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Halitosis: Classification, Causes, and diagnostic as well as Treatment Approach-A Review

Authors:
  • Hindustan College of Arts & Science, Chennai, India

Abstract

Objectives: This coverage reviews the current knowledge on classification, causes, and diagnostic as well as remedial line of attack on malodor of breath. Data: Halitosis, a condition that causes a severe social handicap to those who suffer from it, has a multifactorial etiology. It is anasty or offensive odor originating from the breath. The condition may encompass both oral and non-oral disorders. Sources: A private, monthly with keywords halitosis, malodor, etiology, measurement, and management from Medline and Pub med updated database of literature was reviewed. Conclusions: In majority of cases, halitosis is caused by oral conditions, defined as oral malodor. Oral malodor fallouts from tongue coating, periodontal disease, peri-implant disease, deep carious lesions, exposed necrotic tooth pulps, pericoronitis, mucosal ulcerations, healing (mucosal) wounds, impacted food or debris, imperfect dental restorations, unclean dentures, and factors causing decreased salivary flow rate. The basic progression is microbial degradation of organic substrates. Non-oral etiologies of halitosis include turbulences of the upper and lower respiratory tract, ailments of the gastrointestinal tract, some systemic maladies, metabolic disorders, medications, and carcinomas. Stressful situations are predisposing factors. There are three primary measurement approaches of halitosis. Organoleptic measurement and gas chromatography are very dependable, but not very simply clinically applied techniques. The use of organoleptic measurement is recommended as the ‘gold standard’. Gas chromatography is the preferable method if accurate measurements of specific gases are required. Sulphide monitoring is straightforwardly used method, but has the limitation that important odors are not detected. The scientific and practical value of additional or alternative measurement methods, such as BANA test, chemical sensors, salivary incubation test, quantifying β-galactosidase activity, ammonia monitoring, ninhydrin method, and polymerase chain reaction, has to be established. Last but not least, regarding the usage of probiotics, the oral administration of the probiotic lactobacilli not only seemed to improve the physiologic halitosis, but also showed beneficial effects on bleeding on probing from the periodontal pockets.
Research J. Pharm. and Tech. 8(12): December 2015
1707
ISSN 0974-3618 (Print) www.rjptonline.org
0974-360X (Online)
REVIEW ARTICLE
Halitosis: Classification, Causes, and diagnostic as well as Treatment
Approach A Review
Mahadeva Rao U.S.1, Suganya M. Utharkar2*, C. Shanmuga Sundaram3
1Professor, Faculty of Medicine, Universiti Sultan Zainal Abidin, Terengganu.
2AECS Maaruti College of Dental Sciences & Research Center, Bangalore.
3Head, Department of Biochemistry, Prof. Dhanapalan College of Arts and Science, Kelambakkam, Chennai.
*Corresponding Author E-mail: raousm@gmail.com
ABSTRACT:
Objectives:
This coverage reviews the current knowledge on classification, causes, and diagnostic as well as remedial line of
attack on malodor of breath.
Data:
Halitosis, a condition that causes a severe social handicap to those who suffer from it, has a multifactorial
etiology. It is anasty or offensive odor originating from the breath. The condition may encompass both oral and
non-oral disorders.
Sources:
A private, monthly with keywords halitosis, malodor, etiology, measurement, and management from Medline
and Pub med updated database of literature was reviewed.
Conclusions:
In majority of cases, halitosis is caused by oral conditions, defined as oral malodor. Oral malodor fallouts from
tongue coating, periodontal disease, peri-implant disease, deep carious lesions, exposed necrotic tooth pulps,
pericoronitis, mucosal ulcerations, healing (mucosal) wounds, impacted food or debris, imperfect dental
restorations, unclean dentures, and factors causing decreased salivary flow rate. The basic progression is
microbial degradation of organic substrates. Non-oral etiologies of halitosis include turbulences of the upper and
lower respiratory tract, ailments of the gastrointestinal tract, some systemic maladies, metabolic disorders,
medications, and carcinomas. Stressful situations are predisposing factors. There are three primary measurement
approaches of halitosis. Organoleptic measurement and gas chromatography are very dependable, but not very
simply clinically applied techniques. The use of organoleptic measurement is recommended as the ‘gold
standard’. Gas chromatography is the preferable method if accurate measurements of specific gases are required.
