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JNatSciBiolMed.2013JanJun4(1):1423.

PMCID:PMC3633265

doi:10.4103/09769668.107255

Halitosis:Fromdiagnosistomanagement
BahadrUurAylkcandHakanolak
DepartmentofPeriodontology,KirikkaleUniversityDentalFaculty,Kirikkale,Turkey
1
DepartmentofOperativeDentistry,KrkkaleUniversityDentalFaculty,Krkkale,Turkey
Addressforcorrespondence:Dr.BahadrUurAylk,ResearchAssistant,KirikkaleUniversityDentalFaculty,Departmentof
Periodontology,Kirikkale,Turkey.Email:aylikci@gmail.com
Copyright:JournalofNaturalScience,BiologyandMedicine
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,
whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract
Halitosisisformedbyvolatilemoleculeswhicharecausedbecauseofpathologicalornonpathological
reasonsanditoriginatesfromanoraloranonoralsource.Itisverycommoningeneralpopulationand
nearlymorethan50%ofthegeneralpopulationhavehalitosis.Althoughhalitosishasmultifactorial
origins,thesourceof90%casesisoralcavitysuchaspoororalhygiene,periodontaldisease,tonguecoat,
foodimpaction,uncleandentures,faultyrestorations,oralcarcinomas,andthroatinfections.Halitosis
affectsaperson'sdailylifenegatively,mostofpeoplewhocomplainabouthalitosisrefertotheclinicfor
treatmentbutinsomeofthepeoplewhocansufferfromhalitosis,thereisnomeasurablehalitosis.There
areseveralmethodstodeterminehalitosis.Halitosiscanbetreatedifitsetiologycanbedetectedrightly.
Themostimportantissuefortreatmentofhalitosisisdetectionetiologyordeterminationitssourceby
detailedclinicalexamination.Managementmayincludesimplemeasuressuchasscalingandroot
planning,instructionsfororalhygiene,tonguecleaning,andmouthrinsing.Theaimofthisreviewwasto
describetheetiologicalfactors,prevalencedata,diagnosis,andthetherapeuticmechanicalandchemical
approachesrelatedtohalitosis.
Keywords:Diagnosis,etiology,halitosis,humans,preventionandcontrol
INTRODUCTION
Humanbreathiscomposedofhighlycomplexsubstanceswithnumerousvariableodorswhichcan
generateunpleasantsituationslikehalitosis.Halitosisisalatinwordwhichderivedfromhalitus(breathed
air)andtheosis(pathologicalteration),[1]anditisusedtodescribeanydisagreeablebadorunpleasant
odoremanatingfromthemouthairandbreath.Foetororis,oralmalodor,mouthodor,badbreath,andbad
mouthodoraretheothertermswhichareusedtodescribeandcharacterizethehalitosis.[24]This
undesirableconditionisacommoncomplaintforbothgendersandforallagegroups.Itcreatessocialand
psychologicaldisadvantagesforindividuals,andthesesituationsaffectindividual'srelationwithother
people.[5]Inpresentreviewwedescribetheetiologicalfactors,prevalencedata,etiology,diagnosis,and
thetherapeuticmechanicalandchemicalapproachesrelatedtohalitosis.
PREVELENCE
Halitosisisverycommoningeneralpopulationandnearlymorethan50%ofthegeneralpopulationhave
halitosis.[6]InaSwedishstudyof840men,halitosisassessmentwasonlypresentinaround2%ofthe
population.[7]However,halitosisprevalenceinaChinastudywhichinvolvedmorethan2500participants
wasassessedabove27.5%.[8]Alsointheliterature,theprevalenceofhalitosisreportedasrangingfrom
5%to75%oftestedchildren.[9,10]Originofhalitosisin90%ofthepatientisoralcavity9%ofpatient
sourceofhalitosisisnonoralreasonssuchasrespiratorysystem,gastrointestinalsystem,orurinary
system.In1%ofpatients,thecauseofthehalitosisisdietsordrugs.[11,12]
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ETIOLOGYOFHALITOSIS
Halitosisisformedbyvolatilemoleculeswhicharecausedbecauseofpathologicalornonpathological
reasons,anditoriginatesfromanoraloranonoralsource.Thesevolatilecompoundsaresulfur
compounds,aromaticcompounds,nitrogencontainingcompounds,amines,shortchainfattyacids,
alcoholsorphenylcompounds,aliphaticcompounds,andketones[Table1].[1317]
Volatilesulfurcompounds(VSCs)aremainlyresponsibleforintraoralhalitosis.Thesecompoundsare
mainlyhydrogensulfideandmethylmercaptan.Theyproducebacteriabyenzymaticreactionsofsulfur
containingaminoacidswhichareLcysteineandLmethionine[Table2].[18]Inaddition,someofthe
bacteriaproducehydrogensulfideandmethylmercaptanfromserum.Thebacteriawhicharethemost
activeVSCproducersareshown[Table3].[19]
TheotherVSCisdimethylsulfidewhichmainlyresponsibleforextraoralorbloodbornehalitosis,[20]
butitcanbeacontributortooralmalodor.Ketonessuchasacetone,benzophenone,andacetophenoneare
presentinbothalveolar(lung)andmouthairindoleanddimethylselenidearepresentinalveolarair.
[16,21]ThesecompoundsarealsofactorsforHalitosisoccurrenceanditmaybesimplyclassifiedtheir
originsintothreecategoriesoralcauses,nonoralcauses,andtheothercauses.
Halitosisoriginatesfromoralcavity

