Halitosis
Halitosis - Summary
Halitosis (bad breath) is a general term to describe an unpleasant or offensive odour in the breath, regardless of the cause of the odour.
Halitosis can be classified as:
Non-pathological or transient: this is temporary and normal — for example following ingestion of certain food and drink (such as onion, garlic, alcohol).
Pathological: this is usually persistent, more intense, and less readily reversible. Causes include oral and systemic diseases.
Pseudo-halitosis: in which the person believes that they have halitosis, despite evidence to indicate otherwise. An extreme form of this is halitophobia.
In 80–90% of people with persistent halitosis there is a problem in the mouth. Common oral causes of halitosis include:
Poor oral hygiene (including tongue coating).
Smoking.
Periodontal diseases.
Dry mouth (xerostomia).
Dentures and poor denture hygiene.
Other oral and dental diseases.
All people with dental disease or suspected oral cancer should be referred.
Where possible, any underlying causes of halitosis should be managed.
If no pathological cause is identified, management involves:
Offering self-care advice about oral hygiene — brush teeth twice daily, clean the interdental spaces using an appropriate aid, try an antibacterial mouthwash and/or toothpaste, and consider tongue brushing.
Advising the person to visit their dentist if oral or denture hygiene is poor. Referral to a dentist should be considered for all people with halitosis.
Giving advice on reducing risk factors for halitosis — avoid foods and drinks known to cause transient halitosis; attempt smoking cessation and avoid chewing tobacco; treat dry mouth by increasing fluid intake, suck sugar-free sweets or chew sugar-free gum, and consider the use of an artificial salivary substitute.
Advising that dentures should be left out at night, and that the person consults their dentist if they have problems with their dentures.
Advising regular dental checks to ensure maintenance of oral hygiene.
Empirical treatment with antibiotics and Helicobacter pylori eradication therapy are not recommended.
For people without detectable halitosis:
Reassurance should be offered.
The possibility of pseudo-halitosis or halitophobia should be suspected— particularly if they have good oral and dental health.
Referral for psychological therapy should be discussed if halitophobia is severe.
Have I got the right topic?
This CKS topic covers the management of halitosis (bad breath).
This CKS topic does not cover the assessment and management of oral problems (including halitosis) in people receiving palliative care. This is covered in the CKS topic on Palliative cancer care - oral.
There are separate CKS topics on Candida - oral, Dental abscess, Gingivitis and periodontitis, Head/neck cancer - suspected, and Herpes simplex - oral.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
September 2009 to January 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 August 2009.
HTAs (Health Technology Assessments)
No new HTAs since 1 August 2009.
Economic appraisals
No new economic appraisals relevant to England since 1 August 2009.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Blom, T., Slot, D., Quirynen, M., and Van der Weijden, G. (2012) The effect of mouthrinses on oral malodour: a systematic review. International Journal of Dental Hygiene 10(3), 209-222. [Abstract]
Liou, J., Chen, C., Chen, M., et al. (2013) Sequential versus triple therapy for the first-line treatment of Helicobacter pylori: a multicentre, open-;abel, randomised trial. Lancet 381(9862), 205-213. [Abstract]
Van der Sleen, M., Slot, D., Van Trijffel, E., et al. (2010) Effectiveness of mechanical tongue cleaning on breath odour and tongue coating: a systematic review. International Journal of Dental Hygiene 8(4), 258-268. [Abstract]
Primary evidence
No new randomized controlled trials published in the major journals since 1 August 2009.
New policies
No new national policies or guidelines since 1 August 2009.
New safety alerts
No new safety alerts since 1 August 2009.
Changes in product availability
No changes in product availability since 1 August 2009.
Goals and outcome measures
Goals
To confirm a diagnosis of halitosis
To identify oral and non-oral causes of halitosis
To advise on oral hygiene measures to manage halitosis
Background information
Definition
What is it?
Halitosis (bad breath) is a general term to describe an unpleasant or offensive odour in the breath, regardless of the cause of the odour.
Halitosis can be classified as:
Non-pathological or transient: this is temporary and normal — for example following ingestion of certain food and drink (such as onion, garlic, alcohol).
Pathological: this is usually persistent, more intense, and less readily reversible. Causes include oral and systemic diseases.
Pseudo-halitosis: in which the person believes that they have halitosis, despite evidence to indicate otherwise. An extreme form of this is halitophobia.
[Messadi and Younai, 2003; Porter and Scully, 2006; van den Broek et al, 2007; Hughes and McNab, 2008; Scully and Greenman, 2008; van den Broek et al, 2008]
Causes
What causes it?
