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Periodontology 2000, Vol. 48, 2008, 66–75  2008 The Authors.

Printed in Singapore. All rights reserved Journal compilation  2008 Blackwell Munksgaard

Halitosis (breath odor)


Humans emit a variety of volatile and nonvolatile significance (36, 37, 47, 51, 69), probably resulting
molecules that are influenced by genetics, diet, stress from increased microbial metabolic activity during
and disease. Halitosis, from the Latin for breath hal- sleep that is aggravated by a physiological reduction
itus, is a complaint analogous to body odor (30) and in salivary flow, lack of nocturnal physiologic oral
is used to describe any disagreeable odor in the cleansing (e.g. movement of the facial and oral
breath. Several terms describe and characterize the muscles) and variable oral hygiene procedures prior
different aspects of the problem (Table 1) (37, 47). to sleep. Starvation can lead to a similar malodor.
Halitosis frequently causes embarrassment, may These forms of oral malodor can be readily rectified
affect interpersonal social communication (4) and by eating, oral cleansing and rinsing the mouth with
has also become an important market for the phar- fresh water (17). Tongue cleansing using a scraper
macological and cosmetic industries (with millions of may help but was found to be unable to prevent
pounds spent annually on medications and over-the- morning oral malodor in the absence of tooth
counter products). Oral malodor may rank behind cleaning in periodontally healthy individuals (21).
only dental caries and periodontal disease as the Malodor at other times may be the consequence of
reason for patients visiting the dentist, the perception lifestyle. Halitosis as a result of the ingestion of cer-
of halitosis being different in culturally diverse pop- tain food and drinks, such as spices, garlic, onion,
ulations (38). durian, cabbage, cauliflower and radish, or of habits
The true prevalence of halitosis is unknown and such as smoking tobacco or drinking alcohol, is
some reports are difficult to evaluate unless they usually transient, often caused by sulfur-containing
specify the classification, terminology and method- volatile agents and is considered to arise both from
ology used. Currently available epidemiological data intra-oral (food debris) and extra-oral (respiratory)
are difficult to evaluate as they are mainly based on origins (60). Tobacco smoke contains volatile sulfur
subjective self-estimation of malodor, which is well compounds, which are at least partly responsible for
known to be limited by inaccuracy and low sensitiv- the oral malodor of smokers (57), but tobacco prod-
ity. However, the available evidence suggests that ucts also predispose to dry mouth and periodontal
halitosis is common and can affect people of all ages. disease – further causes of malodor. Alcohol intake
The prevalence of persistent oral malodor in a recent may be a predictor of oral malodor (46). The avoid-
Brazilian study was reported to be 15%, was nearly ance of these foods and habits is the best prevention.
three times higher in men than in women (regardless
of age) and the risk was slightly more than three
times higher in people over 20 years of age compared Halitosis from oral causes
with those aged 20 years or under, controlling for In about 85% of patients with persistent genuine
gender (34). The large majority of studies report that halitosis, the odor originates from the mouth (12),
about 30% of people have halitosis (31, 36, 47) but mainly from microorganisms. It is likely that there is
some studies estimate that more than 50% of the a complex interaction between several oral bacteria
population have halitosis (63). species (mainly gram-negative anerobic flora) be-
cause no single specific bacterial infection has
invariably been associated with halitosis (Box 1). The
Types of breath odor bacterium Solobacterium moorei was found to be
present in all subjects with halitosis, but not in any
Oral malodor is common on awakening (morning control subjects, suggesting that some subjects with
breath), and is transient and rarely of any special halitosis harbor some distinct bacterial species on

Halitosis (breath odor)

Table 1. Terminology related to halitosis

Terms used Definition
Halitosis Any disagreeable odor of expired air, regardless of origin
Bad breath Lay term for halitosis
Genuine halitosis Where breath malodor can be verified objectively
Physiologic halitosis, also termed Pathologic halitosis
transient halitosis
e.g. morning breath Subclassified into
• oral malodor (Foetor oris Foetor ex oris) and
• extra-oral
Pseudo-halitosis No objective evidence of malodor, but the patient thinks they have it
Halitophobia The patient persists in believing they have halitosis despite firm evidence for the absence of
objective evidence