Sulphide monitoring is straightforwardly used method, but has the limitation that important odors are not
detected. The scientific and practical value of additional or alternative measurement methods, such as BANA
test, chemical sensors, salivary incubation test, quantifying β-galactosidase activity, ammonia monitoring,
ninhydrin method, and polymerase chain reaction, has to be established. Last but not least, regarding the usage of
probiotics, the oral administration of the probiotic lactobacilli not only seemed to improve the physiologic
halitosis, but also showed beneficial effects on bleeding on probing from the periodontal pockets.
KEYWORDS: Halitosis; Oral cavity; Blood-borne; Respiratory tract; Dentist.
Received on 24.11.2015 Modified on 05.12.2015
Accepted on 11.12.2015 © RJPT All right reserved
Research J. Pharm. and Tech. 8(12): Dec., 2015; Page 1707-1713
DOI: 10.5958/0974-360X.2015.00307.8
INTRODUCTION:
Halitosis is an nasty modification of the halitus for the
person who has the sign and for related people either,
being a pathological condition or not1is also known as
fetid halitus, stinking mouth, bad breath or oral
Research J. Pharm. and Tech. 8(12): December 2015
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malodor2,3. Halitosis is a common complaint among
adults of both genders all over the world. It has a
multifactorial etiology, but its main cause is the
decomposition of the organic material by
microorganisms of the oral cavity. One of the pioneers in
halitosis research was ‘Howe’ who termed this symptom
in 1874 and since then, halitosis has been considered a
clinical entity1. The majority of the citations concerning
to halitosis before 1930 were not confirmed by facts or
studies, however were perpetuated by literature4.In
1934, Fair and Wells created an instrument called
osmoscope, which was used for measurements of odor
density in a subjective and semi quantitative way4.
Oral malodor is a common problem among general
population and evidences reveal that it forms about85%
of all bad breath. Bad breath can have a distressing effect
that may become a social handicap and the affected
person may avoid socializing. The condition is
multifactorial in etiology and may involve both oral and
non-oral conditions. Volatile sulphur compounds (VSC),
namely hydrogen sulphide (H2S) and methyl mercaptan
(CH3SH) are the main cause of oral malodor. These
substances are by-products of the action of bacteria on
proteins. Gram-positive bacteria produce little or no
malodor; most Gram-negative bacteria are potent
producers of odoriferous compounds. Treatments
corresponding to the causes of oral malodor include
mechanical or chemical tongue cleaning, periodontal
disease treatment, oral hygiene instruction and mouth
rinses or mouthwashes. Halitosis, breathe malodor or
colloquially known as "bad breath" can be subdivided as
real halitosis, pseudo halitosis and halitophobia5.
1.1. True halitosis:6
Real halitosis can be further subdivided into
physiological and pathological halitosis. Physiologic
halitosis includes halitosis caused by dietary
components, deleterious habits, and morning breath,
secondary to xerostomia caused by physiologic factors.
Pathologic halitosis occurs secondary to pathologic
conditions or oral tissues like gingival and periodontal
diseases like Periodontitis, acute necrotizing ulcerative
gingivitis, residual post-operative blood, debris under
dental appliances, ulcerative lesions of the oral cavity,
Halitosis may be associated with coated tongue, may
occur due to xerostomia secondary to salivary gland
diseases, tonsilloliths.
1.2. Pseudo halitosis6
Patients who suffer from pseudo halitosis complain of
the existence of halitosis though it is not perceived by
others. This condition can be managed effectively by
counseling (using literature support, education and
explanation of examination results) and simple oral
hygiene measures Halitophobia6. Some individuals
continue to insist that they have halitosis even after they
have been treated for genuine or pseudo-halitosis. Such
individuals are categorized as halitophobic. Halitophobia
may be considered when no physical or social evidence
exists to suggest that halitosis is present.
1.3. Psychogenic Halitosis:6, 7
Psychogenic Halitosis is the one which is imagined. In
this a person believes that his breath smells bad when it
actually does not. This problem may occur in people
who tend to exaggerate normal body sensations.
sometimes this is caused by a serious mental disorder
such as schizophrenia. A person with obsessional
thoughts have an overwhelmed sense of feeling dirty. A
person who is paranoid may have the delusion that his
organs are rotting. Both these persons feel their breath
smells bad. Such people may be helped by having doctor
or dentist assures them that they do not have bad breath.
If the problem continues, person benefit from seeing
psychotherapist.
