What can halitosis indicate?

Causes of Halitosis (Bad Breath)

Halitosis can indicate various oral and systemic conditions, with approximately 85-90% of cases originating from oral causes and 10-15% from non-oral or systemic causes. 1, 2

Oral Causes (85-90% of cases)

• Poor oral hygiene and tongue coating: The posterior third of the dorsal surface of the tongue is the primary site for bacterial growth that produces volatile sulfur compounds (VSCs), the main cause of bad breath 1, 2
• Periodontal disease: Active gum disease contributes significantly to halitosis through bacterial breakdown of proteins 1
• Dental problems: Deep carious lesions, faulty restorations, and impacted food debris can lead to bacterial overgrowth and malodor 2
• Dry mouth (xerostomia): Reduced salivary flow eliminates the natural cleansing mechanism of the mouth, allowing bacteria to proliferate 3, 2
• Oral infections: Including pericoronitis, peri-implant disease, and mucosal ulcerations 2

Non-Oral/Systemic Causes (10-15% of cases)

• Respiratory tract conditions:

  • Sinusitis: Acute bacterial rhinosinusitis is associated with halitosis due to bacterial infection and postnasal drainage 3, 4
  • Chronic rhinitis: Postnasal drainage from chronic rhinitis can cause persistent bad breath 4
  • Tonsillitis: Can contribute to halitosis and is a common indication for tonsillectomy in children 3

• Gastrointestinal conditions:

  • Certain digestive disorders may contribute to bad breath, though this connection is less common than often believed 5

• Systemic diseases:

  • Renal insufficiency: Kidney disease can cause salivary disorders affecting breath, often producing a distinctive ammonia-like odor 4
  • Hepatic and pancreatic insufficiencies: Liver disease can cause a distinctive breath odor 1
  • Trimethylaminuria: A rare metabolic disorder causing a fishy odor 1

• Lifestyle factors:

  • Alcohol consumption: Moderate to heavy alcohol intake contributes to bad breath 4
  • Tobacco use: Smoking and other tobacco products cause characteristic malodor 2
  • Certain foods: Foods like garlic and onions can cause temporary halitosis as their compounds are absorbed into the bloodstream and released through the lungs 2

Clinical Implications and Evaluation

• Halitosis may serve as a biomarker for underlying systemic diseases, warranting further investigation when oral causes have been ruled out 6

• Assessment methods include:

  • Organoleptic measurement (human sense of smell)
  • Sulfide monitoring
  • Gas chromatography
  • Chemical test strips 5

• When evaluating a patient with halitosis, look for:

  • Signs of periodontal disease
  • Tongue coating (especially posterior third)
  • Dry mouth
  • Nasal discharge or postnasal drip
  • Systemic disease symptoms 1, 5

Management Approach

• For oral causes (majority of cases):

  • Improve oral hygiene with twice-daily brushing and regular flossing 6
  • Implement tongue cleaning, focusing on the posterior third 2
  • Treat active periodontal disease 1
  • Ensure adequate hydration and salivary flow 3
  • Consider antimicrobial mouth rinses for non-responders 6

• For non-oral causes:

  • Refer for appropriate medical evaluation when systemic causes are suspected 7
  • Treat underlying conditions such as sinusitis, rhinitis, or renal disease 3, 4
  • Address lifestyle factors like alcohol consumption and smoking 4

• When halitosis persists despite oral interventions, consider referral for medical evaluation to rule out systemic conditions 5, 6