and peptidolytic activities of the microbes. Peptides

Box 1. Microorganisms mainly associated with hali-
include glutathione (derived from desquamating
tosis (listed in alphabetical order)
cells), which many microbial species can use directly,
Centipeda periodontii and proteins may come from food or saliva (en-
Eikenella corrodens trapped within microbial biofilms). Salivary mucins
Enterobacteriaceae may also be an important source of primary sub-
Fusobacterium nucleatum subsp. nucleatum strates, but microbial deglycosylation may be a nec-
Fusobacterium nucleatum subsp. polymorphum essary first step prior to full proteolytic digestion (58).
Fusobacterium nucleatum subsp. vincentii In common with caries and periodontal disease,
Fusobacterium periodonticum two theories of microbial etiology can be proposed: a
Porphyromonas endodontalis Ôspecific theoryÕ (that just a few ÔsingleÕ species are
Porphyromonas gingivalis etiological and capable of causing malodor; their
Prevotella (Bacteroides) melaninogenica presence solely will explain malodor) and a Ônon-
Prevotella intermedia specific theoryÕ, which suggests that many species
Bacteroides (Bacteroides) loescheii (most being strict anerobes) have the ability to bio-
Solobacterium moorei transform substrates into volatile compounds or
Tannerella forsythia (Bacteroides forsythus) volatile sulfur compounds and that many groups can
Treponema denticola therefore substitute for others; there is no single
causative species. However, there is a relationship
between bacterial numbers on the tongue (as mea-
their dorsal tongue (22). The tongue is the location of sured by determining the colony-forming units per
many of the organisms implicated. square centimeter) and oral malodor, so it does ap-
The odiferous products that cause halitosis arise pear that the load of microbes per mouth (i.e. the
from the interaction of microbes with specific sub- thickness or aerial density of biofilms) is the most
strates, namely the amino acids cysteine, methionine, important feature of chronic oral malodor, rather
tryptophan, arginine and lysine that are biotrans- than the presence or absence of specific microbial
formed into hydrogen sulfide, methylmercaptan, in- agents. It is probably the microbial load that best
dole, putrescine and cadaverine, respectively (20). predicts the total levels of biotransforming enzymes
These and other amino acids can also be fermented (and biotransforming microenvironments) found in
into short-chain organic acids (e.g. propionate and the mouth. However, it is clear that anerobes and
butyrate) by many of the anerobic species listed in anerobic environments are an important feature of
Box 1. Although some free amino acids (primary biogenesis (36, 37, 51, 52, 69). These anerobes pro-
substrates) can be found in saliva (and gingival duce malodor volatile compounds in many instances,
crevicular fluid is a richer source still), the majority of which include (28) (see Table 2) the following:
the immediate substrates are derived from secondary • volatile sulfur compounds, mainly methyl mer-
substrates – proteins and peptides – which are captan and hydrogen sulfide, which are the main
hydrolysed into primary substrates by the proteolytic contributors to intra-oral halitosis. The volatile

Scully & Greenman

disease, disorders of the oral mucosa, reduced sali-

Table 2. Odoriferous components that can give rise
vary flow and the wearing of dental appliances
to oral malodor
(Table 3) (26, 36, 37, 51, 52, 69).
Volatile sulfur compounds Methyl mercaptan Prevention of infective processes, improvement of
Hydrogen sulfide oral hygiene (including the use of topical antimicro-
Dimethyl sulfide bial products, mouthwashes or toothpastes) and
Diamines Putrescine sometimes the use of antimicrobial therapy, if nec-
Cadaverine essary, can usually manage this type of halitosis
Short-chain fatty acids Butyric acid (discussed in a later section).
Valeric acid
Propionic acid
Indoles Indole
Halitosis from extra-oral causes
Methyl-indole (skatole) Halitosis is less frequently associated with extra-oral
causes (i.e. conditions and diseases that do not affect
sulfur compound, dimethyl sulfide, is the main primarily the oral cavity). Respiratory disorders (of
contributor to extra-oral or blood-borne halitosis the nose, sinuses, tonsils and pharyngeal regions), as
(62) but may also contribute to oral malodor. well as diseases of the gastrointestinal system, can
• short-chain fatty acids (butyric, valeric and propi- result in the presence of odiforous gases in the air
onic acids). expelled from the oral cavity and the nose (Table 4)
• polyamines (putrescine and cadaverine). (10, 36, 37, 40, 69).
• acetone, 2-butanone, 2-pentanone and 1-propanol Nasal sepsis or foreign bodies, or infection of the
are common to all volunteers with halitosis and are paranasal sinuses or respiratory tract, may be a cause
present in both alveolar (lung) and mouth air; in- of halitosis. In children, the insertion of foreign
dole and dimethyl selenide are present in alveolar bodies (such as small toys) into the nose, and sub-
air (65, 66). sequent sepsis, is a common cause of halitosis. In
Most compounds appeared to be (partly) produced adults, infections in the respiratory tract, such as
endogenously and ⁄ or in the mouth (65, 66). tonsillitis, bronchitis, bronchiectasis or other lung
Persistent halitosis occurring as a result of intra- infections, or tumours, may be responsible. The
oral causes usually originates from the posterior presence of a tonsillolith represents a 10-fold in-
dorsum of the tongue and ⁄ or oral ⁄ dental diseases, creased risk of abnormal volatile sulfur compound
including periodontal disease, and can be severe halitometry and can be considered as a predictable
enough to be considered socially unacceptable (also factor for abnormal halitometry (40).
known as pathologic halitosis). It is most likely to Halitosis is a frequent symptom of gastro-esopha-
occur in patients with conditions that favour the geal reflux disease and may be considered as an ex-
accumulation of food and bacterial plaque on intra- tra-esophageal manifestation of gastro-esophageal
oral surfaces (teeth, gingiva and mucosal tissues, reflux disease (32, 59). Helicobacter pylori should also
especially the dorsum of the tongue) and the devel- be considered as a possible cause of halitosis (2, 29).
opment of anerobic ecosystems. Predisposing factors Although some have not found an association be-
include poor oral hygiene, gingival and periodontal tween functional dyspepsia, peptic ulcer disease and