Althoughhalitosishasmultifactorialorigins,thesourceof90%casesisoralcavity.Inoralcavity,
temperaturesmaybereachedupto37C(andchangedbetween34and37C).Duringexhaling[22]also
humiditymaybereachedupto96%(andchangedbetween91%and96%)inoralexhalations.[23]These
conditionsmayprovideasuitableenvironmentforbacterialgrowth.Thenumberofbacterialspecies,
whicharefoundinoralcavity,areover500,[8]andmostofthemarecapabletoproduceodorous
compoundswhichcancausehalitosis.Intheseconditions,poororalhygieneplaysakeyfactorfor
multiplicationofhalitosiscausativebacteriaandcausesanincreaseinhalitosis.Thesebacteriainclude
especiallyGrnegativespeciesandproteolyticobligateanaerobes[Table4],[2427]andtheymainly
retainedintonguecoatingandperiodontalpockets.[5,28]Amonghealthyindividuals,withnohistoryof
halitosisandnoperiodontaldiseases,someshowhalitosisbecauseofretentionofbacteriaonthetongue
surface.[29]Thesebacteriadegradeorganicsubstrates(suchasglucose,mucins,peptides,andproteins
presentinsaliva,crevicularfluid,oralsofttissues,andretaineddebris)andproduceodorouscompounds.
[5,30,31]
Bythepoororalhygiene,fooddebrisanddentalbacterialplaqueaccumulateontheteethandtongue,and
causecariesandperiodontaldiseaseslikegingivitisandperiodontitis.Theinflammationofgingivaland
periodontaltissuescreatestypicalsourcesfororalmalodors[32,33]andplaquerelatedperiodontaldisease
canincreasetheseverityofhalitosis.However,theotherformsofperiodontaldisease,especiallyacuteand
aggressiveformssuchasacutenecrotizingulcerativegingivitis,pericoronitis,Vincent'sdiseaseor
aggressiveformsofperiodontitis,canincreaseunpleasantbreathodor.[32]Thetypeofgingival
enlargementwhichisdependentoninflammationordrugs(suchasphenytoin,cyclosporineorcalcium
channelblockers)mayincreasetheriskofbadodor.[34]Theseverityofhalitosisisaffectedfrom
periodontalconditions,alsoperiodontalconditionsareaffectedbyhalitosis.Thepreviousstudiesshoweda
relationshipbetweenoralhalitosisandperiodontaldisease.Periodontaldiseasesmaybedevelopedbythe
volatilesulfurcontainingcompoundtransitiontoperiodontaltissues.[3537]However,itisstillnotwell
understoodwhatistherelationshipbetweenperiodontalhealthandoralmalodors.[3840]
Besidesperiodontalconditions,untreateddeepcariouslesionsalsocreatetheretentionareaforfooddebris
anddentalbacterialplaqueandmaycausehalitosis.Anotherimportantfactorinhalitosisistheflowof
saliva.Theintensityofsulfurcompoundsisincreasedbecauseofsalivaryflowreductionorxerostomia.
[41]Salivafunctionsasabufferingoracleaningagentandkeepsbacteriaatamanageablelevelinthe
mouth.[42]Reductionofthesalivaryflowhasnegativeeffectsonselfcleaningofthemouthand
inadequatecleaningofthemouthcauseshalitosis.[4347]ReductionofSalivaryflowmaybeaffected
frommanyreasonssuchasmedications(e.g.,antidepressants,antipsychotics,diuretic,and
antihypertensive),salivaryglanddiseases(e.g.,diabetes,Sjorgen'ssyndrome),chemotherapy,or
radiotherapy.[4851]
Otherfactorsthatcontributetohalitosisareendodontic,surgical,andpathologicfactorssuchasexposed
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toothpulpsandnonvitaltoothwithfistuladrainingintothemouth,oralcavitypathologies,oralcancer
andulcerations,extractions/healingwoundsorprostheticsordentitionfactorssuchasorthodonticfixed
appliances,keepingatnightornotregularlycleaningdentures,restorativecrownswhicharenotwell
adapted,noncleaningthebridgebody,andinterdentalfoodimpaction.Allthesefactors[Table5]cause
foodorplaqueretentionarea,raisingbacterialamount,tissuebreakdown,putrefactionofaminoacids,and
decreasingofsalivaflow.Alltheseconditionsresultinthereleaseofvolatilecompoundsandcause
halitosis.[5256]
Halitosisoriginatesfromnonoralsources

