
Cysteine
Cysteine is an α-amino acid with the chemical formula HO2CCHCH2SH. It is a non-essential amino acid, which means that it is biosynthesized in humans. Its codons are UGU and UGC. The side chain on cysteine is thiol, which is polar and thus cysteine is usually classified as a hydrophilic amino acid...
and methionine
Methionine
Methionine is an α-amino acid with the chemical formula HO2CCHCH2CH2SCH3. This essential amino acid is classified as nonpolar. This amino-acid is coded by the codon AUG, also known as the initiation codon, since it indicates mRNA's coding region where translation into protein...
produce hydrogen sulfide
Hydrogen sulfide
Hydrogen sulfide is the chemical compound with the formula . It is a colorless, very poisonous, flammable gas with the characteristic foul odor of expired eggs perceptible at concentrations as low as 0.00047 parts per million...
and methyl mercaptan, respectively. Volatile sulfur compounds have been shown to be statistically associated with oral malodor levels, and usually decrease following successful treatment.
Other parts of the mouth may also contribute to the overall odor, 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, faulty dental
Dentistry
Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...
work, food-impaction areas in between the teeth, abscess
Abscess
An abscess is a collection of pus that has accumulated in a cavity formed by the tissue in which the pus resides due to an infectious process or other foreign materials...
es, and unclean dentures
Dentures
Dentures are prosthetic devices constructed to replace missing teeth, and which are supported by surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable, however there are many different denture designs, some which rely on bonding or clasping onto teeth or dental...
. Oral based lesions caused by viral infections like Herpes Simplex and HPV may also contribute to bad breath.
Gum disease
There is some controversy over the role of periodontal diseases in causing bad breath. However, advanced periodontal disease is a common cause of severe halitosis. Waste products from the anaerobic bacteria growing below the gumline (subgingival) have a foul smell and have been clinically demonstrated to produce a very intense bad breath. Removal of the subgingival calculus (i.e. tartar or hard plaque) and friable tissue has been shown to improve mouth odor considerably. This is accomplished by subgingival scaling and root planing and irrigation with an antibiotic mouth rinse.Nose
The second major source of bad breath is the nose. In this occurrence, the air exiting the nostrilNostril
A nostril is one of the two channels of the nose, from the point where they bifurcate to the external opening. In birds and mammals, they contain branched bones or cartilages called turbinates, whose function is to warm air on inhalation and remove moisture on exhalation...
s has a pungent odor that differs from the oral odor. Nasal odor may be due to sinus infections or foreign bodies.
Tonsils
In general, putrefactionPutrefaction
Putrefaction is one of seven stages in the decomposition of the body of a dead animal. It can be viewed, in broad terms, as the decomposition of proteins, in a process that results in the eventual breakdown of cohesion between tissues and the liquefaction of most organs.-Description:In terms of...
from the tonsil
Tonsil
Palatine tonsils, occasionally called the faucial tonsils, are the tonsils that can be seen on the left and right sides at the back of the throat....
s is considered a minor cause of bad breath, contributing to some 3–5% of cases. Approximately 7% of the population suffer from small bits of calcified
Calcium
Calcium is the chemical element with the symbol Ca and atomic number 20. It has an atomic mass of 40.078 amu. Calcium is a soft gray alkaline earth metal, and is the fifth-most-abundant element by mass in the Earth's crust...
matter in tonsillar crypts called tonsillolith
Tonsillolith
Tonsilloliths, also known as a tonsil stones, are clusters of calcified material that form in the crevices of the tonsils. While they occur most commonly in the palatine tonsils, they may also occur in the lingual tonsils. Tonsilloliths have been recorded weighing from 300 mg to 42 g...
s that smell extremely foul when released and can cause bad breath.
Esophagus
The CardiaCardia
The cardia is the anatomical term for the part of the stomach attached to the esophagus. The cardia begins immediately distal to the z-line of the gastroesophageal junction, where the squamous epithelium of the esophagus gives way to the columnar epithelium of the gastrointestinal tract.Just...
, which is the valve between the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
and the esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
, may not close properly due to a Hiatal Hernia or GERD
Gerd
In Norse mythology, Gerðr is a jötunn, goddess, and the wife of the god Freyr. Gerðr is attested in the Poetic Edda, compiled in the 13th century from earlier traditional sources; the Prose Edda and Heimskringla, written in the 13th century by Snorri Sturluson; and in the poetry of skalds...
