See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/269767667

Halitosis: A Review of the Literature on Its Prevalence, Impact and Control

Article  in  Oral Health & Preventive Dentistry · December 2014

DOI: 10.3290/j.ohpd.a33135 · Source: PubMed

CITATIONS READS

52 4,872

3 authors, including:

Ezi Akaji Nkiru Folaranmi

University of Nigeria University of Nigeria
30 PUBLICATIONS   191 CITATIONS    20 PUBLICATIONS   230 CITATIONS   

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Ezi Akaji on 10 August 2015.

The user has requested enhancement of the downloaded file.

 REVIEWAkaji
ARTICLE
et al

Halitosis: A Review of the Literature on Its Prevalence,

Impact and Control

Ezi A. Akajia/Nkiru Folaranmib/Olufunmilayo Ashiwajuc

Summary: Halitosis is the offensive or disagreeable odour that may emanate from the mouth. In 80%–90% of cases,
bacterial activities especially on the dorsum of the tongue are implicated. Current studies on halitosis accessed from
electronic databases were appraised in the light of prevalence, impact and control of halitosis. Halitosis has a world-
wide occurrence with a prevalence range of 22% to 50%. Due to the associated social and psychological effects, it
should be taken seriously in all affected patients. Oral healthcare professionals ought to be well informed, because
their office(s) are usually the first points of call for the affected patients.

Key words: control, halitosis, prevalence, prevention

Oral Health Prev Dent 2014;12:297-304 Submitted for publication: 17.08.13; accepted for publication:08.01.14
doi: 10.3290/j.ohpd.a33135

H alitosis is an offensive or disagreeable odour

emanating from the mouth or hollow cavities of
the nose, sinuses or pharynx.71,73,91 Other general
terms used to describe this unpleasant condition
are fetor oris, fetor ex oris, oral malodour, foul
breath or bad breath.2,18 Halitosis can be classified
as genuine halitosis, pseudo-halitosis or as halito-
phobia.35,94 Genuine halitosis is either physiologi-
cal or pathological in origin, while pseudo-halitosis
is the claim that halitosis exists when no objective
evidence can be found.35,94 In genuine halitosis,
bacterial activities in the oral cavity are implicated
in 80%–90% of cases.26,73 Researchers have de-
tected over 600 species of microorganisms in the
oral microbiota.33,36 These operate mainly by their
action on sulfur amino acids such as cysteine, cys-
tine and methionine to produce volatile sulfur com-
pounds (VSCs) such as hydrogen sulfide (H2S), me-
a
Senior Lecturer and Consultant Public Health Dentist, Depart-
ment of Preventive Dentistry, College of Medicine, University of
Nigeria, Enugu Campus, Enugu, Nigeria. Study concept and de-
sign, the review of study materials, coordinated manuscript writ-
ing, proofread manuscript.
b
Senior Lecturer and Consultant Orthodontist, Department of
Child Dental Health, College of Medicine, University of Nigeria,
Enugu Campus, Enugu, Nigeria. Reviewed study materials, proof-
read manuscript.
c
Lecturer and Consultant Paediatric Dentist, Department of Child
Dental Health, College of Medicine, University of Lagos, Idi-Araba,
Lagos, Nigeria. Provided technical support, proofread manuscript.
Correspondence: Dr. Ezi A. Akaji, Department of Preventive Den-
tistry, College of Medicine, University of Nigeria, Enugu Campus,
Enugu 234, Nigeria. Tel: 234-806-956-5601.
Email: ezi.akaji@unn.edu.ng
thyl mercaptan (CH3SH) and dimethyl sulfide
(CH3SCH3) as metabolites.2,18,24,57 Some micro-or-
ganisms and other conditions associated with hali-
tosis are listed in Table 1.
Various sites in the oral cavity serve as niches
for these bacteria, but the dorsum of the tongue
with its characteristic fissures and grooves is their
primary location.1,35,40,64,83,93,95 The tongue pro-
vides a suitable environment for the growth of
these organisms, as favourable redox potentials
are found in the deep crypts associated with the
structure of the tongue papillae.30 Quirynen et al61
demonstrated that tongue coating – whether pre-
sent alone or with periodontal inflammation – was
associated with halitosis in more than 1200 of
2000 patients of a breath clinic. The aim of the
present study was to assess the prevalence of hal-
itosis, impact on the individual and the wider soci-
ety and the available control measures for this pub-
lic health issue.20 This review may be useful to oral
healthcare professionals in treatment planning de-
cisions and in providing information to share with
patients who are burdened with oral malodour.
DATA SOURCES AND STUDY SELECTION
Articles published between 1990 and 2012 from
the University of Nigeria electronic library and inter-
net-based publications were retrieved. The words
‘halitosis’ and ‘oral malodour’ were used as key
words for the electronic data search. Available full

Vol 12, No 4, 2014 297

Akaji et al

Table 1 Aetiological agents/conditions associated with halitosis

Other oral
contributory
Bacteria in oral cavity factors Consumables (food and drugs) Non-oral sources

Drugs causing dry mouth Non-oral sources of halitosis

Treponema denticola, Porphyr-
omonas gingivalis, Porphyromonas
endodontalis, Prevotella interme-
dia, Bacteroides loescheii,
Enterobacteriaceae, Tannerella
forsythia, Centipeda periodontii,
Eikenella corrodens, Fusobacte-
rium nucleatum, Micromonas
micros, Campylobacter rectus,
Desulfovibrio and Eubacterium
spp.8,16,37,43,58
Tooth decay,
(xerostomia) – anti-cholinergics, include ENT infections (acute
gingival
e.g. atropine, anti-depressants; pharyngitis, purulent sinusitis, and
inflammation,
diuretics, e.g. furosemide; postnasal drip); bronchial and lung
poor oral
anti-hypertensives, e.g. methyl- disease (chronic bronchitis,
hygiene,
dopa and captopril; analgesics, bronchiectasis, bronchial carci-
dental
e.g. codeine, methadone, noma), liver diseases (cirrhosis),
abscesses
ibuprofen and piroxicam; anti- kidney disorders (chronic renal
and presence
histamines, e.g. brompheniramine failure), metabolic disorders
of dental
and diphenhydramin; some (diabetes/diabetic ketoacidosis),
prosthe-
cytotoxic agents, solvent GIT disorders, e.g.
ses6,55
abuse45,58 GERD11,45,58,84,91