Nearly8%ofthehalitosiscasescausedfromanextraoralsource.Thistypehalitosishasmanysources,but
itisrarelyseen.Respiratorysystemproblems,gastrointestinaldisease,hepaticdisease,hematologicalor
endocrinesystemdisordersandmetabolicconditionscanallbethecausesofhalitosis.
Respiratorysystemproblemscanbedividedintoupperandlowerrespiratorytractproblems.Theyare
sinusitis,antralmalignancy,cleftpalate,foreignbodiesinthenoseorlung,nasalmalignancy,subphrenic
abscess,nasalsepsis,tonsilloliths,tonsillitis,pharyngealmalignancy,lunginfections,bronchitis,and
bronchiectasislungmalignancy.[45,5759]Bacterialactivityinthispathologycauseshalitosiswhichleads
toputrefactionofthetissuesorcausestissuenecrosisandulcerationsandproductionofmalodorousgases,
whichareexpiredcausinghalitosis.[53,55]
Gastrointestinaldiseasescausehalitosis.Pyloricstenosis,duodenalobstruction,aortoentericanastomosis,
pharyngealpouches,zenker'sdiverticulum,hiatalherniacausefoodretention.Refluxesophagitis,
achalasia,steatorrhea,orothermalabsorptionsyndromesmaycauseexcessiveflatulenceorHelicobacter
pyloriinfectioncausesgastriculcers[53,60]andVSClevelsincreaseinoralbreath.LevelsofVCS'sin
oralbreathmaybehigherinpatientswitherosivethannonerosiveoesophagogastroduodenalmucosal
diseasealthoughVSClevelsarenotinfluencedbythedegreeofmucosaldamage.[27,61]
Also,hepaticorhematologicaldiseaseswhicharehepaticfailure(foetorhepaticus)andleukemia's,renal
failure(usuallyendstagerenalfailure),endocrinesystemdisorderswhicharediabeticketoacidosisor
menstruation(menstrualbreath),metabolicdisorderwhicharetrimethylaminuriaandhypermethioninemia
maycausehalitosis[Table6].
Othercausesofhalitosis

Dietaryproductssuchasgarlic,onions,spicedfoodscausetransientunpleasantodororhalitosis.
Therewithaldrugssuchasalcohol,tobacco,betel,solventabuse,chloralhydrate,nitritesandnitrates,
dimethylsulfoxide,disulphiram,somecytotoxics,phenothiazines,amphetamines,suplatasttosilate,and
paraldehydemaycreatethesameeffect[62,63][Table7].
ASSESSMENTOFHALITOSIS
Halitosisaffectsaperson'sdailylifenegatively,mostofpeoplewhocomplainabouthalitosisrefertothe
clinicfortreatmentbutinsomeofthepeoplewhocansufferfromhalitosis,thereisnomeasurable
halitosis.Assessmentmethodsofhalitosisensurediscriminationofpseudohalitosisandhalitophobia.For
thesereasons,diagnosisofthehalitosis,andassessmentofitsseverity(conditionsthatpatientshave,isit
genuinehalitosisorpseudohalitosisorhalitophobia)areveryimportant.Therefore,thediagnosticway
andtoolsweredeveloped.Organolepticmeasurement,gaschromatography,sulfidemonitoring,theBANA
test,andchemicalsensorshavemostcommonlyusedthantheothermethodssuchasquantifying
galactosidaseactivity,salivaryincubationtest,ammoniamonitoring,orninhydrinmethod.
Organolepticmeasurement