, allowing acid to enter the esophagus and gases escape to the mouth. A Zenker's diverticulum
Zenker's diverticulum
In anatomy, Zenker's diverticulum, also pharyngoesophageal diverticulum, also pharyngeal pouch, is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle...
may also result in halitosis due to aging food retained in the esophagus.
Stomach
The stomachStomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
is considered by most researchers as a very uncommon source of bad breath (except in belching). The esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
is a closed and collapsed tube, and continuous flow (as opposed to a simple burp) of gas or putrid substances from the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
indicates a health problem—such as reflux serious enough to be bringing up stomach contents or a fistula
Fistula
In medicine, a fistula is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. It is generally a disease condition, but a fistula may be surgically created for therapeutic reasons.-Locations:Fistulas can develop in various parts of the...
between the stomach and the esophagus—which will demonstrate more serious manifestations than just foul odor.
In the case of allyl methyl sulfide
Allyl methyl sulfide
Allyl methyl sulfide is an organosulfur compound with the chemical formula CH2CHCH2SCH3. The molecule features two functional groups, an allyl and a sulfide. It is a colourless liquid with a strong odor characteristic of alkyl sulfides. It is a metabolite of garlic, and "garlic breath" is...
(the byproduct of garlic
Garlic
Allium sativum, commonly known as garlic, is a species in the onion genus, Allium. Its close relatives include the onion, shallot, leek, chive, and rakkyo. Dating back over 6,000 years, garlic is native to central Asia, and has long been a staple in the Mediterranean region, as well as a frequent...
's digestion), odor does not come from the stomach, since it does not get metabolized there.
Systemic diseases
There are a few systemic (non-oral) medical conditions that may cause foul breath odor, but these are extremely infrequent in the general population. Such conditions are:- Fetor hepaticusFetor hepaticusFetor hepaticus or foetor hepaticus , also known as breath of the dead, is a condition seen in portal hypertension where portosystemic shunting allows mercaptans to pass directly into the lungs. It is a late sign in liver failure. Other possible causes are the presence of ammonia and ketones in the...
: an example of a rare type of bad breath caused by chronic liver failureLiver failureAcute liver failure is the appearance of severe complications rapidly after the first signs of liver disease , and indicates that the liver has sustained severe damage . The complications are hepatic encephalopathy and impaired protein synthesis...
. - Lower respiratory tract infectionLower respiratory tract infectionLower respiratory tract infection while often used as a synonym for pneumonia, can also be applied to other types of infection including lung abscess and acute bronchitis...
s (bronchial and lung infections). - Renal infectionsNephritisNephritis is inflammation of the nephrons in the kidneys. The word "nephritis" was imported from Latin, which took it from Greek: νεφρίτιδα. The word comes from the Greek νεφρός - nephro- meaning "of the kidney" and -itis meaning "inflammation"....
and renal failureRenal failureRenal failure or kidney failure describes a medical condition in which the kidneys fail to adequately filter toxins and waste products from the blood...
. - CarcinomaCarcinomaCarcinoma is the medical term for the most common type of cancer occurring in humans. Put simply, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that generally arises from cells originating in the endodermal or ectodermal germ layer during...
. - TrimethylaminuriaTrimethylaminuriaTrimethylaminuria , also known as fish odor syndrome or fish malodor syndrome, is a rare metabolic disorder that causes a defect in the normal production of the enzyme Flavin containing monooxygenase 3...
("fish odor syndrome"). - Diabetes mellitusDiabetes mellitusDiabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
. - MetabolicMetabolismMetabolism is the set of chemical reactions that happen in the cells of living organisms to sustain life. These processes allow organisms to grow and reproduce, maintain their structures, and respond to their environments. Metabolism is usually divided into two categories...
dysfunction.
Individuals afflicted by the above conditions often show additional, more diagnostically conclusive symptoms than bad breath.
Halitophobia (delusion halitosis)
Some one quarter of the patients seeking professional advice on bad breath suffer from a highly exaggerated concern of having bad breath, known as halitophobia, delusionDelusion
A delusion is a false belief held with absolute conviction despite superior evidence. Unlike hallucinations, delusions are always pathological...
al halitosis, or as a manifestation of Olfactory Reference Syndrome
Olfactory Reference Syndrome
Olfactory Reference Syndrome is a psychiatric condition in which the affected person is excessively preoccupied by the concern that one's body odor is foul or unpleasant. This disorder is often accompanied by shame, embarrassment, significant distress, avoidance behavior, social phobia and social...