Table 3. Main oral causes of halitosis

Plaque-related gingival and Gingivitis, periodontitis, acute necrotizing ulcerative
periodontal disease gingivitis, pericoronitis, abscesses
Ulceration Systemic disease (inflammatory ⁄ infectious disorders, cutaneous,
gastrointestinal and hematological disease), malignancy,
local causes, aphthae, drugs
Hyposalivation (e.g. from drugs, SjögrenÕs syndrome, radiotherapy, chemotherapy)
Tongue coating Poor hygiene
Wearing dental appliances Poor hygiene
Dental conditions Food packing
Bone diseases Jaw dry sockets, osteomyelitis, osteonecrosis, malignancy

Halitosis (breath odor)

aminuria-positive individuals present with oral

Table 4. Extra-oral causes of halitosis
symptoms of dysguesia and halitosis, as well as
Respiratory system Sinusitis body odor (66). In trimethylaminuria, trimethyl-
(microbial etiology) Antral malignancy amine is excreted into body fluids and breath,
Cleft palate leading to a persistent oral and body malodor sim-
Foreign bodies in the nose ilar to that of rotten fish. The causal factor of
Nasal malignancy excessive free trimethylamine is substrate overload
Tonsilloliths or reduced enzyme capacity as a result of an
Tonsillitis inherited deficiency, liver damage and ⁄ or hormonal
Pharyngeal malignancy modulation (transient trimethylaminuria). The latter
Lung infections explains the occurrence of transient body and oral
Bronchitis malodor in some women around the time of men-
Bronchiectasis struation (56). Hypermethioninemia is another rare
Lung malignancy metabolic disorder that can lead to oral malodor.
Gastrointestinal Esophageal diverticulum Cystinosis is a rare autosomal-recessive disorder
tract Gastro-esophageal reflux disease characterized by the intralysosomal accumulation of
Malignancy cystine. Cysteamine removes cystine from the lyso-
Metabolic disorders Acetone-like smell in some and slows down the progression of the dis-
(blood borne) uncontrolled diabetes ease, but one of its adverse effects is halitosis as it is
Uremic breath in renal failure converted to dimethyl sulfide and methyl mercap-
Foetor hepaticus in liver disease tan. The expired air of cystinotic patients contains
Trimethylaminuria elevated concentrations of dimethyl sulfide and
(fish odor syndrome) methyl mercaptan (3).
Hypermethioninemia More rarely, halitosis can arise as a side effect of
Cystinosis medications containing a dimethyl sulfide structure
Drugs • amphetamines that can appear in breath air (33).
(blood borne) • chloral hydrate Psychogenic or psychosomatic factors may be at
• cytotoxic agents play in some patients. Interestingly, anxiety itself
• dimethyl sulphoxide increases the levels of volatile sulfur compounds (8).
• disulfiram Not all persons who believe they have halitosis
• nitrates and nitrites actually have any malodor, and this pseudo-hali-
• phenothiazines tosis can be a real clinical dilemma (53). In those in
• solvent abuse whom no evidence of halitosis can be detected,
Psychogenic causes even with objective testing, and in whom the
complaint persists, halitosis may be attributed to a
form of delusion or monosymptomatic hypochon-
driasis (self-halitosis, halitophobia). Such patients
H. pylori infection with halitosis occurrence or rarely wish to visit a psychological specialist be-
severity (32), H. pylori has been suggested as a cause, cause they fail to recognize their own psychological
and can produce volatile sulfur compounds (29). condition and never doubt they have oral malodor.
Furthermore, with some metabolic disorders, Other peopleÕs behavior, or perceived behavior,
odiferous agents circulating in the bloodstream can such as apparently covering the nose or averting
be exhaled, through alveolar gas exchange, into the the face, is typically misinterpreted by these pa-
breath and cause halitosis (also known as blood- tients as an indication that their breath is indeed
borne halitosis). The volatile sulfur compound offensive. Such patients may have latent psycho-
dimethyl sulfide is the main contributor to extra-oral somatic illness tendencies and may be mentally
or blood-borne halitosis, as the result of a hitherto- immature. Many of these patients will adopt
unknown metabolic disorder (62). behavior to minimize their perceived problem, such
Diabetes can give rise to ketone bodies in the as covering the mouth when talking, avoiding or
breath. The genetic metabolic disorder trimethyl- keeping a distance from other people, using
aminuria (fish odor syndrome) is the principal cause chewing gum, mints, mouthwashes or sprays de-
of undiagnosed body odor caused by excessive signed to reduce malodor, or excessively cleaning
blood levels of trimethylamine. Many trimethyl- their tongue or mouth.