Transient halitosis is common and is caused by:
Consumption of certain foods (such as garlic, onion, spices, cabbage, Brussels sprouts, and radishes) and drinks (such as alcohol).
Hunger [Scully and Greenman, 2008].
Reduced saliva flow during sleep.
In 80–90% of people with persistent halitosis there is a problem in the mouth. Common oral causes of halitosis include:
Poor oral hygiene (including tongue coating).
Smoking.
Periodontal diseases.
Dry mouth (xerostomia).
Dentures and poor denture hygiene.
Other oral and dental diseases.
Non-oral causes of halitosis are less common and include:
Disease of the nose, nasal cavity, and nasopharynx.
Disease of the respiratory tract.
Disease of the gastrointestinal tract.
Systemic disease.
Drugs.
Oral causes
What are the oral causes of halitosis?
In 80–90% of people with persistent halitosis there is a problem in the mouth.
Poor oral hygiene is a common cause of halitosis.
The malodour is caused by microbial breakdown of food debris, cells, saliva and other substrates (such as blood, purulent postnasal secretions) lodged between the teeth, gums, and on the fissured surface of the tongue (particularly in the dorsum region). This results in the production of chemicals (such as volatile sulphur compounds, diamines, and short chain fatty acids) that cause halitosis [Rosenberg, 1996; Messadi and Younai, 2003; Porter and Scully, 2006].
Other oral causes of halitosis include [Messadi and Younai, 2003; Verran, 2005; Porter and Scully, 2006; Scully and Greenman, 2008]:
Smoking.
Dry mouth (xerostomia) — this is due the cleansing mechanism of the mouth being impaired by reduced salivary flow. Causes of dry mouth are diverse and include dehydration, drugs (such as those with antimuscarinic effects, for example tricyclic antidepressants), systemic diseases (such as Sjögren's syndrome), and radiotherapy to the head and neck region [Scully and Felix, 2005b].
Dentures and poor denture hygiene (for example not taking dentures out at night).
Oral and dental diseases, including:
Periodontitis and gingivitis — these are the most common causes of oral disease associated with halitosis. Acute necrotizing ulcerative gingivitis is an unusual acute form of periodontal disease and tends to produce a very distinct, foul or putrid smell.
Pericoronitis.
Dry socket (alveolar osteitis).
Dental abscess.
Dental caries — due to food retention.
Oral infection — such as oral candidiasis (which is associated with a sweet, fruity odour) and herpetic gingivostomatitis.
Oroantral fistula.
Oral cancer — due to secondary infections, necrotic tissue, food entrapment.
[Messadi and Younai, 2003; Verran, 2005; Porter and Scully, 2006; Scully and Greenman, 2008]
Non-oral causes
What are the non-oral causes of halitosis?
Non-oral causes of halitosis are less common than oral causes and include [Porter and Scully, 2006; Scully and Greenman, 2008]:
Diseases of the nose or nasal cavity, such as:
Chronic sinusitis.
Nasal polyps.
Foreign bodies which have been inserted accidentally into the nose and left for some time, causing inflammation and secondary infection.
Diseases of the oropharynx, such as [Messadi and Younai, 2003; Porter and Scully, 2006]:
Pharyngeal infections (for example oropharyngeal candidiasis), ulceration, and cancer.
Tonsillitis.
Foreign bodies in the oropharynx, causing infection and pus formation.
Diseases of the respiratory tract, such as [Messadi and Younai, 2003; Porter and Scully, 2006]:
Pulmonary disease, for example anaerobic lung abscess, tuberculosis, necrotizing pneumonia empyema, lung cancer, and bronchiectasis.
Foreign bodies lodged in the respiratory tract, causing infection and pus formation.
Diseases of the gastrointestinal tract, including gastro-oesophageal reflux and other conditions which weaken or inhibit oesophageal closure (such as hiatus hernia).
The odour generally resembles the odour from the most recently ingested meal [Messadi and Younai, 2003].
There is poor evidence to support a role for Helicobacter pylori in causing halitosis [Scully and Felix, 2005a].
Systemic diseases, although this is an unusual cause of halitosis [Loesche and Kazor, 2002; Messadi and Younai, 2003; Porter and Scully, 2006].
Cirrhosis and hepatic failure: rotten egg smell or sulphur odour.
Kidney failure (uraemia): ammonia or fishy smell.
Diabetic ketoacidosis: acetone smell.
Trimethylaminuria (a metabolic disorder): fishy odour.
Leukaemia: smell of decaying blood.
Drugs, although this is rare [Scully and Greenman, 2008].
Drugs reported by manufacturers to cause halitosis include disulfiram, melatonin, nicotine lozenges, mycophenolate sodium, and aztreonam injection.