Theoldestwayforunpleasantodordetectionisbysmellingwiththenose.Measurementofunpleasant
odorsbysmellingtheexhaledairofthemouthandnoseiscalledorganolepticmeasurement.Itisthe
simplewayforthedetectionofhalitosis.
Themeasurementmethodistheorganoleptictestthepatienttakesbreathedeeplybyinspiringtheairby
nostrilsandholdingawhile,thenexpiringbythemouthdirectlyorviaapipette,whiletheexaminersniffs
theodoratadistanceof20cm(thepurposeofusingapipetteistolessentheintensityofexpiringair)and
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theseverityofodorisclassifiedintovariousscales,suchasa0to5pointscale(0:noodor,1:barely
noticeable,2:slightbutclearlynoticeable,3:moderate,4:strong,and5:extremelystrong)[45,64,65]or
morewidelypointscalefrom0to10point.[66]
Thismeasurementisconsideredtobethegoldstandardformeasuringandassessingbadbreath[67]
becauseofnocost,andbeingpracticalandsimple.However,ithassomedifficulties.Itmaybedifficultto
calibratethepractitionerandtogainthecorrectresultinclinicalpractice,thepatientshouldavoidfrom
eatingodiferousfoodsfor48hbeforetheassessmentandthatboththepatientandtheexaminershould
refrainfromdrinkingcoffee,teaorjuice,smokingandusingscentedcosmeticsbeforetheassessment.[45]
Alsotheotherproblemisthewayofmeasurement,itisunlikeablesituationsfortheexaminerbecauseof
smellingunpleasantodorandinconvenientconditionsforthepatient.[14]Tolessenunpleasantsituations
insteadofexpiringairtoexaminers,thepatientcanbreathetheairinsidethebagawhile,thenthe
examinersniffthisodorfromthebagandclassifyitsseverity.Bythiswaytheunpleasantsideof
organolepticmeasurementbecomesamoreacceptableone.
Gaschromatography

Measurementwiththegaschromatographymethodisconsideredtobehighlyobjective,reproducible,and
reliable.[68]UsinggaschromatographywecanmeasureVSCs.Itseparatesandanalyzescompoundsthat
canbevaporizedwithoutdecompositionsamplesarecollectedfromsaliva,tonguecoating,orexpired
breath.Inthismethod,measurementsareperformedandequippedwithaflamephotometricdetectororby
producingmassspectra.TheconcentrationofeachVSC(ng/10mLmouthair)wasdeterminedbasedona
standardofhydrogensulfideandmethylmercaptangaspreparedwithapermeater.[69]
Inthegaschromatographymethod,thepatientclosethemouthandholdair30s,thenmouthair(10mL)
isaspiratedusingagastightsyringe.Aftercollectionsofsamples,itisinjectedintothegaschromatograph
columnat70C.Theresultsarepreciseandreliable,butthismethodtakesalongtimetorun.Moreover,it
isexpensiveandnotusedcommonlyinchairside,andrequiresaskilledoperator.[6,69,70]Mostly,the
resultsofthegaschromatographymethodshowhighcorrelationtoorganolepticmeasurementsbutgas
chromatographyhashighsensitivityanditcandetectlowconcentrationmolecules.Therefore,sometimes
wemayseelowcorrelationbetweengaschromatographyandorganolepticmeasurements.[71,72]
Sulfidemonitoring

