How can I treat halitosis?
This question was submitted by a general dentist: how can I treat halitosis?
Dr. Eric Stoopler, University of Pennsylvania, in collaboration with Dr. Suham Alexander, Oasis Clinical Editor, provided this quick initial response
Halitosis is fairly common in the general population with an estimated prevalence of ~25%. It affects men and women in similar proportions; although, women are more likely to seek treatment for it more quickly as the condition can cause social embarrassment.
There is a lack of scientific evidence in the area of halitosis given there is a subjective nature to the condition. Differences exist in cultural as well as racial appreciation of the odours for both patients as well as researchers. Additionally, there is no uniform method of evaluation for organoleptic and mechanical measurements.
To date the most widely accepted measurement is organoleptic scoring which involves smelling the breath/odour of the patient. Objective measurements include: analysis of breath samples by gas chromatography, or portable VSC analyzers such as The Halimeter (Interscan Corp.) or OralChroma (Abimedical Corp.).
In approximately 85% of all cases of halitosis, the origin of the malodour is the oral cavity. Microbial degradation of predominantly Gram-negative anaerobic bacteria and the release of volatile sulphur compounds (VSC) (eg. hydrogen sulphide, methyl mercaptan and dimethyl sulphide) account for the unpleasant odour. Diamines (indole, skatole) or polyamines (putrescin, cadverin) are less significant molecules contributing to the condition.
- Oral Pathology and Conditions
- Dorsum of the tongue with its irregular surface collects desquamated epithelial cells and food remnants form a coating which is difficult to remove and results in degradation and malodour
- Reduced salivary flow and production at night leads to increased malodour also, but will disappear once oral hygiene resumes upon waking
- Poor oral hygiene, dental plaque/caries and accumulation of food debris in uncleaned acrylic dentures
- Gingivitis and periodontitis (positive correlation between pocket depth and the concentration of VSCs)
- Xerostomia often leads to an increased amount of plaque and tongue coating in afflicted patients
- Stomatitis, intra-oral neoplasia, extraction wounds, crowded teeth, pericoronitis/implantitis, recurrent oral ulcerations and herpetic gingivitis
- ENT & Pulmonary Pathology
- Contributes to 10% of cases of halitosis
- Acute tonsillitis is the major contributing factor as anaerobic bacteria are detectable in tonsilloliths
- Post-nasal drip, foreign bodies in the nasal cavity as well as atrophic rhinitis
- Bacterial sinusitis
- Bronchiectasis, lung abscesses and endobronchial chronic disorders
- Gastrointestinal Pathology
- Zenker’s diverticulum
- Stomach infections with H. pylori may be a contributing cause, but no strong correlation currently exists
- Intestinal obstruction
- Metabolic disorders
- Diabetes mellitus and ketoacidosis leads to the production of a sweet smelling odour
- Trimethylaminuria leads to a fishy odour
- Renal failure, cirrhosis of the liver
- Hepathology & Endocrinology
- Reduced liver function can cause a sweet, excremental odour
- Tyrosinemy, a hereditary disease, causes production of a cabbage-like odour
- Medications which lead to dry mouth
- Bisphosphonates can contribute to malodour as a result of jawbone necrosis
Management of halitosis caused by oral conditions or pathology should focus on:
- Reducing the number of microorganisms and their nutrients mechanically
- Tongue-scraping and cleaning the posterior aspect of the tongue
- Scaling and root planning with chlorhexidine (CHX)
- Chemical reduction of microorganisms
- CHX rinse (0.2%) will reduce of VSCs
- Essential oils produce short-term and restricted effects up to 3 hours and a limited reduction of odour-producing bacteria
- Chlordioxide can lead to a reduction in odour for up to 4 hours
- Triclosan reduces of VSCs after 3 hours
- Hydrogen peroxide (3%) can cause a 90% reduction in VSCs after 8 hours
- Toothpastes with triclosan, zinc or stannous fluoride
- Conversion of volatile components into non-volatile ones
- Rinses containing zinc, mercury and copper are useful in reducing VSCs
- Commercial rinse with 0.005% CHX, 0.05% cetylpyridinium and 0.14% zinc lactate is more effective than CHX alone
- Rinsing products, chewing gums and mints have a transient effect on malodour
Patients should consult their physician for advice and further investigations to rule out other systemic causes for halitosis.
- Bollen, Curd ML, Beikler, Thomas. Halitosis: the multidisciplinary approach. International Journal of Science (2012) 4, 55-63.
- Fedorowicz, Z, Aljufairi, H, Nasser, M, Outhouse, TL, Pedrazzi, V. Mouthrinses for the treatment of halitosis (Review). The Cochrane Collaboration (2008) 4.
- Ata, N, Ovet, G, Alatas, N. Effectiveness of radiofrequency cryptolysis for the treatment of halitosis due to caseums. Am J Orolaryngol-Head and Neck Med and Surg (2014).
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