Halitosis in Otorhinolaryngology Practice

Document Type : Systematic Review


1 Department of Otorhinolaryngology, Ankara Memorial Hospital, Ankara, Turkey.

2 Department of Otorhinolaryngology, Bozyaka Teaching and Research Hospital, Izmir,Turkey.

3 Department of Otorhinolaryngology, School of Medicine, Gazi University, Ankara, Turkey.


Halitosis is a common and devastating condition, which may affect up to 1/3 of the population. It can be classified either as genuine halitosis, pseudohalitosis, or halitophobia. Genuine halitosis is more common and usually related to an organic pathology such as periodontitis. Malodour molecules such as sulfur compounds that arise from bacterial interactions generate the basis of oral malodour. Pathologies of the tongue, poor oral hygiene, deep caries, cryptic tonsillary hypertrophia, and postnasal drainage are also associated with halitosis. Gastro-esophageal pathologies and systemic problems are accepted as extra-oral sources of halitosis. There are various methods for the diagnosis of halitosis including objective and subjective methods. General oral hygiene recommendations and specific interventions for the related etiological factors have to be addressed in order to achieve satisfactory results after the treatment. Clinicians have to be aware of these aspects regarding this unfavorable condition to achieve the best results.


1. Hughes JF, McNab R. Oral malodour-a review. Archives of oral biology 2008;53(1):1-7.
2. Yoneda M, Naito T, Suzuki N, Yoshikane T, Hirofuji T. Oral malodour associated with internal resorption. J Oral Sci 2006;48(2):89-92.
3. Söder B, Johansson B, Söder PO. The relation between foeter ex ore, oral hygiene and periodontal disease. Swed Dent J 2000;24(3):73-82.
4. Liu XN, Shinada K, Chen XC, Zhang BX, Yaegaki K, Kawaguchi Y. Oral malodor-related parameters in the Chinese general population. J Clin Periodontol 2006; 33(1):31-6.
5. Belluzi A, Brignola C, Campieri M, Camporesi EP, Gionchetti P, Rizzelo F, et al. Effects of new fish oil derivative on fatty acid phospholipid-membrane pattern in a group of Crohn’s disease patients. Dig Dis Sci 1994; 39(12):2589-94.
6. Murata T, Fujiyama Y, Yamaga T, Miyazaki H. Breath malodor in an asthmatic patient caused by side-effects of medication: a case report and review of the literature. Oral Dis 2003;9(5):273-6.
7. Steinberg SM, Venuto RC, Kuruvila CK, Taylor DO, Anil Kumar MS, Groothuis JR, et al. Randomized, open-label preference study of two cyclosporine capsule formulations (usp modified) in stable solid-organ transplant recipients. Clin Ther 2003; 25(7):2037-52.
8. Seeman R, Bizhang M,Djamchidi C, Kage A, Nachnani S. The proportion of pseudo-halitosis patients in a multidisciplinary breath malodour consultation. Int Dent J 2006;56(2):77-81.
9. Van den Broek AM, Feenstra L, de Baat C. Areview of the current literature on aetiology and measurement methods of halitosis. J Dent 2007; 35(8):627-35.
10. Delanghe G, Ghyselen J, van Steenberghe D, Feenstra L. Multidisciplinary breath-odour clinic. Lancet 1997; 350(9072):187.
11. Kleinberg I, Wolff MS, Codipilly DM. Role of saliva in oral dryness, oral feel and oral malodour. Int Dent J. 2002; 52(3):236-40.
12. Van Steenberghe D. Breath malodour: a step by step approach. Berlin: Quintessence Publishing; 2004.
13. Tatli MM, San I, Karaoglanoglu M. Paranasal sinus computed tomographic findings of children with chronic cough. Int J Pediatr Otorhinolaryngol 2001; 60(3):213-7.
14.  Katz J, Shenkman A, Stravropoulos F, Melzer E. Oral signs and symptoms in relation to disease activity and site of involvement in patients with inflammatory bowel disease. Oral Dis 2003;9(1):       34-40.
15.  Adler I, Denninghoff VC, Alvarez MI, Avagnina A, Yoshida R, Elsner B. Helicobacter pylori associated with glossitis and halitosis. Helicobacter 2005;10(4):312-7.
16. Querioz 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(5):337-40.
17.  Calil CM, Marcondes FK. Influence of anxiety on the production of oral volatile sulfur compounds. Jife Sci 2006;79(7):660-4.
18. Ermis B, Aslan T, Beder L, Unalacak M. A randomized placebo-controlled trial of mebendazole for halitosis. Arch Pediatr Adolesc Med 2002; 156810):995-8.
