This document discusses halitosis (bad breath), including its definition, classification, causes, diagnosis and treatment. Halitosis can originate from oral or non-oral sources, with the vast majority stemming from conditions in the oral cavity like gingivitis, periodontitis and tongue coating. Diagnosis involves history, examination, and objective tests like organoleptic measurement and gas chromatography. Treatment focuses on reducing oral bacteria and volatile compounds through mechanical cleaning, chemical agents, masking malodor, and addressing underlying conditions. Prevention prioritizes regular dental visits and proper oral hygiene.

2. Dr. Subair
Dept of periodontics.

3. Introduction
• Halitosis is a general term used to define an unpleasant or
offensive odour emanating from the breath regardless of
whether the odour originates from oral or non-oral sources.
• Originates from two Latin words
– Halitus → breath
– Osis → disease
• Halitosis is also termed as fetor ex ore or fetor oris. It is a
foul or offensive odor emanating from the oral cavity.

4. Introduction (Contd.)
• It was described as a clinical entity by HOWE (1874).
• Halitosis should not be confused with the generally
temporary oral odour caused by intake of certain foods,
tobacco, or medications.

5. Synonyms
• Bad or foul breath
• Breath malodour
• Oral malodour
• Foetor ex-ore
• Foetor oris
• Stomato dysodia

6. Epidemiology
• Bad breath has been a common problem for thousands of years.
• It is a considerable social problem.
- Its incidence remains poorly documented in most countries.
- In vast majority- The cause is originated from the oral cavity
i.e. gingivitis, periodontitis, and tongue coating.

7. Classification
• Genuine halitosis
• Physiologic halitosis
• Pathologic halitosis
• Pseudo halitosis
• Halitophobia.

8. Genuine halitosis
• Physiological halitosis
– Morning breath odour
– tobacco smoking
– certain foods
– medications.
– Ageing & poor oral hygiene
– Mouth breathing

9. • Pathological halitosis
– intra oral or extra oral origin
– 90% of patients → oral cavity
– Bacteria, volatile sulphur compounds

10. Pathologic halitosis
• Intra oral origin
– poor oral hygiene
– dental caries
– periodontal diseases in particular NUG, NUP,
periodontitis, pericoronitis, dry socket, other oral
infections, tongue coating & oral carcinoma.
– Stomatitis, xerostomia
– Unclean dentures

11. • The role of tongue coatings in the
aetiology of oral malodour has been
extensively documented.
• Tongue coatings include desquamated
epithelial cells, food debris, bacteria and
salivary proteins and provide an ideal
environment for the generation of VSCs
and other compounds that contribute to
malodour

12. • Extra oral origin
– 10-20%
– gastro intestinal diseases
– infections or malignancy in respiratory tract
– Chronic sinusitis , tonsillitis, rhinitis
– stomach, intestine, liver or kidney affected by systemic
diseases

13. Examples of systemic pathological conditions
that cause halitosis
Systemic condition
• Diabetes mellitus
• Renal failure
• Liver failure
• Tuberculosis/ lung abscess
• Internal hemorrhage/ blood
disorders
• Fever , dehydration
Characteristic odour
• Acetone , sweet fruity.
• Urine or ammonia
• Fresh cadaver
• Foul, putrefactive
• Decomposed blood
• Odour due to xerostomia
and poor oral hygiene.
-

14. • Pseudo halitosis
– Apparently healthy individuals, obvious malodor not
perceived by others; improved by counselling & simple
oral hygiene measures
• Haltophobia / delusional halitosis
– exaggerated fear of having halitosis

15. Etiology
• Halitosis generally arises as a result of the bacterial
decomposition of food particles, cells, blood and some
chemical compounds of the saliva.
– Moss, 1998

16. Etiology (Contd.)
• Volatile sulphur compounds → hydrogensulphide [H2S,
rotten egg smell], dimethyl sulphide [(CH3)2S, rotten
cabbage smell, and methyl mercaptan [CH3SH, fecal
smell].
• Non - sulphur containing substances → diamines
[cadaverine (cadaver smell) and putrescine (rotting meat
smell), acetone and acetaldehyde

17. Etiology (Contd.)
• Food impaction
• Acute necrotising
ulcerative gingivitis
• Acute gingivitis
• Adult and aggressive
periodontitis
• Pericoronitis
• Dry socket
• Xerostomia
• Oral ulceration
• Oral malignancy
• Tongue coatings
Common causes of halitosis
1. Intraoral causes