Scully & Greenman

More objective measurements of halitosis are

Diagnosis available but they are rarely used in routine clinical
practice as they are expensive and time-consuming.
It is important to understand whether a given com- Some centers are able to undertake objective mea-
plaint of bad breath is justified and whether the odor surements of the volatile sulfur compounds using a
originates in the mouth, nose or elsewhere. A full halimeter (Interscan Corp., Chatsworth, CA), a por-
history and an oral examination will be required. table sulfide monitor. However, this machine cannot
The first step in assessment is to determine whe- differentiate between the different types of sulfides
ther halitosis is present. This is important as most and cannot detect other classes of volatile com-
individuals are poor judges of their own breath odor pounds.
(14). There are three primary measurement methods Gas chromatography is considered by many to be
of halitosis. Organoleptic measurement and gas the method of choice for differentiating and quanti-
chromatography are very reliable methods, but clin- fying the volatile sulfur compound and (especially if
ically are not very easily implemented. The use of it runs with a Mass Spectrometry Detector) can also
organoleptic measurement is suggested as the Ôgold distinguish other classes of compound (e.g. indole).
standardÕ. Gas chromatography is the preferable Traditional laboratory gas chromatography or gas
method if precise measurements of specific gases are chromatography–mass spectrometry are cumber-
required. Sulfide monitoring is an easily used meth- some, need inert column carrier gas (gas cylinders of
od, but has the limitation that important odors are nitrogen or helium) and require technicians or
not detected. The scientific and practical value of specialists with adequate training, and are thus clin-
additional or alternative measurement methods, ically impractical. (66). However, a newly developed
such as the BANA (benzoyl–arginine–naphthyl– portable gas chromatograph (OralChromaTM, Abi-
amide) test, chemical sensors, the salivary incubation medical, Abilit Corp., Osaka, Japan) has now been
test, quantifying b-galactosidase activity, ammonia described (61), which does not use a special carrier
monitoring, the ninhydrin method and the poly- gas (using air instead) and is highly sensitive yet
merase chain reaction, have yet to be fully estab- relatively low cost compared with a standard gas
lished (5, 6). chromatograph.
Assessment is thus usually based upon organo- Likewise, secondary tests associating measure-
leptic assessment of exhaled air, namely the clinician ments with oral malodor (e.g. detection of likely
sniffs the air exhaled from the mouth and nose and causative bacteria and ⁄ or microbial enzymatic
subjectively defines the presence or absence of mal- activity) fall outside the routine clinical assessment of
odor (13). Smelling both nose and mouth air is halitosis.
important as malodor detectable from the nose alone Examination of the oral flora, for example using the
(asking the patient to breathe while the mouth is BANA test or dark-field microscopy, can be helpful, at
closed) is likely to come from the nose or the sinuses, least for patient education.
or from respiratory or gastrointestinal tracts. Assay for the major glycosidic enzyme (b-galacto-
For purposes of fine quantification (for example in sidase) in saliva, which deglycosylates oral mucins,
clinical trials of the efficacy of antimalodor com- leading to their subsequent proteolysis and putre-
pounds) it has been suggested that organoleptic faction, may also be useful (58).
assessments should be performed by two or more If no malodor can be found during the initial
different examiners (68) and that both the human examination, the assessment for halitosis should be
subject and the examiners should follow some repeated on two or three different days.
instructions in order to obtain more reliable results. Thereafter, if halitosis is still not present, the pa-
(69). However, unless halitosis is borderline between tient can be considered to be affected by imaginary
detectable and nondetectable, then providing the (pseudo-halitosis) - a diagnosis that can be supported
clinician has full smell acuity, only one judge should by established questionnaires (69). Experienced and
suffice for an individual patient. As a general rule intuitive clinicians are well placed to suspect imagi-
in clinical practice, it is advisable that the patient nary (pseudo-halitosis) at an early stage of the
abstains from eating odiferous foods for 48 h before assessment. In general, obsessive behavior, depres-
the assessment and that both the patient and the sion, phobic anxiety, paranoid ideation, reduced so-
examiner refrain from drinking coffee, tea or juice, cial interactions and the wrong interpretation of
smoking and using scented cosmetics before the peopleÕs actions as an indication that their breath is
assessment (69). offensive (e.g. opening windows, covering their nose),

Halitosis (breath odor)