2. Main causes of halitosis:
2.1.1. Oral Diseases Related To Halitosis:
Oral cavity pathologies that can cause halitosis are,
among others: dental cavities, periodontal disease,
tongue coating, exposed tooth pulps, extractions/healing
wounds, interdentally food impaction, dentures kept at
night or not regularly cleaned, restorative crowns which
are not well adapted, cysts with fistula draining into the
mouth, oral cancer and ulcerations. Most of these factors
cause halitosis due to tissue breakdown, putrefaction of
amino acids and decreasing of saliva flow. All these
conditions result in the release of VSC8, 9.
2.1.2. Otolaryngology and Respiratory Diseases
Related to Halitosis:
Halitosis is a very common complaint among ENT
patients. The main causes of halitosis related to the oro-
nasal cavity are acute viral or bacterial pharyngitis,
chronic/purulent tonsillitis, retropharyngeal abscesses,
deep crypts of the tonsils, caseous retention,
chronic/purulent sinusitis, post-nasal drip, foreign body
in nasaloro-sinusal cavity and ozena. These pathologies
cause halitosis mainly due to bacterial action, which lead
to putrefaction of the tissues and production of VSC10,8.
Fetid samples of the tongue dorsum coating were
compared with nasal mucus and showed the same
composition11. Nasal obstruction leads to mouth
breathing causing dryness of the mouth. A dry mouth
causes more epithelium cells exfoliation, xerostomia,
tongue coating and therefore increases the production of
VSC8.
2.1.3. Digestive Diseases Related to Halitosis:
Many digestive diseases are traditionally associated with
halitosis. Reflux esophagi is, hiatal hernia, Zencker
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diverticulum, achalasia are associated. Actually,
steatorrhea or other malabsorption syndromes, which
cause excessive flatulence, are the most important causes
of halitosis concerning gastrointestinal diseases10,8.
Specialists and internists often require
gastroenterological assessment when facing a halitosis
complaint. Endoscopy is one of the most widely
requested tools in halitosis investigation12.
2.1.4. Temporary halitosis:
It results from hot/spicy food, certain drinks, alcoholic
beverages, coffee and most common from garlic, onion,
salty foods, spices, curries, cured foods like salamis and
cooked food such as kippers8. Tobacco consumption
causes moldy odor and Hypo salivation/Xerostomia (dry
mouth) also leads to bad breath13.
2.1.5. Morning breath:
Everybody has a degree of halitosis, first thing in the
morning. There is a physiological reason for this. During
sleep, the flow of saliva is reduced drastically and tongue
and cheek move very little. This allows food residues to
stagnate in the mouth and dead cells that are normally
shed from the surface of tongue and gums and from the
inside of cheek to accumulate. As bacteria starts to work
on them and digest them, an unpleasant smell is
generated. This process is biologically known as
putrefaction/rotting. Although normal, anyone suffering
from nasal congestion whose mouth breathes is more
likely to suffer from these actions to a greater extent.
Luckily, this morning breath generally disappears after
breakfast and after brushing the teeth because saliva
starts to flow again and any leftover residues are washed
away and swallowed14.
2.1.6. Smoking (cigarettes/cigars):
Breath smells like ash tray. Smoking also reduces the
flow of saliva and therefore further exacerbates the
problem15.
2.2. Crash dieting/fasting:
When the body is no longer supplied with energy giving
carbohydrates it first breaks down glucose stored in the
muscles and liver in the form of glycogen. But this does
not last long. After a few hours, the body begins to
breakdown its fat stores and the waste product of their
metabolism, ketones, endows the breath with a
distinctive sweet and sickly smell. This can be seen in
those who has vigorously worked out and exercised and
not taken sufficient carbohydrates before or after. People
on a strict caveman or high protein diet experience the
same effect for similar reasons.
2.3. Oral source of halitosis
Malodor that arises from the mouth is the consequence
of microbial putrefaction of food debris, cells, saliva,
and blood. The oral microbes most likely to cause the
oral malodor are Gram negative bacteria and include
Prevotella (Bacteroides) melaninogenica,
Treponemadenticola, Porphyromonasgingivalis,
Porphyromonasendodontalis, Prevotellaintermedia,
Bacteroidesloescheii, Enterobacteriaceae,
Tannerellaforsythensis (Bacteroidesforsythus),
Centipedaperiodontii, Eikenellacorrodens,
Fusobacteriumnucleatumvincentii,
Fusobacteriumnucleatumnucleatum,
Fusobacteriumnucleatumpolymorphum, and
Fusobacteriumperiodonticum16,17. However, no obvious
association exists between oral malodor and any specific
bacterial infection, suggesting that halitosis reflects
complex interactions between several oral bacterial
species. The agents that give rise to oral malodor include
especially the VSC, demines, and short chain fatty acids.