. These patients are sure that they have bad breath, although many have not asked anyone for an objective opinion. Halitophobia may severely affect the lives of some 0.5–1.0% of the adult population.
Self diagnosis
Scientists have long thought that smelling one's own breath odor is often difficult due to acclimatizationAcclimatization
Acclimatisation or acclimation is the process of an individual organism adjusting to a gradual change in its environment, allowing it to maintain performance across a range of environmental conditions...
, 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 bad taste
Taste
Taste is one of the traditional five senses. It refers to the ability to detect the flavor of substances such as food, certain minerals, and poisons, etc....
(metallic, sour, fecal, etc.), however bad taste is considered a poor indicator.
For these reasons, the simplest and most effective way to know whether one has bad breath is to ask a trusted adult family member or very close friend ("confidant
Confidant
The confidant is a character in a story that the lead character confides in and trusts. Typically, these consist of the best friend, relative, doctor or boss.- Role :...
"). If the confidant confirms that there is a breath problem, he or she can help determine whether it is coming from the mouth or the nose, and whether a particular treatment is effective or not.
One popular home method to determine the presence of bad breath is to lick
Licking
Licking is the action of passing the tongue over a surface, typically either to deposit saliva onto the surface, or to collect liquid onto the tongue for ingestion, or to provide pleasure. Many animals both groom themselves and drink by licking....
the back of the wrist
Wrist
In human anatomy, the wrist is variously defined as 1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand;...
, let the saliva
Saliva
Saliva , referred to in various contexts as spit, spittle, drivel, drool, or slobber, is the watery substance produced in the mouths of humans and most other animals. Saliva is a component of oral fluid. In mammals, saliva is produced in and secreted from the three pairs of major salivary glands,...
dry for a minute or two, and smell the result. This test results in overestimation, as concluded from research, and should be avoided. 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 of polyamine
Polyamine
A polyamine is an organic compound having two or more primary amino groups .This class of compounds includes several synthetic substances that are important feedstocks for the chemical industry, such as ethylene diamine , 1,3-diaminopropane , and hexamethylenediamine...
s and sulfur compounds on tongue swabs are now available, but there are few studies showing how well they actually detect the odor. Furthermore, since breath odor changes in intensity throughout the day depending on many factors, multiple testing sessions may be necessary.
Professional diagnosis
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. They often use some of several laboratory methods for diagnosis of bad breath:- HalimeterHalimeterA Halimeter is an instrument for measurement of the level of volatile sulfur compounds in the mouth.Halimeter was introduced in the early 1990s as an adjunct method for determining halitosis levels, alongside human assessment of odor levels...
: a portable sulfide monitor used to test for levels of sulfur emissions (to be specific, hydrogen sulfideHydrogen sulfideHydrogen sulfide is the chemical compound with the formula . It is a colorless, very poisonous, flammable gas with the characteristic foul odor of expired eggs perceptible at concentrations as low as 0.00047 parts per million...
) 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 as mercaptan) 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. - Gas chromatography: portable machines, such as the OralChroma, are currently being introduced. This technology is specifically designed to digitally measure molecular levels of the three major VSCs in a sample of mouth air (hydrogen sulfideHydrogen sulfideHydrogen sulfide is the chemical compound with the formula . It is a colorless, very poisonous, flammable gas with the characteristic foul odor of expired eggs perceptible at concentrations as low as 0.00047 parts per million...
, methyl mercaptan, and dimethyl sulfideDimethyl sulfideDimethyl sulfide or methylthiomethane is an organosulfur compound with the formula 2S. Dimethyl sulfide is a water-insoluble flammable liquid that boils at and has a characteristic disagreeable odor. It is a component of the smell produced from cooking of certain vegetables, notably maize,...
). 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 an enzymeEnzymeEnzymes are proteins that catalyze chemical reactions. In enzymatic reactions, the molecules at the beginning of the process, called substrates, are converted into different molecules, called products. Almost all chemical reactions in a biological cell need enzymes in order to occur at rates...
indicating the presence of certain halitosis-related bacteria. - β-galactosidaseBeta-galactosidaseβ-galactosidase, also called beta-gal or β-gal, is a hydrolase enzyme that catalyzes the hydrolysis of β-galactosides into monosaccharides. Substrates of different β-galactosidases include ganglioside GM1, lactosylceramides, lactose, and various glycoproteins...
test: salivary levels of this enzyme were found to be correlated with oral malodor.