Peptostreptococcus anaerobius, Other conditions linked with

Collinsella aerofaciens, Veillonella
spp., Selenomonas flueggei, and
Proteus mirabilis89
Atopobium pavulum, Eubacterium
sulci, Fusobacterium periodonti-
cum, Dialister spp., Solobacterium
moorei, certain uncharacterised
Streptococcus species29,33
Dry mouth,
halitosis: dehydration, old age,
food impac-
anaemia, hypovitaminosis,
tion areas in
emotional stress, inflammatory
between Onions, garlic, coffee, alcohol,
autoimmune diseases and
teeth, oral cigarettes14,35,38,68,74
obstruction of salivary glands,
ulcerations,
malignancy and irradiation for
oral malignan-
head and neck cancers, multiple
cies6,24,39,58,87
sclerosis, menopause45,58

articles were accessed and stored on a CD-ROM.
Sorting was done to exclude all publications before
1990 while those from 1990 and 2012 were includ-
ed. The authors read the articles and extracted data
on prevalence, impact and control of halitosis. If any
author had more than one article on halitosis or its
correlates, the most suitable for each subheading
under focus was selected; this was done to accom-
modate as many authors’ views as possible.
PREVALENCE OF HALITOSIS
Halitosis is a problem that has plagued people for
thousands of years; it ranks third amongst the rea-
sons for patients’ visit to the dentist.14,24 It can be
detected organoleptically (i.e. by nose) and instru-
mentally using sulfide monitors or gas chromatogra-
phy,57,66,68,96 although results of these different
methods do not always agree.15 The prevalence of
halitosis differs across the globe due to variations
in the perception of odours among people of differ-
ent races and cultures, absence of uniformity in
evaluation as well as a disparity between self-per-
ceived and clinically detected halitosis re-
ports.11,44,63 However, the overall prevalence ranges
from 22% to 50%, being higher when self-reported
than clinically detected.18,71 Table 2 shows the prev-
alences of halitosis extracted from some studies.
Tangerman and Winkel,88 in their assessment of
58 subjects without periodontal disease but with
complaint of malodour, found 10.4% of them with
halitosis from non-oral sources. They also reported
dimethyl sulfide (CH3SCH3) and methyl mercaptan
(CH3SH) as the main VSCs associated with extra-
oral and intra-oral halitosis, respectively.12 In their
study on daily variation of oral malodour and related
factors in community-dwelling elderly subjects, Sam-
nieng et al72 found a significant association between
the concentration of CH3SCH3 with systemic diseas-
es and routine intake of medications at all times of
measurements. Subjects with systemic disease and
routine intake of medicines (80.7%) tended to have
a higher concentration of CH3SCH3 than their coun-
terparts. Although halitosis from non-oral sources is
generally not common, records from a multidisciplin-
ary breath clinic show that the most frequent non-
oral source is in the ear, nose and throat area.21,22
IMPACT OF HALITOSIS ON THE INDIVIDUAL
AND SOCIETY
Halitosis has both medical and social aspects, the
latter being responsible for most of the concern in
recent times.9,19,73 Some phrases used to describe
it in the literature include social stigma,6 social
health problem,63 universal medico-social prob-

298 Oral Health & Preventive Dentistry

 Akaji et al

Table 2 Prevalence of halitosis extracted from some studies

Authors / Type of Other observations /
year Location Subjects/N assessment Prevalence report conclusion

41 consecutive The most affected

Odai et al, Benin city, Organoleptic 80.5% with genuine
patients attending a population was the age
201055 Nigeria assessment halitosis
halitosis clinic group 60–69

498 student volun-

Eldarrat et 44.4% in males and Halitosis was perceived
Libya teers and office Self-perceived
al, 200824 54.2% in females mostly upon awakening
workers

Smoking, dry mouth and

Almas et 481 dental students 44% in males and 32% in
Riyadh Self-perceived tea consumption were
al, 20036 (19–24 years) females
the other features

35.4% for all cases: Mean VSC level 157.7 ±

Measurement
Mbodj et 62 dental prostheses 72.2% for fixed denture 152.6 ppb was much
Senegal of VSCs using
al, 201147 users users and 27.3% for users higher than the cut-off
halimeter
of removable dentures point VSC ≥ 152.6

Significant differences
Arowojolu were found in the
14.5% among attendees
and Ibadan, 255 consecutive Organoleptic prevalence of halitosis
of the periodontology
Dosunmu, Nigeria patients (16–74 years) assessment according to age group,
clinic
20047 oral hygiene status and
social class

Tongue coating, peri-

Organoleptic
odontal status and
Liu et al, assessment 27.5% by organoleptic
China 2000 (15–64 years) plaque index had positive
200642 and with score
associations with level of
sulfide monitor
oral malodour

Organoleptic Weak correlation

Bornstein 419 individuals 28% had readings of ≥
Switzer- assessment between self-reported
et al, from Bern, 75 ppb VSCs in their
land and VSC with either organoleptic
2009a12 (18–94 years) breath (halimeter)
measurement or VSC measurement

