| ICD-10 | R19.6 |
|---|---|
| ICD-9 | 784.99 |
| DiseasesDB | 5603 |
| MedlinePlus | 003058 |
Halitosis, or bad breath, is a term used to describe noticeably unpleasant odors exhaled in breathing—whether the smell is from an oral source due to bacteria or otherwise. 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 third-most-frequent reason for seeking dental aid, following tooth decay and periodontal disease.[1]
Contents |
In most cases (85–90%), bad breath originates in the mouth itself.[2] The intensity of bad breath differs during the day, due to eating certain foods (such as garlic, onions, meat, fish, and cheese), obesity, smoking, and alcohol consumption.[3][4] Because the mouth is exposed to less oxygen and is inactive during the night, the odor is usually worse upon awakening ("morning breath"). Bad breath may be transient, often disappearing following eating, brushing one's teeth, flossing, or rinsing with specialized mouthwash.
Bad breath may also be persistent (chronic bad breath), which is a more serious condition, affecting some 25% of the population in varying degrees.[5] It can negatively affect the individual's personal, social, and business relationships, leading to poor self-esteem and increased stress.
Listerine can lay claim to the origins of the word halitosis, which is a combination of the Latin halitus, meaning 'breath', and the Greek suffix osis often used to describe a medical condition, e.g., "cirrhosis of the liver".
The term "halitosis" was introduced by Listerine in 1921, but bad breath is not a modern affliction. It has been causing embarrassment for thousands of years. Records mentioning bad breath have been discovered more than 3,000 years ago, all the way back in 1550 B.C. Back then, exactly what caused bad breath was not known, but a mouthwash of wine and herbs was one recommended way of solving the problem.
The most common location for mouth-related halitosis is the tongue. Tongue bacteria produce malodorous compounds and fatty acids, and account for 80 to 90 percent of all cases of mouth-related bad breath.[6] 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, polyamines, or the "rotten egg" smell of volatile sulfur compounds (VSCs) such as hydrogen sulfide, methyl mercaptan, Allyl methyl sulfide, and dimethyl sulfide.
The most widely-known reason to clean the tongue is for the control of bad breath. Methods used against bad breath, such as mints, mouth sprays, mouthwash or gum, may only temporarily mask the odors created by the bacteria on the tongue, but cannot cure bad breath because they do not remove the source of the bad breath. In order to prevent the production of the sulfur-containing compounds mentioned above, the bacteria on the tongue must be removed, as must the decaying food debris present on the rear areas of the tongue. Most people who clean their tongue use a tongue cleaner (tongue scraper), or a toothbrush. Specially designed tongue cleaners are a lot more effective (collecting and removing the bacterial coating) than toothbrushes (which merely spread the bacterial accumulations on the tongue and in the mouth).
There are over 600 types of bacteria found in the average mouth. Several dozen of these can produce high levels of foul odors when incubated in the laboratory. The odors are produced mainly due to the breakdown of proteins into individual amino acids, followed by the further breakdown of certain amino acids to produce detectable foul gases. 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.[7]
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 order of descending prevalence: inter-dental and sub-gingival niches, faulty dental work, food-impaction areas in-between the teeth, abscesses, and unclean dentures.[8] Oral based lesions caused by viral infections like Herpes Simplex and HPV may also contribute to bad breath.[9]
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.[10][11]
The second major source of bad breath is the nose. In this occurrence, the air exiting the nostrils has a pungent odor that differs from the oral odor. Nasal odor may be due to sinus infections or foreign bodies.[7][8]
In general, putrefaction from the tonsils is considered a minor cause of bad breath, contributing to some 3–5% of cases. Approximately 7% of the population suffer from small bits of calcified matter in tonsillar crypts called tonsilloliths that smell extremely foul when released and can cause bad breath.[7][12]
The Cardia, which is the valve between the stomach and the esophagus, may not close properly due to a Hiatal Hernia or GERD, allowing acid to enter the esophagus and gases escape to the mouth.[13][14] A Zenker's diverticulum may also result in halitosis due to aging food retained in the esophagus.
The stomach is considered by most researchers 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 serious enough to be bringing up stomach contents or a fistula between the stomach and the esophagus—which will demonstrate more serious manifestations than just foul odor.[2]
In the case of allyl methyl sulfide (the byproduct of garlic's digestion), odor does not come from the stomach, since it does not get metabolized there.[15]
There are a few systemic (non-oral) medical conditions that may cause foul breath odor, but these are extremely infrequent in the general population. Such conditions are:[16][17]
Individuals afflicted by the above conditions often show additional, more diagnostically conclusive symptoms than bad breath. People troubled by bad breath should not conclude that they suffer from these conditions or disease.
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.[19]
Scientists have long thought that smelling one's own breath odor is often difficult due to acclimatization, although many people with bad breath are able to detect it in others. Research has suggested that self-evaluation of halitosis is not 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.[20][21]
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.[22]
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.[2] 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. Home tests that use a chemical reaction to test for the presence of polyamines and sulfur compounds on tongue swabs are now available, 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 sessions 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 laboratory methods for diagnosis of bad breath:
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.[1][7][28]
At the current time, chronic halitosis is not very well understood by most physicians and dentists, so effective treatment is not always easy to find. Six strategies may be suggested:
Before discussing them, it is important to note that there has not been a single documented medical case of successfully cured chronic halitosis using any of the currently available mouthwashes. Mouthwashes often contain antibacterial agents including cetylpyridinium chloride, chlorhexidine, zinc gluconate, essential oils, and chlorine dioxide. Zinc and chlorhexidine provide strong synergistic effect.[30][31] They may also contain alcohol, which is a drying agent. 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.
A relatively new approach for home-care of bad breath is by oil-containing mouthwashes. The use of essential oils has been studied,[32] 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.[33] also advances in oral science has made advice websites available world wide.
According to traditional Ayurvedic medicine, chewing areca nut and betel leaf is an excellent remedy against bad breath. In South Asia, it was a custom to chew areca or betel nut and betel leaf among lovers because of the breath-freshening and stimulant drug properties of the mixture. Both the nut and the leaf are mild stimulants and can be addictive with repeated use. The betel nut will also cause tooth decay and dye one's teeth bright red when chewed.[34] Both areca nut and the betel leaf chewing however are recognised risk factors for squamous cell carcinoma. Their use is not recommended.
Bad breath often evokes a reaction characteristic of disgust among those who interact with bad breath sufferers. This is a natural defensive reaction designed to protect the body from potential sources of disease: The major chemical compounds of bad breath are the same as those emitted by rotting food (Putrescine), feces (Skatole), and even dead bodies (Cadaverine), all potential sources of disease and infection.
When the brain detects these compounds, it protects the body by forcing physical recoil (which moves the body away), scrunching up the nose (which constricts the nasal passages, and prevents further intake of noxious odors), and by causing gagging (which stops anything being swallowed). It may also produce nausea and vomiting, which ejects anything that has already been swallowed. Although these reactions are involuntary, they are often misinterpreted as a personal judgement on the sufferer, and can severely damage personal relationships.[35]
In 1996, the International Society for Breath Odor Research (ISBOR) was formed to promote multidisciplinary research on all aspects of breath odors. The eighth international conference on breath odor took place in 2009 in Dortmund, Germany.
|
||||||||||||||||||||||||||||