HALITOSIS

drg. Hafsah Dwi K

Prolanis Citra Medika 51
4 Maret 2018

Halitosis adalah bau nafas yang tidak sedap. Halitosis terutama adalah hasil dari
fermentasi anaerobik partikel makanan oleh bakteri gram negatif di dalam mulut yang
menghasilkan senyawa belerang atsiri seperti hidrogen sulfida dan merkaptan metil. Bakteri
penyebab mungkin hadir di area penyakit gingiva atau periodontal, terutama ketika
terjadi ulserasi atau nekrosis. Organisme penyebab berada dalam kantong-kantong
periodontal di sekitar gigi. Pada pasien dengan jaringan periodontal yang sehat, bakteri ini
dapat tinggal di lidah posterior dorsal.
Faktor-faktor yang berkontribusi terhadap pertumbuhan berlebih dari bakteri penyebab
halitosis termasuk penurunan aliran saliva (misalnya, karena penyakit parotis, sindrom
Sjögren, dan penggunaan antikolinergik. Makanan atau rempah-rempah tertentu, setelah
pencernaan juga mengeluarkan zat berbau ke paru-paru yang lalu dihembuskan. Sebagai
contoh, bau bawang, jengkol dan petai dapat membuat nafas berbau hingga 2 atau 3 jam
setelah dikonsumsi.
Selain makanan, Halitosis juga bisa disebabkan oleh rokok, alkohol, Dehidrasi, penyakit pada
hidung dan tenggorokan, dan penyakit organ dalam lainnya.

Penyebab
Kemungkinan penyebab dari napas tak sedap, selain kebersihan, adalah:
- Xerostomia – kekurangan air liur
- Infeksi: karang gigi, penyakit gusi, radang mulut atau peradangan sinus, tonsil, dan
tenggorokan
- Kondisi medis: kanker atau kelainan metabolism (misalnya, refluks asam lambung)

Faktor-faktor risiko
- Makanan
- Mulut kering.

Obat & Pengobatan

Pada kebanyakan kasus, bau mulut dapat hilang sendirinya jika mengubah kebiasaan
membersihkan mulut seperti lebih sering menggosok gigi, terutama pada gusi dan lidah,
gunkan dental floss dan minum lebih banyak air. Jika situasi tidak membaik, mungkin harus
mengunjungi dokter gigi untuk mengetahui apa yang terjadi.
Tergantung pada kasusnya, dokter akan membantu memilih penanganan yang paling
sesuai. Jika nafas tak sedap muncul karena kondisi medis lainnya, mengobati penyebabnya
mungkin akan menghilangkan nafas tak sedapnya. Dokter gigi mungkin akan memberikan
obat kumur anti bakteri dan sikat gigi untuk mengurangi dampaknya.

Apa saja perubahan gaya hidup atau pengobatan rumahan yang dapat dilakukan
untuk mengatasi bau mulut (halitosis)?

Untuk mencegah napas tak sedap, harus menjalani kebiasaan perawatan mulut sehat seperti
menggosok gigi setelah makan. Flossing sangat membantu karena dapat menyingkirkan sisa
makanan yang tersangkut di bagian di mana sikat gigi tidak dapat menjangkaunya. Jangan
lupakan lidah , karena di situlah bakteri banyak tinggal. Berikut adalah beberapa hal untuk
mengobati napas tak sedap :
- Berhenti merokok
- Minum banyak air
- Kunyah permen karet bebas gula untuk menstimulasi air liur
- Batasi konsumsi makanan bergula
- Hindari makanan seperti bawang bombay atau bawang putih
- Ganti sikat gigi setiap 3 hingga 4 bulan sekali.

Halitosis – An overview: Part-I – Classification, etiology, and

pathophysiology of halitosis
G. S. Madhushankari, Andamuthu Yamunadevi,1 M. Selvamani,2 K. P. Mohan Kumar, and Praveen S.
Basandi

Author information ► Article notes ► Copyright and License information ►

This article has been cited by other articles in PMC.