Compared No correlation between

Bornstein
Switzer- 625 Army recruits self-perceived 20% prevalence of self-reported halitosis
et al,
land (18–25 years) halitosis with halitosis and clinical measure-
2009b13
clinical data ment was detected

Significantly higher
Söder et Clinically rated
Sweden Swedish men/ 1681 41 (2.4%) prevalence probing depth and
al, 200080 halitosis
gingival index

Significant link between

Miyazaki et 2672 individuals aged VSCs scores VSC values and tongue
Japan 6%–23%
al, 199551 18 to 64 years with halimeter coating status; periodontal
conditions were observed

lem63 and social-life killer.9 Hence, it could consti-
tute a handicap leading to withdrawal from social
circles by affected individuals.24,34 Data analysed
from 465 patients who attended the halitosis clinic
at the University of Basel over a 7-year period re-
vealed that social life was affected in about 388 of
them.97 Sufferers of halitosis can also be plagued
with anxiety regardless of whether the condition is
real or imagined.4,75,90 Anxiety in this context is
more or less phobia-mediated, leading to avoidance
of dental visits, poorer oral health and ultimately to
a heightened or real oral malodour.75 Clinicians ob-
served a trend among victims: behavioural practic-
es such as use of mints and chewing gum, mouth-
wash, sprays and dental floss, increased frequency
of toothbrushing and toothbrushing force were ap-
plied to mask bad breath.10,14,49,58 Thus, proper pro-
fessional guidance in employing some of these
practices is strongly encouraged to avoid unwanted
side effects, such as tooth-wear lesions and caries.
Other challenges that can ensue from halitosis
are low self-esteem and self-confidence, hampered
intimate relationships such as dating and marriage,
decreased quality of life, unfulfilled career aspira-
tions, loneliness, depression, substance abuse,
dropping out of school, suicidal tendencies and di-

Vol 12, No 4, 2014 299

Akaji et al
vorce.3,4,9 Ancient Hebraic texts (the Talmud) pro-
vided legal backing to broken marriages if one part-
ner had oral malodour and similar references were
found in writings from Greek, Roman, early Chris-
tian and Islamic cultures.73
The effect of halitosis goes beyond the immedi-
ate sufferer as relatives and friends also share in
the burden.9,19 Apart from the awkward scenario
created by the condition, relatives may need to re-
assure or counsel the sufferers about their bad
breath.9,55 Delanghe et al22 reported that more than
70% of the attendees at a Belgian breath clinic were
advised by others to seek treatment; in a suburban
health facility in Nigeria, 31.7% and 24.4% were in-
formed of the symptoms by friends and spouses,
respectively, before they visited the clinic.55 From
an economic point of view, productive hours are lost
while sufferers seek solutions to their predicament,
with a concurrent boom in the mouthwash indus-
try.9,55 This is evidenced by the $700 million dollars
spent on mouthwashes by Americans in 2000 and
more than $850 million dollars in the previous
years.52,67 Meningaud et al49 reported over 2 billion
dollars spent annually on products to mask halito-
sis. It can be concluded that a great deal of social,
psychological and economic resources are devoted
to halitosis both at the individual and community
levels, since its impact cuts across culture, religion,
race, sex and social taboos.63,73
PREVENTION AND CONTROL OF HALITOSIS
Halitosis, a condition with known microbial and bio-
chemical parameters, can be prevented and/or
controlled.2,41,44,85 Each case is treated differently
depending on its origin, making a holistic approach
necessary.53 Before a treatment plan can be devel-
oped for any patient, an accurate diagnosis based
on the patient’s history, physical examination, or-
ganoleptic assessment and evaluation of any la-
boratory tests must be made.48 Also, a review of
significant aspects of the patient’s family and so-
cial history (such as dietary and smoking habits),
drug histories, illnesses, hospitalisations and sur-
geries are invaluable in reaching an appropriate di-
agnosis.48 In 1999, Miyazaki et al50 established
the recommended classification for halitosis with
the corresponding treatment needs:
• TN-1: Explanation of halitosis and instructions
for oral hygiene (support and reinforcement of a
patient’s own self-care for further improvement
of his/her oral hygiene).
300
• TN-2: Oral prophylaxis, professional cleaning and
treatment of oral diseases, especially periodon-
tal diseases.
• TN-3: Referral to a physician or medical specialist.
• TN-4: Explanation of examination data, further pro-
fessional instruction, education and reassurance.
• TN-5: Referral to a clinical psychologist, psychia-
trist or other psychological specialist.
Dental clinicians may implement the TN-1 modality
as treatment of physiologic halitosis; TN-1 and TN-2
apply to oral pathological halitosis, while TN-1 and
TN-4 would suffice for pseudo-halitosis.50,94 Treat-
ment of extraoral halitosis should be performed by
a physician or medical specialist in line with TN-3,
while treatment of halitophobia should be by a clin-
ical psychologist, psychiatrist or psychologist (TN-
5).50,94 TN-2 procedures entail mechanical reduc-
tion of tongue coating as well as gingivitis and
periodontitis therapy.50,59 Some clinicians have ad-
vised adequate oral hygiene at home: toothbrush-
ing, flossing and moderate tongue scraping or
brushing using an infant toothbrush or a small
tongue brush to remove the microbial causal
agent(s).53,54,85 Chemical agents and use of natural
ingredients such as mouthrinses containing chlor-
hexidine, triclosan, cetylpyridinium chloride, essen-
tial oils or hydrogen peroxide could also be pre-
scribed.18,35,64 Metal ions, e.g. stannous, zinc and
copper ions, are useful in controlling halitosis
through their anti-plaque properties, that is, by the
oxidation of either thiol groups in the sulfur-contain-
ing precursors of VSCs or the odoriferous substanc-
es themselves to non-volatile substances.35 Chlor-
ine dioxide is another antibacterial mouthwash that
may be used against oral malodour.28,79 Two sepa-
rate clinical trials by the same research group found
it effective as an oxidant in both healthy and af-
fected subjects for the control of oral malodour.77,78
Other agents against halitosis include bacterio-
cin-producing microorganisms (probiotics) such as
Streptococcus salivarius K12 and Lactobacillus sali-
varius WB21.16,32,46 Here, the objective is to pre-
vent re-establishment of undesirable bacteria,
thereby limiting the re-occurrence of oral malodour
over a prolonged period, since probiotics are keen
competitors of oral malodour bacteria.11 Herbal
and natural products have also been advocated for
the control of halitosis.31,62,76,81,82,86 Green tea
mouthwash containing green tea extracts demon-
strated an appreciable effect among 60 patients
with gingivitis who had at least 80 ppb VSCs in
mouth air. The reduction in malodour observed was
Oral Health & Preventive Dentistry
 Akaji et al