Other drugs that may cause halitosis include solvent misuse, amyl nitrites, nitrates, phenothiazine, amphetamines, and some cytotoxic drugs [Porter and Scully, 2006].
Prevalence
How common is it?
CKS identified no reliable data on the prevalence of persistent (pathological) halitosis in the UK, but it is considered to be a common problem in all age groups [Porter and Scully, 2006].
Non-UK studies (using different methodologies and outcome measures) have estimated the prevalence of halitosis to be around 2–30% of the population [van den Broek et al, 2007; Hughes and McNab, 2008; Bornstein et al, 2009].
Halitosis may be under-reported, as people are often not aware of their own bad breath (although some people may have exaggerated concerns about their breath) [Rosenberg, 1996].
Diagnosis and assessment
Diagnosis and assessment of halitosis
Diagnosis
How do I know my patient has it?
Confirm that halitosis is present by smelling the person's exhaled breath.
Be aware that:
The person's own assessment is the least reliable measurement.
The odour can vary with time and be influenced by other factors such as diet, hunger, and oral hygiene.
Consider repeating the assessment on two or three different days if no malodour is detected on the initial examination.
Consider feedback from the person's partner or family members.
Basis for recommendation
Basis for recommendation
These recommendations are based on published narrative reviews on halitosis or oral malodour [Rosenberg, 1996; Coventry et al, 2000; Yaegaki and Coil, 2000; Morita and Wang, 2001; Messadi and Younai, 2003; Scully and Felix, 2005a; Porter and Scully, 2006; Lee et al, 2007; Hughes and McNab, 2008; Scully and Greenman, 2008].
Smelling the person's breath is recommended to confirm halitosis and to exclude suspected pseudo-halitosis or halitophobia.
It is generally recognized that individual assessment is a poor measure of halitosis [Hughes and McNab, 2008; Scully and Greenman, 2008].
Because of the difficulty inherent in smelling one's own breath, some people may have exaggerated concerns about their own breath [Rosenberg, 1996; Eli et al, 2001].
In a study involving 2000 consecutive people visiting a Dutch multidisciplinary breath odour clinic, 15.7% had no objective signs of malodour and were grouped as pseudo-halitosis/halitophobia [Quirynen et al, 2009].
Subjective (organoleptic) assessment is regarded as the most simple, reliable, and practical method for evaluating the severity of halitosis [Yaegaki and Coil, 2000; Porter and Scully, 2006; Scully and Greenman, 2008; Vandekerckhove et al, 2009].
Methods such as gas chromatography or measurement of volatile sulphur compounds are more objective and are commonly used in research. However, these methods are impractical, expensive, and unavailable in primary care. The limitations of volatile sulphur compound measurement is discussed in Supporting evidence.
Assessment
How should I assess someone with halitosis?
Enquire about:
The person's own perception of the problem — including the impact on their quality of life (education, work, and social activities).
Severity, timing, and duration of the halitosis — for example breath odour upon waking (morning breath) is normal and transient.
Possible trigger factors — for example certain foods and drinks (including alcohol) and smoking.
Treatments used to manage halitosis — for example oral hygiene measures.
Examine the oral cavity to look for oral causes of halitosis including:
Oral infections — for example oral candidiasis and herpetic gingivostomatitis (see the CKS topics on Candida - oral and Herpes simplex - oral).
Dental and gum diseases — for example dental abscess or decay, periodontitis, and acute necrotizing ulcerative gingivitis (see the CKS topics on Dental abscess and Gingivitis and periodontitis).
Suspected cancer — see Referral.
Dry mouth — which can lead to decreased taste sensation and difficulty in swallowing.
Problems with dentures — including denture hygiene.
Tongue coating.
Review oral hygiene measures — poor oral hygiene is a common cause of halitosis. Ask about:
Methods used (for example brushing, flossing, use of mouthwashes).
Frequency of brushing and inter-dental cleaning (for example flossing).
Denture hygiene — for example whether the person takes their dentures out at night and if they clean their dentures regularly.
Frequency of dental visits.
Consider tongue coating as a source of halitosis — particularly in people with good dental hygiene and oral health.
The posterior region of the tongue is a main source of oral-related halitosis.
Consider gently but thoroughly scraping the area (for example with a clean plastic spoon or proprietary tongue scraper or tongue brush). The odour from the scraping (which is often yellow in colour) is generally similar to overall mouth odour.
Review the person's medical history and consider non-oral causes of halitosis. Certain conditions will produce distinctive odours.
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 or pharyngeal in origin — if odour is detected from the mouth but not from the nose.
Nasal in origin or from the sinus — if odour is detected from the nose but not from the mouth.
