, '''oral malodor''' (scientific term), '''breath odor''', '''foul breath''', '''fetor oris''', or most commonly '''bad breath''' are terms used to describe noticeably unpleasant
Odors exhaled in
Breathing – whether the
Smell is from an oral source or not.
Halitosis has a significant impact — personally and socially — on those who suffer from it or believe they do (
Halitophobia ), and is estimated to be the 3rd most frequent reason for seeking
Dental aid, following
Tooth Decay and
Periodontal Disease .Loesche WJ, Kazor C. Microbiology and treatment of halitosis. ''Periodontology 2000''. 2002;28:256-79. PMID 12013345.
In most cases (85-90%), bad breath originates in the one's
Teeth ,
Flossing , and rinsing with specialized
Mouthwash .
Bad breath may also be (Chronic bad breath), which is a more serious condition, affecting some 25% of the population in varying degrees.Bosy A, Oral malodor: philosophical and practical aspects. ''J Can Dent Assoc''. 1997 Mar;63(3):196-201 PMID 9086681. It can negatively impact the individual's personal, social and business relationships, leading to poor
Self-esteem and increased
Stress . This condition is usually caused by the
Metabolic activity of certain types of oral
Bacteria .
Though the causes of breath odor are not entirely understood, most unpleasant
Odor s are known to arise from
Protein s trapped in the mouth which are processed by oral bacteria. There are over 600 types of bacteria found in the average mouth. Several dozens of these can produce high levels of foul odors when incubated in the
Laboratory .
The most common location for mouth-related halitosis is the . Large quantities of naturally-occurring bacteria are often found on the posterior dorsum of the tongue, where they are relatively undisturbed by normal activity. This part of the tongue is relatively dry and poorly cleansed, and bacterial populations can thrive on remnants of
Food deposits,
Dead Epithelial Cells and
Postnasal Drip . The convoluted microbial structure of the tongue dorsum provides an ideal
Habitat for
Anaerobic Bacteria , which flourish under a continually-forming tongue coating of food debris, dead cells, postnasal drip and overlying bacteria, living and dead. When left on the tongue, the
Anaerobic Respiration of such bacteria can yield either the
Putrescent smell of
Indole ,
Skatole ,
Polyamine s, or the "rotten egg" smell of
Volatile Sulfur Compound s (VSCs) such as
Hydrogen Sulfide ,
Methyl Mercaptan and
Dimethyl Sulfide .
The odors are produced mainly due to the anaerobic breakdown of
Protein s into individual
Amino Acid s, followed by the further breakdown of certain amino acids to produce detectable foul
Gas es. For example, the breakdown of
Cysteine and
Methionine produce hydrogen sulfide and methyl mercaptan respectively. Volatile sulfur compounds have been shown to be statistically associated with oral malodor levels, and usually decrease following successful treatment.Rosenberg M. Clinical assessment of bad breath: current concepts. ''J Am Dent Assoc''. 1996 Apr;127(4):475-82. PMID 8655868.
Other parts of the mouth may also contribute to the overall odor, but are not as common as the back of the tongue. These locations are, in descending prevalence order: inter-dental and sub-gingival niches, faulty
Dental work, food-impaction areas in-between the teeth,
Abscess es and unclean
Dentures .Scully C, Rosenberg M. Halitosis. ''Dent Update''. 2003 May;30(4):205-10. PMID 12830698.
There is some controversy over the role of
Periodontal Diseases in causing bad breath. Whereas bacteria growing below the gumline (subgingival
Dental Plaque ) have a foul smell upon removal, several studies reported no statistical correlation between malodor and periodontal parameters.Stamou E, Kozlovsky A, Rosenberg M. Association between oral malodour and periodontal disease-related parameters in a population of 71 Israelis. ''Oral Dis''. 2005;11 Suppl 1:72-4. PMID 15752105.Bosy A, Kulkarni GV, Rosenberg M, McCulloch CA. Relationship of oral malodor to periodontitis: evidence of independence in discrete subpopulations. ''J Periodontol''. 1994 Jan;65(1):37-46. PMID 8133414.