18. Etiology (Contd.)
• Acute febrile illness
• Leukaemias
• Respiratory tract infection
(usually upper)
• Helicobacter pylori infection
• Gastro-oesophageal reflux disease
• ENT infections
• Hepatic failure (fetor hepaticus)
• Renal failure (end stage)
• Diabetic ketoacidosis
• Trimethylaminuria
• Hypermethioninaemia
• Menstruation (menstrual breath)
• Medications
2) Extraoral causes

19. Role of volatile sulphur compounds in
the pathogenesis of halitosis
Major compounds implicated in halitosis
• VSC’s - Methylmercaptan, Hydrogen sulfide, dimethyl
sulfide & Dimethyl disulfide.
• Polyamides - Putrescein, Cadaverine, Skatole, Indole.
• Short chain FA - Butyric, Propionic, Valeric & Isovaleric
acid.
• Others - Acetone, Acetaldehyde, Ethanol diacyl.

20. Putrefaction products
Oral malodor
Diet, bacteria, epithelial cells
Peptides/proteins
Amino acids
PATHOGENESIS OF ORAL MALODOR:

21. Diagnosis
• Review of medical dental and personal
history
• Clinical examination
• Measurement of oral malodor

22. Review of history
• Frequency
• Time of appearance within the day
• Any other problem
• Medications
• Dryness of mouth

23. Clinical examination
Intraoral examination
• Tongue coating
• Evidence of mouth
breathing
• Xerostomia
• Other oral causes
Complete periodontal
examination
• General personal
care, state of oral
hygiene
• Probing depths
• Past history of
dental hygiene

24. Self assessment tests
 Whole mouth malodor (Cupped breath)
The subjects are instructed to smell the odor emanating
from their entire mouth by cupping their hands over their
mouth and breathing through the nose. The presence or
absence of malodor can be evaluated by the patient
himself/herself.

25.  Wrist lick test
Subjects are asked to extend their tongue and lick their
wrist in a perpendicular fashion. The presence of odor is
judged by smelling the wrist after 5 seconds at a distance
of about 3 cm.

26.  Spoon test
Plastic spoon is used to scrape and scoop material from the
back region of the tongue. The odor is judged by smelling
the spoon after 5 seconds at a distance of about 5 cm
organoleptically.

27.  Saliva odor test
Involves having the subject expectorate approx. 1-2 ml of
saliva into a petridish. The dish is covered immediately,
incubated at 370 C for five minutes and then presented for
odor evaluation at a distance of 4 cm from the examiner’s
nose.

28. OBJECTIVE TESTS
• Organoleptic measurement
• Gas chromatography (GC)
• Sulphide monitoring / halimeter
• Saliva incubation test
• Dark field / phase contrast microscopy
• Electronic nose
• BANA test

29. • Patients should be instructed not to eat, chew,
rinse or smoke for at least 2 hours before
examination.
• Patients who are on antibiotics should be seen 2
weeks after discontinuation of medicines

30. Organoleptic measurement (sniff test)
• Organoleptic measurement is a sensory test scored on the basis of the
examiner’s perception of a subject’s oral malodor.
• Organoleptic measurement can be carried out simply by sniffing the
patient’s breath and scoring the level of oral malodor.

31. • By inserting a translucent tube (2.5 cm diameter, 10 cm length) into
the patient’s mouth and having the person exhale slowly, the breath,
undiluted by room air, can be evaluated and assigned an organoleptic
score.
• The tube is inserted through a privacy screen (50cm-70cm) that
separates the examiner and the patient. The use of a privacy screen
allows the patient to believe that they have undergone a specific
malodor examination rather than the direct-sniffing procedure.

33. VOLATILE SULFIDE MONITOR:
• This electronic (Halimeter, InterScan, Chatsworth, Calif)
analyzes concentration of hydrogen sulfide and methyl-
mercaptan , but without discriminating between them.

34. Gas Chromatography (GC):
• GC, performed with apparatus equipped with a flame
photometric detector, is specific for detecting sulphur in mouth
air.
• It measures directly the three VSC methyl mercaptan, hydrogen
sulfide and dimethyl sulfide.
• GC is considered the gold standard for measuring oral malodor.
• This device can analyze air, saliva, crevicular fluid for a volatile
component.

37. Electronic nose:
.
.
Tanaka M et al used
these electronic noses to
clinically assess oral
malodor and examined the
association between oral
malodor strength and oral
health status.