can be warning signs of pseudo-halitosis (24, 36, 47). remove the volatile sulfur compound that causes bad
However, these factors, alone, are insufficient to breath (64). Other products are available, such as
categorize a patient under the label of pseudo-hali- those containing chlorine dioxide, and alpha ionone,
tosis, as this remains a diagnosis of exclusion. but the evidence demonstrating their efficacy is cur-
rently weak.
Toothpastes containing triclosan and a copolymer
Management (Colgate Total Toothpaste) provide effective control
of breath odor at 12 h after brushing the teeth (35,
The management of halitosis depends largely on the 55). There is significant, immediate antimalodor
cause. activity also for a 0.454% stabilized SnF2 sodium
Avoiding smoking, drugs and foods that might be hexametaphosphate dentifrice (16).
responsible for halitosis is sensible. In addition, If oral malodor persists, the tongue may be the
chewing gum, parsley, mint, cloves or fennel seeds, source of odor and hence gentle and regular tongue
and the use of proprietary Ôfresh breathÕ preparations, cleaning is indicated (11). This is aimed at dislodging
may help. Cosmetic nonpharmacological methods, trapped food, cells and bacteria from between the
such as chewing gums, mints, flavored sprays, and filiform papillae, thus decreasing the concentration
some mouth rinses, however, merely provide a of volatile sulfur compounds. Tongue cleaning
competing and temporary smell that may mask the should be carried out at night (because if done early
unfavourable odor. (36). during the day may induce retching) using a tongue
In the large majority of patients, treatment is pri- scraper or a hard toothbrush and cold water, but no
marily directed towards reducing the accumulation toothpaste. There is weak and unreliable evidence
of food debris and malodor-producing oral bacteria. showing a small, but statistically significant, differ-
This is usually achieved via treating oral ⁄ dental ence in the reduction of volatile sulfur compound
diseases, improving oral hygiene and reducing the levels when tongue scrapers or cleaners, rather than
tongue coating. A combination of treatments typi- toothbrushes, are used to reduce halitosis in adults
cally helps (15, 37, 43, 49–52). (36). There is no high-level evidence comparing
Regular meals are important, as is dental prophy- mechanical cleaning with other forms of tongue
laxis, and the patient should use appropriate regular cleaning. The benefits of tongue scraping seem to be
oral hygiene procedures, which include regular tooth only short term (36).
cleaning (brushing and interdental flossing) and the The results of a range of treatments have been
use of antimicrobial toothpastes and ⁄ or mouth- outlined elsewhere (5) but in Table 5 we show a
washes. Generally, it is recommended that mouth- comparison of various oral malodor therapies or
washes should be used two or three times daily for at treatments made on the basis of objective reduction
least 30 s. A multitude of oral healthcare and phar- of volatile sulfur compound or component gases (by
maceutical products is available over the counter, gas chromatography, halimeter or sensor) in com-
testimony to the extent of the perceived, or indeed parison with appropriate controls (trials of >10
real, problem of halitosis. The effectiveness of active subjects).
ingredients in oral healthcare products is dependent In recalcitrant cases, the specialist empirically may
on their concentration and, above a certain concen- use a 1-week course of metronidazole (200 mg three
tration the ingredients can have unpleasant side ef- times daily) in an effort to eliminate unidentified
fects (5, 6). anerobic infections; metronidazole may reduce ton-
Mouthwashes containing chlorhexidine gluconate, gue microbiota and odor levels (23).
ceptylpyridinium chloride or triclosan, a two-phase Halitosis as a result of extra-oral causes is managed
oil:water mouthwash, may be beneficial (27, 41–43, through the treatment of the underlying cause (see
50). Good short-term results have been reported with Table 1). Medical help may be required to manage
chlorhexidine, essential oils and ceptylpyridinium patients with a systemic background to their com-
chloride for up to 2 or 3 h. Metal ions and oxidizing plaint. Triple-drug eradication therapy in patients
agents, such as hydrogen peroxide, chlorine dioxide with functional dyspepsia and H. pylori infection has
and iminium chloride, can actively neutralize volatile resulted in sustained resolution of halitosis during
sulfur compounds. Zinc seems to be an effective and long-term follow-up in the majority (25). Pseudo-
safe metal at concentrations of at least 1%: at pres- halitosis almost always requires referral for clinical
ent, a combination of low concentrations of zinc and psychologist management. In extreme instances,
chlorhexidine seems to be the most efficient way to patients become socially isolated, may have their

Table 5. Comparison of various oral malodor therapies or treatments made on the basis of reduction of volatile sulfur compounds (VSC) or component gases (by
gas chromatography, halimeter or sensor) in comparison with appropriate controls (trials of n > 10 subjects)
Category of treatments Volunteers Comments Outcomes Instrument used to Statistical Reference
per group measure VSC or gas significance
of reduction
Scully & Greenman

Clinical therapy alone

POHC and n = 923 Post-treatment assessments following 98% of population showed Halimetry NA 39
mouthwash (clinic) visits to bad breath clinic reductions of VSC from
>180p.p.b. to <180
POHC n = 37 Two-year study; test group received 60% reduction in CH3SH when Electronic P < 0.05 1
POHC every week including tongue measured using an electronic
cleaning. Control group (n = 30) did not sensor sensitive to CH3SH
POHC (clinic) n = 92 Before vs. after clinical treatment at 80% reduction in VSC Gas chromatography P < 0.0001 61
bad breath clinic
Short-term (0-8h) effects (single use)
Tongue cleaning n = 30 Three-hour, randomized crossover 42% reduction in VSC immediately Halimetry P < 0.001 54
study (three groups) after treatment and still significantly
reduced for up to 25 minutes
Zn2 + mouthrinse n = 62 Three-hour, parallel-study (three 70-80% reduction of VSC at 1, 2 Gas chromatography P < 0.05 48
groups, Zn2 + vs. controls and 3h
Zn2 + (toothpaste) n = 11 Three-hour, crossover study; five Between 40 and 70% reduction for Gas chromatography P < 0.05 7
treatments (+ 1-week washout periods) both H2S and CH3SH in the Zn
(silica base dentrifice with 2% Zn) pastes compared with controls at 1,
2 and 3 h post-treatment
ClO2 (mouthwash) n = 16 96-h parallel study with two groups: test 21% and 19% reduction in VSC at Halimetry P < 0.01 18
(ClO2 at 0.1%) and control (water; 2 h and 4 h respectively
n = 15)
Two-phase rinse n = 19 One-day, parallel study with three For two-phase rinse, 38% reduction Halimetry P < 0.05 45
(essential oils groups (two-phase mouthwash, in VSC at 8–10 h compared with P < 0.05
plus aqueous CPC) CHX and placebo) placebo.
Chlorhexidine For CHX, 50% reduction in VSC at
gluconate (0.2%) 8–10 h compared with placebo
Mouthrinses n = 12 A six-step double-blind, crossover, For CHX (0.12%), a 63% reduction Halimetry P = 0.01 9
CHX (0.4%) randomized study on morning breath in VSC. P = 0.001
CHX (0.05%) in volunteers with healthy For CHX (0.2%), a 70% reduction in
Triclosan (0.03%) periodontium (who refrained VSC. For other agents, reductions in
CPC (0.05%) from mechanical plaque control VSC were not statistically
during 4-day periods). significant.
Halitosis (breath odor)

teeth extracted and occasionally commit suicide.