Although such instrumentation and examinations are widely used in breath clinics, the most important measurement of bad breath (the gold standard) is the actual sniffing
Inhalation
Inhalation is the movement of air from the external environment, through the air ways, and into the alveoli....
and scoring of the level and type of the odor carried out by trained experts ("organoleptic measurements"). The level of odor is usually assessed on a six-point intensity scale.
Management
Chronic halitosis is not well understood by most physicianPhysician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
s and dentist
Dentist
A dentist, also known as a 'dental surgeon', is a doctor that specializes in the diagnosis, prevention, and treatment of diseases and conditions of the oral cavity. The dentist's supporting team aides in providing oral health services...
s, so effective treatment is not always easy to find. The following strategies may be suggested:
- Gently cleaning the tongue surfaceTongue cleanerA tongue cleaner is an oral hygiene device designed to clean the bacterial build-up, food debris, fungi, and dead cells from the surface of the tongue. The bacteria and fungi that grow on the tongue are related to many common oral care and general health problems...
twice daily is the most effective way to keep bad breath in control; that can be achieved using a tooth brush, tongue cleanerTongue cleanerA tongue cleaner is an oral hygiene device designed to clean the bacterial build-up, food debris, fungi, and dead cells from the surface of the tongue. The bacteria and fungi that grow on the tongue are related to many common oral care and general health problems...
or tongue brush/scraperTongue cleanerA tongue cleaner is an oral hygiene device designed to clean the bacterial build-up, food debris, fungi, and dead cells from the surface of the tongue. The bacteria and fungi that grow on the tongue are related to many common oral care and general health problems...
to wipe off the bacterial biofilmBiofilmA biofilm is an aggregate of microorganisms in which cells adhere to each other on a surface. These adherent cells are frequently embedded within a self-produced matrix of extracellular polymeric substance...
, debris, and mucus. An inverted teaspoonTeaspoonA teaspoon, an item of cutlery, is a small spoon, commonly part of a silverware place setting, suitable for stirring and sipping the contents of a cup of tea or coffee...
may also do the job. Scraping or otherwise damaging the tongue should be avoided, and scraping of the V-shaped row of taste budTaste budTaste buds contain the receptors for taste. They are located around the small structures on the upper surface of the tongue, soft palate, upper esophagus and epiglottis, which are called papillae. These structures are involved in detecting the five elements of taste perception: salty, sour,...
s found at the extreme back of the tongue should also be avoided. Brushing a small amount of antibacterial mouth rinse or tongue gel onto the tongue surface will further inhibit bacterial action. - Eating a healthy breakfast with rough foods helps clean the very back of the tongue.
- Chewing gumChewing gumChewing gum is a type of gum traditionally made of chicle, a natural latex product, or synthetic rubber known as polyisobutylene. For economical and quality reasons, many modern chewing gums use rubber instead of chicle...
: Since dry-mouth can increase bacterial buildup and cause or worsen bad breath, chewing sugarless gum can help with the production of salivaSalivaSaliva , referred to in various contexts as spit, spittle, drivel, drool, or slobber, is the watery substance produced in the mouths of humans and most other animals. Saliva is a component of oral fluid. In mammals, saliva is produced in and secreted from the three pairs of major salivary glands,...
, and thereby help to reduce bad breath. Chewing may help particularly when the mouth is dry, or when one cannot perform oral hygieneOral hygieneTeeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
procedures after meals (especially those meals rich in proteinProteinProteins are biochemical compounds consisting of one or more polypeptides typically folded into a globular or fibrous form, facilitating a biological function. A polypeptide is a single linear polymer chain of amino acids bonded together by peptide bonds between the carboxyl and amino groups of...
