SCIENTIFIC SECTION Review Article E.L. ATTIA, MD, FRCS[C] Halitosis K.G. MARSHALL, MD, FRCP[C], CCFP Bad breath, halitosis, is an unpleasant problem most cells and other debris causes an unpleasant odour, people try to avoid. Physicians seem particularly adept which quickly disappears after the usual oral toilet and at avoiding halitosis by referring patients with this the resumption of normal salivary flow. problem to a dentist. However, halitosis may be a Food symptom of a serious disease. Even if a serious disorder is not present, the cause of bad breath can The metabolism of certain foods and beverages usually be determined and appropriate therapy given. produces volatile fatty acids or other malodorous sub- In this article the causes of halitosis and suggestions stances that are excreted through the lungs. The most for treatment are outlined. common examples are alcohol, garlic, onions and pas- La mauvaise haleine est un ph6nombne d6plaisant que trami. Studies in the 1930s and 1940s showed that if la plupart des gens cherchent A Aviter. Les m6decins garlic were introduced into the peritoneal cavity or semblent les plus aptes a Aviter ce probl6me en rubbed into the soles of the feet it still produced an rbf6rant chez un dentiste les patients avec de la unpleasant odour on the breath.23 It was also found that mauvaise haleine. Toutefois, la mauvaise haleine peut if onion or garlic were swallowed without being chewed Otre un sympt6me d'une s6rieuse maladie. MAme si il the odour would still be detected on the breath.4 n'existe pas un s6rieux d6sordre, la cause probable de Smoking la mauvaise haleine peut habituellement Otre d6termi- nbe et une th6rapie appropri6e donn6e. Dans cet There is no doubt that smoking causes an odour on article les causes de la mauvaise haleine et des the breath. However, whether this is considered halito- suggestions pour le traitement sont tracbes. sis is subjective: if both partners of a couple smoke they will usually not notice each other's bad breath. Halitosis is a lyrical term derived from the Latin halitus (breath) and the Greek suffix osis (condition, Menstruation action or pathologic process); in plain English it means It has been reported that during menstruation some bad breath. women have bad breath, probably secondary to hor- The one certainty about bad breath is that it is monal changes;5 however, to our knowledge this observa- profitable; in 1969 the American public spent more tion has not been verified. than $250 000 000 to combat this disorder. From such a figure and the emphasis it receives in television Pathologic causes of halitosis advertisements it seems that halitosis has great social significance. However, physicians have tended to ignore Disorders of the oral cavity halitosis. Most available literature is in dental journals. Bad breath is caused by mixture of the breath with It is thought that disorders of the oral cavity cause malodorous compounds emanating from different areas 56% to 85% of all cases of halitosis.6 Hence, it is of the respiratory and upper digestive tracts. The causes important to understand how bad breath develops in of halitosis can be divided into two categories: physi- these disorders. and (Table Normal saliva generates an unpleasant odour after it ologic pathologic I). has been incubated for 1 hour.7 However, saliva from Physiologic causes of halitosis individuals with periodontitis becomes malodorous more rapidly; volatile compounds are produced through the Lack offlow ofsaliva during sleep putrefactive action of microorganisms on substances There is no flow of saliva during sleep.' Therefore, within the saliva, such as leukocytes, epithelial cells and of the retained exfoliated oral mucopolysaccharides. However, putrefaction of saliva is putrefaction epithelial only one source of oral halitosis; a healthy mouth is From the departments of otolaryngology and family practice, McGill replete with proteinaceous materials ripe for putrefac- University and the Montreal General Hospital tion, the main ones being exfoliated epithelial cells and Reprint requests to: Dr. E.L. Attia, Department of otolaryngology, food debris. Montreal General Hospital, 1650 Cedar Ave., Montreal, PQ H3G While putrefaction may occur in everyone's mouth, I A4 the process is accentuated when degenerative and CMA JOURNAL/JUNE 1, 1982/VOL. 126 1281 inflammatory disorders are present. For example, gin- manufacturers of nine brands of mouthwash to stop givitis and periodontitis are almost always associated using advertisements that claim that the mouthwash with severe halitosis.8 Several factors enhance the pu- "effectively destroys bacteria that cause bad breath", trefactive processes in such diseases: an increase in the because there is a lack of evidence for this action.'3 