Causes of
unpleasant smell in the mouth |Halitosis.
What is Halitosis?
Halitosis have different names known as (Fetor Oris; Bad Breath; Oral Malodor) but
simply you can say halitosis is a frequent or persistent unpleasant breath odor.
Halitosis most often caused due to fermentation of food particles by
anaerobic gram-negative bacteria in the mouth, producing volatile sulfur
compounds such as hydrogen sulfide and methyl mercaptan. Causative bacteria may
be present in areas of periodontal disease, particularly when ulceration
or necrosis is present. The causative organisms reside deep in periodontal
pockets around teeth. In patients with healthy periodontal tissue, these
bacteria may proliferate on the dorsal posterior tongue.
Factors contributing
to the overgrowth of causative bacteria include decreased salivary flow (eg,
due to parotid disease, Sjögren syndrome, or use of anticholinergic
drugs), salivary stagnation, and increased salivary pH.
Certain foods or
spices, after digestion, release the odor of that substance to the lungs; the
exhaled odor may be unpleasant to others. For example, the odor of garlic is
noted on the breath by others 2 or 3 hours after consumption, long after it is
gone from the mouth.
About 85% of cases
result from oral conditions. A variety of systemic and extraoral conditions
account for the remainder.
The most
common causes overall are the following:
- Gingival disorders or periodontal
disease
- Smoking
- Ingested foods that have a volatile
component eg: meat, nuts, and coffee etc.
Gastrointestinal
disorders rarely cause halitosis, because the esophagus is normally collapsed.
However, certain disorders (eg, gastroesophageal reflux disease (GERD),
esophageal diverticula, stomach cancer) may cause halitosis. It is a fallacy
that breath odor reflects a state of digestion and bowel function.
Other breath odors
Several systemic
diseases produce volatile substances detectable on the breath, although not the
particularly foul, pungent odors typically considered halitosis. Diabetic ketoacidosis (DKA)
produces a sweet or fruity odor of acetone, liver failure produces a unique mousy odor
(musty, sweet, and/or sulfurous), and renal failure produces an odor of
urine or ammonia.
History
History of present
illness should ascertain
duration and severity of halitosis (including whether other people have noticed
or complained), adequacy of the patient’s oral hygiene, and the relationship of
halitosis to ingestion of causative foods.
Review of systems should seek symptoms of causative
disorders, including nasal discharge and face or head pain (sinusitis, nasal foreign body), productive cough and
fevers (pulmonary infection), and regurgitation of undigested food when lying
down or bending over (Zenker diverticulum). Predisposing factors such as dry
mouth, dry eyes, or both (Sjögren syndrome) should be noted.
Past medical
history should ask about
duration and amount of use of alcohol and tobacco. Drug history should
specifically ask about use of drugs that can cause dry mouth (eg, those with
anticholinergic effects.
Physical examination
Vital signs are
reviewed, particularly for presence of fever.
The nose is examined
for discharge and foreign body.
The mouth is examined
for signs of periodontal disease, dental infection, and cancer. Signs
of apparent dryness are noted (eg, whether the mucosa is dry, sticky, or moist,
and whether saliva is foamy, stringy, or normal in appearance).
The pharynx is examined
for signs of infection and cancer.
Sniff test
A sniff test of
exhaled air is conducted. In general, oral causes of halitosis result in a
putrefying, pungent smell, whereas systemic conditions result in a more subtle,
abnormal odor. Ideally, for 48 hours before the examination, the patient avoids
eating garlic or onions, and for 2 hours before, the patient abstains from
eating, chewing, drinking, gargling, rinsing, or smoking. During the test, the
patient exhales 10 cm away from the examiner’s nose, first through the mouth
and then with the mouth closed. Malodor that is perceived as worse through the
mouth suggests an oral etiology; malodor that is perceived as worse through the
nose suggests a nasal or sinus etiology. Similar malodor through both nose and
mouth may suggest a systemic or pulmonary cause.
If site of origin is
unclear, the posterior tongue is scraped with a plastic spoon. After 5 seconds,
the spoon is sniffed 5 cm from the examiner’s nose; a bad odor suggests the
malodor is caused by bacteria on the tongue.
Red flags
The following findings
are of particular concern:
- Fever
- Purulent nasal discharge or sputum
- Visible or palpable oral lesions
Interpretation of findings
Because oral causes
are by far the most common, any visible oral disease may be presumed to be the
cause of halitosis in patients with no extraoral symptoms or signs, and a
dentist should be consulted. When other disorders may be involved, clinical
findings often suggest a diagnosis.
In patients whose
symptoms seem to be related to intake of certain food or drink and who have no
other findings, a trial of avoidance (followed by a sniff test) may clarify the
diagnosis.
Testing
Extensive diagnostic
evaluation should not be undertaken unless the history and physical examination
suggest an underlying disease . Portable sulfur monitors, gas chromatography,
and chemical tests of tongue scrapings are available but best left to research
protocols or to specific dental offices that focus on halitosis evaluation and
treatment.
Treatment of Halitosis
- Regular oral hygiene and dental care
- Cause treated (treatement based on underlying causes)
Underlying diseases
are treated.
If the cause is oral,
the patient should see a dentist for professional cleaning and treatment
of gingival disease and caries. Home treatment involves enhanced
oral hygiene, including thorough flossing, toothbrushing, and brushing of the
tongue with the toothbrush or a scraper. Mouthwashes are of limited benefit,
but some with oxidant formulations (typically containing chlorine dioxide) have
shown greater short-term success. If the patient has a history of alcohol
abuse, nonalcoholic mouthwashes should be used. Psychogenic halitosis may
require psychiatric consultation.
Geriatrics Essentials
Older patients are
more likely to take drugs that cause dry mouth, which leads to difficulties
with oral hygiene (as do limited manual dexterity and conditions such as rheumatoid
arthritis and Parkinson disease) and hence to halitosis, but
they are otherwise not more likely to have halitosis. Also, oral cancers are
more common with aging and are more of a concern among older than younger
patients.
NB:
- Most halitosis results from fermentation
of food particles by anaerobic gram-negative bacteria that reside around
the teeth and on the dorsum of the tongue.
- Extraoral disorders may cause halitosis
and are often accompanied by suggestive findings.
- Home treatment includes enhanced
toothbrushing, flossing, and tongue brushing or scraping.
- Mouthwashes provide only brief benefit.