Abstract
Halitosis (Synonyms: Bad breath, fetid halitus, mouth odor, bad breath, bad mouth odor,
malodor) “is a condition in which halitus/breath is altered in a manner unpleasant for the
affected individual and affects both the individual and also those with whom he/she
interacts.”[1] It set backs an individual from his/her social interactions and also affects
psychologically. Here, the responsibility comes to the dentist in assessing and treating this
apparently common phenomenon, since oral cavity is the most common source of halitosis.
At times, bad breath can also reflect the systemic pathologies and is of real concern to
diagnose these pathologies at the earliest. References related to this common problem are rare
and, this article gives an overview on the different aspects of halitosis.
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Epidemiology
Flipping through the pages of ancient Greek and Roman[2] literature thousands of years back,
bad breath is mentioned in their writings also, and Mediterranean countries have used
ladaneey (a resion) for freshening the breath. Parsley (Italy), cloves (Iraq), guava peels
(Thailand), and egg shells (China) are the folk cures for halitosis. Thus, it is revealed that oral
halitosis is a problem of all centuries, occurring universally in both the genders. All age
groups are affected and the incidence of halitosis increases with age, with varying prevalence
rate (5–75%,[3,4]60%,[1]14.6%[5]) in children and (8–50%)[6] in general population.
Moderate chronic halitosis is common in one-third of the population, and the rest are affected
by halitosis at least during a part of the day (morning mouth/morning halitosis is widely
prevalent). Severe halitosis affects less than 5% of the population[7] that requires immediate
attention.
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Classification
In general, halitosis can be either primary or secondary:[1]

 Primary halitosis: Refers to respiration exhaled by the lungs[1]

 Secondary halitosis: Originates either in the mouth or upper airways.[1]

Clinically, halitosis can be classified into three groups,[8] namely:

 Real/Genuine halitosis
 Physiologic halitosis: E.g.: Morning halitosis
 Pathologic halitosis:
 Oral pathologic halitosis
 Extra-oral pathologic halitosis
 Pseudohalitosis – Complains of halitosis without the actual existence and can be treated by
the dental practitioner by counseling and simple oral hygiene procedures.
 Halitophobia – People with a fear of halitosis. Interestingly, this group of patients present
with symptoms of halitosis in the absence of objective oral malodor. This symptom may be
attributable to a form of delusion or monosymptomatic hypochondriasis (self-oral malodor,
halitophobia, phantom bad breath).[9] This condition can be identified by questionnaire
method and require psychological investigation or support rather than a dental
treatment.[9]

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Etiology
Bad breath can originate either from oral and related (ear, nose, throat) sources (87%) or
extra-oral (systemic) in origin (13%).[7] Poor oral hygiene, gingivitis and periodontitis,
tongue coating, ear, nose, and throat problems (e.g.: Tonsillitis, sinusitis, presence of foreign
bodies and rhinitis), decrease in saliva, dry mouth, habits such as smoking, alcohol, tobacco,
and betel nut chewing are the leading oral factors associated with halitosis,[7] with male
gender being affected more commonly.[10] Caries experience, age, habits such as mouth
breathing leading to dryness of mouth[1] are associated with malodor in children. Extraoral
or systemic conditions leading to halitosis include gastrointestinal (GIT) problems[11,12] and
even stress.[13]
Enumeration of possible etiological sources[9,14,15,16,17,18,19,20,21] is given in Table 1.

Table 1

Etiology of bad breath/halitosis (original source[9])

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Pathophysiology
Though the exact pathogenesis of oral malodor is not known, the most accepted one is that
the microbial putrefaction of food debris, desquamated cells, saliva and blood causes oral
malodor. The bacterial interactions are mainly due to several proteolytic and anaerobic,
Gram-negative bacterial species and are not associated with any specific bacterial infection.
The only Gram-positive bacteria so far proved to be associated with halitosis is
Stomatococcus mucilaginous.[14]
Various agents such as volatile sulfur compounds (VSCs), diamines and short chain fatty
acids are produced due to this microbial breakdown of amino acids by enzymes, resulting in
oral malodor (For e.g.: Breakdown of cystine, cysteine, and methionine produces VSC[1])
[Figures [Figures11 and and22].

Figure 1

Pathophysiology of halitosis

Figure 2

Enzymatic breakdown of amino acids, resulting in production of VSCs

The intensity of malodor corresponds to the level of odoriferous substances in the oral
cavity[1] and gingival crevices, periodontal pockets, and posterior dorsum of the tongue are
the most likely sites involved in the whole process.
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Factors in the Pathophysiology of Halitosis