Systemic in origin — if odour from the nose and mouth are of equal intensity (generally rare).
Review the person's medication history for drugs known, or suspected, to cause or contribute to halitosis (uncommon).
Basis for recommendation
Basis for recommendation
These recommendations are extrapolated from published narrative reviews on halitosis or oral malodour [Rosenberg, 1996; Coventry et al, 2000; Messadi and Younai, 2003; Scully and Felix, 2005a; Porter and Scully, 2006; Lee et al, 2007; Hughes and McNab, 2008; Scully and Greenman, 2008].
Examination of oral cavity and assessment of oral hygiene
The recommendations to examine the oral cavity for oral and dental disease and to review dental hygiene are in line with published expert opinion and reflect the fact that in 80–90% of people with persistent halitosis there is a problem in the mouth.
In a study involving 2000 consecutive people visiting a Dutch multidisciplinary breath odour clinic, an oral cause was found in 76% of people — with the main causes being tongue coating (43%), gingivitis/periodontitis (11%), or a combination of the two (18%) [Quirynen et al, 2009]. Xerostomia was responsible for 2.5% of cases. Only around 2% had an extra-oral cause, no cause was found in 0.8%, and 16% were classified as pseudo-halitosis/halitophobia.
The recommendation on how to assess tongue coating is based on expert opinion [Rosenberg, 1996; Messadi and Younai, 2003].
Assessment of non-oral causes of halitosis
The recommendation to assess exhaled air from the nose and mouth separately is based on published narrative reviews [Rosenberg, 1996; Messadi and Younai, 2003; Porter and Scully, 2006; Lee et al, 2007; Scully and Greenman, 2008].
Management
Management
Scenario: Management: covers the management of people with halitosis.
Scenario: Management
Scenario: Management of halitosis
Management
How should I manage someone complaining of halitosis?
Refer all people with dental disease or suspected oral cancer.
Manage any underlying causes of halitosis.
If no pathological cause is identified:
Offer self-care advice about oral hygiene and advise the person to visit their dentist if oral or denture hygiene is poor.
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.
Give advice on reducing risk factors for halitosis.
Avoid foods and drinks known to cause transient halitosis — such as garlic, onion, and alcohol.
Advise smoking cessation and to avoid chewing tobacco (for further information, see the CKS topic on Smoking cessation).
Treat dry mouth by increasing fluid intake, sucking sugar-free sweets or chewing sugar-free gum. Consider the use of an artificial salivary substitute if these measures are insufficient.
Advise that dentures should be left out at night, and that the person consults their dentist if they have problems with their dentures.
Advise regular dental checks to ensure maintenance of oral hygiene.
Empirical treatment with antibiotics and Helicobacter pylori eradication therapy are not recommended.
For people without detectable halitosis:
Offer reassurance.
Suspect the possibility of pseudo-halitosis or halitophobia — particularly if they have good oral and dental health.
Discuss referral for psychological therapy if halitophobia is severe.
Basis for recommendation
Basis for recommendation
These recommendations (including the management of people with suspected pseudo-halitosis or halitophobia) are based on published narrative reviews on halitosis or oral malodour [Rosenberg, 1996; Coventry et al, 2000; Morita and Wang, 2001; Messadi and Younai, 2003; Scully and Felix, 2005a; Porter and Scully, 2006; Lee et al, 2007; Hughes and McNab, 2008; Scully and Greenman, 2008; van den Broek et al, 2008].
Oral hygiene measures
The recommendation for oral hygiene measures is based on expert opinion and aims to reduce the accumulation of debris and bacteria in the mouth.
Referral to a dentist for people with halitosis
The recommendation to consider referring all people with halitosis (including people without pathological causes) is based on feedback from some CKS expert reviewers. This is because some oral diseases (such as periodontitis) may be difficult to diagnose by visual examination alone.
Treatments for halitosis that are not recommended
Empirical antibiotic treatment
In the absence of oral or dental infection, empirical antibiotic treatment (such as metronidazole 200 mg three times daily for 7 days) should only be initiated by a specialist; antibiotics may be used for recalcitrant cases of halitosis, to eliminate unidentified anaerobic infections [Coventry et al, 2000; Scully and Greenman, 2008].
Helicobacter pylori eradication
H. pylori has been implicated as a cause of halitosis, but the evidence for this is sparse [Scully and Felix, 2005a].
Although evidence from two very small trials reported improvement in halitosis following H. pylori eradication therapy in people with dyspepsia, these results should be interpreted with caution, given that [van den Broek et al, 2008]:
These trials generally did not examine the participants for oral causes of halitosis.
