Received: 8 June 2017 | Accepted: 11 June 2017

DOI: 10.1111/odi.12699

INVITED MEDICAL REVIEW

Detection of halitosis in breath: Between the past, present, and

future

MK Nakhleh1,2,3 | M Quatredeniers1,2,3 | H Haick4

1
Univ Paris-Sud, Faculté de Médecine,
Université Paris-Saclay, Le Kremlin Bicêtre, To develop a new generation of diagnostics for halitosis, replacing the subjective or-
France ganoleptic assessment, a series of exhaled breath analyzers has been developed and
2
AP-HP, DHU TORINO, Service de assessed. All three devices rely on the assessment of exhaled volatile sulfuric com-
Pneumologie, Hôpital Bicêtre, Le Kremlin
Bicêtre, France pounds (VSCs), which are mainly generated in and emitted from the oral cavity, con-
3
Inserm UMR_S 999, LabExLERMIT, Hôpital tributing to the malodor. Portable, on-­site and easy to use, these devices have potential
Marie Lannelongue, Le Plessis Robinson,
for non-­invasive diagnosis of halitosis. However, global assessment of exhaled VSCs
France
4
Department of Chemical Engineering
alone has two main drawbacks: (i) the absence of VSCs does not rule out halitosis; (ii)
and Russell Berrie Nanotechnology non-­sulfuric volatile compounds that could be biomarkers of systemic diseases, found
Institute, Technion–Israel Institute of
Technology, Haifa, Israel
in up to 15% of halitosis cases, are neglected. In this article, we review and discuss
progress to date in the field of oral/exhaled volatile compounds as potential non-­
Correspondence
Hossam Haick, Department of Chemical
invasive diagnostics for halitosis. We will briefly describe the generation of these com-
Engineering and Russell Berrie pounds both from local (oral) and distal (extra-­oral) sources. In addition, we debate the
Nanotechnology Institute, Technion–Israel
Institute of Technology, Haifa, Israel.
different analytical approaches in use and discuss the potential value of bio-­inspired
Email: hhossam@technion.ac.il artificially intelligent olfaction in diagnosing and classifying oral and systemic diseases
by analyzing exhaled breath.

KEYWORDS
artificial intelligence, halitosis, sensor array, volatile compounds, volatolome

1 | INTRODUCTION
1.1 | Halitosis
Halitosis, also known as “bad breath” or “oral malodor,” is identified in
up to 50% of the adult population. The term denotes the unpleasant
exhaled breath (halitus) of an individual, which can significantly affect
him/her socially as well as the individuals with whom he/she inter-
acts (Bollen & Beikler, 2012; Kapoor, Sharma, Juneja, & Nagpal, 2016;
Madhushankari, Yamunadevi, Selvamani, Mohan Kumar, & Basandi,
2015). Besides the social effect, pathological halitosis is considered
one of the most common symptoms/indications of oral pathologies.
In up to 85% of cases, the malodor originates from oral cavity itself
and/or an otorhinolaryngological source; thus, it is termed oral patho-
logical halitosis (Bollen & Beikler, 2012; van den Broek, Feenstra, & de
Baat, 2007; Kapoor et al., 2016; Ongole & Shenoy, 2010). However,
in the remaining 15% of cases, the source is non-­oral and the malodor
can indicate a distal systemic disease, so it is termed extra-­oral patho-
logical halitosis. The cause could be, for example, an acute or chronic
kidney, liver, gastrointestinal (GIT) or respiratory disease, diabetes,
or even cancer (Bollen & Beikler, 2012; van den Broek et al., 2007;
Kapoor et al., 2016; Madhushankari et al., 2015; Ongole & Shenoy,
2010).
Oral halitosis is usually treated by mechanical/chemical reduction
in intra-­oral microorganisms, precipitates (plaque and calculus), and
nutrients, and by masking the malodor. However, this management is
ineffective in extra-­oral cases and could delay the diagnosis and treat-
ment of a systemic disease. In these cases, the intervention should tar-
get the original (distal) source, which should be treated by a designated
specialist (pulmonologist/gastroenterologist, etc.).
The gold standard diagnosis of halitosis remains organoleptic as-
sessment, based on smelling the air exhaled from the mouth and nose

© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. All rights reserved

Oral Diseases. 2018;24:685–695. 