). This aids in provision of saliva, which washes away oral bacteria, has antibacterial properties and promotes mechanical activity which helps cleanse the mouth. Some chewing gums contain special anti-odor ingredients. Chewing on fennelFennelFennel is a plant species in the genus Foeniculum . It is a member of the family Apiaceae . It is a hardy, perennial, umbelliferous herb, with yellow flowers and feathery leaves...
seeds, cinnamonCinnamonCinnamon is a spice obtained from the inner bark of several trees from the genus Cinnamomum that is used in both sweet and savoury foods...
sticks, masticMastic (plant resin)Mastic is a resin obtained from the mastic tree . In pharmacies and Nature shops it is called "arabic gum" and "Yemen gum". In Greece it is known as the "tears of Chios," being traditionally produced on that Greek island, and, like other natural resins is produced in "tears" or droplets...
gum, or fresh parsleyParsleyParsley is a species of Petroselinum in the family Apiaceae, native to the central Mediterranean region , naturalized elsewhere in Europe, and widely cultivated as an herb, a spice and a vegetable.- Description :Garden parsley is a bright green hairless biennial herbaceous plant in temperate...
are common folk remedies. - GarglingGarglingGargling is the act in which one bubbles a liquid in one's mouth. It usually requires that the head be tilted back, allowing a mouthful of liquid to sit in the upper throat. The head can be tilted by extending either the neck or the back, depending on what is comfortable for the gargler...
right before bedtime with an effective mouthwash (see below). Several types of commercial mouthwashes have been shown to reduce malodor for hours in peer-reviewed scientific studies. Mouthwashes may contain active ingredients that are inactivated by the soapSoapIn chemistry, soap is a salt of a fatty acid.IUPAC. "" Compendium of Chemical Terminology, 2nd ed. . Compiled by A. D. McNaught and A. Wilkinson. Blackwell Scientific Publications, Oxford . XML on-line corrected version: created by M. Nic, J. Jirat, B. Kosata; updates compiled by A. Jenkins. ISBN...
present in most toothpasteToothpasteToothpaste is a paste or gel dentifrice used with a toothbrush as an accessory to clean and maintain the aesthetics and health of teeth. Toothpaste is used to promote oral hygiene: it serves as an abrasive that aids in removing the dental plaque and food from the teeth, assists in suppressing...
s. Thus it is recommended to refrain from using mouthwash directly after toothbrushing with paste (also see mouthwashes, below). - Maintaining proper oral hygieneOral hygieneTeeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
, including daily tongue cleaningTongue cleanerA tongue cleaner is an oral hygiene device designed to clean the bacterial build-up, food debris, fungi, and dead cells from the surface of the tongue. The bacteria and fungi that grow on the tongue are related to many common oral care and general health problems...
, brushingTooth brushingTooth brushing is the act of cleaning teeth with a toothbrush.Modern medical research has shown that brushing teeth properly can prevent cavities, and periodontal, or gum disease, which causes at least one-third of adult tooth loss. If teeth are not brushed correctly and frequently, it could lead...
, flossing, and periodic visits to dentistDentistA dentist, also known as a 'dental surgeon', is a doctor that specializes in the diagnosis, prevention, and treatment of diseases and conditions of the oral cavity. The dentist's supporting team aides in providing oral health services...
s and hygienists. Flossing is particularly important in removing rotting food debris and bacterial plaque from between the teeth, especially at the gumline. DenturesDenturesDentures are prosthetic devices constructed to replace missing teeth, and which are supported by surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable, however there are many different denture designs, some which rely on bonding or clasping onto teeth or dental...
should be properly cleaned and soaked overnight in antibacterial solution (unless otherwise advised by your dentist). - ProbioticProbioticProbiotics are live microorganisms thought to be beneficial to the host organism. According to the currently adopted definition by FAO/WHO, probiotics are: "Live microorganisms which when administered in adequate amounts confer a health benefit on the host"...
treatments, specifically Streptococcus salivarius K12 has been shown suppress malodor bacteria growth .
Mouthwashes
There has not been a single documented medical case of successfully cured chronic halitosis using any of the currently available mouthwashes. However a 2008 systematic review determined the efficacy of antibacterial mouthrinses for treating bad breath. MouthwashMouthwash
Mouthwash or mouth rinse is a product used to enhance oral hygiene. Some manufacturers of mouthwash claim that antiseptic and anti-plaque mouth rinse kill the bacterial plaque causing cavities, gingivitis, and bad breath. Anti-cavity mouth rinse uses fluoride to protect against tooth decay...
es often contain antibacterial agents including cetylpyridinium chloride
Cetylpyridinium chloride
Cetylpyridinium chloride is a cationic quaternary ammonium compound in some types of mouthwashes, toothpastes, lozenges, throat sprays, breath sprays, and nasal sprays. It is an antiseptic that kills bacteria and other microorganisms. It has been shown to be effective in preventing dental plaque...