Table 3 Summary of some interventional data on prevention and control of halitosis

Authors/ Effectiveness of the
year Study design Strategy used Results method
Prospective study of 41
Scaling and polishing;
Odai et al, consecutive patients Reduced bacterial load in Satisfactory outcome in 90.2%
restorations of cavities and
201055 given clinical interven- patients’ mouth of cases
replacement of dentures
tions

VSCs production diminished

Double blind crossover Use of 2 chewing gums as
VSCs production was same for after chewing gum; reduction
study involving 14 masking agents measured in 2
Rösing et both over time in the 2 series, enhanced by cysteine rinses.
subjects (20–35 years) series: 1st without and 2nd
al, 200970 largest reduction (71% to 52%) Effect was not sustained; only
with healthy periodon- after a mouthrinse containing
observed after 5 and 15 min served as a temporary
tium cysteine
measure

In periodontally healthy
Blinded crossover Tongue scraping and interdental Reduced VSCs in morning
Faveri et subjects, tongue scraping was
study involving 19 cleaning done thrice a day for 7 breath in subjects with healthy
al, 200625 an important method of
volunteers days, then washouts periodontium
reducing halitosis

Efficacy of 2 methods for tongue The tongue scraper yielded a

Pedrazzi Crossover trial Tongue scraper performed
cleaning – toothbrush and tongue 75% reduction in VSCs, while
et al, involving 10 healthy better in reducing the
scraper were compared through the toothbrush only achieved a
200456 subjects (20–50 years) production of VSCs
a handheld sulfide monitor 45% reduction in VSCs

Experimental study
Zinc cations added to CHX
involving 16 dental
Quirynen Rinsing with CHX-Alc, CHX-CPC- mouthrinse yielded 40% Sulfur binding to zinc produced
students who rinsed
et al, Zn, or AmF/SnF 2 mouthrinse, reduction in VSC, 80% an enhanced effect of halitosis
with one of the 3
200260 used twice daily for 1 week reduction in organoleptic reduction
solutions in a
expired ratings
randomised order

Randomised double- Reduced VSCs formation. Best Beneficial impact of mouth

Carvalho Use of 4 different mouth rinses
blind crossover study result using 0.2% CHX, then rinses on VSCs even in
et al, twice daily without mechanical
involving 12 dental 0.12% CHX + triclosan+ absence of mechanical plaque
200417 plaque control
students essential oils then CPC control

Double-blind ran-
Van CHX-CPC-Zn was more
domised study Randomised daily rinse with 1 Beneficial effect on halitosis
Steen- effective in reducing organo-
involving 12 (aged of the following: CHX, CHX- NaF although the mode of action
berghe et leptic scores and sulfide
21–23 years) medical or HX-CPC-Zn was unclear
al, 200192 monitoring readings
student volunteers

Randomised double- Divided subjects into 2 groups Concentrations of VSCs Further investigations on
Shinada blind crossover, that rinsed with either mouth- decreased for those who used long-term effects of ClO2 and
et al, placebo-controlled trial wash containing chlorine dioxide the experimental mouthwash its effect on periodontal
201078 involving 15 male volun- (ClO2) or placebo mouthwash for 7 days; plaque and tongue diseases and plaque accumula-
teers (19–38 years) without ClO2 for 7 days coating also decreased tion are needed

Randomised con- The stannous-containing NaF Halitosis reduced at all three

trolled, single-blind, Brushing with stannous-contain- dentifrice showed greater points analysed, stannous-
Feng et 3- or 4-period ing sodium fluoride (NaF) breath benefits through containing NaF dentifrice
al, 201027 crossover investigation dentifrice in 4 independent reduction of VSCs compared provided additional, simultane-
involving 100 subjects trials to the negative control ous cosmetic and therapeutic
aged 19–62 years dentifrice oral health benefits

Replacement of bacteria implicat- Bacteriocin-producing S.

Recruitment of 23 85% and 30% of S. salivarius
ed in halitosis by S. salivarius salivarius given after mouth-
subjects (18–69 years) and placebo groups,
Burton et K12. A 3-day CHX mouthrinsing wash treatment reduced VSCs
from a population who respectively, showed
al, 200616 followed at intervals with levels – randomised clinical
asserted they had substantial reduction of the
lozenges containing S. salivarius studies needed to validate the
halitosis implicated bacteria.
or a placebo result

Oral malodour parameters

2.01 x 109 Lactobacillus significantly decreased at 2
Oral administration of probiotic
Recruitment of 20 salivarius WB21 and 840mg weeks in the subjects with
lactobacilli primarily improved
Iwamoto patients who xylitol tablets were dissolved in physiological halitosis. The
physiological halitosis and also
et al, complained of halitosis the mouth daily. Evaluation after scores of an organoleptic test
showed beneficial effects on
201032 at the clinic within a 2 to 4 weeks was done at the and bleeding on probing
bleeding on probing from the
period of 14 months same time of day for each decreased at 4 weeks the
periodontal pocket
subject subjects with oral pathologic
halitosis