Saliva
Saliva, performing numerous functions in the oral cavity, has protective and anti-bacterial
properties as prime functions. Its protective function is mainly due to cleansing action
causing constant removal of bacteria and food debris, and the anti-bacterial property is
attributed to the presence of salivary Ig A, lysozyme, lactoferrin, and several glycoproteins.
Furthermore, the normal salivary pH is slightly acidic in nature (pH - 6.5) and helps in
suppressing the growth and proliferation of Gram-negative and anaerobic bacteria. Thus, the
activation of enzymes necessary for the putrefaction of amino acids such as cystine, cysteine,
and methionine is hindered, preventing the production of foul smelling sulfur-containing
compounds.[22,23]
Xerostomic conditions causing reduction in salivary flow causes a negative effect on the self-
cleansing action of saliva and produces odoriferous volatile compounds.[22,23] Mucin
precipitation and alkalization of the oral environment enhances proteolytic bacterial growth.
Thus, dehydration, salivary gland diseases, certain drugs, mouth breathing remain as one of
the causes for halitosis by causing xerostomia.
The people with morning breath (evening breath in night shift workers!!) will not experience
halitosis during the day, but during sleep, the body produces less saliva, and unpleasant odor
is experienced in the morning.

Gingivitis and periodontitis

About 10% of the population with severe periodontitis are accompanied by bad breath. The
applied reasons are,

 The spaces between the teeth and the gums act as site of entrapment of food for the people
with periodontitis and eventually bacteria acts on these entrapped food substances,
producing odoriferous substances[24]
 Also, the bleeding tendency of gums in gingivitis and periodontitis, makes the condition
worse.[24] Initially, it will impart an iron or metallic smell and later as the blood
decomposes, a more foul smell is produced.[24]

Tongue coating
Malodor can arise from the patients even with good oral hygiene and the source is from the
posterior dorsal tongue,[9] as the large, papillary surface area of the dorsum of tongue can
retain large amounts of desquamated cells, leukocytes, salivary constituents, and
microorganisms and can facilitate putrefaction. Though, the microbial content of the tongue
is greater,[25,26] it is not necessarily different for the people with and without
periodontitis.[27] Tongue cleaning along with regular brushing improves the condition.

Mouth breathing
Mouth breathing accounts for 40%[1] in children with halitosis by causing surface drying of
mucosa due to evaporation of water from saliva.[1] Notoriously, humming facilitates nasal
breathing in these patients by increased nitric oxide production that causes smooth muscle
relaxation and vasodilatation.[28] As a treatment option, mouth breathing children are
suggested to hum with the tongue on the palate to ensure nose breathing.

Respiratory related illness and increased mucus production

In respiratory-related illness like postnasal drip, sinus related illness, and tonsillitis, excessive
mucus and phlegm accumulation is seen, which attracts more bacteria. This cause of halitosis
is more common in children, as the children are more susceptible to postnasal drip and
tonsillitis.
Drinking and/or smoking (active and passive), beyond giving alcoholic and nicotinic smell on
the intakers, adds to halitosis by increasing mucus and phlegm in the throat.[24] Eating dairy
rich food also increases mucus production.[24] Eliminating the above-mentioned etiologies
reduces halitosis.

Gastrointestinal pathologies
Other than oral and related causes, halitosis due to GIT disorders is considered to be rare, as
the esophagus is normally collapsed and closed.[14] Two important GIT pathologies where
association with halitosis is proved are Helicobacter pylori infection and gastroesophageal
reflux disease.[29,30] Furthermore, halitosis is significantly associated with heartburn,
regurgitation, sour taste, belching, and borborygmus but not with functional dyspepsia, peptic
ulcer disease, upper abdominal pain, bloating, early satiety or chest pain.[12]
The association of H. pylori infection with halitosis was initially suggested by Marshall et
al. in 1985.[31] Controversies with their association are noted in different studies and the
researchers speculate that the strain-specific production of VSCs is responsible for variation
in the study results that is, the production of VSC are observed only in three strains of H.
pylori namely, H. pylori ATCC 43504, H. pylori SS 1, H. pylori DSM 4867. The other
species of H. pylori does not produce odoriferous substances and thus not associated with
halitosis.[8] H. pylori infection increases with age and has a prevalence rate of 19.6–
43.9%.[8] Crowded families promote cross infection and its carcinogenic potential alarms us
for early detection and treatment. Urea breath test, serum antibody detection, saliva analysis,
biopsies and molecular DNA analysis helps in H. pylori detection. Treatment with antibiotics
and proton pump inhibitors eliminates the infection and can bring down halitosis.[12]

Systemic conditions
Different medical conditions, impart different odor on the patient's breath.