CH3SH, methyl mercaptan; CHX, chlorhexidine; ClO2, chlorine dioxide; CPC, cetylpyridinium chloride; GC, gas chromatography; H2 S, hydrogen sulfide; POHC, professional oral healthcare; Sn, stannous; VSC, volatile sulfur
However, patients often refuse to acknowledge that
they may have a psychological problem. Therefore,


the involvement of a third party (e.g. a confidant such
as a close family member or a trusted friend) in the
management may provide the patient with additional
of reduction

psychological support to consider the problem in a

P < 0.05

P < 0.01
more objective manner (44).


Exclusions: trials that have fewer than 11 subjects; those that only use organoleptic or hedonic methods; and those where subjects have known inflammatory periodontal disease.
measure VSC or gas
Instrument used to

1. Adachi M, Ishihara K, Abe S, Okuda K, Ishikawa T. Effect of

professional oral health care on the elderly living in nursing
homes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod


2002: 94: 191–195.

2. Adler I, Denninghoff VC, Alvarez MI, Avagnina A, Yoshida
R, Elsner B. Helicobacter pylori associated with glossitis and
halitosis. Helicobacter 2005: 10: 312–317.
3. Besouw M, Blom H, Tangerman A, de Graaf-Hess A,
50-60% reduction for VSC

Levtchenko E. The origin of halitosis in cystinotic patients

for Sn-containing paste
compared with control

due to cysteamine treatment. Mol Genet Metab 2007: 91:

45% reduction in VSC
after cumulative use)
(reduction increases

4. Bosy A. Oral malodor: philosophical and practical aspects.
J Can Dent Assoc 1997: 63: 196–201.
5. van den Broek AM, Feenstra L, de Baat C. A review of the

current literature on aetiology and measurement methods

of halitosis. J Dent 2007: 35: 627–635.
6. van den Broek AM, Feenstra L, de Baat C. A review of the
current literature on management of halitosis. Oral Dis
2008: 14: 30–39.
7. Brunette DM, Proskin HM, Nelson BJ. The effects of den-
control. Reduction measured
parallel study of test product
(CHX+CPC+Zn) vs. placebo

tifrice systems on oral malodor. J Clin Dent 1998: 9: 76–82.

8. Calil CM, Marcondes FK. Influence of anxiety on the pro-
Two-week double-blind
of four groups (n = 96
Five-day, randomized,

duction of oral volatile sulfur compounds. Life Sci 2006: 79:

controlled, examiner
blind, parallel study

9. Carvalho MD, Tabchoury CM, Cury JA, Toledo S, Nogueira-
in each group):

Filho GR. Impact of mouthrinses on morning bad breath in

healthy subjects. J Clin Periodontol 2004: 31: 85–90.

on day 14

10. Castellani A. Foetor oris of tonsillar origin and certain

bacilli causing it. Lancet 1930: 215: 623–624.
11. Danser MM, Mantilla Gómez S, Van der Weijden GA.
Tongue coating and tongue brushing: a literature review.
Int J Dent Hyg 2003;1:151–158.

12. Delanghe G, Ghyselen J, Van Steenberghe D, Feenstra L.

per group

Multidisciplinary breath-odour clinic. Lancet 1997: 350:

n = 96

n = 40

13. Donaldson AC, Riggio MP, Rolph HJ, Bagg J, Hodge PJ.
Clinical examination of subjects with halitosis. Oral Dis
2007: 13: 63–70.
Mouthrinse (14-day effect)

14. Eli I, Baht R, Koriat H, Rosenberg M. Self-perception of

Long-term or cumulative

breath odor. JADA 2001: 132: 621–626.

Category of treatments

effect (regular use)

CHX + CPC + Zn2 +

15. Farrell S, Baker RA, Somogyi-Mann M, Witt JJ, Gerlach RW.

Table 5. Continued

Sn2 + (toothpaste)

Oral malodor reduction by a combination of chemothera-

compounds; Zn, zinc.
(5-day effect)

peutical and mechanical treatments. Clin Oral Invest 2006:

10: 157–163.
16. Farrell S, Barker ML, Gerlach RW. Overnight malodor effect
with a 0.454% stabilized stannous fluoride sodium hexa-
metaphosphate dentifrice. Compend Contin Educ Dent
2007: 662: 671.