The second major source of bad breath is the
Nose . In this instance, the odor exiting the
Nostril s has a pungent odor which differs from the oral odor. Nasal odor may be due to
Sinus Infection s or
Foreign Bodies .
Putrefaction from the
Tonsil s is generally considered a minor cause of bad breath (contributing to some 3-5% of cases). Although some people (approximately 5% of the population) suffer from small bits of
Calcified matter in tonsillar crypts (called
Tonsillolith s), which themselves smell extremely foul when released, they do not necessarily cause bad breath.Finkelstein Y, Talmi YP, Ophir D, Berger G. Laser cryptolysis for the treatment of halitosis. ''Otolaryngol Head Neck Surg''. 2004 Oct; 131(4):372-7. PMID 15467602.
There are a few systemic (non oral) medical conditions which may cause foul breath odor, but these are extremely infrequent in the general population. Such conditions are: Tangerman A. Halitosis in medicine: a review. ''Int Dent J''. 2002 Jun;52 Suppl 3:201-6. PMID 12090453.Tonzetich J. Production and origin of oral malodor: a review of mechanisms and methods of analysis. ''J Periodontol''. 1977 Jan;48(1):13-20. PMID 264535.
# .
#
Lower Respiratory Tract Infection s (Bronchial and lung infections).
#
Renal Infections and
Renal Failure .
#
Carcinoma .
#
Trimethylaminuria ("fish odor syndrome").
#
Diabetes Mellitus .
#
Metabolic dysfunction.
People suffering from halitosis should not immediately conclude that they suffer from these conditions or diseases just by deducing from the breath odor alone, since these conditions are rare, may not display bad breath at all and will most likely show additional characters, which are more definitive than the breath odor.
Most researchers consider the
Stomach as a very uncommon source of bad breath (except in
Belching ). The
Esophagus is a closed and collapsed tube, and continuous flow (as opposed to a simple burp) of gas or putrid substances from the
Stomach indicates a health problem - such as
Reflux or a
Fistula between the stomach and the esophagus - which will demonstrate more serious manifestations than just foul odor.
Scientists have long thought that smelling one's own breath odor is often difficult due to
Habituation , although many people with bad breath are able to detect it in others. Research has suggested that self-evaluation of halitosis isn't easy because of preconceived notions of how bad we think it should be. Some people assume that they have bad breath because of bad
Taste (metallic, sour, fecal, etc), however bad taste is considered a poor indicator.Tanaka M, Anguri H, Nishida N, Ojima M, Nagata H, Shizukuishi S. Reliability of clinical parameters for predicting the outcome of oral malodor treatment. ''J Dent Res''. 2003 Jul; 82(7):518-22. PMID 12821711.Rosenberg M, Kozlovsky A, Gelernter I, Cherniak O, Gabbay J, Baht R. and Eli I. Self-estimation of oral malodor. ''J Dent Res''. 1995 Sep; 74(9):1577-82. PMID 7560419.
For these reasons, the simplest and most effective way to know whether one has bad breath is to ask a trusted adult family member or very close friend ("
Confidant "). If the confidant confirms that there is a breath problem, he or she can help determine whether it is coming from the mouth or the nose, and whether a particular treatment is effective or not.Eli I, Baht R, Koriat H, Rosenberg M. Self-perception of breath odor. ''J Am Dent Assoc''. 2001 May; 132(5):621-6. PMID 11367966.
One popular home method to determine the presence of bad breath is to
Lick the back of the
Wrist , let the
Saliva dry for a minute or two, and smell the result. This test results in
Overestimation , as concluded from research, and should be avoided. A better way would be to lightly scrape the posterior back of the tongue with a plastic disposable spoon and to smell the drying residue. A spouse, family member, or close friend may be willing to smell one's breath and provide honest
Feedback . Home tests are now available which use a chemical reaction to test for the presence of
Polyamines and sulfur compounds on tongue swabs, but there are few studies showing how well they actually detect the odor. Furthermore, since breath odor changes in intensity throughout the day depending on many factors, multiple testing may be necessary.