 Diabetes – Fruity or citrusy breath

 Asthma or cystic fibrosis – Acidic breath
 Kidney problem – Scent of ammonia
 Hepatic cirrhosis – Musty or mousey odor[32]
 Trimethylaminuria – Foul fishy odor
 Nasal malodor – Slightly cheesy character
 Bowel obstruction – Fecal odor.[32]

Ketoacidosis (uncontrolled diabetes can produce diabetic ketoacidosis) – Sweet fruity and/or
acetone breath or rotten apple breath.
Excessive ketone production can also result from dieting. Low carbohydrate diet, burns
body's fat content for energy production and produces excessive ketones. Stopping the
dieting, changing the diet with high carbohydrate content and low-fat content, drinking extra
water to flush out the body prevents ketone breath.[24]

Eating strongly odoriferous food substances

Food substances with strong odor like garlic and onion, after being absorbed into the
bloodstream during digestion, are transferred to the lungs, and the exhaled air is characterized
by the odor of that particular food substance.[15]
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Need for Early Detection of these Volatile Sulfur Compounds

These VSCs released during microbial interactions are capable of initiating and accelerating
periodontal pathology. Recently, it has been reported that hydrogen sulfide induce
mitochondria-mediated apoptosis and DNA damage in human gingival fibroblasts by
increasing the levels of reactive oxygen species.[33] Extracellular matrix degradation is
facilitated by induction of immune responses, matrix metalloproteinase activity by these
VSCs. VSCs inhibit osteoblastic activity,[34] activate osteoclastic activity, thus leading to
pathogenic bone loss. Thus, the effects of VSCs are much more than simple halitosis, and
early detection and removal saves from periodontal disease progression also.
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Conclusion
The patients with halitosis initially approach the dentists for the betterment of the condition
and here the responsibility lies on the dentists to treat the condition. Thus, a thorough
understanding of the etiology and pathophysiology can upgrade us to a better treatment
option. Researches on VSCs and their effect on oral tissues have given a real concern to the
problem of halitosis and thus early remedy to this apparently normal phenomenon is
essential.

Financial support and sponsorship

Nil.

Conflicts of interest
There are no conflicts of interest.
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References
1. Motta LJ, Bachiega JC, Guedes CC, Laranja LT, Bussadori SK. Association between halitosis and
mouth breathing in children. Clinics (Sao Paulo) 2011;66:939–42. [PMC free article] [PubMed]

2. Geist H. Halitosis in ancient literature. Dent Abstr. 1957;2:417–8.

3. Kharbanda OP, Sidhu SS, Sundaram K, Shukla DK. Oral habits in school going children of Delhi: A
prevalence study. J Indian Soc Pedod Prev Dent. 2003;21:120–4. [PubMed]

4. Polanco CM, Saldna AR, Yanez EE, Araujo RC. Respiracion buccal. Ortodoncia. 9th ed. [Last
accessed on 2013 May 02]. pp. 5–11. Especial Available
from: http://www.ncb.in.lmnih.gov/pmc/articles/PMC3129960 .

5. Nalçaci R, Dülgergil T, Oba AA, Gelgör IE. Prevalence of breath malodour in 7- 11-year-old children
living in Middle Anatolia, Turkey. Community Dent Health. 2008;25:173–7. [PubMed]

6. Scully C, Felix DH. Oral medicine – update for the dental practitioner: Oral malodour. Br Dent
J. 2005;199:498–500. [PubMed]

7. Rösing CK, Loesche W. Halitosis: An overview of epidemiology, etiology and clinical

management. Braz Oral Res. 2011;25:466–71. [PubMed]

8. Yilmaz AE, Bilici M, Tonbul A, Karabel M, Dogan G, Tas T. Paediatric halitosis and Helicobacter
pylori infection. J Coll Physicians Surg Pak. 2012;22:27–30. [PubMed]
9. Porter SR, Scully C. Oral malodour (halitosis) BMJ. 2006;333:632–5. [PMC free article] [PubMed]

10. Nadanovsky P, Carvalho LB, Ponce de Leon A. Oral malodour and its association with age and sex
in a general population in Brazil. Oral Dis. 2007;13:105–9. [PubMed]

11. Moshkowitz M, Horowitz N, Leshno M, Halpern Z. Halitosis and gastroesophageal reflux disease:
A possible association. Oral Dis. 2007;13:581–5. [PubMed]

12. Kinberg S, Stein M, Zion N, Shaoul R. The gastrointestinal aspects of halitosis. Can J
Gastroenterol. 2010;24:552–6. [PMC free article] [PubMed]

