Halitosis is a condition where patient feels unpleasent or a type of offensive odors in air, it may be due to poor oral hygiene or oral cavity usually seen in patients who are social handicap, some times raely it is a presentation of serious systemic illness which require diagnosis and treatment.
Etiology
Physiologic halitosis, such as with eating onions and garlic or with morning breath, is temporary. These odors are reversible, transient, and responsive to Simple oral hygiene. pathologic halitosis is more intense and not easily reversible. It may arise from similar mechanisms but results more frequently from regional or systemic pathology, leading to persistent odors that ultimately require treatment.Persistent halitosis (usually noted by individuals around the patient) is more severe than physiologic halitosis. The important task initially is to categorize the halitosis as either localized to the oral cavity or originating systemically. In 80% to 90% of patients, halitosis is due to bacterial activity from disorders
of the oral cavity, and in the remainder of patients, the condition is attributed to nonoral or systemic sources. Volatile sulfur compounds arising through the microbia degradation of amino acids are the presumed source of most offending odors. Bad breath may originate from the following areas: oral cavity 85% to 88%, nasal passages 8%, tonsils 3%, and other sites 2% to 3% . In addition, the causes of halitosis can be subcategorized into pathologic and nonpathologic types.
Nonpathologic causes Morning breath is due to decreased salivary flow overnight associated with increased fluid pH, elevated gram-negative bacterial growth, and volatile sulfur
compounds production. Xerostomia of any cause (e.g., sleep, diseases, medication, mouth breathing, and especially age-related declines in salivary quantity and quality) can contribute to halitosis. Missed meals can lead to halitosis secondary to decreased salivary flow and the absence of the mechanical action of the food on the tongue surface to wear down filiform papillae. Tobacco or alcohol can be a contributing cause of halitosis. Metabolites from ingested food (onions, garlic, alcohol, pastrami, and other meats) are absorbed into the circulation and then excreted through the lungs. Medications such as anticholinergic drugs can cause xerostomia, especially in the elderly. Other agents include amphetamines, psychiatric drugs,
antihistamines, decongestants, narcotics, antihypertensives, anti-parkinsonian agents, chemotherapy, and radiation therapy.
Pathologic causes Local oropharynx Chronic periodontal disease and gingivitis are common sources through the promotion of bacterial overgrowth. In their absence, the most likely oral source is the posterior dorsum of the tongue with posterior nasal drainage being a frequent contributing factor to local bacterial overgrowth. Stomatitis and glossitis caused by systemic disease, medication, or vitamin deficiencies can lead to trapped food particles and desquamated tissue. An improperly cleaned prosthetic appliance can be a local contributor, as can primary pharyngeal cancer. Other conditions associated with parotid dysfunction (e.g., viral and bacterial infections, calculi, drug reactions, systemic conditions including 'sgren's syndrome) are also important. Tonsils infrequently cause halitosis (found in 7% of the population), even with crypt tonsillitis. These may alarm patients but are usually asymptomatic and not associated with any
pathology. Gastrointestinal tract Gastrointestinal sources occasionally contribute to intermittent bad breath. Potential sources include gastroesophageal reflux disease, gastrointestinal bleeding, gastric cancer, malabsorption syndromes, and enteric infections. Respiratory tract Chronic sinusitis, nasal foreign bodies or tumors, postnasal drip, bronchitis, pneumonia, bronchiectasis, tuberculosis, and malignancies may cause halitosis. Psychiatric Halitophobia is imaginary halitosis associated with psychiatric disorders. Systemic sources include diabetic ketoacidosis (sweet, fruity, acetone breath), renal failure (ammonia or fishy odor), hepatic failure (fetor hepaticus a sweet amine odor), high fever with dehydration, and vitamin or mineral deficiencies leading to a dry mouth
Physiologic halitosis, such as with eating onions and garlic or with morning breath, is temporary. These odors are reversible, transient, and responsive to Simple oral hygiene. pathologic halitosis is more intense and not easily reversible. It may arise from similar mechanisms but results more frequently from regional or systemic pathology, leading to persistent odors that ultimately require treatment.Persistent halitosis (usually noted by individuals around the patient) is more severe than physiologic halitosis. The important task initially is to categorize the halitosis as either localized to the oral cavity or originating systemically. In 80% to 90% of patients, halitosis is due to bacterial activity from disorders
of the oral cavity, and in the remainder of patients, the condition is attributed to nonoral or systemic sources. Volatile sulfur compounds arising through the microbia degradation of amino acids are the presumed source of most offending odors. Bad breath may originate from the following areas: oral cavity 85% to 88%, nasal passages 8%, tonsils 3%, and other sites 2% to 3% . In addition, the causes of halitosis can be subcategorized into pathologic and nonpathologic types.
