The Journal of Dental Hygiene. Halitosis: A Review of Current Literature. Brenda L. Armstrong Key Words: halitosis, oral malodor, bad breath, assessment. Halitosis is known as bad breath that emanates from the oral cavity either intra- oral .. Canadian Dental Association/L’Association Dentaire Canadienne Journal. Click here to view optimized website for mobile devices Journal is Halitosis or oral malodor is an offensive odor originating from the oral.

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Halitosis is formed by volatile molecules which are caused because of pathological or nonpathological reasons and it originates from an oral or a non-oral source.

Halitosis affects a person’s daily life negatively, most of people who complain about halitosis refer halitosjs the clinic for treatment but in some of the people who can suffer from halitosis, there is no measurable halitosis. There are several methods to determine halitosis.

Halitosis can be treated if its etiology can be detected rightly. The most important issue for treatment of halitosis is detection etiology or determination its source by detailed clinical examination.

Management may include simple measures such as scaling and root planning, instructions for oral hygiene, tongue cleaning, and mouth rinsing. The aim of this review was to describe the etiological factors, prevalence data, diagnosis, and the therapeutic mechanical and chemical approaches related to halitosis.

Human breath is composed of highly complex substances with numerous variable odors which can generate unpleasant situations like halitosis.

Halitosis is a latin word which derived from halitus breathed air and the osis pathologic alteration ,[ 1 ] and it is used haliosis describe any disagreeable bad or unpleasant odor emanating from the mouth air and breath. Foetor oris, oral malodor, mouth odor, bad breath, and bad mouth odor are the other terms which are used to describe and characterize the halitosis. It creates social and psychological disadvantages for individuals, and these situations affect individual’s relation with other people.

Halitosis is formed by volatile molecules which jjrnal caused because of pathological or nonpathological reasons, and it originates from an oral or a non-oral source. These volatile compounds are sulfur compounds, aromatic compounds, nitrogen-containing compounds, amines, short-chain fatty acids, alcohols or phenyl compounds, aliphatic compounds, and ketones [ Table 1 ].

Odoriferous components cause halitosis[ 17 ]. Volatile sulfur compounds VSCs are mainly responsible for intra-oral halitosis. These compounds are mainly hydrogen sulfide and methyl mercaptan.

They produce bacteria by enzymatic reactions of sulfur-containing amino acids which are L-cysteine and L-methionine [ Table 2 ]. The bacteria which are the most active VSC halitowis are shown [ Table 3 ]. Bacteria which is active producers of volatile sulfur compounds in vitro adapted from Persson et al.

The other VSC jjrnal dimethyl sulfide which mainly responsible for extra-oral or blood-borne halitosis,[ 20 ] but it can be a contributor to oral malodor.

Ketones such as acetone, benzophenone, and acetophenone are present in both alveolar lung and mouth air; indole and dimethyl selenide are present in alveolar air. The number of bacterial species, which are found in oral cavity, are over ,[ 8 ] and most of them are capable to produce odorous compounds which can cause halitosis.

In these conditions, poor oral hygiene plays a key factor for multiplication of halitosis causative bacteria and causes an increase in halitosis. These bacteria include especially Gr-negative species and proteolytic obligate anaerobes [ Table 4 ],[ 24 — 27 ] and they mainly retained in tongue coating and periodontal pockets.

Halitosis – An overview: Part-I – Classification, etiology, and pathophysiology of halitosis

By the poor oral hygiene, food debris and dental bacterial plaque accumulate on the teeth and tongue, and cause caries and periodontal diseases like gingivitis and periodontitis. The inflammation of gingival and periodontal tissues creates typical sources for oral malodors[ 3233 ] and plaque-related periodontal disease can increase the severity of halitosis.

However, the other forms of periodontal disease, especially acute and aggressive forms such as acute necrotizing ulcerative gingivitis, pericoronitis, Vincent’s disease or aggressive forms of periodontitis, can increase unpleasant breath odor.

The previous studies showed a relationship between oral halitosis and periodontal disease. Periodontal diseases may be developed by the volatile sulfur-containing compound transition to periodontal tissues.