, chlorhexidine (which can cause temporary staining of the teeth), zinc gluconate
Zinc gluconate
Zinc gluconate is the zinc salt of gluconic acid. It is an ionic compound consisting of two moles of gluconate for each mole of zinc...
, essential oil
Essential oil
An essential oil is a concentrated hydrophobic liquid containing volatile aroma compounds from plants. Essential oils are also known as volatile oils, ethereal oils or aetherolea, or simply as the "oil of" the plant from which they were extracted, such as oil of clove...
s, and chlorine dioxide
Chlorine dioxide
Chlorine dioxide is a chemical compound with the formula ClO2. This yellowish-green gas crystallizes as bright orange crystals at −59 °C. As one of several oxides of chlorine, it is a potent and useful oxidizing agent used in water treatment and in bleaching....
. Zinc and chlorhexidine provide strong synergistic effect. They may also contain alcohol
Alcohol
In chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....
, which is a drying agent.
Other solutions rely on odor eliminators, such as oxidizers
Oxidizing agent
An oxidizing agent can be defined as a substance that removes electrons from another reactant in a redox chemical reaction...
, to eliminate existing bad breath on a short-term basis.
A new approach for home treatment of bad breath is the use of oil-containing mouthwashes and two-phase (oil:water) mouthwashes. Essential oils have been found effective in reducing halitosis, and are being used in several commercial mouthwashes.
Traditional remedies
According to traditional Ayurvedic medicine, chewing areca nut and betelBetel
The Betel is the leaf of a vine belonging to the Piperaceae family, which includes pepper and Kava. It is valued both as a mild stimulant and for its medicinal properties...
leaf is an excellent remedy against bad breath. 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 cause tooth decay and dye one's teeth bright red when chewed. Both areca nut and the betel leaf chewing however are recognised risk factors for squamous cell carcinoma (i.e., oral cancer). Their use is not recommended.
Research
In 1996, the International Society for Breath Odor Research (ISBOR) was formed to promote multidisciplinary research on all aspects of breath odors. The eighth international conference on breath odor took place in 2009 in Dortmund, Germany.See also
- Periodontitis
- Dental cariesDental cariesDental caries, also known as tooth decay or a cavity, is an irreversible infection usually bacterial in origin that causes demineralization of the hard tissues and destruction of the organic matter of the tooth, usually by production of acid by hydrolysis of the food debris accumulated on the...
- Tooth abscessTooth abscessA tooth abscess or root abscess is pus enclosed in the tissues of the jaw bone at the apex of an infected tooth's root. Usually the abscess originates from a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth. This can be caused by untreated tooth decay, cracked...
- Postnasal drip
- Oral hygieneOral hygieneTeeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
- ToothbrushToothbrushThe toothbrush is an oral hygiene instrument used to clean the teeth and gums that consists of a head of tightly clustered bristles mounted on a handle, which facilitates the cleansing of hard-to-reach areas of the mouth. Toothpaste, which often contains fluoride, is commonly used in conjunction...
- Tongue cleaner (scraper)Tongue cleanerA tongue cleaner is an oral hygiene device designed to clean the bacterial build-up, food debris, fungi, and dead cells from the surface of the tongue. The bacteria and fungi that grow on the tongue are related to many common oral care and general health problems...
- MouthwashMouthwashMouthwash or mouth rinse is a product used to enhance oral hygiene. Some manufacturers of mouthwash claim that antiseptic and anti-plaque mouth rinse kill the bacterial plaque causing cavities, gingivitis, and bad breath. Anti-cavity mouth rinse uses fluoride to protect against tooth decay...
- ToothpasteToothpasteToothpaste is a paste or gel dentifrice used with a toothbrush as an accessory to clean and maintain the aesthetics and health of teeth. Toothpaste is used to promote oral hygiene: it serves as an abrasive that aids in removing the dental plaque and food from the teeth, assists in suppressing...
- TrimethylaminuriaTrimethylaminuriaTrimethylaminuria , also known as fish odor syndrome or fish malodor syndrome, is a rare metabolic disorder that causes a defect in the normal production of the enzyme Flavin containing monooxygenase 3...