What are the treatment options for halitosis?

Treatment Options for Halitosis

The most effective treatment for halitosis involves identifying and eliminating the underlying cause, with 90% of cases originating from the oral cavity requiring proper oral hygiene practices, tongue cleaning, and antimicrobial mouthwashes. 1, 2

Causes and Diagnosis

Halitosis (bad breath) primarily stems from:

• Oral causes (90% of cases) 1, 3:

  • Poor oral hygiene
  • Periodontal disease
  • Tongue coating (most common site)
  • Food impaction
  • Unclean dentures
  • Faulty dental restorations
  • Oral carcinomas
  • Throat infections

• Non-oral causes (10% of cases) 4, 3:

  • Ear-nose-throat disorders (10%)
  • Gastrointestinal/endocrine disorders (5%)
  • Systemic conditions (renal/hepatic failure, diabetes)

Treatment Algorithm

Step 1: Oral Hygiene Optimization

• Brushing teeth twice daily using the Bass or modified Bass method with fluoride-containing toothpaste 5
• Tongue cleaning/scraping to remove coating on the dorsal surface 2, 6
• Interdental cleaning with appropriate tools (floss, interdental brushes) once daily 5
• Regular professional dental cleaning (scaling and root planing) to reduce bacterial load 2

Step 2: Antimicrobial Approaches

• Alcohol-free mouthwash used 4 times daily (upon awakening and after brushing) for approximately 1 minute 5, 6
• Chlorhexidine 0.2% for antimicrobial action, particularly effective for denture soaking 5
• Zinc-containing toothpastes which can neutralize volatile sulfur compounds 6

Step 3: Additional Measures

• Adequate hydration to maintain moisture in the oral cavity 5
• Sugar-free chewing gum to stimulate saliva production 6
• Dietary modifications to avoid foods that contribute to halitosis (garlic, onions, spicy foods) 5
• Avoid triggers such as smoking, alcohol, and certain foods (tomatoes, citrus fruits) 5

Step 4: Management of Specific Conditions

• For denture wearers:

  • Remove dentures before oral care
  • Clean dentures thoroughly with toothpaste and water
  • Soak in antimicrobial solution (chlorhexidine 0.2%) for 10 minutes 5

• For dry mouth (xerostomia/sicca syndrome):

  • Systemic sialagogues (cevimeline or pilocarpine) for moderate to severe cases
  • Saliva substitutes
  • Increased fluid intake 5

Special Considerations

• Persistent halitosis despite proper oral hygiene may require investigation for underlying systemic conditions 4
• Halitosis with oral pain/burning sensation may indicate oral dysesthesia requiring additional management with steroids or gabapentin 5
• Psychological halitosis (halitophobia) where patients perceive halitosis without measurable evidence requires different management approaches 1

Common Pitfalls to Avoid

1. Focusing only on mouthwash without addressing the underlying cause (especially periodontal disease or tongue coating)
2. Ignoring tongue cleaning, which is crucial as the tongue dorsum harbors odor-causing bacteria
3. Using alcohol-based mouthwashes which can cause dry mouth and potentially worsen halitosis
4. Overlooking systemic causes in cases of persistent halitosis despite good oral hygiene
5. Neglecting denture hygiene in patients with removable prostheses

By following this structured approach to halitosis management, focusing first on oral hygiene optimization and then addressing specific contributing factors, most cases can be effectively treated and controlled.