Besides periodontal conditions, untreated deep carious lesions also create the retention area for food debris and dental bacterial plaque and may cause halitosis. Another important factor in halitosis is the flow of saliva. The intensity of sulfur compounds is increased because of salivary flow reduction or xerostomia. All these factors [ Table 5 ] cause food or plaque retention area, raising bacterial amount, tissue breakdown, putrefaction of amino acids, and decreasing of saliva flow.

All these conditions result in the release of volatile compounds and cause halitosis. This type halitosis has many sources, but it is rarely seen. Respiratory system problems, gastrointestinal disease, hepatic disease, hematological or endocrine system disorders and metabolic conditions can all be the causes of halitosis.

Respiratory system problems can jalitosis divided into upper and lower respiratory tract problems. They are sinusitis, antral malignancy, cleft palate, foreign bodies in the nose or lung, nasal malignancy, subphrenic abscess, nasal sepsis, tonsilloliths, tonsillitis, pharyngeal malignancy, lung infections, bronchitis, and bronchiectasis lung malignancy. Gastrointestinal diseases cause halitosis.

Pyloric stenosis, duodenal obstruction, aorto-enteric anastomosis, pharyngeal pouches, zenker’s diverticulum, hiatal hernia cause food retention. Reflux esophagitis, achalasia, steatorrhea, halitosia other malabsorption syndromes may cause excessive flatulence or Helicobacter pylori infection causes gastric ulcers[ 5360 ] and VSC levels increase in oral breath.

Levels of VCS’s in oral breath may be higher in patients with erosive than nonerosive oesophagogastro-duodenal mucosal disease although VSC levels are not influenced by the degree of mucosal damage. Also, hepatic or hematological diseases which are hepatic failure foetorhepaticus and leukemia’s, renal failure usually end-stage renal failureendocrine system disorders which are diabetic ketoacidosis or menstruation menstrual breathmetabolic disorder which halitosls trimethylaminuria and hypermethioninemia may cause halitosis [ Table 6 ].

Dietary products such as garlic, onions, spiced foods cause transient unpleasant odor or halitosis. Therewithal drugs such as alcohol, tobacco, betel, solvent abuse, chloral haalitosis, nitrites and nitrates, dimethyl sulfoxide, disulphiram, somecytotoxics, phenothiazines, amphetamines, suplatast tosilate, and paraldehyde may create the same effect[ 6263 ] [ Table halitosix ].

Assessment methods of halitosis ensure discrimination of pseudo-halitosis and halitophobia. For these reasons, diagnosis of the halitosis, and assessment of its severity conditions that patients have, is it genuine halitosis or pseudo-halitosis or halitophobia are very important.

Therefore, the diagnostic way and tools were developed. The oldest way for unpleasant odor detection is by smelling with the nose. Measurement of unpleasant odors by smelling the exhaled air of the mouth and nose is called organoleptic measurement. It is the simple way for the detection of halitosis. The measurement method is the organoleptic test; the patient takes breathe deeply by inspiring the air by nostrils and holding awhile, then expiring by the mouth directly or via a jurna, while the examiner sniffs the odor at a distance of 20 cm the purpose hallitosis using a pipette is to lessen the intensity of expiring air halitlsis the severity of odor is classified into various scales, such as a 0- to 5-point scale 0: This measurement is considered to be the gold standard for measuring and assessing bad jurnzl 67 ] because of no-cost, and being practical and simple.

However, it has some difficulties. It may be difficult to calibrate the practitioner and to gain the correct result; in clinical practice, the patient should avoid from eating odiferous foods for 48 h before the assessment and that both the patient and the examiner should refrain from drinking coffee, tea or juice, smoking and using scented cosmetics before the assessment.

By this way the unpleasant side of organoleptic measurement becomes a more acceptable one. Measurement with the gas chromatography method is considered to be highly objective, reproducible, and reliable. It separates and analyzes compounds that can be vaporized without decomposition; samples are collected from saliva, tongue coating, or expired breath. In this method, jurnxl are halitosos and equipped with a flame photometric detector or by producing mass spectra.

