This lecture describes the causes , etiology of bad breath odour, how to avoid , and how to manage this condition.

1. Halitosis
Hossam Thabet, M.D.
Otolaryngology-Head & Neck Surgery
Alexandria University
Egypt

3. DEFINITION of Halitosis
 An unpleasant, disagreeable, or
offensive breath odor
 Alternative names:
 Bad breath,
 Oral malodor,
 Fetor Oris

4.  Extremely common.
 Majority of adult population have had it at some
point in time! Up to ¼ on a regular basis.[*]
 Very subjective “it’s a perception rather than a real thing,
everybody’s breath smells to a certain extent”.
 Unpleasant condition which creates huge
embarrassment with potentially grave
consequences.
 Most seek help from GP initially, not the dentist!
* Tonzeitch J.1977
Epidemiology of Halitosis

5. WHO SEEKS HELP ?
 Most are unaware of the problem !
 People are poor judges of their own breath odor (?
adaptation/desensitisation due to chronic exposure).[*]
 Some may have exaggerated concerns !
 Poor judgement, personal experiences, childhood
memories, perception of other people’s behaviours etc
leading to preoccupation with concealing perceived
malodour, social avoidance etc. Concept of
“HALITOPHOBIA”.
*Rosenberg M. Bad breath; diagnosis & treatment.Dent J:1990; 3:7-11
Epidemiology of Halitosis

6. WHERE DOES IT COME FROM ?
 85-90% comes from the mouth itself.
 Formed by bacterial putrefaction of food debris,
cells, saliva and blood.
 Proteolysis of proteins peptides  aminoacids 
free thiol groups & volatile sulphides.
 Results from any form of sepsis : increased
anaerobic activity of pathogens (inc. Treponema
denticola, P.Gingivalis and Bacteroides forsythus).
 Despite rigorous hygiene, good dentition, posterior
dorsum of tongue is often a source (? Post nasal
drip related).
Pathophysiology of Halitosis

7. WHERE DOES IT COME FROM ?
 Anaerobic Sulfur Producing Bacteria which normally
live BELOW the surface of the tongue and in the
throat (Fusobacterium ,Actinomyces, and
Bacteroides forsythus, among others).
 They assist humans in digestion by breaking down
proteins found in specific foods, mucus or phlegm,
blood, and in diseased or “broken-down” oral
tissue. Under certain conditions, these bacteria
start to break down proteins at a very high rate.
Pathophysiology of Halitosis

8. WHERE DOES IT COME FROM ?
 Proteins are made up of Amino Acids. Two of
Amino Acids in the mouth (Cysteine and
Methionine) are dense with sulfur.
 When “beneficial” bacteria break down these
compounds, the odorous and “lousy-tasting”
Volatile sulphur compounds (VSCs) are
released, (Hydrogen Sulfide, Dimethyl
sulphide, & Methyl Mercaptan), with other bad
tasting compounds.
Pathophysiology of Halitosis

9. Compounds commonly produced by mouth
bacteria and their odours:
 Hydrogen sulfide- Rotten eggs
 Methl mercaptan- Faeces
 Skatole- Faeces
 Cadaverine- Corpses
 Putrescine- Decaying meat
 Isovaleric acid- Sweaty feet
Pathophysiology of Halitosis

10. Etiology of Halitosis
1. Oral & Throat Causes
2. Nasal/ Nasopharyngeal problems
3. Systemic disease
4. Physiologic considerations
5. Drugs
6. Food
7. Psychologic disorders

11. Oral & Throat Causes
1. Poor dental hygiene & food impaction
2. Dental & Gum diseases
3. Bacteria accumulation on the posterior tongue
dorsum & tonsils
4. Post nasal drip
5. Chronic tonsillitis &Tonsilloliths (Tonsil Stones)
6. Dry mouth
7. Oral sepsis
8. Oral Ulcerative lesions
9. Oral malignancy