wileyonlinelibrary.com/journal/odi | 685

686 | NAKHLEH et al.
and comparing the two. However, this method relies on the skills of
the performer, so the results are subjective and can be controver-
sial. Therefore, there is interest in a modern standardized and objec-
tive diagnostic method (Bollen & Beikler, 2012; Kapoor et al., 2016;
Madhushankari et al., 2015; Ongole & Shenoy, 2010).
1.2 | Exhaled volatile compounds as biomarkers of
diseases
As halitosis is defined as a “bad smell,” it could easily be concluded
that one or more volatile compounds are produced and present in
the oral cavity and/or exhaled breath leading to the unpleasant odor
(Bollen & Beikler, 2012; van den Broek et al., 2007; Kapoor et al.,
2016; Madhushankari et al., 2015; Ongole & Shenoy, 2010). Such vol-
atile organic compounds (VOCs) are physiological products that are
continuously produced in the body. Owing to their volatility, VOCs
diffuse readily and are excreted via different body fluids, including
the exhaled air. However, during disease states, pathophysiological
mechanisms can alter VOC production, leading eventually to shifts in
the exhaled VOC profile (referred to as the volatolome) (Haick, Broza,
Mochalski, Ruzsanyi, & Amann, 2014; Hakim et al., 2012; Nakhleh,
Haick, Humbert, & Cohen-­Kaminsky, 2017). Inflammation, oxidative
stress, anaerobic conditions, enzymatic activity, bacteria and micro-
biome populations, and other patho-­mechanisms are known causes
of volatolomic alterations (Amann, Miekisch, Pleil, Risby, & Schubert,
2010; Broza, Mochalski, Ruzsanyi, Amann, & Haick, 2015; Miekisch,
Schubert, & Noeldge-­Schomburg, 2004). Non-­invasive and easy to
perform, the analysis of exhaled breath revealed the presence of
dozens of VOCs, detectable in low concentrations, so analysis of
the exhaled volatolome has the potential for both disease diagnosis
and classification (Amann, Corradi, Mazzone, & Mutti, 2011; Barash,
Peled, Hirsch, & Haick, 2009; Baumbach et al., 2011; Hakim et al.,
2011; Karban et al., 2016; Nakhleh, Amal et al., 2014; Nakhleh et al.
2015; Sinues, Zenobi, & Kohler, 2013; Tisch et al., 2012). Indeed,
studies have shown increased levels of volatile sulfuric compounds
(VSCs), which have been measured in the oral cavity and exhaled
breath of patients with halitosis. Linked to bacterial activity and pro-
duced by local microbial-­enzymatic breakdown of amino acids and
other mechanisms, exhaled VSCs have been proposed as biomarkers
for diagnosis and monitoring of halitosis (Avincsal et al., 2016; Aydin,
Bollen, & Ozen, 2016; Kapoor et al., 2016; Laleman, Dadamio, De
Geest, Dekeyser, & Quirynen, 2014).
2 | VOLATILE SULFURIC COMPOUNDS:
FROM BAD SMELL TO POTENTIAL
BIOMARKERS
The first evidence linking oral pathophysiology to halitosis was pub-
lished during the 1940s, when the malodor was correlated with pu-
trefaction of saliva due to various conditions such as retained saliva,
desquamated epithelial cells, and decaying teeth (Law, Berg, & Fosdick,
1943; Sulser, Brening, & Fosdick, 1939). Lacking the appropriate
16010825, 2018, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/odi.12699 by Nat Prov Indonesia, Wiley Online Library on [30/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
analytical tools, scientists and physicians adapted the organoleptic
approach for assessing halitosis both in vivo and in vitro. Using differ-
ent scoring models based on organoleptic assessment, it was shown
that halitosis could be identified and correlated with different oral dis-
eases, and that mouth-­hosted microorganisms contribute to breath
malodor (Berg, Burrill, & Fosdick, 1946, 1947; Morris & Read, 1949).
Interestingly, Morris and Read also reported that in at least 7% of the
subjects, halitosis was resistant to mouth hygiene and standard oral
management techniques, so they alleged that in these cases halitosis
was not due to an oral disease/state but could arise from a distal origin
(Morris & Read, 1949). Later, Tonzetich et al. explored the chemicals’
composition emitted by pooled saliva from halitosis patients by quan-
tifying the volatile reducing substances (VRSs). Using an industrial
procedure to measure odor intensity (Lang, Farber, Beck, & Yerman,
1944), they found that VRSs are indeed produced in the oral cavity in
halitosis, and they identified mainly VSCs, in particular methyl mercap-
tan (CH3SH) and hydrogen sulfide (H2S) (Tonzetich & Richter, 1964).
Since then, dozens of scientific reports using state-­of-­the-­art tech-
nologies (chromatography, spectrometry, and different chemical gas
sensors) have confirmed the presence of measurable exhaled VSCs
and their potential as non-­invasive biomarkers for the diagnosis and
monitoring of halitosis (Avincsal et al., 2016; Coli & Tonzetich, 1992;
Koshimune et al., 2003; Rosenberg, Kulkarni, Bosy, & McCulloch,
1991; Van den Velde, Quirynen, van Hee, & van Steenberghe, 2007a;
Waler, 1997; Yaegaki & Sanada, 1992b).
Moreover, accumulating evidence suggests that increased levels
of VSCs in the oral cavity could lead directly to the acceleration for
periodontal diseases via mitochondria-­mediated apoptosis, DNA dam-
age in fibroblasts, and increasing the levels of reactive oxygen species.
Therefore, aside from their diagnostic potential, it is very important to
monitor VSCs levels in order to prevent/diminish further damage to
the oral cavity (Fujimura et al., 2010; Imai et al., 2009).
In the following sections, we will discuss the sources of volatile
compounds from both oral and systemic sources and their potential as
biomarkers for detecting and monitoring halitosis. We will also review
the development and feasibility of designated commercially available
devices for assessing VSCs in halitosis. Then, we will explore the po-
tential of artificially intelligent sensors to fill the gap in both oral and
extra-­oral halitosis.
2.1 | Physiological halitosis: VSCs production in the
healthy mouth
Increase in production and/or accumulation of VSCs in the mouth
cavity could be due to various processes in both health and disease
states (Bollen & Beikler, 2012; Kapoor et al., 2016; Madhushankari
et al., 2015; Ongole & Shenoy, 2010). For instance, morning halitosis,
or halitosis due to mouth breathing—widespread among children—
is caused by decreased salivary flow and a dry tongue (Koshimune
et al., 2003; Tonzetich & Johnson, 1977). On the other hand, halitosis
could be due to the deposition of food debris after food intake. Each
of these cases results in increased anaerobic activity, or augmenta-
tion of Gram-­negative bacterial species, which in turn metabolize