19. Porter SR, Scully C. Oral malodour (halitosis). BMJ 2006;333(7569):632-5.
20. Persson S, Edlund MB, Claesson R, Carlsson J. The formation of hydrogen sulfide and methyl mercaptan by oral bacteria. Oral Microbiol Immunol 1990; 5(4):195-201.
21.  Kleinberg I, Westbay G. Salivary and etabolic factors involved in oral malodor formation. J Periodontol 1992;63(9):768-75.
22. Tonzetich J. Production and origin of oral malodour: a review of mechanisms and methods of analysis. J Periodontol 1977;48(1):13-20.
23.  Kato H, Yoshida A, Awano S, Ansai T, Takehara T. Quantitative detection of volatile sulfur compound-producing microorganisms in oral specimens using real-time PCR. Oral Dis 2005;11(1):67-71.
24.  Donaldson AC, McKenzie D, Riggio MP, Hodge PJ, Rolph H, Flanagan A, et al. Microbiological culture analysis of the tounge anaerobic microflora in subjects with and without halitosis. Oral Dis 2005; 11(1):61-3.
25. Krespi YP, Shrime MG, Kacker A. The relationship between oral malodour and volatile sulfur compound-producing bacteria. Otolaryngol Head Neck Surg 2006;135(5):671-6.
26. Levine MJ, Reddy MS, Tabak LA, Loomis RE, Bergey EJ, Jones PC, et al. Structural aspects of salivary glycoproteins. J Dent Res 1987;66(2):436-41.
27. Sterer N, Rosenberg M. Effect of deglycosylation of salivary glycoproteins on oral malodour production. Int Dent J 2002; 52(3):229-32.
28.  Sterer N, Rosenberg M. Streptococcus salivarious promotes mucin putrefaction and malodour production by Porphyromonas gingivalis. J Dent Res 2006; 85(10):910-4.
29. Sterer N, Shaharabany M, Rosenberg M. β- Galactosidase activity and H(2)S production in an experimental oral biofilm. J Breath Res 2009; 3(1): 016006.
30. Loesche WJ, Kazor C. Microbiology and treatment of halitosis.Periodontol 2000 2002; 28:         256-79.
31. Waler SM. On the transformation of sulfur-containing amino acids and peptides to volatile sulphur compounds (VSC) in the human mouth. Eur J Oral Sci 1997; 105:534-7.
32. Amona A, Yoshida Y, Oho T, Koga T. Monitoring ammonia to assess halitosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 94(6):692-6.
33.  Masuo Y, Suzuki N, Yoneda M, Naito T, Hirofuji T. Salivary β-galactosidase activity affects physiological oral malodour. Arch Oral Biol 2012; 57(1):87-93.
34. Kazor CE, Mitchell PM, Lee AM, Stokes LN, Loesche WJ, Dewhirst FE, et al. Diversity of bacterial populations on the tounge dorsa of patients with halitosis and healthy patients. J Clin Microbiol 2003; 41(2):558-63.
35. Tangerman A. Halitosis in medicine: a review. Int Dent J 2002; 52(3):201-6.
36. Tangerman A, Winkel EG. Intra- and extra- oral halitosis: finding of a new form of extra-oral blood-borne halitosis caused by dimethyl sulphide. J Clin Periodontol 2007; 34(9):748-55.
37. Tangerman A, Meuwese-Arends MT, Jansen JB. Cause and composition of foeter hepaticus. Lancet 1994; 343(8895):483.
38. Van den Velde S, Nevens F, Van Hee P, van Steenberghe D, Quirynen M. GC-MS analysis of breath odor compounds in liver patients. J Chromatogr B Analyt Technol Biomed Life Sci 2008; 875(2):344-8.
39. Lanzotti V. The analysis of onion and garlic. J Chromatogr A 2006; 1112(1-2):3-22.
40. Besouw M, Blom H, Tangerman A, de Graaf-Hess A, Levtchenko E. The origin of halitosis in cystinotic patients due to cysteamine treatment. Mol Genet Metab 2007; 91(3):228-33.
41. O’Hara ME, Clutton-Brock TH, Green S, Mayhew CA. Endogenous volatile organic compounds in breath and blood of healthy volunteers: examining breath analysis as a surrogate for blood measurements. J Breath Res 2009; 3(2): 027005.
42. Suarez F, Springfield J, Furne J, Levitt M. Differentiation of mouth versus gut as site of origin of odoriferous breath gases after garlic ingestion Am J Physiol 1999;276(2):425-30.
43. Rosenberg MJ. Clinical ssessment of bad breath: current concepts. J Am Dent Assoc 1996; 127(4):475-82.
44.  Lee H, Kho HS, Chung JW, Chung SC, Kim YK. Volatile sulfur compounds produced by Helicobacter pylori. J Clin Gastroenterol 2006; 40(5):421-6.
45. Tangerman A, Winkel EG, de Laat L, van Oijen AH, de Boer WA. Halitosis and Helicobacter pylori infection. J Breath Res 2012;6(1):017102.