12. Dental & Gumm Disease
 Periodontal disease
 Dental caries
 Faulty restoration
 Denture
 Impacted or abscessed tooth, etc
 Infected extraction sites
 Residual post-operative blood
 Debris under bridges or appliances kept in mouth
at night or not cleaned properly.
Oral & Throat Causes

13.  The real reason for most bad breath is
Bacteria that accumulate on the back of
the tongue, in pockets of the gum or in the
throat.
 Anaerobic bacterias produce volatile sulfide
compounds (VSC) such as hydrogen sulfide,
methyl mercaptan gases.
 These VSC is the source of malodor.
Oral & Throat Causes

14. Oral & Throat Causes

15. Tonsil Stones (tonsilloliths) are caused by an
accumulation of sulfur-producing bacteria,
post nasal drip, and debris that become
lodged in the tonsil crypts
When this debris combines with the Volatile
Sulfur Compounds produced by the
anaerobic bacteria beneath the surface of
the tongue, it can also create chronic
Halitosis
Oral & Throat Causes

16. Breaking open one of these white
tonsilloliths, causes an absolutely terrible
smell! which is actually a combination of
volatile sulfur compounds(Methyl Mercaptan
and Hydrogen Sulfide), post nasal drip, and
bacteria
Oral & Throat Causes

17. Dry Mouth is a Leading Cause of Bad Breath
 Dry mouth is naturally occurring in elderly, most
cases are caused by medications, adult beverages
and mouthwashes with alcohol
 Saliva contains Oxygen, which helps oxygenate
the mouth keep it healthy and fresh
 Dry mouth with less saliva and less oxygen,
makes bad breath gets worse by creating an
anaerobic environment, perfect for the bacteria to
produce more of these odorous & sour/bitter
compounds
Oral & Throat Causes

18. Excess Mucus (Post-Nasal Drip) is actually a
Food Source For Anaerobic Bacteria
 When a person has post-nasal drip, mucus coats
the back of the tongue and throat. Since mucus is
made up of interlinked strands of protein, the
bacteria, break down these proteins into odorous
and sour tasting sulfur type compounds.
 Strong antihistamines don’t help, because the
drying effect of the antihistamines also creates a
problem (by reducing the amount of germ-
controlling saliva).
Oral & Throat Causes

19. Gigivitis acute necrotizing ulcerative gingivitis (ANUG)
or French mouth
Oral & Throat Causes

20. Dangers of Gum Disease
Gum Disease is the leading cause of tooth loss
among adults. More importantly, the infection
releases toxins into the bloodstream leading to
serious health risks

21. Dangers of Gum Disease

22. Chronic Tonsillitis
Oral & Throat Causes

23. Black Hairy Tongue
Oral & Throat Causes

24. Patients with fissured tongue dorsum
may have elongated filiform papillae
along the fissure walls
Black Hairy Tongue
Oral & Throat Causes

25. Low-magnification photo-
micrograph, the elongation
of filiform papillae is
clearly evident. The debris
between papillae consists
of desquamated epithelial
cells and microbial
colonies
Black Hairy Tongue
Oral & Throat Causes

26. Tonsillolith
Oral & Throat Causes

27. Oral ulcerative lesions
Pemphigus Vulgaris
Oral & Throat Causes

28. Angiokeratoma of the tongue
Oral & Throat Causes

29. 1ry herptic gnigvostomatitis
Oral & Throat Causes

30. Peritonsillar Abscess
Oral & Throat Causes

31. Chronic Peritonsillar Abscess

32. Bilateral Recurrent Suppurative Parotitis
Oral & Throat Causes

33. Recurrent Suppurative Parotitis
Oral & Throat Causes

34. Mouth origins
Leukemia and paraph. abscess

35. Oroantral fistula
Oral & Throat Causes

36. Nasal/Nasopharyngeal problems
1. Sinusitis & Nasopharyngitis
2. Chronic nasal airway obstruction
3. Adenoid hypertrophy
4. F.B. Nose or Nasopharynx
5. Rhinolithiasis & Nasopharyngeal lithiasis
5. Nasal & Sinus granulomas
6. Nasal & Sinus tumors.
7. Nasopharyngeal Carcinoma

