Intra-Oral Halitosis Review

Intra-Oral Halitosis: An Expert Consensus Review

• Intra-oral halitosis accounts for about 90% of all halitosis cases
• Halitosis is an unpleasant odor from the mouth, sometimes called bad breath, chronic bad breath, oral malodor, etc.
• A preferred term, to reduce stigma, is breath odor.
• Halitosis significantly impacts quality of life, causing social, professional, and emotional limitations.
• Oral diseases (gingivitis, periodontitis, pericoronitis, etc.), tongue coating, food impaction, and oral sores can cause intra-oral halitosis.
• Xerostomia (dry mouth) and hyposalivation are associated with intra-oral halitosis
• An imbalanced oral microbiome (bacteria) contributes to intra-oral halitosis
• Volatile sulfur compounds (VSCs) are the primary odor compounds in intra-oral halitosis, formed by anaerobic bacteria
• Tongue coating is a major cause (Figure 1)
• Candida species have a conflicting role in intra-oral halitosis, with some studies showing correlation with VSC measurements and others showing no correlation.
• Extra-oral halitosis (5-10% of cases) originates from ENT or respiratory conditions (sinusitis, tonsillitis, etc.) or airway foreign bodies.

Halitosis Classification

• Halitosis types: Genuine (intra-oral, extra-oral), Transient, Pseudohalitosis/Halitophobia
• Oral halitosis is often linked to tongue coating (43%), gingivitis/periodontitis (11%), or a combination (18%).
• Other contributory factors: xerostomia, hyposalivation, imbalanced oral microbiome, open caries, stress, age-related factors (decreased oral mobility, medications).

Halitosis Diagnosis

• Accurate diagnosis is key for appropriate management.
• A clinical evaluation (anamnesis, oral health, assessment of oral care) is crucial.
• Key assessment points include: medical history, dental history, and details about halitosis symptoms.
• Objective measurements are possible (e.g., tongue coating index-Figure 2).
• Direct methods (organoleptic method) use the ability to smell odors (gas chromatography, portable sulfide monitoring available).

Halitosis Management

• Halitosis is most effectively managed by addressing its source (intra-oral is primarily the source).
• Treatment focuses on improving oral hygiene/removing biofilm, treating oral pathologies, and, if necessary, using a zinc-based mouth rinse, particularly if oral hygiene alone is not sufficient.
• Probiotics may be another potential therapeutic approach
• A simple step-wise approach is recommended (Figure 4): screening, examining for coating, addressing oral pathologies, co-treating with mouthwash if needed).