Halitosis: From diagnosis to management

In the gas chromatography method, the patient close the mouth and hold air 30 s, then mouth air 10 mL halitpsis aspirated using a gas-tight syringe. The results are precise and reliable, but this method takes a long time to run. Moreover, it is expensive and not used hqlitosis in chairside, and requires a skilled operator. Therefore, sometimes we may see low correlation between gas chromatography and organoleptic measurements.


Gas chromatography has high accuracy and sensitivity, but the application method in chairside is difficult and expensive. In order to avoid these disadvantages, a halitosus portable device which is a sulfide monitor was developed to measure VSCs.

In this method before taking measurement, patients should close the mouth and refrain from talking food for 5 min prior to measurement, then a disposable tube of the sulfide monitor is inserted into patient’s mouth to collect mouth air. Meanwhile, the patient is breathing through the nose and the disposable tube is connected to the monitor.

Halitosis – An overview: Part-I – Classification, etiology, and pathophysiology of halitosis

Sulfur-containing compounds in the breath can generate an electro-chemical reaction. This reaction related directly with levels of volatile sulfur-containing compounds. The jurnl and specificity of the sulfide monitor is less than the gas chromatography but correlations of measurements are highly significant.

On the other hand, the sulfide monitor and organoleptic measurements show low correlation because of volatile compounds such as alcohols, phenyl compounds, alkenes, ketones, polyamines.

Short-chain fatty acids can be detected by organoleptic measurements, but cannot be detected by the sulfide monitor so the correlations between measurements may be inconsistent. Because of difficulties of gas chromatography and less sensitivity of sulfide monitors, a more sensitive and easy device was made. Chemical sensors have an integrated probe to measure sulfur compounds from periodontal pockets and on the tongue surface.

The working principle of chemical sensors is similar to sulfide monitors. Through the sulfide-sensing probe, sulfide compounds generate an electrochemical voltage and this voltage is measured by an electronic unit.

The measurement is shown on device’s screen as a digital score. Using the new chemical sensors, ammonia and methyl mercaptan compounds can be measured from breath air and some new types of sensors measure each volatile sulfur-containing compounds separately.

The sensitivity is similar to gas chromatography and results of the measures are highly close to organoleptic scores so chemical sensors are called the electronic nose. The BANA test is practical for chair-side usage. It is a test strip which composed of benzoyl-DL-arginine-a-naphthylamide and detects short-chain fatty acids and proteolytic obligate gram-negative anaerobes, which hydrolyze the synthetic trypsin substrate and cause halitosis. It detects especially Treponema denticolaP. By using the BANA test, we can detect not only halitosis, but also periodontal risk assessment.

To detect halitosis, the tongue is wiped with a cotton swab. For periodontal risk assessment, the subgingival plaque is obtained with a curette.

To evaluate, the samples are placed on the BANA test strip, which is then inserted into a slot on a small toaster-sized incubator.

Deepening of the blue color shows existence of the higher the concentration and halitoss greater the number of organisms. The close relationships are found between the BANA test and organoleptic measurements, but the relationship between the BANA test and sulfur monitor measurements are poor.

Performing multiple-regression analysis with organoleptic measurements and the BANA score as the dependent variable, both peak VSC levels and BANA scores factored into the regression, yielding highly significant associations. The BANA test results demonstrate a significant positive correlation with the increasing pocket depth. Deglycosylation is the removed link of glycosyl groups from glycoproteins.

Deglycosylation of glycoproteins are initial step in oral malodor production. Proteolysis of glycoprotein depends on the initial removal of the carbohydrate side-chains which are O- and N-linked carbohydrates. The salivary incubation is one of the assessment methods to measure halitosis indirectly. First time, Marc Quirynen et al. After incubation, an examiner evaluates the odor.

Although this method has some similarities with the organoleptic measurements, it has some advantages over them. The most important advantage is that the salivary incubation test has much less influenced by external parameters such as smoking, drinking coffee, eating garlic, onion, spicy food, and scented cosmetics.

However in organoleptic measurements, external parameters have negative halitowis on the result so the patient and examiner should avoid some odiferous food and drink before 48 h.