Gaschromatographyhashighaccuracyandsensitivity,buttheapplicationmethodinchairsideisdifficult
andexpensive.Inordertoavoidthesedisadvantages,anewportabledevicewhichisasulfidemonitorwas
developedtomeasureVSCs.
Inthismethodbeforetakingmeasurement,patientsshouldclosethemouthandrefrainfromtalkingfood
for5minpriortomeasurement,thenadisposabletubeofthesulfidemonitorisinsertedintopatient's
mouthtocollectmouthair.Meanwhile,thepatientisbreathingthroughthenoseandthedisposabletubeis
connectedtothemonitor.Sulfurcontainingcompoundsinthebreathcangenerateanelectrochemical
reaction.Thisreactionrelateddirectlywithlevelsofvolatilesulfurcontainingcompounds.[7375]
Thesensitivityandspecificityofthesulfidemonitorislessthanthegaschromatographybutcorrelations
ofmeasurementsarehighlysignificant.Ontheotherhand,thesulfidemonitorandorganoleptic
measurementsshowlowcorrelationbecauseofvolatilecompoundssuchasalcohols,phenylcompounds,
alkenes,ketones,polyamines.Shortchainfattyacidscanbedetectedbyorganolepticmeasurements,but
cannotbedetectedbythesulfidemonitorsothecorrelationsbetweenmeasurementsmaybeinconsistent.
[13,74,7679]
Chemicalsensors

Becauseofdifficultiesofgaschromatographyandlesssensitivityofsulfidemonitors,amoresensitiveand
easydevicewasmade.Chemicalsensorshaveanintegratedprobetomeasuresulfurcompoundsfrom
periodontalpocketsandonthetonguesurface.Theworkingprincipleofchemicalsensorsissimilarto
sulfidemonitors.Throughthesulfidesensingprobe,sulfidecompoundsgenerateanelectrochemical
voltageandthisvoltageismeasuredbyanelectronicunit.Themeasurementisshownondevice'sscreen
asadigitalscore.[35,80,81]
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Usingthenewchemicalsensors,ammoniaandmethylmercaptancompoundscanbemeasuredfrombreath
airandsomenewtypesofsensorsmeasureeachvolatilesulfurcontainingcompoundsseparately.The
sensitivityissimilartogaschromatographyandresultsofthemeasuresarehighlyclosetoorganoleptic
scoressochemicalsensorsarecalledtheelectronicnose.[74,8285]
BANAtest

TheBANAtestispracticalforchairsideusage.ItisateststripwhichcomposedofbenzoylDLarginine
anaphthylamideanddetectsshortchainfattyacidsandproteolyticobligategramnegativeanaerobes,
whichhydrolyzethesynthetictrypsinsubstrateandcausehalitosis.ItdetectsespeciallyTreponema
denticola,P.gingivalis,andT.forsythensisthatassociatedwithperiodontaldisease.ByusingtheBANA
test,wecandetectnotonlyhalitosis,butalsoperiodontalriskassessment.[13,64,8688]
Todetecthalitosis,thetongueiswipedwithacottonswab.Forperiodontalriskassessment,the
subgingivalplaqueisobtainedwithacurette.Toevaluate,thesamplesareplacedontheBANAteststrip,
whichistheninsertedintoaslotonasmalltoastersizedincubator.Theincubatorautomaticallyheatsthe
sampleto55for5min.IfT.denticola,P.gingivalis,orB.forsythusarepresent,theteststripturnsblueor
thebluer.Deepeningofthebluecolorshowsexistenceofthehighertheconcentrationandthegreaterthe
numberoforganisms.
ThecloserelationshipsarefoundbetweentheBANAtestandorganolepticmeasurements,butthe
relationshipbetweentheBANAtestandsulfurmonitormeasurementsarepoor.Performingmultiple
regressionanalysiswithorganolepticmeasurementsandtheBANAscoreasthedependentvariable,both
peakVSClevelsandBANAscoresfactoredintotheregression,yieldinghighlysignificantassociations.
[88,89]ThisresultmaybecausedbyBANApositivemicroorganismswhichcontributehalitosisvianon
sulfurodorants,suchascadaverine.[13]
TheBANAtestresultsdemonstrateasignificantpositivecorrelationwiththeincreasingpocketdepth.
[9092]Periodontalconditionscanbeassessedbythisway,butperiodontalconditionscanbechangedby
BANAnegativemicroorganismsorthepercentageofBANApositivemicroorganismsmaybebelowthe
detectionlimitoftheBANAtest.ComparingthesensitivityoftheBANAtestandofELISAthe9%rate
offalsepositiveresultswasfound.[93,94]TheBANAtestresultsreflectperiodontaldiseaseactivity
whichmaycausehalitosisbybleedinggums.
Quantifyinggalactosidaseactivity