These bacterial interactions are most likely to occur in
the gingival crevices and periodontal pockets, but oral
malodor can also arise from the posterior dorsal tongue
(and this explains why oral malodor may sometimes
occur in people with good oral hygiene). As a
consequence of its large and papillary surface area, the
dorsum of the tongue canretain large amounts of
desquamated cells, leucocytes, and micro-organisms
(and presumably salivary constituents). The microbial
content on the tongue may be greater18, 19 but not
necessarily different, in people with periodontal disease
than in others.
2.4. Miscellaneous Causes:
Renal impairment is normally a result of a chronic
glomerulonephritis, which damage the glomerular
function, leading to an increased urea level in the blood.
Breathed air is described as ammonium-like breath and
generally is accompanied by complaints of dysgeusia
(salty taste)20. Diabetes can result in accumulation of
ketene bodies, which are breathed out producing a very
characteristic halitus, moreover, diabetes causes dry
mouth. In addition, diabetes and other insulin-resistance
states are related to impaired secretion of body fluids,
like tear and saliva. There is a decrease in saliva
production and xerostomia can occur21.
Trimethylaminuria or “fish odor syndrome” is agenetic
metabolic disorder characterized by a failure in the
oxidation route from trim ethylamine (TMA) to trim
ethylamine N-oxide (TMA-O) in the liver. This occurs
due to a mutation in the FMO gene22. High levels of
TMA in urine and others body fluids confer that typical
unpleasant, intermittent characteristic fishy odor to the
breath20. Examples of drugs that may cause oral malodor
include alcohol, tobacco, betel, solvent misuse, chloral
hydrate, nitrites and nitrates, dimethyl sulphoxide,
disulphiram, some cytotoxic agents, phenothiazines,
amphetamines etc.
Research J. Pharm. and Tech. 8(12): December 2015
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3. Professional diagnosis for halitosis:
Scientists have long thought that smelling one's own
breath odor is often difficult due to acclimatization,
although many people with bad breath are able to detect
it in others. Research has suggested that self-evaluation
of halitosis is not easy because of preconceived notions
of how bad we think it should be. Some people assume
that they have bad breath because of bad taste (metallic,
sour, fecal, etc.), however bad taste is considered a poor
indicator. Patients often self-diagnose by asking a close
friend23.
One popular home method to determine the presence of
bad breath is to lick the back of the wrist, let the saliva
dry for a minute or two, and smells the result. This test
results in overestimation, as concluded from research,
and should be avoided24. A better way would be to
lightly scrape the posterior back of the tongue with a
plastic disposable spoon and to smell the drying residue.
Home tests that use a chemical reaction to test for the
presence of polyamines and sulfur compounds on tongue
swabs are now available, but there are few studies
showing how well they actually detect the odor.
Furthermore, since breath odor changes in intensity
throughout the day depending on many factors, multiple
testing sessions may be necessary.
3.1.1. Halimeter:
a portable sulfide monitor used to test for levels of sulfur
emissions (to be specific, hydrogen sulfide) in the mouth
air. When used properly, this device can be very
effective at determining levels of certain VSC-producing
bacteria. However, it has drawbacks in clinical
applications. For example, other common sulfides (such
as mercaptan) are not recorded as easily and can be
misrepresented in test results. Certain foods such as
garlic and onions produce sulfur in the breath for as long
as 48 hours and can result in false readings. 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 accurate25.
3.1.2. Gas chromatography:
Portable machines, such as the OralChroma, are
currently being introduced. This technology is
specifically designed to digitally measure molecular
levels of the three major VSCs in a sample of mouth air
(hydrogen sulfide, methyl mercaptan, and dimethyl
sulfide). It is accurate in measuring the sulfur
components of the breath and produces visual results in
graph form via computer interface.
3.1.3. BANA test:
This test is directed to find the salivary levels of an
enzyme indicating the presence of certain halitosis-
related bacteria.
3.1.4. β-Galactosidase test:
Salivary levels of this enzyme were found to be
correlated with oral malodor.