Abbreviations: CHX = chlorhexidine (0.2%); CHX-Alc = 0.2% chlorhexidine-alcohol mouthrinse; CHX-CPC-Zn = 0.05% CHX + 0.05% cetylpyridinium
chloride + 0.14% zinc lactate mouthrinse; AmF/SnF = an amine fluoride/stannous fluoride (125 ppm F-/125 ppm F-) containing mouthrinse; CPC
= cetylpyridinium chloride; CHX-NaF = 0.12% chlorhexidine + 0.05% sodium fluoride; CHX-CPC-Zn = 0.05% chlorhexidine + 0.05 cetylpyridinium
+ 0.14% zinc lactate; VSCs = volatile sulfur compounds.

Vol 12, No 4, 2014 301

Akaji et al
linked to the ability of the green tea catechins to
transform VSCs to non-odorigenic substances;
they were especially anti-microbially active against
P. gingivalis.62 Other herbal agents, such as Euca-
lyptus extract in chewing gum and extracts of me-
dicinal herbs – e.g. Scutellariae radix, Phellodendri
cortex, Moutancortex and Magnoliae cortex – had a
masking effect on oral malodour.31,86 Each of these
has been used to develop a gargle solution which
produced a positive outcome on halitosis. Palatal
muco-adhesive formulations containing herbal ex-
tracts also alleviated oral malodour for few hours
up to one day.81,83 These muco-adhesive formula-
tions reduced VSC scores to an extent comparable
to that of chlorhexidine and zinc mouthrinses.
Finally, it is advised that diagnosis of pseudo-hali-
tosis or halitophobia be made with caution; abnor-
mal oral deposits, carious teeth and other oral con-
ditions which suggest genuine halitosis must first be
ruled out.5,23 Evaluation of the psychological predis-
position of such patients is invaluable; thus, the
TN-5 regimen is advised.94 For halitosis from non-
oral sources, a multi-disciplinary approach is indicat-
ed as prescribed by TN-3.50,94 Referrals to special-
ists such as otolaryngologists, gastroenterologists
or mental health specialists should be done once
possible oral contributors are excluded.5,21,41 Since
existing data show that patients’ response to treat-
ment is enhanced by educating the public and
healthcare personnel (especially dental clinicians),21
it is imperative to convey correct information on hali-
tosis both at the individual and public level. Undoubt-
edly, this will dispel some myths about halitosis and
aid in the prevention and control of the condition.
Some interventional studies on prevention and con-
trol of oral malodour are summarised in Table 3.
CONCLUSIONS
Halitosis is a public health issue which leads to social
embarrassment as well as decreased quality of life
and may be an indication of systemic diseases or seri-
ous conditions in the nasopharynx, oropharynx, hy-
popharynx, larynx and oesophagus. However, the ma-
jority of cases are of oral origin. It is prevalent worldwide,
affecting the individual and society, but in most cases
it can be controlled. Due to the associated social and
psychological effects on the individual, halitosis needs
to be handled with great care and should be taken seri-
ously by the dentist and dental hygienist. Where neces-
sary, interdisciplinary management should be initiated
as early as possible after the diagnostic process.
302
REFERENCES
1. ADA Council on Scientific affairs: Oral malodor. J Am Dent
Assoc 2003;134:209–214.
2. Adeyemi AT. An update on halitosis. Nigerian Dent J
2008;16:59–63.
3. Akira T, Joji U, Yoshimoto N, Toshihiro K, Haruhiko M. A
case of a halitosis patient who needed behaviour restric-
tion therapy. J Psychosom Dent 2000;15:197–202.
4. Akpata O, Omoregie O, Akhighe K, Ehikhamenor E. Fre-
quency of delusional halitosis in a university community.
Benin J Postgraduate Med 2006;8:8–11.
5. Akpata O, Omoregie OF, Akhigbe K, Ehikhamenor EE.
Evaluation of oral and extra-oral factors predisposing to
delusional halitosis. Ghana Med J 2009;43:61–64.
6. Almas K, Al-Hawish A, Al-Khamis W. Oral hygiene practices,
smoking habits, and self- perceived oral malodor among
dental students. J Contemp Dent Pract 2003;4:77–90.
7. Arowojolu MO, Dosunmu EB. Halitosis (Fetor oris) in pa-
tients seen at the periodontology clinic of the University
College Hospital, Ibadan – a subjective evaluation. Niger
Postgrad Med J 2004;11:221–224.
8. Awano S, Gohara K, Kurihara E, Ansai T, Takehara T. The
relationship between the presence of periodontopatho-
genic bacteria in saliva and halitosis. Int Dent J
2002;52(suppl 3):212–216.
9. Azodo CC, Osazuwa-Peters N, Omili M. Psychological and
social impact of halitosis: A review. J Soc Psycho Sci
2010;3:74–91.
10. Azodo CC, Onyeagba MI, Odai CD. Does concern about
halitosis influence individual’s oral hygiene practices? Ni-
ger Med J 2011;52:254–259.
11. Bollen CML, BeiklerT. Halitosis: the multidisciplinary ap-
proach. IntJ Oral Sci 2012;4:55–63.
12. Bornstein MM, Kislig K, Hoti BB, Seeman R, Lussi A. Prev-
alence of halitosis in the population of the city of Bern,
Switzerland: a study comparing self-reported and clinical
data. Euro J Oral Sci 2009;117:261–267.
13. Bornstein MM, Stocker BL, Seeman R, Bϋrgin WB, Lussi
A. Prevalence of halitosis in young male adults: a study in
Swiss army recruits comparing self–reported and clinical
data. J Periodontol 2009;80:24–31.
14. Bosy A. Oral malodor: philosophical and practical aspects.
J Can Dent Assoc 1997;63:196–201.
15. Brunner F, Kurmann M, Filipi A. The correlation of organo-
leptic and Instrumental halitosis measurements. Schweiz
Monatsschr Zahnmed 2010;120:402–405.
16. 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 Applied Mi-
crobiol 2006;100:754–764.
17. Carvalho MD, Tabchoury CM, Cury JA, Toledo S, Nogueira-
Filho GR. Impact of mouthrinses on morning bad breath in
healthy subjects. J Clin Periodontol 2004;31:85–90.
18. CortelliJR, Silva BarbosaMD, WestphalMA. Halitosis: a re-
view of associated factors and therapeutic approach. Braz
Oral Res 2008;22(suppl 1):44–54.
19. Dal Rio A.C, Nicola E.M.D, Franchi-Teixeira AR. Halitosis–
an assessment protocol proposal. Rev Bras Otorinolarin-
gol 2007;73:835–842.
20. Daly B, Watt R, Batchelor PB, Treasure E. Essential dental
public health, ed 2. New York: Oxford University Press,
2003;8–9.
Oral Health & Preventive Dentistry