13. Queiroz CS, Hayacibara MF, Tabchoury CP, Marcondes FK, Cury JA. Relationship between
stressful situations, salivary flow rate and oral volatile sulfur-containing compounds. Eur J Oral
Sci. 2002;110:337–40. [PubMed]

14. Rosenberg M. Clinical assessment of bad breath: Current concepts. J Am Dent

Assoc. 1996;127:475–82. [PubMed]

15. Zamani R. Bad Breath: An Embarassing Problem. Provided by California Childcare Health
Program. [Last cited on 2013 May 13]. Available
from: http://www.education.com/reference/article/Ref_Bad_Breath.

16. Giersbergen PV. Children and Halitosis, Bad Breath. [Last cited on 2013 May 26]. Available
from: http://www.badbreathgone.com .

17. Lin MI, Flaitz CM, Moretti AJ, Seybold SV, Chen JW. Evaluation of halitosis in children and
mothers. Pediatr Dent. 2003;25:553–8. [PubMed]

18. Bornstein MM, Kislig K, Hoti BB, Seemann R, Lussi A. Prevalence of halitosis in the population of
the city of Bern, Switzerland: A study comparing self-reported and clinical data. Eur J Oral
Sci. 2009;117:261–7. [PubMed]

19. Haumann TJ, Kneepkens CM. Halitosis in two children caused by a foreign body in the nose. Ned
Tijdschr Geneeskd. 2000;144:1129–30. [PubMed]

20. Amir E, Shimonov R, Rosenberg M. Halitosis in children. J Pediatr. 1999;134:338–43. [PubMed]

21. Ermis B, Aslan T, Beder L, Unalacak M. A randomized placebo-controlled trial of mebendazole for
halitosis. Arch Pediatr Adolesc Med. 2002;156:995–8. [PubMed]

22. Alamoudi N, Farsi N, Faris J, Masoud I, Merdad K, Meisha D. Salivary characteristics of children
and its relation to oral microorganism and lip mucosa dryness. J Clin Pediatr Dent. 2004;28:239–
48. [PubMed]

23. Kleinberg I, Wolff MS, Codipilly DM. Role of saliva in oral dryness, oral feel and oral malodour. Int
Dent J. 2002;52(Suppl 3):236–40. [PubMed]

24. [Last cited on 2013 May 27]. Available from: http://www.twitter.com/dr_connelley .

25. Yaegaki K, Sanada K. Volatile sulfur compounds in mouth air from clinically healthy subjects and
patients with periodontal disease. J Periodontal Res. 1992;27:233–8. [PubMed]

26. Yaegaki K, Sanada K. Biochemical and clinical factors influencing oral malodor in periodontal
patients. J Periodontol. 1992;63:783–9. [PubMed]

27. [Last cited on 2013 Jun 01]. Available from: http://www./bmj.com .

28. Weitzberg E, Lundberg JO. Humming greatly increases nasal nitric oxide. Am J Respir Crit Care
Med. 2002;166:144–5. [PubMed]

29. Ierardi E, Amoruso A, La Notte T, Francavilla R, Castellaneta S, Marrazza E, et al. Halitosis

and Helicobacter pylori: A possible relationship. Dig Dis Sci. 1998;43:2733–7. [PubMed]

30. Fedorowicz Z, Aljufairi H, Nasser M, Outhouse TL, Pedrazzi V. Mouthrinses for the treatment of
halitosis. Cochrane Database Syst Rev. 2008;4:CD006701. [PubMed]

31. Marshall BJ, Armstrong JA, McGechie DB, Glancy RJ. Attempt to fulfil Koch's postulates for
pyloric Campylobacter. Med J Aust. 1985;142:436–9. [PubMed]

32. Ongole R, Shenoy N. Halitosis: Much beyond oral malodor. Kathmandu Univ Med J
(KUMJ) 2010;8:269–75. [PubMed]

33. Fujimura M, Calenic B, Yaegaki K, Murata T, Ii H, Imai T, et al. Oral malodorous compound
activates mitochondrial pathway inducing apoptosis in human gingival fibroblasts. Clin Oral
Investig. 2010;14:367–73. [PubMed]

34. Imai T, Ii H, Yaegaki K, Murata T, Sato T, Kamoda T. Oral malodorous compound inhibits
osteoblast proliferation. J Periodontol. 2009;80:2028–34. [PubMed]