The reduction or disappearance of halitosis after eradication therapy could be due to the simultaneous eradication of halitosis-producing bacteria in the oral cavity.
Self-care advice
What self-care advice should I offer someone with halitosis?
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.
Give advice on general oral hygiene measures.
Brush teeth twice daily (particularly last thing at night).
Clean the interdental spaces using an appropriate aid (floss, tape, sticks, or single-tufted brush).
Reduce the frequency and amount of sugary food and drinks consumed. These should be limited to mealtimes and consumed not more than four times a day.
Advise the person to seek advice from a dentist or dental hygienist if they have problems maintaining dental hygiene (for example with brushing or using interdental aids).
Encourage regular dental checks to ensure maintenance of oral hygiene.
Recommend or prescribe a trial of an antibacterial mouthwash and/or toothpaste if the above oral hygiene measures are insufficient (see Additional information).
Improvement will indicate that the halitosis is related to oral hygiene.
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 while brushing the teeth (with toothpaste). Although a proprietary tongue scraper can be considered, there is insufficient evidence to recommend one product over another.
Excessive scraping should be avoided as this can cause damage and bleeding to the tongue.
Care should be taken to avoid triggering the gagging reflex.
Explain that non-antibacterial products (such as mints, flavoured/perfumed mouth sprays/rinses, and chewing gums) only provide transient masking of halitosis. They are no substitute for good oral hygiene.
Additional information
Additional information
Antibacterial toothpastes and mouthwashes
These preparations are widely available from supermarkets and pharmacies.
Antibacterial agents include cetylpyridinium chloride, chlorhexidine, hexetidine, hydrogen peroxide, and triclosan.
Given the lack of good evidence to support these products, the choice of preparation will depend on individual preference and product tolerability.
Of the mouthwashes, chlorhexidine gluconate 0.2% mouthwash is most commonly prescribed in primary care. However, some people may find it difficult to use chlorhexidine in the long term because [Porter and Scully, 2006]:
Chlorhexidine-based products (dental gel, mouthwash, and spray) can cause discolouration of the tongue and teeth (this is reversible on discontinuation of treatment) [ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2009b].
Tooth staining can be minimized by reducing consumption of tea, coffee, or red wine and by brushing teeth before using the chlorhexidine product.
Staining of dentures can be reduced by cleaning with a conventional denture cleanser.
Chlorhexidine products can cause transient taste disturbance and a burning sensation of the tongue (particularly if used too frequently).
These effects may occur initially and usually diminish with continued use [ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2009b].
Some experts do not recommend the use of mouthwashes with a high alcohol content as this can cause a drying effect on the mouth [Morita and Wang, 2001]. Alcohol-free mouthwashes are available.
Basis for recommendation
Basis for recommendation
These recommendations are mainly based on expert opinion published in narrative reviews on halitosis or oral malodour [Rosenberg, 1996; Coventry et al, 2000; Loesche and Kazor, 2002; Messadi and Younai, 2003; Scully and Felix, 2005a; Porter and Scully, 2006; Lee et al, 2007; Hughes and McNab, 2008; Scully and Greenman, 2008; van den Broek et al, 2008]. Evidence is lacking for treatments of halitosis (such as mouthwashes, tongue scraping, toothpaste, and interdental aids).
General hygiene measures
These general measures are based on guidance issued by the British Association for the Study of Community Dentistry and the Department of Health for the prevention of dental caries, periodontal diseases, and oral cancer [DH and British Association for the Study of Community Dentistry, 2009].
Antibacterial mouthwashes and toothpaste
The recommendation to offer antibacterial mouthwashes and/or toothpastes is based on expert opinion [Messadi and Younai, 2003; Porter and Scully, 2006; Scully and Greenman, 2008].
Although acknowledging that certain mouthwashes can be useful in reducing levels of halitosis-producing bacteria (for example chlorhexidine or cetylpyridinium chloride mouthwashes), a Cochrane systematic review found poor evidence to support their use [Fedorowicz et al, 2008].
CKS found a lack of good evidence for the various types of toothpastes (antibacterial and non-antibacterial) for the treatment of halitosis.
Consequently, CKS is unable to recommend a specific mouthwash or toothpaste for the management of halitosis.
Tongue scraping
A Cochrane systematic review found weak and unreliable evidence to support the use of tongue scraping for the management of halitosis [Outhouse et al, 2006].
Given that the back of the tongue is regarded as a major oral source of halitosis, the recommendation to consider tongue scraping is based on expert opinion — particularly in people with halitosis who have good dental hygiene [Rosenberg, 1996; Messadi and Younai, 2003; Quirynen, 2003; Porter and Scully, 2006].
