Bad Breath

OVERVIEW OF Bad Breath :

It is also known as Halitosis. It is an subjective perception when one inhales the breathe

STRUCTURE of Bad Breath :


Two main classification schemes exist for bad breath, although neither are universally accepted.

The Miyazaki et al. classification was originally described in 1999 in a Japanese scientific publication,] and has since been adapted to reflect North American society, especially with regards halitophobia. The classification assumes three primary divisions of the halitosis symptom, namely genuine halitosis, pseudohalitosis and halitophobia. This classification has been suggested to be most widely used, but it has been criticized because it is overly simplistic and is largely of use only to dentists rather than other specialties.

  • Genuine halitosis
    • A. Physiologic halitosis
    • B. Pathologic halitosis
      • (i) Oral
      • (ii) Extra-oral
  • Pseudohalitosis
  • Halitophobia

The Tangerman and Winkel classification was suggested in Europe in 2002. This classification focuses only on those cases where there is genuine halitosis, and has therefore been criticized for being less clinically useful for dentistry when compared to the Miyazaki et al. classification.

  • Intra-oral halitosis
  • Extra-oral halitosis
    • A. Blood borne halitosis
      • (i) Systemic diseases
      • (ii) Metabolic diseases
      • (iii) Food
      • (iv) Medication
    • B. Non-blood borne halitosis
      • (i) Upper respiratory tract
      • (ii) Lower respiratory tract

The same authors also suggested that halitosis can be divided according to the character of the odour into 3 groups:[20]

  • "Sulfurous or fecal" caused by volatile sulphur compounds such as mercaptan,disulphide,hydrogen sulphide
  • Fruity odour caused by the acetone in diabetic ketoacidosis.

Based on the strengths and weaknesses of previous attempts at classification, a cause based classification has been proposed:

  • Type 0-physiological
  • Type 1 -oral
  • Type 2 -airway
  • Type 3 -gastro esophageal
  • Type 4  -blood borne
  • Type 5 -subjective


it accounts for 20% of gingival infection



Systemic infections

Poor oral hygiene

Oral infections

Gum diseases such as gingivitis,periodontitis, dry mouth


Gastrointestinal infections

Tongue: the tongue acts as an harbour for many infectious organismsa which might leads to the infection

smell of volatile sulphur compounds (VSCs) such as hydrogen sulphide,methyl mercaptan  , and dimethyl sulphate.

  • Deep carious lesions (dental decay) – which cause localized food impaction and stagnation
  • Recent dental extraction sockets – fill with blood clot, and provide an ideal habitat for bacterial proliferation
  • Interdental food packing – (food getting pushed down between teeth) - this can be caused by missing teeth, tilted, spaced or crowded teeth, or poorly contoured approximal dental filling. Food debris becomes trapped, undergoes slow bacterial putrefaction and release of malodourous volatiles. Food packing can also cause a localized periodontal reaction, characterized by dental pain that is relieved by cleaning the area of food packing with interdental brush or floss.
  • Acrylic dentures (plastic false teeth) – inadequate denture hygiene practises such as failing to clean and remove the prosthesis each night, may cause a malodour from the plastic itself or from the mouth as microbiota responds to the altered environment. The plastic is actually porous, and the fitting surface is usually irregular, sculpted to fit the edentulous oral anatomy. These factors predispose to bacterial and yeast retention, which is accompanied by a typical smell.
  • Oral infections
  • Oral ulcerations
  • Fasting
  • Stress/anxiety
  • Menstrual cycle – at mid cycle and during menstruation, increased breath VSC were reported in women.
  • Smoking – Smoking is linked with periodontal disease, which is the second most common cause of oral maloduor. Smoking also has many other negative effects on the mouth, from increased rates of dental decay to pre malignant lesion and oral cancer.
  • Alcohol
  • Volatile foods  – e.g. onion, garlic, durian, cabbage, cauliflower and radish. Volatile foodstuffs may leave malodourous residues in the mouth, which are the subject to bacterial putrefaction and VSC release. However, volatile foodstuffs may also cause halitoisis via the blood borne halitosis mechanism.
  • Medication – often medications can cause  xerostomia (dry mouth) which results in increased microbial growth in the mouth.



Diet,bacteria,epithelial cells leads to breakdown of peptides and proteins and release of amino acids resulting in putrefaction reaction. This leads to formation of malodour.

If bad breathe is ruled out the first step is to find out whether it is systemic cause or local factors should be obtained.they ar various diagnostic aids by which the dentist  finds out the underlyinfg cause



bad odour

calcified masses surrounding the teeth structure in some areas

xerostomia(dry mouth)

Increase in viscosity in saliva

Metallic taste

Whitish coating on the tongue.




  • Halimeter: it is a portable substance usually used to monitor the sulphur compounds especially hydrogen sulphide.
  • When placed in the mouth it detects the halitosis causing bacteria mainly the volatile sulphur compounds.
  • Other sulphur compounds such as mercaptan are difficulty to detect in halimeter.
  • The other foods such as garlic,onion cannot be assesses when it crossess 48 hours. The Halimeter is also very sensitive to alcohol, so one should avoid drinking alcohol or using alcohol-containing mouthwashes for at least 12 hours prior to being tested. This analog machine loses sensitivity over time and requires periodic recalibration to remain accurate.
  • Gas chromatography:portable machines are being studied.] This technology is designed to digitally measure molecular levels of major VSCs in a sample of mouth air (such as hydrogen sulphide,methyl mercapton,disulphide). It is accurate in measuring the sulfur components of the breath and produces visual results in graph form via computer interface.
  • BANA test: this test is directed to find the salivary levels of an enzyme indicating the presence of certain halitosis-related bacteria.
  • beta galactosidase test: salivary levels of this enzyme were found to be correlated with oral malodour.
  • Organoleptic: The patient inhale deeply and the examiner uses the pippete to evaluate the halitosis and scoring is done.


Scaling and root planning:

 When the plaque or calculus(hard depositions surrounding the teeth structure) covers the teeth it results in bad odour and it can be prevented by cleaning the teeth using ultrasound intruments.

Avoid those food substances which are rich in sulphur components such as garlic,onion,

Masking the malodour:

Masking the malodour with lozenges,mouth washes,flavoured chocolates.The typical example is the substance with lozenges  present with mint in it without adding any antibacterial components.

Minimizing the intraoral nutrients:

Reducing the bacterial activity by using the tongue scrapper or tongue  cleaner. Interdental cleaning with cleaning aids such as floss and interdental tooth brushes.


Chemical reduction of oral microbial load:


Chlorine dioxide

Triclosan aminofluoride

Hydrogen peroxide

Oxidizing lozenges

 Baking soda


The prognosis purely depends upon the oral healthcare status of an individual.The prognosis is good incase if the halitosis is caused by the local factors



Maintain the oral health properly

Brush the twice daily

Swish the oral cavity with normal water after havimg meals

Use mouthwashes.The mouthwashes should be diluted with water for better use.

Avoid the food substance that causes the oral malodor

Check if any cavities I present and gets treated earlier

Use tongue cleaner and floss regularly.


Recovery Period :

The recovery period usually is 4-8 weeks from the starting of treatment

Medicines used in the Treatment :


Chlorine dioxide

Triclosan aminofluoride

Hydrogen peroxide