Scully & Greenman

17. Faveri M, Hayacibara MF, Pupio GC, Cury JA, Tsuzuki CO, 34. Nadanovsky P, Carvalho LB, Ponce de Leon A. Oral mal-
Hayacibara RM. A cross-over study on the effect of various odour and its association with age and sex in a general
therapeutic approaches to morning breath odour. J Clin population in Brazil. Oral Dis 2007: 13: 105–109.
Periodontol 2006: 33: 555–560. 35. Niles HP, Vazquez J, Rustogi K, Williams M, Gaffar A. The
18. Frascella J, Gilbert RD, Fernandez P, Hendler J. Efficacy of a clinical effectiveness of a dentifrice containing triclosan
chlorine dioxide-containing mouthrinse in oral malodor. and a copolymer for providing long-term control of breath
Compend Contin Educ Dent 2000: 21: 241–254. odor measured chromatographically. J Clin Dent 1999: 10:
19. Gerlach RW, Hyde JD, Poore CL, Stevens DP, Witt JJ. Breath 135–138.
effects of three marketed dentifrices: a comparative study 36. Outhouse TL, Al-Alawi R, Fedorowicz Z, Keenan JV. Tongue
evaluating single and cumulative use. J Clin Dent 1998: 9: scraping for treating halitosis. Cochrane Database Syst Rev
83–88. 2006: 19;(2):CD005519.
20. Greenman J. Microbial aetiology of halitosis. In: Newman 37. Porter SR, Scully C. Oral malodour (halitosis). BMJ 2006:
HN, Wilson M eds. Dental Plaque Revisited; Oral Biofilms 333: 632–635.
in Health and Disease. Cardiff, UK: Bioline Publications, 38. Rayman S, Almas K. Halitosis among racially diverse pop-
1999: 419–442. ulations: an update. Int J Dent Hyg 2008: 6: 2–7.
21. Haas AN, Silveira EM, Rösing CK. Effect of tongue cleansing 39. Richter JL. Diagnosis and treatment of halitosis. Compend
on morning oral malodour in periodontally healthy indi- Contin Educ Dent 1996: 17: 370–386.
viduals. Oral Health Prev Dent. 2007: 5: 89–94. 40. Rio AC, Franchi-Teixeira AR, Nicola EM. Relationship
22. Haraszthy VI, Zambon JJ, Sreenivasan PK, Zambon MM, between the presence of tonsilloliths and halitosis in
Gerber D, Rego R, Parker C. Identification of oral bacterial patients with chronic caseous tonsillitis. Br Dent J 2008:
species associated with halitosis. J Am Dent Assoc 2007: 204: E4.
138: 1113–1120. 41. Roldán S, Herrera D, OÕConnor A, González I, Sanz M. A
23. Hartley MG, McKenzie C, Greenman J, El-Maaytah MA, combined therapeutic approach to manage oral halitosis: a
Scully C, Porter SR. Tongue microbiota and malodour; Ef- 3-month prospective case series. J Periodontol 2005: 76:
fects of metronidazole mouth rinse on tongue microbiota 1025–1033.
and breath odour levels. Microb Ecol Health Dis 2000; 42. Roldán S, Herrera D, Santa-Cruz I, OÕConnor A, González I,
11:226–233 Sanz M. Comparative effects of different chlorhexidine
24. Iwu CO, Akpata O. Delusional halitosis. Review of the mouth-rinse formulations on volatile sulfur compounds
literature and analysis of 32 cases. Br Dent J 1990: 168: 294– and salivary bacterial counts. J Clin Periodontol 2004: 31:
296. 1128–1134.
25. Katsinelos P, Tziomalos K, Chatzimavroudis G, Vasiliadis T, 43. Roldán S, Winkel EG, Herrera D, Sanz M, Van Winkelhoff
Katsinelos T, Pilpilidis I, Triantafillidis I, Paroutoglou G, AJ. The effects of a new mouthrinse containing chlorhexi-
Papaziogas B. Eradication therapy in Helicobacter pylori- dine, cetylpyridinium chloride and zinc lactate on the
positive patients with halitosis: long-term outcome. Med microflora of oral halitosis patients: a dual-centre, double-
Princ Pract 2007: 16: 119–123. blind placebo-controlled study. J Clin Periodontol 2003: 30:
26. Koshimune S, Awano S, Gohara K, Kurihara E, Ansai T, 427–434.
Takehara T. Low salivary flow and volatile sulfur com- 44. Rosenberg M. Clinical assessment of bad breath: current
pounds in mouth air. Oral Surg Oral Med Oral Pathol Oral concepts. JADA 1996: 127: 475–482.
Radiol Endod 2003: 96: 38–41. 45. Rosenberg M, Gelernter I, Barki M, Bar-Ness R. Day-long
27. Kozlovsky A, Goldberg S, Natour I, Rogatky-Gat A, Gel- reduction of oral malodor by a two-phase oil:water
ernter I, Rosenberg M. Efficacy of a 2-phase oil-water mouthrinse as compared to chlorhexidine and placebo
mouthrinse in controlling oral malodour, gingivitis and rinses. J Periodontol 1992: 63: 39–43.
plaque. J Periodontol 1996: 67: 577–582. 46. Rosenberg M, Knaan T, Cohen D. Association among bad
28. Krespi YP, Shrime MG, Kacker A. The relationship between breath, body mass index, and alcohol intake. J Dent Res
oral malodor and volatile sulfur compound-producing 2007: 86: 997–1000.
bacteria. Otolaryngol Head Neck Surg 2006: 135: 671–676. 47. Sanz M, Roldán S, Herrera D. Fundamentals of breath
29. Lee H, Kho HS, Chung JW, Chung SC, Kim YK. Volatile malodour. J Contemp Dent Pract 2001: 4: 1–17.
sulfur compounds produced by Helicobacter pylori. J Clin 48. Schmidt NF, Tarbet WJ. The effect of oral rinses on orga-
Gastroenterol 2006: 40: 421–426. noleptic mouth odor ratings and levels of volatile sulfur
30. Lee SS, Zhang W, Li Y. Halitosis update: a review of causes, compounds. Oral Surg 1978: 45: 876–883.
diagnoses, and treatments. J Calif Dent Assoc 2007: 262: 49. Scully C, Felix DH. Oral medicine – update for the dental
264–268. practitioner: oral malodour. Br Dent J 2005: 199: 498–500.
31. Liu XN, Shinada K, Chen XC, Zhang BX, Yaegaki K, Kaw- 50. Scully C, Porter SR. Halitosis. Clin Evid 2005; 14: 436–437,
aguchi Y. Oral malodor-related parameters in the Chinese 2006; 15: 472–473, 2006; 16: 547–548.
general population. J Clin Periodontol 2006: 33: 31–36. 51. Scully C, Porter S, Greenman J. What to do about halitosis.
32. Moshkowitz M, Horowitz N, Leshno M, Halpern Z. Hali- BMJ 1994: 308: 217–218.
tosis and gastroesophageal reflux disease: a possible asso- 52. Scully C, Rosenberg M. Halitosis. Dent Update 2003: 30:
ciation. Oral Dis 2007: 13: 581–585. 205–210.
33. Murata T, Fujiyama Y, Yamaga T, Miyazaki H. Breath 53. Seemann R, Bizhang M, Djamchidi C, Kage A, Nachnani S.
malodor in an asthmatic patient caused by side-effects of The proportion of pseudo-halitosis patients in a multidis-
medication: a case report and review of the literature. Oral ciplinary breath malodour consultation. Int Dent J 2006: 56:
Dis 2003: 9: 273–276. 77–81.