38. BANA test (Benzoyl-d, L-arginine-napthylamide)
Used to determine the
proteolytic activity of
certain oral anaerobes
like P.gingivalis,
T.denticola, &
B.forsythus that
contribute to oral
malodor.

39. Saliva incubation test
• 0.5ml stimulated saliva collected in a glass tube&
the tube is flushed with CO2 and sealed.
• Incubated at 37c in an anerobic chamber under
an atmospheric pressure of 80% N2,10% CO2 &
10% H2 over 3 hours
• Under chromatography, it reveals presence of
any of the VSCs.

40. Dark field or phase contrast
microscopy
• Can assess the presence of motile
organisms & spirochetes causing
halitosis.
• Patient becomes aware about presence
of these in saliva, plaque & tongue
coating.

41. PREVENTIVE MEASURES
Preventive measures rather than curative aspects are highly
recommended.
– Visit dentist regularly
– Periodical tooth cleaning by dental professional.
– Brushing of teeth twice daily with appropriate brushing techniques and
for a duration of 2-3 mins.
– Use of a tongue scraper to get rid of the lurking odour causing bacteria
in the tongue surface.

42. – Flossing after brushing to remove food particles stuck in
between the tooth surfaces.
– Limit intake of strong odour species.
– Limit sugar and caffeine intake.
– Drink plenty of liquids.
– Chew sugar free gum for a minute when mouth feels dry.
– Eat fresh fibrous vegetables such as carrots.

43. MANAGEMENT:
• Treatment needs (TN) for halitosis have been categorized into 5 classes
in order to provide guidelines for clinicians in treating halitosis
patients:
• Treatment of physiologic halitosis (TN-1),
• Oral pathologic halitosis (TN-1 and TN-2), and
• Pseudo-halitosis (TN-1 and TN-4) should be the responsibility of a
dentist,
• However, treatment of extra-oral pathologic halitosis (TN-3) or
halitophobia (TN-5) should be undertaken by a physician or medical
specialist such as a psychiatrist or psychologist.

45. TREATMENT
(i) Mechanical reduction of intraoral nutrients and micro-
organisms
(ii)Chemical reduction of oral microbial load
(iii) Rendering malodorous gases nonvolatile
(iv) Masking the malodor.

46. 1. Mechanical reduction of intraoral nutrients and micro-organisms
- Tongue cleaning
- Tooth brush
- Inter-dental cleaning
- Professional periodontal therapy
- Chewing gum

47. 2. Chemical reduction of oral microbial load
- Chlorhexidine
- Essential oils
- Chlorine dioxide : oxidises VSCs
- Two-phase oil- water rinse
- Triclosan
- Aminefluoride/ Stannous fluoride
- Hydrogen peroxide
- Oxidising lozenges

48. 3.Conversion of volatile sulfide compounds : conversion into
non volatile compunds with a metal with more affinity for
sulfur in VSCs like Zn.
- Metal salt solutions : HALITA, 0.05% CHX,0.05%CPC &
0.14% Zn lactate
- Toothpastes – baking soda dentifrices
- Chewing gum- with tea extracts like
epigalloatchin

49. 4. Masking the malodor
-Rinses
-Mouth sprays
-Lozenges containing volatiles
-Chewing gum

50. Herbal treatment:
 Herbs and essential oils can be made into very effective mouthwash
remedies to sweeten breath and help keep gums and teeth
healthy fennel not only improves digestion, but also can reduce bad
breath and body odor that originates in the intestines.
 Give raw carrots as a midday treat to help scour teeth of bacteria-laden
plaque, a common cause of bad breath.
 Cardamom tea contains cineole, a potent antiseptic that kills bad-
breath bacteria and sweetens breath.

51.  Thymol, one of the constituents of thyme, is
contained in antiseptic mouthwashes.
 Neem leaf powder can be used as an effective tooth
powder to fight plaque and gingivitis when mixed
with astringent herb powders and/or baking soda.
 A few drops of Tea tree oil , lemon or peppermint
essential oils can be added to warm water for an
effective mouth rinse to freshen breath

52. Conclusion:
• It’s a common complaint that may periodically affect most
of the adult population. Oral maldor, which is commonly
noticed by patients, is an important clinical sign and
symptom that has many etiologies which include local and
systemic factors. It is often difficult for the clinician to find
the underlying pathologies.
• Although consultation and treatment may result in
dramatic reduction in bad breath, patients may find it
difficult to sense the improvement themselves