If bad breath is persistent, and all other medical and dental factors have been ruled out, specialized testing and treatment is required. Hundreds of dental offices and commercial breath clinics now claim to diagnose and treat bad breath. They often use some of several laboratorial methods for diagnosis of bad breath:
# ''') in the mouth air. When used properly this device can be very effective at determining levels of certain VSC-producing bacteria. However, it has drawbacks in clinical applications. For example, other common sulfides (such as
Mercaptan ) are not recorded as easily and can be misrepresented in test results. Certain foods such as garlic and onions produce sulfur in the breath for as long as 48 hours and can result in false readings. The Halimeter is also very sensitive to alcohol, so one should avoid drinking alcohol or using alcohol-containing mouthwashes for at least 12 hours prior to being tested. This analog machine loses sensitivity over time and requires periodic recalibration to remain accurate.Rosenberg M, McCulloch CA. Measurement of oral malodor: current methods and future prospects. ''J Periodontol''. 1992 Sep;63(9):776-82. PMID 1474479.
# ''',
Methyl Mercaptan , and
Dimethyl Sulfide ). It is accurate in measuring the sulfur components of the breath and produces visual results in graph form via computer interface.Murata T, Rahardjo A, Fujiyama Y, Yamaga T, Hanada M, Yaegaki K, Miyazaki H. Development of a compact and simple gas chromatography for oral malodor measurement. ''J Periodontol''. 2006 Jul;77(7):1142-7. PMID 16805675.
# ''' indicating the presence of certain halitosis-related bacteria.Kozlovsky A, Gordon D, Gelernter I, Loesche WJ, Rosenberg M. Correlation between the BANA test and oral malodor parameters. ''J Dent Res''. 1994 May; 73(5):1036-42. PMID 8006229.
# : salivary levels of this enzyme were found to be correlated with oral malodor.Sterer N, Greenstein RB, Rosenberg M. Beta-galactosidase activity in saliva is associated with oral malodor. ''J Dent Res''. 2002 Mar;81(3):182-5. PMID 11876272.
Although such instrumentation and examinations are widely used in breath clinics, the most important measurement of bad breath (the gold standard) is the actual
Sniffing and scoring of the level and type of the odor carried out by trained experts ("organoleptic measurements"). The level of odor is usually assessed on a six point intensity scale. Greenman J, Duffield J, Spencer P, Rosenberg M, Corry D, Saad S, Lenton P, Majerus G, Nachnani S, El-Maaytah M. Study on the Organoleptic Intensity Scale for Measuring Oral Malodor. ''J Dent Res''. 83(1): 81-85, 2004. PMID 14691119.
Currently, is not very well understood by most
Physician s and
Dentist s, so effective treatment is not always easy to find. Six strategies may be suggested:
# with rough foods helps clean the very back of the tongue .
# twice daily with a tongue brush,
Tongue Scraper or tongue cleaner to wipe off the bacterial
Biofilm , debris and mucus. An inverted
Teaspoon is also effective; a
Toothbrush should be avoided, as the bristles will grip the tongue, causing a gagging reflex. Scraping or otherwise damaging the tongue should be avoided, and scraping of the V-shaped row of
Taste Bud s found at the extreme back of the tongue should also be avoided. Brushing a small amount of
Antibacterial mouth rinse or tongue gel onto the tongue surface will further inhibit bacterial action.
# ''', and thereby help to reduce bad breath. Chewing may help particularly when the mouth is dry, or when one cannot perform
Oral Hygiene procedures after meals (especially those meals rich in
Protein ). This aids in provision of saliva, which washes away oral bacteria, has antibacterial properties and promotes mechanical activity which helps cleanse the mouth. Some chewing gums contain special anti-odor ingredients. Chewing on
Fennel seeds,
Cinnamon sticks,
Mastic gum or fresh
Parsley are common
Folk Remedies .
# right before bedtime with an effective mouthwash (see below). Several types of commercial
Mouthwashes have been shown to reduce malodor for hours in
Peer-reviewed scientific studies. Mouthwashes may contain active ingredients which are inactivated by the
Soap present in most
Toothpaste s. Thus it is recommended to refrain from using mouthwash directly after toothbrushing with paste (also see mouthwashes, below).Yaegaki K, Coil JM, Kamemizu T, Miyazaki H. Tongue brushing and mouth rinsing as basic treatment measures for halitosis. ''Int Dent J''. 2002 Jun;52 Suppl 3:192-6. PMID 12090451.