21. Delanghe G, Ghyselen J, Bollen C, van Steenberghe D,
Vandekerchove BN, Feenstra L. An inventory of patients’
response to treatment at a multidisciplinary breath odor
clinic. Quintessence Int 1999;30:307–310.
22. Delanghe G, Ghyselen J, Feenstra L, van Steenberghe D.
Experiences of a Belgian multidisciplinary breath odour
clinic. Acta Otorhinolaryngol Belg 1997;51:43–48.
23. Dosunmu EB. Management of halitosis secondary to peri-
odontal disease: report of four cases. Nigerian Dent J
2009;17:69–71.
24. Eldarrat A, Alkhabuli J, Malik A. The prevalence of self-report-
ed halitosis and oral hygiene practices among Libyan stu-
dents and office workers. Libyan J Med 2008;3:170–176.
25. Faveri M, Hayacibara MF, Pupio GC, Cury JA, Tsuzuki CO,
Hayacibara RM. A cross-over study on the effect of various
therapeutic approaches to morning breath odour. J Clin
Periodontol 2006;33:555–560.
26. Feller L, Blignaut E. Halitosis – a review. SADJ 2005;60:1
7–19.
27. Feng X, Chen X, Cheng R, Sun L,Zhang Y, He T. Breath
malodor reduction with use of a stannous-containing so-
dium fluoride dentifrice: A meta-analysis of four rand-
omized and controlled clinical trials. Am J Dent
2010;23(special issue B):27B–31B.
28. Frascella J, Gilbert R, Fernandez P. Odor reduction poten-
tial of a chlorine dioxide mouthrinse. J Clin Dent 1998;9:
39–42.
29. Haraszthy VI, Gerber D, Clark B, Moses P, Parker C,
Sreenivasan PK, Zambon JJ. Characterization and preva-
lence of Solobacterium moorei associated with oral halito-
sis. J Breath Res 2008; Mar 2(1):017002.
30. Hughes FJ, McNab R. Oral malodour—a review. Arch Oral
Biol 2008;53(suppl 1):S1–S7.
31. Hyun-Kyung K, Jae-Woo P, Seong-Woo Y, Bong-Ha, Jinsung
K. Deodorizing effect of several antibacterial medicinal
herbs on oral malodor. J Korean Oriental Med 2010;31:
151–163.
32. Iwamoto T, Suzuki N. Tanabe K, Takeshita T, Hirofuji T. Ef-
fects of probiotic Lactobacillus salivarius WB21 on halito-
sis and oral health: an open-label pilot trial. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2010;110:201–208.
33. Jindal V, Gautam, Singh A, Tuli A. Breath odour-A Review.
Indian J Dent Sci 2009;1:23–27.
34. John M, Vandana KL. Detection and measurement of oral
malodour in periodontitis patients. Indian J Dent Res
2006;17:2–6.
35. Kapoor A, Grover V, Malhotra R, Kaur S, Singh K. Halitosis
revisited. Indian J Dent Sci 2011;3:102–111.
36. Kazor CE, Mitchell PM, Lee AM, Stokes LN, Loesche WJ,
Dewhirst FE, Paster BJ. Diversity of bacterial populations
on the tongue dorsa of patients with halitosis and healthy
patients. J Clin Microbiol 2003;41:558–563.
37. Khaira N, Palmer RM, Wilson RF, Scott DA, Wade WG. Pro-
duction of volatile sulphur compounds in diseased perio-
dontal pockets is significantly increased in smokers. Oral
Dis 2000;6:371–375.
38. Knaan T, Cohen D, Rosenberg M. Predicting bad breath in the
non-complaining population. Oral Dis 2005;11:105–106.
39. Koshimune S, Awano S, Gohara K, Kurihara E, Ansai T,
Takehard T. Low salivary flow and volatile sulfur com-
pounds in mouth air. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2003;96:38–41.
Vol 12, No 4, 2014
Akaji et al
40. Krespi YP, Shrime MG, Kacker A. The relationship between
oral malodor and volatile sulfur compound-producing bac-
teria. Otolaryngol Head Neck Surg 2006;135:671–676.
41. Lee SS, Zhang W, Li Y. Halitosis update: a review of caus-
es, diagnoses, and treatments. J Calif Dent Assoc
2007;35:258–268.
42. Liu XN, Shinada K, Chen XC, Zhang BX, Yaegaki K, Kawa-
guchi Y. Oral malodour related parameters in the Chinese
general population. J Clin Periodontol 2006;33:31–36.
43. Loesche WJ, De Boever EH. Strategies to identify the main
microbial contributors to oral malodour. In: Rosenberg M
(ed). Bad breath: research perspectives. Tel-Aviv: Ramot
Publishing, 1995:41–54.
44. Loesche WJ, Kazor C. Microbiology and treatment of hali-
tosis. Periodontol 2000 2002;28:256–279.
45. Luqman M. Systemic origin of halitosis: a review. Int J Clin
Dent Sci 2012;3:15–19.
46. Masdea L, Kulik EM, Hauser- Gerspach I, Ramseier AM,
Filipi A, Waltimo T. Antimicrobial activity of Streptocococ-
cus salivarius K12 on bacteria involved in oral malodour.
Arch Oral Biol 2012;57:1041–1047.
47. Mbodj EB, Faye B, Faye D, Seck MT, Sarr M, Ndiaye C, Dabo