Provided it is done gently and regularly, tongue scraping is regarded as not harmful, and may provide transient benefits in controlling halitosis [Porter and Scully, 2006].
Referral
When should I refer?
Urgently refer to an appropriate specialist, anyone with:
Acute necrotizing ulcerative gingivitis. See the section on Acute necrotizing ulcerative gingivitis in the CKS topic on Gingivitis and periodontitis.
Unexplained tooth mobility for more than 3 weeks.
Unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks.
Unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful or swollen or bleeding.
Unexplained or atypical enlargement of the gingivae (possibly indicative of leukaemia).
Non-urgent referral to a dentist is required for people with:
Clinically-apparent gingivitis that is not responding to standard oral hygiene measures.
Periodontitis.
Unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are not painful, swollen, or bleeding.
Poorly-fitted dentures.
Poor oral or denture hygiene.
Some experts recommend referring all people with halitosis (including those without pathological causes) to a dentist for a full oral examination, as some oral diseases (such as periodontitis) may be difficult to diagnose by visual examination alone.
Refer non-urgently to an ear nose and throat specialist people with the following conditions in whom an oral cause has been excluded:
Recurrent tonsillitis (see the CKS topic on Sore throat - acute).
Sinonasal disease such as septal deviation, and frequent recurrent sinusitis (see the CKS topic on Sinusitis).
For people with other persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made, refer or follow up until the symptoms and signs disappear. If the symptoms and signs have not disappeared after 6 weeks, make an urgent referral.
Basis for recommendation
Basis for recommendation
These recommendations are based on referral guidance issued by the National Institute for Health and Clinical Excellence for suspected cancer [NICE, 2005], expert opinion published in a narrative review [Porter and Scully, 2006], and feedback from CKS expert reviewers.
Referral to a dentist for people with halitosis
The recommendation to consider referring all people with halitosis (including people without pathological causes) to a dentist is based on feedback from some CKS expert reviewers. This is because some oral diseases (such as periodontitis) may be difficult to diagnose by visual examination alone.
Evidence
Evidence
Supporting evidence
CKS found a lack of good quality evidence on treatments for halitosis.
Apart from two Cochrane systematic reviews on mouthrinses and tongue scraping (which found poor evidence for their use), no systematic reviews or meta-analyses were identified for other treatments such as toothpastes, interdental aids (such as dental floss), chewing gums, and mouth sprays.
Most trials were generally small with less than 40 participants in each treatment arm and were short term (for example, a single treatment or treatment for 1–2 days) [Loesche and Kazor, 2002; Quirynen et al, 2002b]. Few trials were of double-blind design. Most were sponsored by industry.
In addition, outcome measurements were generally based on secondary outcomes.
Most studies utilized portable sulphide monitors (such as the Halimeter®) to measure the level of volatile sulphur compounds (VSCs) as a measure of oral malodour.
Given that other compounds are also responsible for oral malodour, VSC measurement alone can provide an inaccurate assessment of the source and intensity of the malodours [Messadi and Younai, 2003; Porter and Scully, 2006; Hughes and McNab, 2008; Scully and Greenman, 2008; Van den Velde et al, 2009]. In addition, it explains why oral malodour is sometimes detected by the examiner (subjective organoleptic assessment), but the VSC levels are in the low range [Loesche and Kazor, 2002].
Other methods (such as gas chromatography) are regarded as more accurate but are not routinely used in studies.
Mouthwashes
Evidence on mouthwashes for the management of halitosis
Limited evidence from a Cochrane systematic review suggests that mouthwashes are more effective than placebo in controlling halitosis, but these results should be interpreted with caution.
The evidence on mouthwashes in controlling halitosis was examined in a Cochrane systematic review (search date: up to August 2008) [Fedorowicz et al, 2008]. Randomized controlled trials (RCTs) were only considered if the interventions were administered for 1 week or more. Five RCTs (involving 293 participants) met the inclusion criteria. However, it was not possible to pool these studies due to significant heterogeneity. No trials involving the use of triclosan mouthwashes met the inclusion criteria.
Based on organoleptic assessment and/or measurement of volatile sulphur compounds (VSCs), all five studies reported the following test mouthwashes (when used twice daily for 2–6 weeks) to be more effective in reducing oral malodour compared with placebo or control:
A proprietary mouthwash containing cetylpyridinium plus chlorine dioxide and zinc (4 weeks' use, 99 participants). This was also more effective than two other proprietary mouthwashes containing essential oils or chlorine dioxide plus zinc [Borden et al, 2002].
A test mouthwash containing zinc chloride and sodium chlorite (4 weeks' use, 48 participants). This was also more effective than a zinc chloride mouthwash [Codipilly et al, 2004].
