About halitosis
Halitosis is the technical term for bad breath, a condition estimated to affect 50 to 65%
of the population.1
Up to 90% of cases are thought to originate from sources in the mouth, including poor oral
hygiene, periodontal disease, coating on the
tongue, impacted food, faulty dental restorations, and throat infections.2
3 4 The remaining 10% are due to systemic disorders, such as peptic ulcer (when associated with
infection),5 6 lung infections (bad breath can be the first sign in some
cases),7 liver or kidney
disease,8 9 diabetes
mellitus, cancer,10 or even a
person’s imagination (healthy individuals sometimes complain of bad breath that cannot
be smelled by anyone else and is not linked to any clinical disorder).11
In most cases, bad breath in the mouth can be traced to sulfur gases produced by bacteria
in the mouth.12 13 Factors that support the growth of these bacteria
will predispose a person to halitosis. Examples include accumulation of food within pockets
around the teeth,14 among the bumps at the back of the tongue,15 or in
small pockets in the tonsils; sloughed cells from the mouth; and diminished saliva flow. Mucus
in the throat or sinuses can also serve as a breeding ground for bacteria. Conditions are most
favorable for odor production during the night and between meals.16
Although bad breath primarily represents a source of embarrassment or annoyance, research
has shown that the sulfur gases most responsible for halitosis (hydrogen sulfide and methyl
mercaptan) are also potentially damaging to the tissues in the mouth, and can lead to periodontitis (inflammation of the gums and ligaments
supporting the teeth).17 18 As periodontal disease progresses, so may
the halitosis, as bacteria accumulate in the pockets that form next to the teeth.
Lifestyle changes that may be helpful
Home oral hygiene is probably the most effective way to reduce accumulations of debris and
bacteria that lead to halitosis. This includes regular tooth brushing and flossing, and/or the
use of mechanical irrigators to remove accumulations of food after eating. Brushing the tongue
or using a commercial tongue scraper, especially over the bumpiest region of the tongue, may
help remove the odor-causing agents as well as lower the overall bacteria count in the
mouth.
Because of the role of gum disease in
halitosis, regular dental care is recommended to prevent or treat gum disease. Treatment for a
person with periodontal pockets might include scaling of the teeth to remove
tartar.19
A reduced saliva flow increases the concentration of bacteria in the mouth and worsens bad
breath.20 One of the most common causes of dry mouth is medication, such as
antihistamines, some antidepressants, and diuretics; however, chronic mouth breathing,
radiation therapy, dehydration, and various diseases can also contribute.21
Measures that help increase saliva production (e.g., chewing sugarless gum and drinking
adequate water) may improve halitosis associated with poor saliva flow. Avoiding alcohol
(ironically found in many commercial mouthwashes) may also help, because alcohol is drying to
the mouth.
Access by oral bacteria to sulfur-containing amino acids will enhance the production of
sulfur gases that are responsible for bad breath. This effect was demonstrated in a study in
which concentrations of these sulfur gases in the mouth were increased after subjects used a
mouth rinse containing the amino acid
cysteine.22 Cleaning the mouth after eating sulfur-rich foods, such as dairy,
fish, and meat, may help remove the food sources for these bacteria.
1. Bollen CM, Rompen EH, Demanez JP. Halitosis: a multidisciplinary
problem. Rev Med Liege 1999;54:32–6 [in French].
2. Meningaud JP, Bado F, Favre E, et al. Halitosis in 1999. Rev
Stomatol Chir Maxillofac 1999;100:240–4.
3. Spielman AI, Bivona P, Rifkin BR. Halitosis. A common oral problem.
NY State Dent J 1996;62:36–42.
4. Touyz LZ. Oral malodor—a review. J Can Dent Assoc
1993;59:607–10.
5. Tiomny E, Arber N, Moshkowitz M, et al. Halitosis and Helicobacter
pylori. A possible link? J Clin Gastroenterol 1992;15:236–7.
6. Ierardi E, Amoruso A, La Notte T, et al. Halitosis and Helicobacter
pylori: a possible relationship. Dig Dis Sci 1998;43:2733–7.
7. Lorber B. “Bad breath”: presenting manifestation of
anaerobic pulmonary infection. Am Rev Respir Dis 1975;112:875–7.
8. Touyz LZ. Oral malodor—a review. J Can Dent Assoc
1993;59:607–10.
9. Durham TM, Malloy T, Hodges ED. Halitosis: knowing when “bad
breath” signals systems disease. Geriatrics 1993;48:55–9.
10. Spielman AI, Bivona P, Rifkin BR. Halitosis. A common oral problem.
NY State Dent J 1996;62:36–42.