RS, Diallo PD. Prevalence of halitosis in patients with den-
tal prostheses in Senegal. Med Trop 2011;71:272–274.
48. McDowell JD, Kassebaum DK. Diagnosing and treating
halitosis. J Am Dent Assoc 1993;124:55–64.
49. Meningaud JP, Bado F, Favre E, Bertrand JC, Guilbert F.
Halitosis in 1999. Rev Stomatol Chir Maxillofac
1999;100:240–244.
50. Miyazaki H, Arao M, Okamura K, Kawaguchi Y, Toyofuku A,
Hoshi K et al. Tentative classification of halitosis andits
treatment needs. Niigata Dent J 1999;32:7–11.
51. Miyazaki H, Sakao S, Katoh Y, Takehara T. Correlation be-
tween volatile sulphur compounds and certain oral health
measurements in the general population. J Periodontol
1995;66:679–684.
52. Mouthwashes. Consumer Reports 1992 (Sept):607–610.
53. Nachnani S. The effects of oral rinses on halitosis. J Calif
Dent Assoc 1997;25:145–150.
54. Nachnani S. Oral malodor: causes, assessment, and
treatment. Compendium of Continuing Education in Den-
tistry. January/February 2011. Available at http://www.
cdeworld.com/courses/4493-oral-malodor-causes-as-
sessment-and-treatment#sthash.l7XAr8YD.dpuf, Ac-
cessed March 15 2013.
55. Odai CD, Azodo CC, Osazuwa-Peters N, Obuekwe ON.
Characteristics and treatment outcome of patients with
halitosis at a sub-urban health facility. Int J Biomed Health
Sci 2010;6:181–190.
56. Pedrazzi V, Sato S, de Mattos M da G, Lara EH, Panzeri
H.Tongue-cleaning methods: a comparative clinicaltrial
employing a toothbrush and a tongue scraper. J Periodon-
tol 2004;75:1009–1012.
57. Persson S, Edlund MB, Claesson R, Carlsson J. The forma-
tion of hydrogen sulfide and methyl mercaptan by oral bac-
teria. Oral Microbiol Immunol 1990;5:195–201.
58. Porter SR, Scully C. Oral malodour (halitosis). BMJ
2006;333:632–635.
59. Quirynen M. Management of oral malodour. J Clin Perio-
dontol 2003;30(suppl 5):17–18.
60. Quirynen M, Avontroodt P, Soers C, Zhao H, Pauwels M,
Coucke W, van Steenberghe D. The efficacy of amine fluor-
ide/stannous fluoride in the suppression of morning
breath odour. J Clin Periodontol 2002;29:944–954.
303
 Akaji et al
61. Quirynen M, Dadamio J, Van den Velde S, De Smit M, De-
keyser C, Van Tornout M, Vandekerckhove B. Characteris-
tics of 2000 patients who visited a halitosis clinic. J Clin
Periodontol 2009;36:970–975.
62. Rassameemasmaung S, Phusudsawang P, Sangalungkarn
V. Effect of Green tea mouthwash on oral malodour. Prev
Med 2013;975148. Available at http://doi.
org/10.5402/2013/975148. Accessed April 27 2013.
63. Rayman S, Almas K. Halitosis among racially diverse pop-
ulations: an update. Int J Dent Hygiene 2008;6:2–7.
64. Roldan S, Herrera D, Sanz M. Biofilms and the tongue:
therapeutical approaches for the control of halitosis. Clin
Oral Invest 2003;7:189–197.
65. Roldan S, Winkel EG, Herrara D, Sanz M, van Winkehoff AJ.
The effects of new mouthrinse containing chlorhexidine,
cetylpyridium chloride and zinc lactate on the microflora of
oral halitosis patients: a dual-centre, double blind placebo
controlled study. J Clin Periodontol 2003;30:427–434.
66. Rosenberg M. Clinical assessment of bad breath: current
concepts. J Am Dent Assoc 1996;127:475–482.
67. Rosenberg M. Science of bad breath. Scientific Am
2002;286:72–79.
68. Rosenberg M, Knaan T, Cohen D. Association among bad
breath, body mass index, and alcohol intake. J Dent Res
2007;86:997–1000.
69. Rosenberg M, Septon I, Eli I, Bar-ness R, Gelernter I, Bren-
ner S, Gabbay J. Halitosis measurement by an industrial
sulphide monitor. J Periodontol 1991;62:487–489.
70. Rösing CK, Gomes SC, Bassani DG, Oppermann RV. Effect of
chewing gums on the production of volatile sulfur compounds
(VSC) in vivo. Acta Odontol Latinoam 2009;22:11–14.
71. Rösing CK, Loesche W. Halitosis: an overview of epidemi-
ology, etiology and clinical management. Braz Oral Res
2011;25:466–471.
72. Samnieng P, Ueno M, Shinada K, Zaitsu T, Kawaguch Y. Dai-
ly variation of oral malodour and related factors in communi-
ty-dwelling elderly Thai. Gerodontol 2012;29:e964–e971.
73. Sanz M, Roldan S, Herrera D. Fundamentals of breath
malodour. J Contemp Dent Pract 2001;2:1–17.
74. Scully C, Felix DH. Oral medicine-update for the dental
practitioner: oral malodour. Br Dent J 2005;199:498–500.
75. Settineri S, Mento C, Gugliotta SC, Saitta A, Terranova A,