number of bacteria, disintegrating epithelial cells or Unfortunately, such official actions seem to have had damaged leukocytes, reduced salivary flow and an little effect on the public, which spends more and more increase in alkalinity in the oral cavity. No single type each year on highly promoted and widely advertised of microorganism is responsible for halitosis.9 Bacillus breath deodorants.'4 The prolonged use of certain subtilus, Proteus vulgaris, Pseudomonas aeruginosa, so-called deodorants, such as sodium perborate or coliforms, Bacteroides melanogenicus, Clostridium hydrogen peroxide, is probably not only ineffective but sporogenes and C. histolyticum have all been associated also may have undesirable results, such as producing a with proteolytic activity in the mouth. The products of black, hairy tongue.'2 bacterial action that are primarily responsible for bad breath are methylmercaptan and hydrogen sulfide.'" Disorders of the upper respiratory tract Halitosis originating in the oral cavity is most frequently associated with poor oral hygiene, dental Breathing through the mouth: Breathing through the plaque, dental caries, gingivitis, stomatitis, periodonti- mouth causes bad breath because the amount of saliva tis, hairy tongue and oral carcinoma. Dental plaque and in the mouth is reduced by evaporation. There are hairy tongue are important sources of malodour, most several precipitating causes of breathing through the of the odour emanating from the dorsoposterior surface mouth, such as hypertrophied adenoids in children, a of the tongue." Carcinomas of the cheek, the floor of deviated nasal septum, allergic rhinitis and vasomotor the mouth, the gum, the tongue and the palate, even rhinitis. when the lesions are small, tend to ulcerate and necrose; Sinusitis: Chronic suppurative sinusitis may produce because they are usually secondarily infected, halitosis a foul-smelling purulent discharge. If the sinusitis is is a consistent problem. Carcinoma, while an uncom- secondary to an abscess at the root of one of the upper mon cause of halitosis, must be considered in a patient teeth the discharge will be present from the onset of the with bad breath. disease. Oral halitosis, when it is not secondary to a specific Foreign bodies: Long-standing nasal discharge that is disease, can usually be overcome with proper dental and unilateral and accompanied by a foul odour should be periodontal care and good oral hygiene, which includes considered to be due to a foreign body until proven frequent brushing and flossing of the teeth and brush- otherwise. The odour is caused by secondary infection, ing of the tongue, so that bacteria and degenerating tissue necrosis or lack of normal drainage. The dis- squamous cells are removed. The role of mouthwash charge should stop once the foreign body has been and other commercial products in controlling halitosis is removed."' controversial. Such products probably serve only to Atrophic rhinitis (ozena): The inability of the nasal mask bad breath and to increase salivary flow. How- mucosa to cleanse itself because of atrophic changes ever, the American Council on Dental Therapeutics with ciliary destruction results in the accumulation of believes that mouthwash does not substantially dried nasal secretions that become infected. A charac- contribute to oral health.'2 Further, the Food and Drug teristic foul odour (ozena) results. Frequent cleansing Administration of the United States has advised the with normal saline and occasionally surgical interven- Table I-Causes of halitosis Physiologic Carcinoma of the larynx Disorders of lower gastrointestinal tract Lack of flow of saliva during sleep Laryngoscleroma Gastric carcinoma Food Hiatus hernia Smoking Disorders of lower respiratory tract Pyloric stenosis Menstruation Pulmonary abscess Carcinoma of the lung Enteric infections Pathologic Other Neurologic disorders Disorders of the oral cavity Bronchiectasis Dysosmia Poor oral hygiene Necrotizing pneumonitis Dysgeusia Dental plaque Zinc deficiency Dental caries Empyema Gingivitis Gastrointestinal conditions Systemic diseases Stomatitis Salivary gland dysfunction Leukemia Periodontitis Dehydration Agranulocytosis Hairy tongue Anticholinergic drugs Febrile illness with dehydration Oral carcinoma Radiotherapy Ketoacidosis Disorders of upper respiratory tract Sjogren's syndrome Hepatic failure Breathing through the mouth Peritonsillar abscess Azotemia Chronic sinusitis Retropharyngeal abscess Drugs Foreign bodies Cryptic tonsillopathy Lithium salts Atrophic rhinitis (ozena) Vincent's angina Penicillamine Wegener's granulomatosis (midline granuloma) Carcinoma of the tonsil or pharynx Griseofulvin Tuberculosis Pharyngitis sicca Thiocarbamide Syphilis Gangrenous angina Dimethylsulfoxide