Bad Breath

Essentials

• Neglecting oral hygiene is the most important reason for bad breath. In at least 80% of the cases the cause is found in the mouth. The smell is mainly caused by volatile sulphur compounds (VSC) produced by bacteria.

• The sense of smell adapts quickly even to a strong smell, and the patient is often unaware of the problem.
• Transient oral malodour on awakening is a natural phenomenon. Mouth breathing aggravates the malodour.
• Halitosis may cause significant social impairment, fear of social situations and social withdrawal.
• If no specific treatable cause is found, management of halitosis is based on careful oral hygiene, stimulation of salivary flow and use of refreshing mouthwashes or gargles.

Causes of bad breath

• Poor oral hygiene, dental caries Dental Caries and other Diseases of the Hard Tissues of the Teeth and Dental Pulp, periodontal diseases Periodontal Diseases (Gingivitis and Periodontitis), and difficulty in cleaning prostheses.
• Reduced salivation and drying of the mouth
  • Sjögren's syndrome Primary Sjögren's Syndrome
  • Radiotherapy and post-operative conditions
  • Anticholinergic drugs
• Bad-smelling nutrients, drugs, and stimulants and their degradation products
  • Garlic
  • Tobacco
  • Alcohol
  • Disulfiram
• Infectious reactions
  • Surface of the tongue Benign Lesions of the Tongue, ulcers and lesions of the oral mucosa
• Infection of the tonsils, adenoids or lingual tonsil
• Tonsillary plugs: whitish or yellowish foul-smelling grainy mass is accumulated in the tonsillary crypts and is shed by pressure on the crypt.
• Retropharyngeal or nasopharyngeal accumulation of mucus and pus, adenoids (cause mouth breathing, particularly in children), maxillary sinusitis
• Nasal infections, tumours, crusting, foreign bodies, other causes increasing mouth breathing
• Dry nose and ozaena Atrophic Rhinitis and Ozaena
• Oesophageal diverticles, achalasia, reflux disease
• Bronchitis, bronchiectasis, pulmonary empyema
• Some systemic diseases
  • Diabetes
  • Renal and hepatic failure
• If no outside person has reported on the patient having oral malodour, the patient may suffer from a disturbance of the sense of smell Disturbances of the Sense of Smell or from olfactory hallucinations.

Treatment Interventions for Managing Halitosis

• Treatment is aetiology-specific. Severe tonsil-associated malodour problem may warrant tonsillectomy.
• When no specific treatable cause is found, the management consists of attempts to increase salivary secretion, to decrease the amount of bacteria in the mouth and to mask the odour.
  • Good oral hygiene, tongue brushing or scraping
  • Stimulation of salivation by the use of chewing gum or lozenges; artificial saliva
  • Non-alcoholic antimicrobial mouthwashes and gargles
    • Mouthwashes and toothpastes containing e.g. chlorhexidine, cetylpyridinium or triclosan temporarily decrease the amount of odour-producing bacteria. Disadvantages of chlorhexidine include unpleasant taste and staining of teeth.
  • Lozenges, mouthwashes and sprays intended for masking the odour have a momentary effect only.

A comatose patient with abnormal odour of breath

• Alcohol poisoning
• Diabetic coma (acetone)
• Hepatic coma (ammonia)
• Uraemia