Usually referred to as bad breath, halitosis is a common complaint in the adult population and can be a significant social problem. It may however affect people of all ages.
It is characterized by unpleasant breath of air emanating consistently from the mouth. In extreme cases, affected individuals lose self-confidence and become social isolates.
The mouth (oral cavity) is the chief origin (90%) of bad breath and less often the nose, tonsils, sinus, pharynx, lungs, stomach, and metabolic diseases may contribute.
Dental decay, gum disease, oral infections, mouth sores, oral cancer, food impaction between teeth (such as meat), poor oral hygiene, poor denture/prosthesis hygiene, low salivary flow rates are all reasons for intraoral halitosis.
Even in the mouth, we find out that the tongue is the major site of oral malodor production. The mouth is home to many hundreds of microorganisms that have complex interactions with one another. Majority of these organisms hide in small crevices, crypts and pockets where there is less oxygen because oxygen tension can be detrimental to their survival.
These microbes feed on minute proteinaceous debris in the oral cavity, digest them and release certain sulphur by-products and acids. The Sulphur products are volatile and mix with every breath of air before it is exhaled. This accounts for the malodorous smell we know as halitosis.
Studies have shown these microorganisms reside in large amounts on the surface of the tongue closer to the back (or throat area). Many patients I see in the clinic avoid brushing this part of the tongue because of the fear of stimulating the unpleasant gag reflex.
Saliva is a very important bodily fluid responsible for oral self-cleansing among other functions. Aside physically neutralizing any bacterial by-products, it has antimicrobial factors that control the reproduction and balance of the oral microbial population.
During sleep, salivary flow is significantly reduced, the mouth is closed for a considerable length of time (meaning less oxygen entry), and the anaerobic microbes flourish and produce concentrated amounts of these Volatile Sulphur Compounds (VSCs). This explains why everyone experiences some bad breath first thing in the morning. We refer to this as transient halitosis and its worse if you forget to clean the night before.
Other reasons for reduced salivary flow may be; during fasting periods (food stimulates saliva secretion to aid in chewing and digestion), dehydration, cigarette smoking etc.
Some very healthy foods we eat can have a high impact on our breath. Onions, garlic, and fish are notoriously known for causing bad breath. Most of us have had arguments at work or school with people who are chronic garlic eaters. Remember onions and garlic to be Sulphur-containing foods.
Systemic diseases such as diabetes mellitus (fetor diabeticus), chronic kidney disease (uremic fetor), chronic liver disease (fetor hepaticus) and gastric reflux disease are less common reasons for halitosis.
So far we have been discussing what is termed as “Genuine halitosis”, which is halitosis that actually exists and can be confirmed by professional testing. Treatment of genuine halitosis will involve identifying causative factors and eliminating them.
More importantly however, some individuals complain of bad breath yet do not have confirmable halitosis even with objective testing. Such people wrongly interpret other people’s gestures as an indication that their breath is offensive. These individuals become so much aware of themselves that they tend to adopt behaviors to minimize their perceived problem (eg. Mouth covering during conversations or distancing themselves from social interactions).
We term this as “Halitophobia”. Some authors regard this as a form of social phobia where individuals are anxious about another person’s behavior toward them. They are unable to accept their perception of bad breath as unreal. These individuals will require clinical psychological assistance.
Dr Randy Chance, BSc. Med. Sci, BDS
Korle-Bu Teaching Hospital & Official Doctor at Bisa
JA Regezi, JJ Sciubba, RCK Jordan. Oral pathology- Clinical pathologic correlations; 5th Ed 2008, pp 193-194
José Roberto Cortelli, Mônica Dourado Silva Barbosa, Miriam Ardigó Westphal. Halitosis: a review of associated factors and therapeutic approach. Braz. oral res. vol.22 supl.1 São Paulo Aug. 2008
Ken Yaegaki Jeffrey M. Coil Examination, Classification, and Treatment of Halitosis; Clinical Perspectives J Can Dent Assoc 2000; 66:257-61
van den Broek AM, Feenstra L, de Baat C. A review of the current literature on management of halitosis. Oral Dis. 2008; 14(1):30-9. Review
S R Porter, C Scully Oral malodour (halitosis); BMJ. 2006 Sep 23; 333(7569): 632–635.