Halitosis

Overview

This Guidelines summary has been developed for community pharmacy teams to support recognition of the signs and symptoms of halitosis and when to refer to a dentist for definitive diagnosis and treatment. It aims to explain appropriate treatment while the person is awaiting a dental assessment and will aid community pharmacy teams to:

• confirm a diagnosis of halitosis in primary care
• identify intra- or extra-oral causes of halitosis, and manage appropriately
• arrange specialist referral where appropriate
• advise on oral hygiene and lifestyle measures to manage halitosis.

Reflecting on Your Learnings

Definition

• Halitosis (‘bad breath’ or ‘oral malodour’) is a general term used to describe an unpleasant or offensive odour in the breath, or malodour beyond a socially acceptable level, regardless of the underlying cause
  • physiological halitosis is usually transient and normal, for example, following a night’s sleep (‘morning breath’) or fasting. Non-pathological halitosis may also be lifestyle-related, for example caused by smoking or ingesting certain odiferous foods or drinks
  • pathological halitosis is usually intra-oral (for example caused by tongue coating, gingivitis, periodontitis, poor denture hygiene) or more rarely extra-oral (such as nasal, paranasal, or laryngeal conditions; respiratory tract conditions; gastrointestinal conditions; metabolic disorders; drugs)
  • psychogenic or subjective (the person believes that they have halitosis when it is not objectively perceived or confirmed by others. In extreme forms this is termed halitophobia)
• Halitosis is common, and may have a negative psychosocial impact including affecting the person’s mood and quality of life.

Assessment

Ask the Person About:

• Their own perception of the halitosis, including the impact on their quality of life (education, work, and social activities, relationships, anxiety and mood), and changes in behaviour (such as covering the mouth when talking and avoiding social interactions). Note: be aware that the person’s own assessment of their breath is not always reliable
• The severity, timing during the day, and duration of symptoms, for example relation to certain foods or drinks, or following periods of hunger or starvation (may suggest physiological halitosis)
• Additional symptoms such as dry mouth (which can lead to decreased taste sensation and difficulty in swallowing), mouth breathing, nasal discharge or obstruction, loss of sense of smell, cough, or weight loss
• Possible lifestyle factors, such as diet, smoking, and alcohol intake
• Dental history and oral hygiene routine, such as:
  • history of dental surgery including faulty restorations or ill-fitting prostheses
  • oral hygiene measures and frequency of toothbrushing, inter-dental cleaning, tongue cleaning, and use of mouthwashes/chewing gums/mints/sprays
  • use of a dental prosthesis (denture, orthodontic appliance, bridge); denture hygiene (if appropriate), including whether dentures are taken out at night and cleaned regularly
  • frequency of routine dental checks and any dental hygienist input
• Any medical history, including possible extra-oral causes of halitosis
• Any medications or recreational drugs that may cause or contribute to halitosis
• Any concerns from the person’s partner, friends, or family members; their perception of the halitosis; and how they feel it is affecting the person (if possible and appropriate).

Organoleptic Testing

• Confirm that objective halitosis is present by assessing the person’s breath (so-called ‘organoleptic testing’)
  • ideally, the person should not wear fragrances prior to the assessment. In addition, the person should not consume odiferous foods or drinks for 48 hours (and should ideally only drink water on the morning of the assessment); should not smoke for 12 hours; and should omit their usual oral hygiene routine for 24 hours prior to the assessment. This may be difficult to achieve in primary care
  • ask the person to breathe out of their mouth (pinching the nose), and then to breathe out of their nose (with the mouth closed), and smell the person’s exhaled breath. Halitosis is likely to be:
    • oral or pharyngeal in origin—if malodour is detected from the mouth but not from the nose
    • nasal or sinus in origin—if malodour is detected from the nose but not from the mouth
    • systemic in origin—if malodour from the nose and mouth are of equal intensity (rare)
    • consider repeating the assessment on two or three occasions if no halitosis is detected on the initial examination
    • consider a diagnosis of pseudo-halitosis or halitophobia if halitosis is not detected on any occasion.

Assessing the Person’s Oral Health

• Examine the person’s teeth, tongue, and oral cavity to assess for oral causes of halitosis, such as malaligned teeth, dental caries, periodontal disease, tongue coating, and plaque
  • be aware that tongue coating may be a cause of halitosis even in people with otherwise good dental hygiene and oral health
  • consider gently scraping the posterior tongue area (for example, with a clean plastic spoon), as the odour from the scraping is generally similar to overall mouth odour.