Deglycosylationistheremovedlinkofglycosylgroupsfromglycoproteins.Deglycosylationof
glycoproteinsareinitialstepinoralmalodorproduction.[95]Bydeglycosylationofglycoproteins,
proteolyticbacteriadegradeproteinswhichareespeciallysalivaryglycoproteinsandcausehalitosis.
ProteolysisofglycoproteindependsontheinitialremovalofthecarbohydratesidechainswhichareO
andNlinkedcarbohydrates.Galactosidaseisoneoftheimportantenzymeswhichareresponsibleforthe
removalofbothOandNlinkedcarbohydratesidechains.[96,97]
Galactosidaseactivitycanbeeasilydeterminedbytheuseofchromogenicsubstratesabsorbedontoa
chromatographypaperdisc.[74,95,98]Inordertomeasuregalactosidaseactivity,salivawastakenina
paperdiscanddiscoloringofthepaperdiscchangesbasedongalactosidaseactivityandthesechanges
arerecordednocolor:0,faintbluecolor:1,moderatetodarkbluecolor:2.[95]Stereretal.founda
positivecorrelationbetweenorganolepticscoresandgalactosidase.[99]
Salivaryincubationtest

Thesalivaryincubationisoneoftheassessmentmethodstomeasurehalitosisindirectly.Firsttime,Marc
Quirynenetal.carriedoutastudytoevaluatesalivaryincubationandhalitosis.Tomeasurehalitosiswith
thesalivaryincubationtest,salivawascollectedinaglasstubeandthenincubatingthetubeat37Cinan
anaerobicchamberunderanatmosphereof80%nitrogen,10%carbondioxide,and10%hydrogenfor36
h.Afterincubation,anexaminerevaluatestheodor.Althoughthismethodhassomesimilaritieswiththe
organolepticmeasurements,ithassomeadvantagesoverthem.Themostimportantadvantageisthatthe
salivaryincubationtesthasmuchlessinfluencedbyexternalparameterssuchassmoking,drinkingcoffee,
eatinggarlic,onion,spicyfood,andscentedcosmetics.Howeverinorganolepticmeasurements,external
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parametershavenegativeeffectsontheresultsothepatientandexaminershouldavoidsomeodiferous
foodanddrinkbefore48h.Theotheradvantagesareunpleasantconditionsofthesemeasurements
comparedtoorganolepticmethods.Theresultsofthesalivaryincubationtestareshownastrong
correlationwiththeorganolepticmeasurement.[79]Ifthehardnessoftheincubationprocessdoesnotbe
counted,thesalivaryincubationtestcouldbeoneofthevaluabletestsforhalitosismeasurements.
Ammoniamonitoring

BesidesVSCs,ammoniaisanotherimportantfactorinhalitosis.Sulfurcompoundscanbedetectedbya
portablesulfidemonitor,butunfortunatelyammoniacannotbemeasuredusingthismethod.Ammoniais
themajorbasicgasinavarietyofimportantsamplematrixes,forexample,theambientatmosphere,indoor
air,andhumanbreath.Comparatively,breathcontainshighlevelsofammoniaitis1ppmvinthebreathof
ahealthyindividualormaybehigherinindividualswithrenalfailure.[100]
Toperformmeasuringhalitosis,anewlyportablemonitorhasbeendeveloped.Thismonitordetects
ammoniaquantitywhichisproducingbyoralbacteria.Atleast2hbeforemeasurements,thepatients
shouldrefrainfromeatinganddrinkingactivity.Thenpatientsusespecialmouthrinsefor30sandclose
themouthfor5min.Thisrinseincludeureasolutionandthebacteriaproduceammoniafromurea.To
measuretheconcentrationofammoniaadisposablemouthpiecewhichispartofthedeviceisplaced
insideapatient'smouth.Thisdisposablepartconnectedtoanammoniagasdetectorwhichcontaineda
pumpthatdrew50mLofairthroughantubeandtheconcentrationofammoniaisnoteddirectlyfromthe
scaleonthedetectortube.[15]
Thereisnocorrelationbetweentheorganolepticscoreandtheammonialevelmeasuredwithammonia
monitoring,butmeasurementsoftheammonialevelwithammoniamonitoringshowsignificant
correlationwiththetotallevelofVSCsmeasuredwithgaschromatography.[15]
Ninhydrinmethod