Although such instrumentation and examinations are
widely used in breath clinics, the most important
measurement of bad breath (the gold standard) is the
actual sniffing and scoring of the level and type of the
odor carried out by trained experts ("organoleptic
measurements"). The level of odor is usually assessed on
a six-point intensity scale26-41.
3.2. Proposal for a rational protocol:
The intention of this protocol is to assess the main causes
of halitosis concerning their frequency and importance.
A logical knowledge organization must be kept to avoid
diagnosis failures and useless/expensive tests. Initially a
physician must have in mind that halitosis complaint is
very common in the general population. Nevertheless,
there is a bias concerning differences between true
halitosis and “bad taste in the mouth”. Some patients
look for halitosis treatment due to relatives/friends
warnings and others due to self-awareness. It has to be
considered the level of confidence in the information
given by relatives/friends. In our experience, some cases
have been mistreated due to biased information given by
an unhappy consort. Moreover, there is physiologic
halitosis, which is sometimes misinterpreted as a disease,
and it can be normal. The halitosis most people
experience when wake up is considered physiologic once
it disappears after eating and/or brushing teeth. It is
considered physiologic because of the decreased salivary
flow, the increased putrefaction process at night and
because of the long period of starvation while sleeping.
If it persists even after eating or brushing teeth, further
investigation is necessary42.
4. Food source for anaerobic bacteria that cause bad
breath:
Most of the odoriferous compounds that cause bad
breath are waste products created by anaerobic bacteria,
as they digest proteins. This means that as we consume
food items such as meat and fish, bacteria living in our
mouth also get meal and waste products from their meals
are precisely the compounds that cause bad breath. There
is always naturally occurring protein food sources
floating around in our mouth such as dead skin cells or
protein compounds found in the saliva. And then also
especially for those who are not diligent with brushing
and flossing, there is always the leftover food debris
from yesterday’s meal and the meal before that and the
one before that. High protein foods include meat, fish,
sea food and eggs; dairy foods such as milk, cheese,
yoghurt; cereal grains and products; desserts especially
cakes and pies.
Research J. Pharm. and Tech. 8(12): December 2015
1711
4.1. Where do the bacteria that cause bad breath
live?
For most of us, bad breath causing bacteria live on the
surface of tongue. Secondary locations can be at or
below person's gum line. Bacteria that live on person's
tongue, the most common odor producing region of the
tongue is its posterior region; covered by a whitish layer,
dental plaque and its chocked full of anaerobic bacteria.
The precise surface texture found on individual's tongue
will influence the amount of coating that tends to
accumulate. Fissured tongue, grooved tongue, and lingua
plicata have more potential to accumulate bacteria laden
coating than those with smoother tongue surface.
5. Correlation studies:
5.1. Association of oral malodor with Periodontitis:
A correlation has been found between VSC
concentration in mouth air and increased pocket depth in
Periodontitis patients.43,44 The uptake of volatile sulphurs
by epithelial cells may play an important role in the
pathogenesis of periodontal disease: it has-been
proposed that volatile sulphurs may alter the
permeability of affected cells and facilitate the access of
toxic metabolites into the underlying connective tissue
thereby contributing to collagen degradation. There is
also general agreement that the VSC content of exhaled
mouth air and the concentration of VSC precursors
increases with the severity of periodontal disease.
5.2. Correlation between halitosis and mouth
breathing in children:
Lara Jansiski Motta et al., has carried out a correlation
study between halitosis and mouth breathing in
children.45 Accordingly, fifty five children between 3 and
14 years of age were divided into two groups (nasal and
mouth breathing) for the assessment of halitosis. There
were a significantly greater number of boys with the
mouth-breathing pattern than girls. Based on their study,
a total of23.6% of the participants had no mouth odor,
12.7% had mild odor, 12.7% had moderate odor and
50.9% had strong odor. There was a statistically
significant association between halitosis and mouth
breathing. Thus the occurrence of halitosis was high
among the children evaluated, and there was a
statistically significant association between halitosis and
mouth breathing.
6. Treatment of oral malodor46
It includes investigating and managing possible systemic
(non-oral) source if organoleptic method detects malodor
from both mouth and nose; improving oral hygiene by
professional and patient administered tooth cleaning;
regularizing atraumatic tongue cleaning; to use regularly
the antimicrobial toothpastes and mouthwashes; rinsing
with oil-water; having regular clinical review to ensure
maintenance of effective oral hygiene etc,.
