01/09/2014
HALITOSIS
Halitosis is also called bad breath, malodour, offensive or foul odour of the mouth. Halitosis could be normal or psychological. The normal would be typically seen in the so called “morning breath” which results from enzymatic break down of cellular protein and amino acids. Other psychological origins of halitosis include hunger, dehydration or it may be related to ingestion of certain foods and may be a sign of other health problems.
This is a common complaint in adults; it is an unpleasant smell on your breath that other people notice when one speaks or breaths out. In most cases of persistent bad breath, the smell comes from a build-up of bacteria within the mouth in food debris due to plaque and gum disease or in a ‘coating’ on the back of the tongue.
The main problem with halitosis is that the only person not to notice is the person affected. Often the only way one gets to know about it is if a person comments on it.
Causes of Halitosis: this is classified into two
Local causes
Systemic causes
LOCAL CAUSES:
Poor oral hygiene: plaques and calculus contain bacteria which results in gingivitis and periodontitis. Could also be due to coating on the back of the tongue (due to improper brushing) which contains bacteria and this explains why halitosis can occur in patients with seemingly good oral hygiene.
Gingivitis and periodontitis: destructive effects of anaerobic bacteria cause an offensive smell. Also, occult blood from gingivitis may degenerate resulting in foul odour.
Dental caries: food packing within the tooth cavity, when they rot due to bacteria action gives off the foul odour.
Poorly fitted dental appliances
Oral candidiasis
Oral sepsis from either of tonsillitis, ANUG, NUP, necrotizing stomatitis, ulcers, pericoronitis e.t.c
Dry mouth (xerostomia)
Starvation
Oral tumour
Smoking , which starves the mouth of oxygen
Food stagnation: normal teeth brushing may not clear food bits which get stuck between teeth. The food then rots and becomes riddled with bacteria.
SYSTEMIC CAUSES
Certain foods: e.g. garlic, spicy foods, alcoholic drinks, onion, beans, high protein diet. As these foods are digested the chemical in the food gets into the blood stream from where it goes to the lungs, and is then given off in the breath.
Fasting: this is due to the dryness of the mouth and break down of fats releasing ketones, resulting in ketotic halitosis.
Nasal and sinus infections: e.g. Sinusitis, nasal polyp, foreign body in the nasal cavity, post nasal drip into the mouth, URTI, bronchitis or pneumonia, tonsillitis and other tumours of the nasal tract.
Xerostomia: caused by side effects of various medications, salivary gland problems or continuous mouth breathing. Saliva is necessary to moisten and cleanse the mouth by neutralizing acids produced by plaque and washing away dead cells that accumulate on the tongue, gums and cheeks. If not removed, these cells decompose and can cause bad breath.
Gastro oesophageal reflux
Systemic disease such as:-
v Gastrointestinal diseases: e.g. diarrhoea, constipation, indigestion etc.
v Diabetes mellitus especially uncontrolled diabetes mellitus, which results in breakdown of fat producing ketones to give ketotic halitosis.
v Hepatic disease
v Renal disease
Psychological factors: e.g. Depression, anxiety.
AETIOLOGY: The micro-organisms implicated in oral malodour are predominantly gram-negative; Gram positive bacteria have also been implicated.
CLINICAL FEATURES OF HALITOSIS
A white coating on the tongue
Dry mouth and teeth
Post nasal drip
Morning bad breath and a burning tongue
Thick saliva and a constant need to clear the throat
Constant sour, bitter metallic taste
Lack of confidence and self esteem
MORNING BAD BREATH: most people have some degree of bad breath after a night’s sleep. This is normal and occurs because the mouth tends to get dry and stagnate overnight. This usually clears when the flow of saliva increases soon after starting to eat breakfast.
PSYCHOGENIC HALITOSIS: the complaint of malodour in the absence of odour. Complaints are made by patients who think they have halitosis, but do not. No evidence of oral malodour can be detected even with an objective test
The symptom may be attributed to some form of delusion or mono symptomatic hypochondriasis (elf oral malodour halitophobia)
Other people’s behaviour or perceived behaviour such as covering of nose or averting the face is often misinterpreted. Many of such patients will adopt behaviours such as: covering their mouths while talking, avoiding or keeping the distance from people, avoiding social situations, using chewing gums, mints, frequent tooth brushing(“over brushing”) mouthwashes, etc. with no improvement. Thus, their oral hygiene is superb. Medical help may be sought to manage these patients.
TREATMENT OF HALITOSIS
Once the cause of the condition is discovered the patient is already treated half way.
Oral prophylaxis such as scaling and polishing will go a long way in eliminating the bacteria accumulation in the mouth.
Oral hygiene instructions: tooth brushing technique should be re-emphasised, vigorous cleaning of the tongue towards the back to eliminate the white coating, brushing at least twice daily with good tooth brush and fluoride containing toothpaste.
Use of tongue scrapper can also be useful
Tooth brushing and flossing after meals to eliminate debris and bacteria
Spend at least 2 minutes brushing the teeth and change toothbrush at least every 3 months.
Antimicrobial mouth rinses are very effective in eliminating the bacteria in the oral cavity e.g. chlorhexidine 0.2%, Listerine, hydrogen peroxide in 1:4 dilution also eliminates the anaerobes within the oral cavity.
Treat every dental caries, periodontal disease, infections and other identifiable dental problems responsible for the odour
Drugs causing halitosis could be discussed with the physician and alternatives would be administered
Avoid all odour-producing foods or adjust to suit need
Stop smoking is the only cure for odour caused by smoking
Treat all systemic disorders responsible for halitosis e.g. diabetes, URTI, gastrointestinal diseases.
Constant sipping of water keeps the mouth moist; chewing of sugar free chewing gums could also be effective.
Regular dental visits
A chat with the psychologist could help in cases where psychogenic halitosis is suspected
Conclusion:
Although malodour has a varying range of causes, careful assessment of the various local and systemic causes could help us arrive at a definite solution. Where a systemic cause is inferred, it may be necessary to involve the medical specialist in the management of the patient.
As clinicians we should not be quick to conclude that halitosis is psychological.
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This piece was written by Dr. Tola Eweka of the Dept. of Preventive Dentistry LUTH