37. Nasal/Nasopharyngeal problems
Thornwaldet's cyst
Midline cystic mass (arrow)
in the upper nasopharynx
presenting with high signal
intensity on T1-MRI. The
lesion is located in the midline
between the longus capitis
muscles, which are seen in cross
section
The mass (arrow)
displays a high signal
intensity on T2-MRI,
indicating a cystic
nature
cystic mass (arrow), show no
enhancement with GD but
surrounding normal mucosa
shows physiological contrast
uptake (axial T1-weighted view

38. Nasal/Nasopharyngeal problems
Thornwaldet's cyst
On the sagittal T1 view, the cystic mass (arrow) is seen in the
upper nasopharynx, nestled between the prevertebral muscles
within the pharyngeal raphe

39. Nasal/Nasopharyngeal problems
Nasal F.B. & rhinolith

40. Nasal/Nasopharyngeal problems
Nasopharyngeal Lithiasis

41. Nasopharyngeal Lithiasis

42. Nasopharyngeal Carcinoma
Nasal/Nasopharyngeal problems

43. Systemic diseases
 Diabetes mellitus, Diabetic ketoacidosis,
 Renal failure, Bowel obstruction, etc.
 Liver failure
 Lung abscess, Bronchiectasis
 Severe GERD with H. Pylori
 Pharyngeal pouch
 Gastric & Esophageal carcinoma
 Carcinoma of the Larynx & Tracheobronchial Tree
 Granuloma of the Larynx & Tracheobronchial Tree
 Sjogren syndrome & Post irradiation therapy
 Trimethylaminuria (Fish-odour syndrome)

44. Physiologic considerations
1. Reduction of salivation
2. Dehydration
3. Vitamin deficiency
4. Hunger
5. Morning breath
6. Aging
7. Gastroesophageal reflux
8. Menstruation, etc.

45. Physiologic considerations
It must be kept in mind that bad breath under the following circumstances
is normal:
Morning breath because the function of salivary glands slows down
over night and saliva thickens, which stops it from bathing mouth
tissues properly, therefore mouth breathers face the problem more
often, but it disappears when you eat or drink.
Hunger breath accompanies morning breath and arises from
putrefaction of pancreatic juice, which pours into the stomach when
nothing is eaten or drunk. Hunger breath is more apparent even after
brushing, if morning meals are omitted.
Menstrual breath is caused because of hormonal disturbances,
which trigger sloughing of the body’s lining tissues and oral tissues
and creates more ridges for bacteria, leading to halitosis

47. Drugs
1. Antihistamines
2. Anticholinergics
3. Antihypertensives
4. Anorexiant
5. Anxiolytic,Tranquilizers
6. Antidepressants
7. Antiparkinson
8. Decongestants
9. Diuretics
10. Sulfa drugs
11. Long term use of antibiotics, etc.

48. Drugs
 Anorexiant Preludin, Tenuate
Aventyl, Elavil
Marplan, Nardil
Sinequan,Tofranil
 Antihistamine Actifed,Phenergan
Benadryl, Vistaril
Dimetane, Atarax
Chlor-trimeton
 Anticholinergics Atropisol, Banthine
Bentyl,Combid
Daricon, Lomotil
Pro-Banthine
 Antihypertensive Aldomet, Catapres
Eutonyl, Hytrin
Ismelin, Minipress
Serpasil
 Antiparkinson Akineton, Artane
Cogentin, Lardopa
Parsidol, Tolserol
 Antipsychotic Compazine, Haldol
Mellaril, Sparine
Stelazine, Thorazine
Triavil
 Anxiolytic Equanil, Librium
Miltown, Serax
Marijuana, Valium
 Decongestant Dimetapp,
Sudactone
 Diuretic Agent Aldactone, Diuril
Dyrenium, Lasix
HydroDiuril