11. Iwakura M, Yasuno Y, Shimura M, Sakamoto S. Clinical characteristics
of halitosis: differences in two patient groups with primary and secondary complaints of
halitosis. J Dent Res 1994;73:1568–74.
12. Reiss M, Reiss G. Bad breath—etiological, diagnostic and
therapeutic problems. Wien Med Wochenshchr 2000;150:98–100 [in German].
13. Tonzetich J. Production and origin of oral malodor: a review of
mechanisms and methods of analysis. J Periodontol 1977;48:13–20.
14. Kleinberg I, Westbay G. Salivary and metabolic factors involved in
oral malodor formation. J Periodontol 1992;63:768–75 [review].
15. Reiss M, Reiss G. Bad breath—etiological, diagnostic and
therapeutic problems. Wien Med Wochenshchr 2000;150:98–100 [in German].
16. Waler SM. Bad breath from the oral cavity. Tidsskr Nor
Laegeforen 1997;117:1618–21 [in Norwegian].
17. Ratcliff PA, Johnson PW. The relationship between oral malodor,
gingivitis, and periodontitis. A review. J Periodontol 1999;7:485–9.
18. Waler SM. Bad breath from the oral cavity. Tidsskr Nor
Laegeforen 1997;117:1618–21 [in Norwegian].
19. Bollen CM, Rompen EH, Demanez JP. Halitosis: a multidisciplinary
problem. Rev Med Liege 1999;54:32–6 [in French].
20. Tonzetich J. Production and origin of oral malodor: a review of
mechanisms and methods of analysis. J Periodontol 1977;48:13–20.
21. Astor FC, Hanft KL, Ciocon JO. Xerostomia: a prevalent condition in
the elderly. Ear Nose Throat J 1999;78:476–9.
22. Waler SM. On the transformation of sulfur-containing amino acids and
peptides to volatile sulfur compounds (VSC) in the human mouth. Eur J Oral Sci
1997;105:534–7.
23. Frascella J, Gilbert R, Fernandez P. Odor reduction potential of a
chlorine dioxide mouthrinse. J Clin Dent 1998;9:39–42.
24. Brunette DM, Proskin HM, Nelson BJ. The effects of dentifrice systems
on oral malodor. J Clin Dent 1998;9:76–82.
25. Ng W, Tonzetich J. Effect of hydrogen sulfide and methyl mercaptan on
the permeability of oral mucosa. J Dent Res 1984;63:994–7.
26. Waler SM. The effect of some metal ions on volatile sulfur-containing
compounds originating from the oral cavity. Acta Odontol Scand
1997;55:261–4.
27. Vaananen MK, Markkanen HA, Tuovinen VJ, et al. Periodontal health
related to plasma ascorbic acid. Proc Finn Dent Soc 1993;89:51–9.
28. Murray M, Pizzorno J. Encyclopedia of Natural Medicine, rev2d
ed. Rocklin, CA: Prima Publishing, 1998, 722–9.
29. Pack AR. Folate mouthwash: effects on established gingivitis in
periodontal patients. J Clin Periodontol 1984;11:619–28.
30. Kato T, Iijima H, Ishihara K, et al. Antibacterial effects of
Listerine on oral bacteria. Bull Tokyo Dent Coll 1990;31:301–7.
31. Cosentino S, Tuberoso CI, Pisano B, et al. In-vitro antimicrobial
activity and chemical composition of Sardinian Thymus essential oils. Lett Appl
Microbiol 1999;29:130–5.
32. Petersson LG, Edwardsson S, Arends J. Antimicrobial effect of a
dental varnish, in vitro. Swed Dent J 1992;16:183–9.
33. Cox SD, Mann CM, Markham JL, et al. The mode of antimicrobial action
of the essential oil of Melaleuca alternifolia (tea tree oil). J Appl Microbiol
2000;88:170–5.
34. Serfaty R, Itic J. Comparative trial with natural herbal mouthwash
versus chlorhexidine in gingivitis. J Clin Dent 1988;1:A34–7.
35. Dolara P, Corte B, Ghelardini C, et al. Local anaesthetic,
antibacterial and antifungal properties of sesquiterpenes from myrrh. Planta Med
2000;66:356–8.
36. Hannah JJ, Johnson JD, Kuftinec MM. Long-term clinical evaluation of
toothpaste and oral rinse containing sanguinaria extract in controlling plaque, gingival
inflammation, and sulcular bleeding during orthodontic treatment. Am J Orthod Dentofacial
Orthop 1989;96:199–207.