Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Bad Breath (Halitosis) article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Synonym: bad breath
Halitosis is an unpleasant odour emitted from the mouth.
Breath smells when certain aromatic chemicals are found within it; these include hydrogen sulfide, methyl mercaptan and dimethyl sulfide.
Occasionally, patients may confuse bad breath with bad taste in the mouth.
The most common causes of occasional halitosis include:
- Smoking cigarettes or cigars.
- Dry mouth.
- Drinking alcohol.
- Artificially induced halitosis - after eating a particularly aromatic meal - eg, garlic, onions, highly spiced food.
Crash dieting, or protein-only diets
- After a few hours the body begins to break down its fat stores and ketones are released. These give the breath a distinctive sweet and sickly smell.
Originating from the mouth
- Altered blood around the gum can be an important cause and may be found with debris or pus due to gingivitis and periodontal pockets.
- Acute ulcerative gingivitis is associated with a typical form of halitosis.
- Acute necrotising ulcerative gingivitis (Vincent's disease, trench mouth) causes the most notable halitosis.
- Bad morning breath:
- During sleep the flow of saliva is drastically reduced and the tongue and cheeks move very little. This allows food residues to stagnate in the mouth and dead cells that are normally shed from the surface of the tongue and gums and from the inside of the cheeks to accumulate. As bacteria start to work on them and digest them, an unpleasant smell is generated.
- Although normal, anyone suffering from nasal congestion who mouth-breathes is more likely to suffer from these actions to a greater extent.
- Bacteria colonising the tongue and periodontal pockets play an important role in the production of volatile sulfur compounds which can cause halitosis. Regular brushing of the tongue is helpful. Note that plaque on the teeth is not a major cause of halitosis but patients should be advised to exercise careful tooth care.
- Fixed dentures intensify the development of halitosis, as they make difficult, or even completely impede, the complex of oral cavity hygiene measures.
- Tonsilloliths (tonsil stones) These are clusters of calcified material that form in the tonsillar crypts, or crevices of the tonsils. They are made up mostly of calcium but can contain other ingredients such as magnesium and phosphorus, and can feel like a small lump in the tonsils. Rarely harmful, they can be a nuisance and hard to remove and can often cause bad breath.
Originating from the nasopharynx
- Chronic sinusitis and postnasal drip are common causes.
- Foreign bodies in the nose can produce a striking odour to the breath.
- Occasionally, chronic tonsillitis and atrophic rhinitis can be causes.
Respiratory tract infections
- These include, for example, bronchiectasis and other lung infections.
- Acid reflux - this is commonly believed to be a cause, although there is little evidence. In one postal survey of 160 GPs, 1% of all the proton pump inhibitor prescriptions were for symptoms of halitosis and/or bitter taste (94% response rate).
- Helicobacter pylori has been found in up to 87% of patients with halitosis, acid taste and burning sensations in the mouth.
- Diabetes, renal or liver disease.
Fish odour syndrome (trimethylaminuria)
- This is is a rare disorder, characterised by long-standing oral and body malodour.
- It is caused by an excess of trimethylamine due to a metabolic oxidation defect that produces a pungent ammoniacal odour similar to that of rotten fish.
- This is another rare metabolic disorder that can lead to oral malodour:
- This is a condition where people falsely believe they have bad breath.
Often, all these can be excluded and still no cause found.
The following may also cause halitosis:
- Solvent misuse
- Chloral hydrate
- Nitrites and nitrates
- Dimethyl sulfoxide
- Some cytotoxic agents
There are no reliable estimates of prevalence, although several studies report the population prevalence of halitosis (physiological or because of underlying disease) to be about 50%.
The clinical assessment of halitosis is usually subjective and is based on smelling air from the mouth and nose and comparing the two - organoleptic assessment.
- Odour detectable from the mouth, but not from the nose, is likely to be of oral or pharyngeal origin.
- Odour from the nose alone is likely to be coming from the nose or sinuses.
- In rare instances when the odour from the nose and mouth are of similar intensity, a systemic cause of the malodour may be likely.