# , including
Brushing , daily
Flossing , and periodic visits to
Dentist s and
Hygienist s. Flossing is particularly important in removing rotting food debris and bacterial plaque from between the teeth, especially at the gumline.
Dentures should be properly cleaned and soaked overnight in antibacterial solution (unless otherwise advised by your dentist).
# in the body by drinking several glasses of water a day.
Mouthwash es often contain antibacterial agents including
Cetylpyridinium Chloride ,
Chlorhexidine ,
Zinc Gluconate ,
Essential Oil s, and
Chlorine Dioxide . They may also contain
Alcohol , which is a drying agent and may worsen the problem. Rinses in this category include Scope™ and
Listerine ™.
Other solutions rely on odor eliminators like
Oxidizers to eliminate existing bad breath on a short-term basis. Rinses in this category include TheraBreath™, Closys II™ and others.
Bad breath may be temporarily reduced by using a
Hydrogen Peroxide rinse. Hydrogen peroxide at a
Concentration of 1.5% can be taken as an oral
Antiseptic by gargling 10 ml, about two
Teaspoon s. Hydrogen peroxide is commonly available at a concentration of 3% and should be diluted to 1.5% by mixing it with an equal volume of water. Hydrogen peroxide is a powerful
Oxidizer which kills most bacteria, including useful
Aerobic Bacteria . Prolonged use of hydrogen peroxide may be harmful. Concentrated hydrogen peroxide (>50%) is
Corrosive , and even domestic-strength solutions can cause irritation to the
Eye s,
Mucous Membrane s and
Skin . Swallowing hydrogen peroxide solutions is particularly dangerous, as decomposition in the stomach releases large quantities of gas (10 times the volume of a 3% solution) leading to internal
Bleeding . Inhaling over 10% can cause severe
Pulmonary irritation.
A relatively new approach for home-care of bad breath is by oil-containing mouthwashes. The use of essential oils has been studied,Carvalho MD, Tabchoury CM, Cury JA, Toledo S, Nogueira-Filho GR. Impact of mouthrinses on morning bad breath in healthy subjects. ''J Clin Periodontol''. 2004 Feb;31(2):85-90. PMID 15016031. was found effective and is being used in several commercial mouthwashes, as well as the use of two-phase (oil:water) mouthwashes, which have been found to be effective in reducing oral malodor.Rosenberg M, Gelernter I, Barki M, Bar-Ness R. Day-long reduction of oral malodor by a two-phase oil:water mouthrinse as compared to chlorhexidine and placebo rinses. ''J Periodontol''. 1992 Jan;63(1):39-43. PMID 1552460.
Some one quarter of the patients seeking professional advice on bad breath suffer from a highly exaggerated concern of having bad breath, known as ''
Halitophobia '',
Delusional halitosis, or as a manifestation of
Olfactory Reference Syndrome . These patients are sure that they have bad breath, although many have not asked anyone for an objective opinion. Halitophobia may severely affect the lives of some 0.5-1.0% of the adult population.Lochner C, Stein DJ. Olfactory reference syndrome: diagnostic criteria and differential diagnosis. ''J Postgrad Med''. 2003 Oct-Dec;49(4):328-31. PMID 14699232. Only few psychologists and health professionals have tried to come to terms with this debilitating and difficult-to-treat emotional problem.Seemann R, Bizhang M, Djamchidi C, Kage A, Nachnani S. The proportion of pseudo-halitosis patients in a multidisciplinary breath malodour consultation. ''Int Dent J''. 2006 Apr; 56(2):77-81. PMID 16620035.Eli I, Baht R, Kozlovsky A, Rosenberg M. The complaint of oral malodor: possible psychopathological aspects. ''Psychosom Med''. 1996 Mar-Apr; 58(2):156-9. PMID 8849633.
In 1996, an international scientific organization (The International Society for Breath Odor Research,
ISBOR ) was formed to promote
Multidisciplinary research on all aspects of breath odors.
The seventh international conference on breath odor took place in August, 2007 in Chicago, and the next conference is expected to take place in 2009 in Dortmund, Germany.
