Halitosis (bad breath)

Bad breath (Halitosis) is a widespread condition affecting a significant proportion of adults. The most common causes of bad breath are decaying food debris between the teeth and gum disease. It is important to enquire about the person’s own perception of the problem including the impact on their quality of life as halitosis, although not life-threatening, can be socially embarrassing and has been known to cause psychological distress in some individuals.

Other causes that need to be considered include:

  • Tonsil or throat infections
  • Smoking, spicy food and alcohol
  • Oral infections — for example oral candidiasis and herpetic gingivostomatitis
  • Dental and gum diseases — for example poor dental hygiene including but not limited to dental abscess/decay, periodontitis
  • Suspected oral cancer
  • Dry mouth — which can lead to decreased taste sensation and difficulty in swallowing
    • This may be due to a blocked nose causing a tendency to mouth breathe
  • Problems with dentures
  • Tongue coating
  • Non-oral causes: Consider asking the person to breathe out of their mouth (pinching the nose) and then to breathe out of their nose (with the mouth closed). The condition is likely to be:
    • Oral/pharyngeal: if odour is detected from the mouth but not from the nose
    • Nasal or sinus: if odour is detected from the nose but not from the mouth
    • Systemic: if odour from the nose and mouth are of equal intensity (generally rare). For example:
      1. Oesophagitis or acid reflux
      2. Liver failure
      3. Kidney disease
      4. Diabetic ketoacidosis
    • Medication history: Drugs reported to cause halitosis include nicotine, solvent misuse, amphetamines, and some cytotoxic drugs

Management of halitosis:

General advice:

It is important to explain that transient bad breath is common upon waking (morning breath) and resolves with eating or drinking, or upon brushing the teeth or rinsing the mouth with water. Persistent halitosis is commonly caused by accumulation of food debris and dental bacterial plaque on the teeth and tongue, so regular brushing and good oral hygiene are essential.

  • Brush teeth twice daily (particularly last thing at night)
  • Interdental cleaning (floss, tape, sticks)
  • Reduce the frequency and amount of sugary food and drinks consumed. These should ideally be limited to mealtimes
  • Reduce strong flavours such as garlic or spicy foods
  • Stop smoking
  • Advise the person to seek advice from a dentist or dental hygienist

Specific advice:

If the above oral hygiene measures are insufficient, consider the following:

  • Antibacterial mouthwash and/or toothpaste
  • Consider tongue brushing, particularly for people with halitosis who have good oral hygiene and health
    • This can be done by gently brushing the surface of the tongue (in particularly the posterior region) with a soft headed toothbrush with toothpaste
    • Excessive scraping should be avoided as this can cause damage to the tongue
  • Mints, sprays/rinses and chewing gum only provide transient masking of halitosis. They are no substitute for good oral hygiene but may be helpful in certain situations
  • Consider referring all people with halitosis (including those without a pathological cause) to a dentist for a full oral examination as some oral diseases may be difficult to diagnose by visual examination alone
  • Treatment for non-oral causes of halitosis may need to be considered, for example
    • Proton pump inhibitors for gastro-oesophageal reflux disease
    • Management of nasal and sinus disease