A two-phase oil-water mouthwash containing 0.05% cetylpyridinium chloride (6 weeks' use, 50 participants). This was also more effective than a proprietary essential oil-based mouthwash [Kozlovsky et al, 1996].
A herbal-based mouthwash containing an extract of Garcinia mangostana L (15 days' use, 60 participants) [Rassameemasmaung et al, 2007].
A mouthwash containing chlorhexidine (0.05%), cetylpyridinium chloride (0.05%), and zinc lactate (0.14%), (2 weeks' use, 40 participants) [Winkel et al, 2003].
Based on these results, the authors of the Cochrane systematic review acknowledged that antibacterial products (such as chlorhexidine and cetylpyridinium chloride) 'may play an important role in reducing the levels of halitosis-producing bacteria on the tongue' and mouth rinses containing chlorine dioxide or zinc 'can be effective in neutralisation of odouriforous sulphur compounds'.
However, given that there was incomplete reporting of results in three trials and sole use of portable sulphide monitors (such as the Halimeter®) for assessment of VSC levels as outcomes in the other two trials, the authors of the Cochrane systematic review concluded that these results should be interpreted with caution.
Other limitations highlighted included:
All the trials were small with only 16–30 participants in each group.
Overall, the quality of the trials was poor; only one RCT (in 60 people, [Rassameemasmaung et al, 2007]) had adequate randomization and concealment, with a low risk of bias.
It is difficult to assess and to compare the clinical significance of these findings, given the diversity in baseline characteristics of the participants and the methods used to assess outcome.
Tongue scraping
Evidence on tongue scraping for the management of halitosis
CKS found a lack of good evidence on tongue scraping for the management of halitosis.
A Cochrane systematic review (search date: up to September 2005) found the evidence for tongue scrapers and cleaners to be weak and unreliable [Outhouse et al, 2006].
Different mechanical methods of tongue cleaning
Two very small crossover trials (40 adults) reported a small but statistical reduction in levels of oral volatile sulphur compounds (VSCs) — a difference of 10–30% — when proprietary tongue cleaners and scrapers were compared with a regular toothbrush [Seemann et al, 2001; Pedrazzi et al, 2004].
However, the effect was short lived, as one study (30 participants) found no difference in VSC levels 30 minutes after using a tongue cleaner, a tongue scraper, or a regular toothbrush [Seemann et al, 2001].
The reliability of these results is questionable, given that both studies failed to report any self-assessed measurements of halitosis (regarded as the outcome most relevant to the person) or any follow up for a period of 4 weeks or more.
Tongue scraping or cleaning compared with other interventions
No other trials comparing other interventions (such as mouthwashes or brushing alone) were found.
Subsequent to this Cochrane systematic review, CKS identified two other small trials with conflicting results. It is not possible to draw any conclusion from these studies, given their small size and methodological weaknesses.
Triclosan toothpaste with or without tongue brushing compared with non-triclosan toothpaste alone
One small, single-blind crossover trial (29 participants with morning malodour) reported regimens using a proprietary triclosan-containing toothpaste with or without tongue brushing to be more effective than a control toothpaste alone (without triclosan) in reducing VSC levels [Farrell et al, 2006]. However, this was an extremely short-term study with treatment performed four times and only over a 27 hour period, with a 2-day wash-out period between treatments.
Tongue scraping compared with no tongue scraping
One single-blind crossover found no statistical difference in VSC levels between periods of use and non-use of a tongue scraper (used for 4 days) [Haas et al, 2007]. However, this was an very small study, involving only 10 participants.
Toothpastes
Evidence on toothpastes for the management of halitosis
CKS found a lack of good evidence on the use of toothpaste (antibacterial and non-antibacterial) for the management of halitosis.
CKS identified no systematic review or meta-analysis examining the various types of toothpastes for the management of halitosis.
Eighteen studies were identified involving the use of antibacterial toothpastes (for example triclosan-based toothpaste) or non-antibacterial toothpastes (for example sodium bicarbonate or zinc-based toothpaste). Most studies involved proprietary toothpastes and were sponsored by industry.
However, a number of these studies were excluded as the toothpastes were used for less than 7 days (for example as a one-off treatment or for just 1–2 days) [Grigor and Roberts, 1992; Brunette et al, 1998; Gerlach et al, 1998; Sharma et al, 1999; Olshan et al, 2000; Sharma et al, 2002; Farrell et al, 2006; Farrell et al, 2007; Sharma et al, 2007; Farrell et al, 2008; Hu et al, 2008; Newby et al, 2008].