49. Foods
1. Food eaten (onions, garlic, cabbage, etc. )
2. High protein diet, Fish, red meat
3. Dairy food, etc
4. Acidic food
5. Sugars
6. Coffee
7. Tobacco
8. Alcohol

50. Foods
Dense Protein Foods:
 A high protein diet is always ideal for
anaerobic bacteria,e.g. Fish, eggs,red meat
 The end result is a buildup of amino acids,
which are easily converted into volatile
sulfur compounds by the anaerobic
bacteria found within the surface of your
tongue and throat.

51. Foods
Sugars:
 Sugar, which are fuel for the bacteria to
reproduce and create more sulfur
compounds.
 In addition, other bacteria can take the
sugars and produce glycan strands, which
in turn end up causing thick layers of
plaque on enamel and around gums. This
leads to tooth decay and gum disease -
and of course, worse breath

52. Foods
Acidic Foods:
 Coffee - both decaf and regular contains
high levels of acids.
 Tea is a much better alternative.
 Tomato Juice
 All Citrus Juices - Orange Juice, Pineapple
Juice, Grapefruit Juice

53. Foods
Acidic Foods:
 The reason why acidic foods are a concern
has to do with the way the bacteria react
to an acidic environment.
 The oral cavity has a normal pH of 6.5 (7 is
neutral) which is in the acid range.
 Acids make the bacteria reproduce much
faster.

54. Foods
 Onions and garlic already contain powerful
volatile sugar compounds, called mercaptans --
eating them simply adds more odor -- which can
sometimes enter the lungs and bloodstream.
 Milk and other dairy products may cause
problems for most people (The fat content does
not matter, so low fat milk is just as problematic
as butter.)
 In lactose intolerant, the system cannot digest
these dairy products properly,& so they are
available to the bacteria for an extended period
of time.

55. Foods
Trimethylaminuria-TMA “Fish Odour Syndrome”
 A rare problem occurs in people who have an
inability to breakdown certain proteins found in
beans.The odour produced is similar to decaying
fish.
 The odor consists of sulfur compounds, plus
nitrogen compounds (amines).
 People with this condition must abstain from beans
and other dense protein foods.

56. Foods
Smoking (nicotine)
 Smoking have a drying effect on oral tissues
 Destroys ascorbic acid (vitamin C), an essential for
immunity
 Odor associated with smoking depends on a
number of factors, directly related to the tar,
nicotine, and other foul smelling substances that
accumulates on teeth and oral soft tissues (tongue,
cheeks, gums,...).
 Short of quitting smoking there is no effective way
to totally eliminate smoker's breath, although oral
hygiene can help to minimize it.

58. Psycologic disorder
 Delusional halitosis
 Hallucinatory feature of psychotic illness
 Halitophobia
 Temporal Lobe Epilepsy

59. DIAGNOSIS
1. Oral examination
2. History taking
3. Smelling
4. Sampling by spoon, gauze, cotton
5. Information from family, friend
6. Self examination
7. Use of the halimeter

60. EXAMINATION
 Some of the characteristic smells
accompanied by various diseases include
acetone (a fruity smell) caused by diabetic
ketoacidosis, sweaty smell caused by liver
dysfunction and and extremely foul smell
caused by diphtheria.

61. INVESTIGATIONS
 Halimeter
 Level of intra oral Volatile Sulphur
Compounds can be estimated using
portable sulphide monitors. Concentration
of VSC’s correlate well with level of
malodour reported by observers.

