Management of Halitosis
The primary treatment of halitosis involves twice-daily tooth brushing (including the gingival sulcus), daily flossing, vigorous rinsing with bland saline solution (1 teaspoon salt, 1 teaspoon baking soda in 4 cups water) several times daily, and routine tongue cleaning, as these address the oral bacterial source responsible for 90% of cases. 1, 2, 3
Identify and Address the Source
Oral Causes (90% of cases)
The vast majority of halitosis originates from volatile sulfur compounds produced by bacterial breakdown of protein in the mouth. 2, 3, 4 The most common specific causes include:
- Tongue coating on the posterior dorsal surface (most common single cause) 2, 5
- Periodontal disease and inadequate plaque control 2, 3, 4
- Poor oral hygiene, food impaction, and faulty restorations 2, 3, 6
- Dry mouth (xerostomia) 2
Systemic Causes (10% of cases)
Consider non-oral sources including hepatic, renal, or pancreatic insufficiency, respiratory tract infections, diabetes, trimethylaminuria, or medication side effects. 2, 6 Physical examination should specifically assess for halitosis, dental malocclusion, tonsillar hypertrophy, and oropharyngeal abnormalities. 7
Primary Treatment Protocol
Essential Daily Oral Hygiene
- Brush teeth twice daily with prescription-strength fluoride toothpaste, ensuring coverage of the gingival portion and periodontal sulcus 1
- Floss at least once daily using waxed floss to minimize gingival trauma 1
- Clean the tongue routinely using a soft toothbrush or tongue scraper on the dorsal surface 8, 5, 4
- Rinse vigorously with bland saline solution (1 teaspoon salt, 1 teaspoon baking soda in 4 cups water) several times daily 1
Mouthwash Considerations
- Avoid alcohol-based or astringent commercial mouthwashes as they dry the mouth 1, 8
- Use alcohol-free mouthwash at least four times daily 8
- For bacterial reduction, hydrogen peroxide mouthwash 1.5% (10 mL twice daily) can be used 1
- Chlorhexidine can be diluted by up to 50% to reduce associated soreness 1
Management of Underlying Conditions
Periodontal Disease
- Perform dental scaling and root planing to reduce bacterial loading in periodontal pockets 3, 4
- Schedule regular dental follow-ups every 6 months minimum 1
- Treat active periodontal disease, caries, and replace faulty restorations 3, 5
Dry Mouth Management
When xerostomia contributes to halitosis:
- Improve hydration and limit caffeine intake 1
- Use saliva substitutes and moisture-preserving mouth rinses 1
- Stimulate saliva with sugarless chewing gum, lozenges, or candy 1
- For severe cases, consider systemic sialagogues (cevimeline or pilocarpine) 1
- Moisturize the mouth with water, artificial saliva products, or water-soluble lubricants 1
Oral Candidiasis (if white tongue present)
If fungal infection is suspected or confirmed:
- First-line treatment: Nystatin oral suspension (100,000 units) four times daily for 1 week, or miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 8
- For resistant cases: Fluconazole 100 mg/day for 7-14 days 8
Critical Pitfalls to Avoid
- Never use glycerin or lemon-glycerin swabs as they dry the mouth 1, 8
- Avoid petroleum-based lip products as they cause drying and cracking; use animal or plant-based oils instead 1, 8
- Do not use club soda for rinsing due to carbonic acid content 1
- Avoid smoking, alcohol, spicy foods, and hot beverages as these are irritants 8