Nonpathologic causes Morning breath is due to decreased salivary flow overnight associated with increased fluid pH, elevated gram-negative bacterial growth, and volatile sulfur
compounds production. Xerostomia of any cause (e.g., sleep, diseases, medication, mouth breathing, and especially age-related declines in salivary quantity and quality) can contribute to halitosis. Missed meals can lead to halitosis secondary to decreased salivary flow and the absence of the mechanical action of the food on the tongue surface to wear down filiform papillae. Tobacco or alcohol can be a contributing cause of halitosis. Metabolites from ingested food (onions, garlic, alcohol, pastrami, and other meats) are absorbed into the circulation and then excreted through the lungs. Medications such as anticholinergic drugs can cause xerostomia, especially in the elderly. Other agents include amphetamines, psychiatric drugs,
antihistamines, decongestants, narcotics, antihypertensives, anti-parkinsonian agents, chemotherapy, and radiation therapy.
Pathologic causes Local oropharynx Chronic periodontal disease and gingivitis are common sources through the promotion of bacterial overgrowth. In their absence, the most likely oral source is the posterior dorsum of the tongue with posterior nasal drainage being a frequent contributing factor to local bacterial overgrowth. Stomatitis and glossitis caused by systemic disease, medication, or vitamin deficiencies can lead to trapped food particles and desquamated tissue. An improperly cleaned prosthetic appliance can be a local contributor, as can primary pharyngeal cancer. Other conditions associated with parotid dysfunction (e.g., viral and bacterial infections, calculi, drug reactions, systemic conditions including 'sgren's syndrome) are also important. Tonsils infrequently cause halitosis (found in 7% of the population), even with crypt tonsillitis. These may alarm patients but are usually asymptomatic and not associated with any
pathology. Gastrointestinal tract Gastrointestinal sources occasionally contribute to intermittent bad breath. Potential sources include gastroesophageal reflux disease, gastrointestinal bleeding, gastric cancer, malabsorption syndromes, and enteric infections. Respiratory tract Chronic sinusitis, nasal foreign bodies or tumors, postnasal drip, bronchitis, pneumonia, bronchiectasis, tuberculosis, and malignancies may cause halitosis. Psychiatric Halitophobia is imaginary halitosis associated with psychiatric disorders. Systemic sources include diabetic ketoacidosis (sweet, fruity, acetone breath), renal failure (ammonia or fishy odor), hepatic failure (fetor hepaticus a sweet amine odor), high fever with dehydration, and vitamin or mineral deficiencies leading to a dry mouth
Epidemiology
The prevalence of halitosis is not known, but many individuals worry about it. In one study, 20% of adults worried about bad breath, when little was measured. Approximately 25% of individuals seeking help for halitosis may be halitophobic or suffering from pseudohalitosis.
History
History
Focus on the characteristics of the bad breath, although the patient is often unable to describe his or her condition accurately because of olfactory desensitization. Is the odor transient or constant? Constant odor suggests chronic systemic disease or serious disorders of the oral cavity. What are the precipitating, aggravating, or relieving factors? Ask about smoking habits, diet, drugs, dentures, mouth breathing, snoring, hay fever, and nasal obstruction. Because the therapy for halitosis of oral origin, beyond the limitation of aggravating factors, is proper oral hygiene and vigorous tongue brushing, an evaluation of the patient's tooth brushing and flossing regimen is imperative.
Physical examination
Physical examination
This should be undertaken with an emphasis on the oral cavity, particularly looking for ulceration, dryness, trauma, postnasal drainage, infections, inflamed cryptic tonsils, or neoplasms. Techniques for localizing the odor source (systemic vs. oral cavity) include: Seal the lips and blow air through the nose. If a fetid odor is noted, this is suggestive of a systemic source. If an odor is only noted from the nose, then a nasal source is likely. Pinch the nose with the lips closed. Hold respiration and exhale gently through the mouth. Odors detected in this fashion generally are local in origin. If a similar odor is noted from both sources then a systemic source may be suspected.
Testing
Testing
For most patients, clinical laboratory testing and diagnostic imaging are unnecessary, and should only be pursued on the basis of specific findings indicated by the history and physical examination. The Schirmer's test may be useful in identifying xerophthalmia and associated xerostomia seen with Sjgren's syndrome and some other rheumatologic conditions. If indicated, radiologic studies and imaging procedures of the sinuses, thorax, and abdomen may be used to
identify infectious processes and neoplasms.
In addition to fetid odor, there may be ulceration, dryness, trauma, postnasal drainage, infections, inflamed cryptic tonsils, or neoplasms.
identify infectious processes and neoplasms.
In addition to fetid odor, there may be ulceration, dryness, trauma, postnasal drainage, infections, inflamed cryptic tonsils, or neoplasms.