 46. Eli I, Baht R, Koriat H, Rosenberg M. Self-perception of breath odor. J Am Dent Assoc 2001; 132(5):621-6.
 47. Quirynen M, Zhao H, Avondtroodt P, Soers C, Pauels M, Coucke W, et al. A salivary incubation test for evaluation of oral malodor: a pilot study. J Periodontol 2003; 74(7):937-44
 48. Furne J, Majerus G, Lenton P, Springfield J, Levitt DG, Levitt MD. Comprasion of volatile sulfur compound concentrations measured with a sulfide detector vs. gas hromatography. J Dent Res 2002;
49. Murata T, Rahardjo A, Fujiyama Y, Yamaga T, Hanada M, Yaegaki K, et al. Development of a compact and simple gas hromatography for oral malodor measurement. J Periodontol 2006; 77(7): 1142-7.
50. Preti G, Clark L, Cowart BJ, Feldman RS, Lowry LD, Weber E, et al. Non-oral etiologies of oral malodor and altered chemosensation. J Periodontol 1992; 63(9):790-6.
51. Van den Velde S, Quirynen M, van Hee P, van Steenberghe D. Halitosis associated volatiles in breath of healthy subjects. J Chromatogr B Analyt Technol Biomed Life Sci 2007;853(1-2):54-61.
52. Iwanicka-Grzegorek K, Lipkowska E, Kepa J, Michalik J, Wierzbicka M. Comprasion of ninhydrin method of detecting amine compounds with other methods of halitosis detection. Oral Dis 2005; 11(1): 37-9.
53. Suzuki N, Yoshida A, Nakano Y. Quantitative analysis of multi-species oral biofilms by TaqMan real-time PCR. Clin Med Res 2005;3(3):176-85.
54. Kara C, Tezel A, Orbak R. Effect of oral hygiene instruction and scaling on oral malodour in a population of Turkish children with gingival inflammation. Int J Paediatr Dent 2006;16(6):        399-404.
55. Roldan S, Herrera D, Santa-Cruz I, O’Connor A, Gonzales I, Sanz M. Comperative effects of different chlorhexidine mouth-rinse formulations on volatile sulphur compounds and salivary bacterial counts. J Clin Periodontol 2004;31(12):1128-34.
56. Winkel EG, Roldan S, van Winkelhoff AJ, Herrera D, Sanz M. Clinical effects of a new mouthrinse containing clorhexidine, cetylpyridinium chloride and zinc-lactate on oral halitosis. A dual-center, double-blind placebo-controlled study. J Clin Periodontol 2003; 30(4):300-6.
57. Danser MM, Gomez SM, van der Weijden GA. Tounge coating and tounge brushing: a literature review. Int J Dent Hyg 2003;1(3):151-8.
58. Seeman R, Kison A, Bizhang M, Zimmer S. Effectiveness of mechanical tounge cleaning on oral levels of volatile sulfur compounds. J Am Dent Assoc 2001; 132(9):1263-7.
 59. Outhouse TL, Fedorowicz Z, Keenan JV, Al-Alawi R. A Cochrane systematic review finds tounge scrapers have short-term efficacy in controlling halitosis. Gen Dent 2006;54(5):352-9.
60. Farrell S, Baker RA, Somogyi-Mann M, Witt JJ, Gerlach RW. Oral malodor reduction by a combination of chemotherapeutical and mechanical treatments. Clin Oral Investig 2006;10(2):157-63.
61. Volpe AR, Petrone ME, Prencipe M, DeVizio W. The efficacy of a dentifrice with caries, plaque, gingivitis, tooth whitening and oral malodor benefits. J Clin Dent 2002; 13(2):55-8.
62. Fukamachi H, Nakano Y, Okano S, Shibata Y, Abiko Y, Yamashita Y. High production of methyl mercaptan by L-methionine-alpha-deamino-gama-mercaptomethane lyase from Treponema denticola. Biochem Biophys Res Commun 2005;331(1):127-31.
63. Horz HP, Meinelt A, Houben B, Conrads G. Distribution and persistence of probiotic Strepto- coccus salivarius K12 in the human oral cavity as determined by real-time quantitative polymerase chain reaction. Oral Microbiol Immunol 2007; 22: 126-30.
64. Upton M, Tagg JR, Wescombe P, Jenkinson HF. Intra- and interspecies signaling between Strepto- coccus salivarius and Streptococcus pyogenes mediated by Sal A and SalA1 lantibiotic peptides. J Bacteriol 2001; 183(13):3931-8.
65. Tagg JR, Dierksen KP. Bacterial replacement therapy: adapting ‘germ warfare’ to infection prevention. Trends Biotechnol 2003;21(5):217-23.
66. Burton JP, Chilcott CN, Moore CJ, Speiser G, Tagg JR. A preliminary study of the effect of probiotic Streptococcus salivarius K12 on oral malodour parameters. J Appl Microbiol 2006;100 (4): 754-64.
67. Feusner JD, Phillips KA, Stein DJ. Olfactory reference syndrome: issues for DSM-V. Depress Anxiety 2010; 27(6):592-9.