This is in line with inclusion criteria set by a Cochrane systematic review on mouthwashes, which only considered trials if the interventions were administered for 1 week or more [Fedorowicz et al, 2008].
The clinical significance of the remaining six studies (where treatment was used for 7 days or longer) is uncertain.
Four trials were very small in size.
Two studies involved 16 and 25 dental students [Quirynen et al, 2002a; Peruzzo et al, 2008] while another study involved only 19 participants [Niles et al, 1999].
One study involved less than 30 participants in each treatment arm (16–27 participants, comparing three different strengths of a zinc citrate and triclosan toothpaste) [Raven, 1996].
One double-blind study (involving 81 participants; reported in two papers [Hu et al, 2003; Hu et al, 2005]) found a proprietary triclosan/copolymer/sodium-fluoride toothpaste to be more effective than a proprietary fluoride toothpaste in reducing malodour, both over a 12-hour period and over 3 weeks (based on point scores from four expert assessors). However, no information was given on how the treatments were randomized or whether the proprietary products were matched in appearance or fragrance.
One study compared a 0.2% zinc sulphate toothpaste with placebo (no zinc) after a single brushing and after 4 weeks of use (198 participants completed the study) [Navada et al, 2008]. This study comprised two independent double-blind studies of common design except that different odour assessments were performed (organoleptic or volatile sulphur compounds measurement). Although a statistical difference was reported in terms of volatile sulphur compound scores and organoleptic scores recorded 12 hours after the last brushing, the differences were variable, ranging from 16–46%.
Interdental aids
Evidence on interdental aids for the management of halitosis
CKS found no good quality randomized controlled trials examining the use of interdental aids (such as floss, tape, sticks, or single tufted brush) in people with halitosis.
One small crossover trial was identified which compared brushing with or without tongue brushing and/or inter-dental flossing [Faveri et al, 2006]. However, this study only involved 19 participants with morning breath and is too small to be reliable.
Chewing gum
Evidence on chewing gums for management of halitosis
CKS found no good quality randomized controlled trials (RCTs) examining the use of chewing gum in people with halitosis.
Three studies involving the use of chewing gum were identified.
Two studies were too small to be reliable.
One open-label exploratory study (involving 12 dental students) compared a test gum and an unsweetened gum base with no chewing [Reingewirtz et al, 1999].
One non-randomized study (involving 11 participants with morning breath) compared the effect of zinc solutions and chewing gum on volatile sulphur compound levels [Wåler, 1997].
The third study was a single-blind RCT which randomized 123 participants to one of the following six treatments: two different strengths of an oxidizing lozenge, a chewing gum (with no active ingredients), two different breath mints, and no treatment [Greenstein et al, 1997]. However, the number of participants in each treatment arm was small (around 20 people), and the duration of treatment was short (before bedtime to early afternoon the next day).
Mouth sprays
Evidence on mouth sprays for the management of halitosis
CKS found no randomized controlled trials examining the use of mouth sprays (antibacterial or non-antibacterial) for the management of halitosis.
H. pylori eradication therapy
Evidence on Helicobacter pylori eradication for management of halitosis
CKS found very poor evidence on the use of Helicobacter pylori eradication therapy for the management of halitosis.
CKS identified two trials which found H. pylori eradication therapy reduced halitosis in people complaining of dyspepsia and who tested positive for H. pylori [Ierardi et al, 1998; Katsinelos et al, 2007].
However, the reliability of these results is questionable given the small size of the studies.
One trial involved 30 H. pylori-positive participants: 19 were treated with double therapy (amoxicillin and omeprazole) plus chlorhexidine while 11 were treated only with a chlorhexidine mouthwash [Ierardi et al, 1998].
The other trial involved 18 H. pylori-positive participants who were treated with triple therapy; there was no control group [Katsinelos et al, 2007].
In addition, these results should be interpreted with caution, given that [van den Broek et al, 2008]:
These trials did not examine the participants for intraoral causes of halitosis.
The reduction or disappearance of halitosis after eradication therapy could be due to the simultaneous eradication of halitosis-producing bacteria in the oral cavity.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Halitosis, with additional searches for evidence in the following areas:
Mouthwashes
Tongue-brushing
Lozenges
Toothpastes
Chewing gum
Oral hygiene
Search dates
Dates not restricted – August 2009
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
halitosis/, halitosis.tw, bad breath.tw, oral malodo$.tw, breath odo$.tw, malodo$.tw
exp mouthwashes/, mouthwash$.tw
toothpaste/, toothpaste.tw
oral hygiene/ oral hygiene.tw
tongue/, tongue brush$.tw, tongue scrap$.tw
chewing gum/, gum.tw, lozenge.tw
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
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