6.1. Alternative medicine:
According to traditional ayurvedic medicine, chewing
areca nut and betel leaf is a remedy for bad breath. In
South Asia, it was a custom to chew areca or betel nut
and betel leaf among lovers because of the breath-
freshening and stimulant drug properties of the mixture.
Both the nut and the leaf are mild stimulants and can be
addictive with repeated use. The betel nut will also cause
dental decay and red or black staining of teeth when
chewed47. Both areca nut and betel leaf chewing,
however, can cause premalignant lesions such as
leukoplakia and sub mucous fibrosis, and are recognized
risk factors for oral and oropharyngealsquamous cell
carcinoma (oral cancer)48. Other traditional remedies for
halitosis include Guava leaves in Thailand, eggshells in
China, parsley in Italy, and urine-based mouth rinse in
certain European cultures49. Practitioners and purveyors
of alternative medicine sell a vast range of products that
claim to beneficial in treating halitosis, including dietary
supplements, vitamins, oral probiotics. Halitosis is often
claimed to be a symptom of the so-called "candida
hypersensitivity syndrome" or related fictitious diseases,
and is claimed to be treatable with antifungal
medications or alternative medications claimed to treat
fungal infections.
6.2. Probiotics50, 51
A diverse consortium of gram-negative and gram-
positive bacteria have been found to contribute to the
problem and by contrast, certain bacterial species that
predominate in the mouths of healthy subjects become
noticeably absent in subjects with halitosis. Current
treatments focus on the use of chemical or physical
antibacterial regimes to reduce the numbers of these
bacteria. Antimicrobial treatment indiscriminately
depletes populations of both the problematic bacteria and
those bacteria that are not thought to be implicated in
halitosis, but which are likely to be important in the
maintenance of a normal oral micro-environment. The
outcome of antimicrobial treatment is inevitably only a
temporary reduction in malodor, until the halitosis-
causing bacteria become re-established. Preventing the
re-growth of odor-causing organisms by pre-emptive
colonization of the oral cavity with nonvirulent,
commensal microorganisms seems like a reasonable
alternative.
Recently several studies were performed to replace
bacteria responsible for halitosis with probiotics as
Streptococcus salivarius,Lactobacillus salivarius or
Weissellacibaria and concluded that probiotic bacterial
strains, originally sourced from the indigenous oral
microbiotas of healthy humans, may have potential
application as adjuncts for the prevention and treatment
of halitosis. The oral administration of the probiotic
lactobacilli not only seemed to improve the physiologic
Research J. Pharm. and Tech. 8(12): December 2015
1712
halitosis, but also showed beneficial effects on bleeding
on probing from the periodontal pockets.
7. CONCLUSION:
The prevalence of halitosis has been reported to be as
high. However, only a few patients visit dental clinicians
to seek help for halitosis. This fact suggests that the
patients who do visit clinicians may have different
psychological characteristics or values concerning their
own breath than other individuals. Since the biochemical
pathogenesis of oral malodor was elucidated earlier, the
simple treatment measures have proven very effective in
controlling halitosis. Nevertheless, halitosis treatments
are generally unsuccessful in halitophobic patients
because clinicians are unable to find any signs of bad
breath. Patients with psychosomatic halitosis frequently
receive only treatment for genuine halitosis and do not
receive care from a psychological specialist. Patients
persistent complaints about malodor are often ignored by
dental clinicians. Consequently, these patients may start
“doctor shopping.” Many patients with psychosomatic
halitosis are not able to obtain proper treatment for their
condition because of a clinician’s mismanagement. Since
a few of these patients go so far as to commit suicide,
they need appropriate management by a psychological
specialist. Therefore, it is important for the general
practitioner to distinguish between patients with real
halitosis and those with psychological halitosis.
A successful protocol for distinguishing or diagnosing
psychosomatic halitosis has not yet been established.
Although more than 100 papers about psychosomatic
halitosis have been published during the past quarter
century, classification of and criteria for genuine
halitosis and the psychosomatic condition remain
unclear. To clarify the appropriate management of a
patient with psychosomatic halitosis, a simple
classification of the types of halitosis must be
established. To conclude, bad breath is a major concern
for many people. Because it nearly always originates
from the mouth, it can and should be diagnosed and
treated professionally by dentists. There is no "stand-
alone" product solution for halitosis nor do traditional
standards of dental or periodontal care necessarily
eliminate the problem. Recent developments in the
understanding of the etiologies of breath malodor have
spawned new techniques for its assessment and
management.
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