Halitosis (breath odor)

54. Seemann R, Kison A, Bizhang M, Zimmer S. Effectiveness 62. Tangerman A, Winkel EG. Intra- and extra-oral halitosis:
of mechanical tongue cleaning on oral levels of volatile finding of a new form of extra-oral blood-borne halitosis
sulfur compounds. JADA 2001: 132: 1263–1267. caused by dimethyl sulphide. J Clin Periodontol 2007: 34:
55. Sharma NC, Galustians HJ, Qaqish J, Galustians A, Rustogi 748–755.
K, Petrone ME, Chaknis P, Garcı́a L, Volpe AR, Proskin HM. 63. Tessier JF, Kulkarni GV. Bad breath: etiology, diagnosis and
Clinical effectiveness of a dentifrice containing triclosan treatment. Oral Health 1991: 81: 19–22.
and a copolymer for controlling breath odor. Am J Dent 64. Thrane PS, Young A, Jonski G, Rölla G. A new mouthrinse
2007: 20: 79–82. combining zinc and chlorhexidine in low concentrations
56. Shimizu M, Cashman JR, Yamazaki H. Transient trimeth- provides superior efficacy against halitosis compared to
ylaminuria related to menstruation. BMC Med Genet 2007: existing formulations: a double-blind clinical study. J Clin
8: 2. Dent 2007: 18: 82–86.
57. Stedman RL. The chemical composition of tobacco and 65. van den Velde S, Quirynen M, van Hee P, van Steenberghe
tobacco smoke. Chem Rev 1968: 68: 153–207. D. Halitosis associated volatiles in breath of healthy sub-
58. Sterer N, Bar-Ness Greenstein R, Rosenberg M. b-Galacto- jects. J Chromatogr B Analyt Technol Biomed Life Sci 2007:
sidase activity in saliva is associated with oral malodor. 853: 54–61.
J Dent Res 2002: 81: 182–185. 66. Whittle CL, Fakharzadeh S, Eades J, Preti G. Human breath
59. Struch F, Schwahn C, Wallaschofski H, Grabe HJ, Völzke H, odors and their use in diagnosis. Ann N Y Acad Sci 2007:
Lerch MM, Meisel P, Kocher T. Self-reported halitosis and 1098: 252–266.
gastro-esophageal reflux disease in the general population. 67. Winkel EG, Roldán S, Van Winkelhoff AJ, Herrera D, Sanz
J Gen Intern Med 2008: 23: 260–266. M. Clinical effects of a new mouthrinse containing
60. Suarez F, Springfield J, Furne J, Levitt M. Differentiation of chlorhexidine, cetylpyridinium chloride and zinc-lactate
mouth versus gut as site of origin of odoriferous breath on oral halitosis. A dual-center, double-blind placebo-
gases after garlic ingestion. Am J Physiol 1999: 276: G425– controlled study. J Clin Periodontol 2003: 30: 300–306.
G430. 68. Wozniak WT. The ADA guidelines on oral malodor prod-
61. Tanaka M, Anguri H, Nishida N, Ojima M, Nagata H, ucts. Oral Dis 2005: 11: 7–9.
Shizukuishi S. Reliability of clinical parameters for pre- 69. Yaegaki K, Coil JM. Examination, classification, and treat-
dicting the outcome of oral malodor treatment. J Dent Res ment of halitosis; clinical perspectives. J Can Dent Assoc
2003: 82: 518–522. 2000: 5: 257–261.