62. Management
 Identify & eliminate obvious causes
 Dental & Oral hygine
 Dietary advice
 Nasal & Sinus Irrigation
 Laser Tonsillotomy or tonsillectomy
 Adenoidectomy, FESS
 Referral
 Gastroenterology, Rare despite common belief !
 Psychology/psychiatric,? Halitophobia.
 Internist, D.M., Renal, & Liver impairment
Neti pot

63. Management
Dental & Oral hygine
 Regular Dental Consultation
 Regular proper tooth brushing
 Interdental flossing
 Tongue cleaning, brushing, scraping
 Tongue cleansing by tongue scrapper,
gauze, tooth brush without paste
 Mouthrinses
 Baking soda toothpaste or mouthwash. This changes the
acidity of the mouth
 Denture care & soaking in antiseptic solution over night

64. Management
Dental & Oral hygine

65. Management
 The only effective method of treating
Halitosis is by attacking the bacteria’s ability
to produce VSC’s and by converting the
VSC’s into non-odorous and non-tasting
organic salts.
 Nearly all cases of “real” bad breath and/or
taste disorders (or Halitosis) involve good
bacteria and should never be treated with
antibiotics.

66. The Ingredients in Most Commercial Toothpastes and
Mouthwashes Can Actually Facilitate Bad Breath!
 Sodium Lauryl Sulfate (SLS) is a soap that they put in
toothpaste and other cleansers for making it foam. SLS will
dry out the mouth creating an optimal environment for the
bad breath bacteria to produce volatile sulfur compounds
(it's also been linked to the production of painful and
annoying canker sores or mouth ulcers too!).
 Alcohol, causes dry mouth and aggravates the bad odour
 Sugar, creates an excellent source of food for the bad
breath bugs to thrive
Management

67. Management
Types of mouthwashes used to cure bad breath
1. Mouthwashes that contain chlorine dioxide or sodium
chlorite. [Antibacterial and Neutralizes VSCs], Chlorine
dioxide is an oxidizing agent & has the ability to neutralize VSCs
2. Mouthwashes that contain zinc. [Neutralizes VSCs] zinc
ions convert VSC to non-malodourous zinc sulphides
3. "Antiseptic" type mouthwashes. [Antibacterial]
"Antiseptic"mouthwashes (i.e.,Listerine & its generic equivalents)

68. Management
Types of mouthwashes used to cure bad breath
4.Chlorehexatidine gluconate (CHG) in 0.2% ,A cationic
mouthwash like helps a lot it and it has the ability to bind oral tissues.
5. Cetlyperadium chloride (CPC) mouthwashes.
[Antibacterial]
6. Hydrogen peroxide mouthwash releases free oxygen, which is
harmful to bacteria

69. Management
Dietary advice
 Avoid odiferous foods: Onion, Garlic, Spices
 Avoid habits: Smoking, Alcohol, Coffee
 Take regular meals, fresh fruit: Pineapples
 Eat fresh, fibrous vegetables such as carrots
 Drink tea regularly: Polyphenols in tea
inhibit bacterial growth
 Don’t drink too much coffee

70. Management
Dietary advice
 Don't miss breakfast. Hunger lead to killing-breath.
 Drink plenty of liquids/ 8 glasses of water a day.
 Eat parsley or wintergreen with your main meals.
These herbs release pleasant oils as they chew them
which linger for hours.
 Avoid fats - cheese, butter, milk, fat meats - in your
diet if indigestion is the source of your bad breath
 Avoid beans &high protein diet in Trimethylaminuria

71. Management
Dietary advice
 Stay away from candies, mints, and chewing gum if
they contain sugar.
 Chew sugar-free gum for a minute or two at a time,
especially if your mouth feels dry, chewing parsley,
mint, cloves or fennel seeds may also help.
 In Xerostamic, increase your fluid intake (at least
18-20 glasses per day), suck on sugarless lozenges.
 Citrous fruits, Vitamin C makes you resistant to
coughs and colds

72. • CO 2laser beam, 10 - 20 W over
the tonsils. A scanner quickly rotates
the focused laser beam over a 3 -
4 mm circle to vaporize the tonsils
without causing thermal damage to
surrounding tissue.
•This technique can be performed in
an office setting with the patient
under local anaesthetic
Management
Laser Tonsillotomy

73. Management
Laser Tonsillotomy