There is no consensus regarding duration of bad breath for diagnosis of halitosis, although the standard organoleptic test for bad breath involves smelling the breath on at least two or three different days.
- Investigate and manage possible systemic (non-oral) source if the organoleptic method detects malodour from both the mouth and the nose.
- Improve oral hygiene by professional and patient-administered tooth cleaning.
- Regular atraumatic tongue cleaning.
- Regular use of antimicrobial toothpastes and mouthwashes, such as:
- Two randomised controlled trials (RCTs) have found that regular use of a mouthwash reduces breath odour at two to four weeks compared with placebo.[14, 15] People in the active treatment group had significantly more tongue discolouration than people using placebo mouthwash after two weeks.
- Regular dental review to ensure maintenance of effective oral hygiene.
- Halitophobia (fixated with teeth cleaning and tongue cleaning and frequently using chewing gums, mints, mouthwashes, and sprays in the hope of reducing their distress) warrants referral to clinical psychologist.
- Eradication of H. pylori in patients with functional dyspepsia and halitosis results in sustained resolution of halitosis during long-term follow-up in the majority of cases.
Further reading and references
Halitosis; NICE CKS, January 2010
Gingivitis and periodonitis; NICE CKS, August 2012
Coventry J, Griffiths G, Scully C, et al; ABC of oral health: periodontal disease. BMJ. 2000 Jul 1321(7252):36-9.
Scully C, Felix DH; Oral medicine--update for the dental practitioner: oral malodour. Br Dent J. 2005 Oct 22199(8):498-500.
Morita M, Wang HL; Association between oral malodor and adult periodontitis: a review. J Clin Periodontol. 2001 Sep28(9):813-9.
Danser MM, Gomez SM, Van der Weijden GA; Tongue coating and tongue brushing: a literature review. Int J Dent Hyg. 2003 Aug1(3):151-8.
Zigurs G, Vidzis A, Brinkmane A; Halitosis manifestation and prevention means for patients with fixed teeth dentures. Stomatologija. 20057(1):3-6.
Ram S, Siar CH, Ismail SM, et al; Pseudo bilateral tonsilloliths: a case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Jul98(1):110-4.
Porter SR, Scully C; Oral malodour (halitosis). BMJ. 2006 Sep 23333(7569):632-5.
Karkos PD, Thomas L, Temple RH, et al; Awareness of general practitioners towards treatment of laryngopharyngeal reflux: a British survey. Otolaryngol Head Neck Surg. 2005 Oct133(4):505-8.
Hoshi K, Yamano Y, Mitsunaga A, et al; Gastrointestinal diseases and halitosis: association of gastric Helicobacter pylori infection. Int Dent J. 2002 Jun52 Suppl 3:207-11.
Mitchell S; Trimethylaminuria (fish-odour syndrome) and oral malodour. Oral Dis. 200511 Suppl 1:10-3.
Periodontology 2000, Vol. 48, 2008, 66–75
Uguru C, Umeanuka O, Uguru NP, et al; The delusion of halitosis: experience at an eastern Nigerian tertiary hospital. Niger J Med. 2011 Apr-Jun20(2):236-40.
Yaegaki K, Coil JM; Examination, classification, and treatment of halitosis clinical perspectives. J Can Dent Assoc. 2000 May
Outhouse TL, Al-Alawi R, Fedorowicz Z, Keenan JV; Tongue scraping for treating halitosis, Cochrane Database Syst Rev 2006(2):CD005519.
Hu D, Zhang Y, Petrone M, et al; Clinical effectiveness of a triclosan/copolymer/sodium fluoride dentifrice in controlling oral malodor: a 3-week clinical trial. Oral Dis. 200511 Suppl 1:51-3.
Adler I, Denninghoff VC, Alvarez MI, et al; Helicobacter pylori associated with glossitis and halitosis. Helicobacter. 2005 Aug10(4):312-7.
Winkel EG, Roldan S, Van Winkelhoff AJ, et al; Clinical effects of a new mouthrinse containing chlorhexidine, cetylpyridinium chloride and zinc-lactate on oral halitosis. A dual-center, double-blind placebo-controlled study. J Clin Periodontol. 2003 Apr30(4):300-6.