Gaseswhicharecomponentsofhalitosiswereproducedfromthebreakdownofpeptidesand
glycopeptidesbybacterialputrefactionintheoralcavity.Duringthisprocess,peptidesarehydrolyzedto
aminoacidswhichfurtheraremetabolizedtoaminesorpolyamines.Thesemoleculescannotmeasuredby
sulfidemonitoring.Hence,theninhydrinmethodwasusedforexaminationofaminoacidsandlow
molecularweightamines.
Levelsoflowmolecularweightaminesmaygiveinformationforhalitosiscausedfrombacterial
putrefactionoflowmolecularweightamines.Theninhydrinmethodissimple,rapid,andinexpensive.
Thismethodisakindofcolorimetricreaction.Thecollectedsalivaismixedwithisopropanoland
centrifuged.Thesupernatantwasdilutedwithisopropanol,buffersolution(pH5),andninhydrinreagent.
Themixturewasrefluxedinawaterbathfor30min,cooledto218C,anddilutedwithisopropanol.Light
absorbancereadingsweredeterminedusingaspectrometer.Theresultsofninhydrinmethodsshowa
significantcorrelationwithorganolepticscoresandsulfidemonitormeasurements.[101]
Impactofdailylife

Peopleinteractwitheachothereveryday,andhalitosishasanegativeeffectonaperson'ssociallife.The
personwhohashalitosismaynotbeawareofthissituation[102]becausethispersonmayhavedeveloped
toleranceorolfactorydisturbance.Duetothiscause,thepatientgenerallycannotidentifyhis/herhalitosis
anditisidentifiedbyhis/herpartner,familymember,orfriends.Thisconditioncausesadistressingeffect
onpersonswhohavehalitosisandsotheaffectedpersonmayavoidsocializing.
Selfcareproducts

Halitosisinterfereswithnormalsocialinteractions.Forthesereasons,selfcareproductsareusedby
halitosispatientsforpreventingunpleasantodor.However,bytheseproductsdirecttreatmentofhalitosis
isnotpossibletheseproductssuchaschewinggumandmints,toothpastes,mouthrinses,andsprays
decreasetheodorandattempttomaskhalitosiswithpleasantfragrances.Theuseofchewinggummay
decreasehalitosis,especiallythroughincreasingthesalivarysecretion.[103]Mouthrinsescontaining
chlorinedioxideandzincsaltshaveasubstantialeffectonmaskinghalitosis,notallowingthe
volatilizationoftheunpleasantodor.[103,104]Especiallydietarycausedhalitosissuchasonion,garlic,or
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cigarettecanbemaskedbytheseapproaches.Theseapproachesshouldbeonlyusedasatemporarily
solutiontorelieveandimprovethesatisfactionofthepatient.Professionaltreatmentofrealhalitosishas
crucialseverity.
Professionaltreatment