Management

If a Person Self-reports Halitosis and Has Been Assessed

• Reassure the person that transient halitosis (such as ‘morning breath’ on waking) is normal and common, and usually resolves with eating or drinking, toothbrushing, and/or rinsing the mouth with water
• Offer advice about sources of information and support, such as:
  • the NHS information leaflet on bad breath
  • the patient information leaflet on bad breath (halitosis) available on the patient.info website
• If there is any uncertainty about the possibility of oral disease (such as gingivitis or periodontitis), arrange a routine dental appointment for a full oral examination, especially if the person does not attend dental appointments regularly
• Encourage lifestyle changes if appropriate, such as:
  • avoiding or limiting causative foods or drinks
  • drinking sufficient fluids; eating breakfast, chewing or eating acidic foods; and sucking sugar-free sweets or chewing sugar-free gum, if the person reports a dry mouth
  • stopping smoking. See the CKS topic on smoking cessation for more information
  • limiting excess alcohol intake. See the CKS topic on alcohol—problem drinking for more information
• If an underlying cause of halitosis has been identified, arrange appropriate management in primary care or arrange specialist referral if needed
  • consider the use of an artificial salivary substitute if lifestyle measures are insufficient to manage dry mouth symptoms. See the CKS topic on palliative care—oral for more information
• If no underlying cause of halitosis has been identified:
  • advise on the importance of general oral hygiene measures, including cleaning the teeth, interdental spaces, and tongue. The NHS leaflet, Take care of your teeth and gums, may be helpful
  • advise to limit the frequency and amount of sugary food and drinks (ideally maximum of four times a day, mainly at mealtimes)
  • advise on the importance of attending regular dental appointments to ensure maintenance of good oral hygiene
  • it may be difficult for people to accurately assess the severity and improvement of their own oral odour following treatment
• For people without detectable halitosis following repeated assessment of the person’s exhaled breath on two or three occasions:
  • offer reassurance, explanation, and advise on self-management measures. These may be sufficient to resolve symptoms if the person has a diagnosis of pseudo-halitosis
  • consider a diagnosis of halitophobia if a person continues to report halitosis following this, and offer specialist referral.

Oral Hygiene Measures

• Advise the person that the management of persisting halitosis is based on good oral hygiene, in particular, clearing or reducing any accumulation of food debris and bacteria on the tongue and teeth:
  • give advice on general oral hygiene measures
    • clean daily between the teeth to below the gumline before brushing
    • for small interdental spaces, use dental floss or tape
    • for larger interdental spaces, use interdental or single-tufted brushes
    • for around orthodontic appliances and bridges, use the kit suggested by the person’s dentist
  • brush the teeth and gumline with a fluoridated toothpaste last thing at night, and at least on one other occasion in the day
    • use a manual or powered toothbrush with a small head and medium texture
    • thorough cleaning takes at least 2 minutes
    • spit out after brushing and do not rinse, to maintain fluoride concentration
  • perform daily tongue cleaning, ideally before bedtime
    • in particular, clean the posterior part of the upper tongue, where bacteria flourish
    • advise to use a proprietary tongue cleaner/scraper rather than a toothbrush
    • use a gentle scraping action, and avoid excessive scraping as this can cause damage and bleeding to the tongue
    • cleaning should be repeated until no more coating material can be removed
    • care should be taken to avoid triggering the gag reflex
  • advise denture wearers that these should be left out at night and cleaned
    • the person should consult their dentist if there are any issues with the dentures or other dental prostheses, including how they fit
  • give advice on antibacterial mouthwashes/toothpastes and non-antibacterial preparations, if halitosis persists despite these measures:
    • an antibacterial mouthwash such as chlorhexidine and/or toothpaste such as triclosan may help symptoms, and can be bought over the counter
    • other antibacterial agents include cetylpyridinium chloride, hexetidine, hydrogen peroxide, and zinc; the choice of preparation will depend on individual preference and product tolerability
    • advise that chlorhexidine products may cause reversible discolouration of the tongue, teeth, or dentures (which can be minimised by brushing teeth before using a chlorhexidine-based product, and cleaning dentures with a conventional denture cleanser). They may also cause transient taste disturbance and a burning sensation of the tongue, which usually diminish with continued use
    • various non-antibacterial products (such as mints, flavoured/perfumed mouth sprays/rinses, and chewing gums) may provide transient masking of halitosis.

When to Refer

• Arrange specialist referral if halitosis is secondary to an underlying cause that cannot be managed in primary care, or if self-reported halitosis persists despite initial oral hygiene measures and lifestyle changes. Refer to full guideline for further information.