Trimarchi G, Mallamace D. Self-reported halitosis and
emotional state: impact on oral conditions and treat-
ments. Health Qual Life Outcomes 2010;8:34.
76. Shin K, Yaegaki K, Murata T, Ii H, Tanaka T, Aoyama I,
Yamauchi K, Toida T, Iwatsuki K. Effects of a composition
containing lactoferrin and lacto peroxidase on oral malo-
dor and salivary bacteria: a randomized, double-blind,
crossover, placebo-controlled clinical trial. Clin Oral Inves-
tig 2011;15:485–493.
77. Shinada K, Ueno M, Konishi C, Takehara S, Yokoyama S,
Kawaguchi Y. A randomized control double blind, crosso-
ver, placebo-controlled clinical trial to assess the effects
of a mouthwash containing chlorine dioxide on oral malo-
dor. Trials 2008;9:71.
78. Shinada K, Ueno M, Konishi C, Takehara S, Yokoyama S,
Zaitsu T, Ohnuki M, Wright FAC, Kawaguchi Y. Effects of a
mouthwash with chlorine dioxide on oral malodor and sali-
vary bacteria: a randomized placebo controlled 7-day trial.
Trials 2010;11:14.
79. Silwood CJ, Grootveld MC, Lynch E. A multifactorial investiga-
tion of the ability of oral health care products (OHCPs) to al-
leviate oral malodour. J Clin Periodontol 2001;28:634–641.
304
View publication stats
80. Söder B, Johansson B, Söder PO. The relation between
foetor ex ore, oral hygiene and periodontal disease. Swed
Dent J 2000;24:73–82.
81. Sterer N, Nuas S, Mizrahi B, Goldenberg C, Weiss EI,
Domb A, Perez Davidi M. Oral malodor reduction by a pala-
tal mucoadhesive tablet containing herbal formulation. J
Dent 2008;36:535–539.
82. Sterer N, Ovadia O, Weiss EI, Perez Davidi M. Day-long reduc-
tion of oral malodor by a palatal mucoadhesive tablet con-
taining herbal formulation. J Breath Res 2013; 7:026004.
83. Sterer N, Rosenberg M. Streptococcus salivarius pro-
motes mucin putrefaction and malodor production by Por-
phyromonas gingivalis. J Dent Res 2006;85:910–914.
84. Struch F, Schwahn C, Wallaschofski H, Grabe HJ, Völzke H,
Lerch MM, Meisel P, Kocher T. Self-reported halitosis and
gastro-esophageal reflux disease in the general popula-
tion. J Gen Intern Med 2007;23:260–266.
85. Takeshita T, Suzuki N, Nakano Y, Shimazaki Y, Yoneda M,
Hirofuji T, Yamashita Y. Relationship between oral malodor
and the global composition of indigenous bacterial popula-
tions in saliva. Appl Environ Microbiol 2010;76:2806–
2814.
86. Tanaka M, Toe M, Nagata H, Ojima M, Kuboniwa M, Shimi-
zu K, Osawa K, Shizukuishi S. Effect of eucalyptus-extract
chewing gum on oral malodor: a double-masked, rand-
omized trial. J Periodontol 2010;81:1564–1571.
87. Tangerman A. Halitosis in medicine: a review. Int Dent J
2002;52(suppl 3):201–206.
88. Tangerman A, Winkel EG. Intra- and extra-oral halitosis:
finding of a new form of extra-oral blood-borne halitosis
caused by dimethy sulphide. J Clin Periodontol 2007;34:
748–755.
89. Tyrrell KL, Citron DM, Warren YA, Nachnani S, Goldstein
EJ. Anaerobic bacteria cultured from the tongue dorsum of
subjects with oral malodor. Anaerobe 2003;9:243–246.
90. Uguru C, Umeanuka O, Uguru NP, Adigun O, Edafioghor O.
The delusion of halitosis: experience at an eastern Nigeria
tertiary hospital. Nigerian J Med 2011;20:236–240.
91. Vandana KL, Sridhar A. Oral malodour: a review. J Clin Di-
agnos Res 2008;2:768–773.
92. Van Steenberghe D, Avontroodt P, Peeters W, Pauwels M,
Coucke W, Lijnen A, Quirynen M. Effect of different mouth
rinses on morning breath. J Periodontol 2001;72:1183–
1191.
93. Washio J, Sato T, Koseki T, Takahashi N. Hydrogen sulfide
producing bacteria in tongue biofilm and their relationship
with oral malodour. J Med Microbiol 2005;54:889–895.
94. Yaegaki K, Coil JM. Examination, classification, and treat-
ment of halitosis: clinical perspectives. J Can Dent Assoc
2000;66:257–261.
95. Yaegaki K, Sanada K. Biochemical and clinical factors in-
fluencing oral malodor in periodontal patients. J Periodon-
tol 1992;63:783–789.
96. Yaegaki K, Sanada K. Volatile sulphur compounds in
mouth air from clinically healthy subjects and patients
with periodontal disease. J Periodontol Res 1992;27:
233–238.
97. Zürcher A, Fillipi A. Findings, diagnoses and results of a
halitosis clinic over a seven year period. Schweiz Monats-
schr Zahnmed 2012;122:205–210.
Oral Health & Preventive Dentistry