Halitosiscanbetreatedifitsetiologycanbedetectedproperly.Therefore,themostimportantissuefor
treatmentofhalitosisisdetectingofetiologyordeterminingofitssourcebydetailedclinicalexamination.
Althoughmostofthecasesarecausedfromoralcavity,sometimesotheretiologiescancontributeoral
halitosis.Ifitisnotdetectedoftheetiologyaccurately,thetreatmentcanbeunsuccessfultherefore
investigationandadequatediagnosisarecrucial.
Intheeventoforalcavitycausedbyhalitosis,reductionofthebacterialloadisessential.Appropriate
periodontalmanagementisthefirststep.[105]Necrotizingulcerativegingivitis,gingivitis,adultand
aggressiveperiodontitisorperiodontalpocketscanincreasethebacterialloadsoperiodontalhealthhas
significantimportanceincontrollingtheamountofhalitosiscausedbybacteria.Initialperiodontal
treatmentincludesscalingandrootplanningwhichmayalleviatethedepthoftheperiodontalpocketsand
severityofgingivalinflammationanditeliminateshalitosiscausingbacteria.[106]Duringperiodontal
therapy,usageofantisepticmouthwashrelievesreductionofthebacterialload.Chlorhexidinecanbeused
asavaluableantisepticagent,butlongtermusesofchlorhexidinecancausestainingofteethandmucosal
surfaces.[107,108]
Goodoralhygieneinstructionisanotherimportantissuefororalcausedhalitosis.Properbrush,dental
floss,andinterdentalbrushusageareveryimportant.However,sometimeseveniftheperiodontalhealth
isperfect,tonguecoatingcanbeanimportantsourceofhalitosis.Thetonguedorsumcanbeashelterfor
thesebacteria.Ifapatienthasgeographicorfissuretongue,thecoatingwillbemore.Duetothesereasons,
cleaningoftonguedorsumbybrushing,tonguescraperortonguecleanerisimportant.Oneofthestudies
showedtheimportanceoftonguecleaningreductionofVSClevelswasfoundwiththetoothbrush33%,
withthetonguescraper40%,andwiththetonguecleaner42%.[109]
Existingandnecessaryrestorativeconditionsofapatientmustbereviewed.Unsuitableprostheticsand
conservativerestorations,suchascausingfoodimpactions,uncleaningareaorfoodretention,createa
reservoirareaforbacteria.Replacementorrenewingofoldrestorationswithproperrestorationprovides
preventionofthesereservoirareas.Alsoexistingofthenontreatedcavityofdecayedteeth,nonvitaltooth
withfistulaorexposedtoothpulpsmaycreateareservoirareaforbacteria,sotreatmentsoftheseteeth
withproperrestorationareimportant.
Theotherconditionscausehalitosissuchasxerostomia,pericoronitis,oralulceration,ormalignancy
whichmustbediagnosedandtreatedwell.Mostly,xerostomiamaybeanoversightbecauseofsuperficial
clinicalexamination.Thisconditionleadstopatientsdeprivedfromprotectiveandmechanicalwashing
effectsofsaliva.Thereasonsofxerostomiamustbeexaminedindetail.Ifxerostomiacausedbyheadand
neckradiotherapyorsalivaryglandspathology,theartificialsalivaproductsmustbesuggesttothe
patients.
Medicalconditionsorhistorycanbeilluminatinginformationaboutthecauseofhalitosis.Ifhalitosis
originatefromnonoralcausessuchasrespiratory,gastrointestinalandhepatic,renal,endocrineor
hematologicaldisease,consultationshouldbedonewiththespecialist.Iftheactualdiseaseisnotproperly
diagnosedandtreated,theeffectofhalitosiswillaffectaperson'ssociallifeandbecomesbothersome.
Accordinglydutiesofadentistinextraoralcausehalitosisareawareofpatientaboutsourceofhalitosis
andsendinghim/hertothespecialist.
Asmentionedabove,detailedclinicalexaminationonhalitosisiscrucial.Sometimespeoplecanthink
havehalitosisinspiteoftheyhavenomeasurablehalitosis.Thisconditioniscalledahalitophobiaandthis
conditioncanbemonosymptomaticdelusion(delusionalhalitosis)ormanifestationofolfactory
referencesyndrome.[110]Managementofhalitophobiamaybemorecomplexthanmanagementofreal
halitosis.Halitophobiapersonsavoidsocializingandevenavoidingtalkingwithpeopletherefore,
treatmentofhalitophobiaisveryimportant.Priortotreatingpeoplewhohavehalitophobia,itmustbe
proventhathe/shehasnomeasurablehalitosisbymeasuringdevices.Ifpersonsareobsessedwiththeidea
ofhavingbadbreath,consultationwithahyuapsychologistisrequired.
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Footnotes
SourceofSupport:Nil
ConflictofInterest:Nonedeclared

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FiguresandTables
Table1

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Odoriferouscomponentscausehalitosis[17]
Table2

Enzymaticwayofthehydrogensulfideandmethylmercaptan
Table3

Bacteriawhichisactiveproducersofvolatilesulfurcompoundsinvitro(adaptedfromPerssonetal.[19])
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Table4

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Bacteriawhichcontributehalitosis
Table5

Reasonsofhalitosiswhichisoriginatedfromoralcavity
Table6

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Nonoralcauseofhalitosis
Table7

Anexternalfilethatholdsapicture,illustration,etc.ObjectnameisJNSBM414g007.jpg
Othercausesofhalitosis
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