NAKHLEH et al.
sulfur-­containing amino acids and peptides such as methionine,
cysteine, glutathione, or peptones, leading eventually to local accu-
mulation of byproducts including VSCs such as methyl mercaptan and
hydrogen sulfide (Krespi, Shrime, & Kacker, 2006; Waler, 1997). The
oral flora includes a wide range of VSCs-­producing bacteria. Strains
such as Fusobacterium nucleatum, Veillonella parvula, Treponema den-
ticola, Porphyromonas gingivalis, Eubacterium limosum, Selenomona
artemidis, Actinomyces odontolyticus, and Prevotella veroralis continu-
ally produce low concentrations of VSCs under normal health condi-
tions (Awano, Gohara, Kurihara, Ansai, & Takehara, 2002; Kleinberg
& Codipilly, 1995; Krespi et al., 2006; Persson, Claesson, & Carlsson,
1989; Tanaka et al., 2004; Washio, Sato, Koseki, & Takahashi, 2005;
Yasukawa, Ohmori, & Sato, 2010).
2.2 | VSCs in pathological oral halitosis
Pathologies in the oral cavity often lead to a new-­onset halitosis or
worsening of an existing one (Yaegaki & Sanada, 1992b). This is partly
because the injured/infected intra-­oral areas open new locations in
which bacteria can colonize, proliferate, and metabolize proteins.
Also, the increased blood supply to inflamed areas or in hemorrhagic
conditions accompanying these periodontal diseases provides the
bacteria with supplemental substrates (e.g., iron), creating favorable
conditions for perio-­pathogenic Gram-­negative anaerobic bacteria
to thrive, thus leading to excessive production of VSCs in the oral
cavity (Loesche & Kazor, 2000). For example, a quantitative exhaled
breath analysis using gas chromatography-­linked mass spectrometry
(GC/MS), comparing 17 patients with periodontal diseases with 14
cases of physiological morning halitosis, revealed increased VSC pro-
duction associated with gum bleeding and periodontal pocket depth
in periodontal cases (Yaegaki & Sanada, 1992b). Furthermore, it has
been reported that patients suffering from periodontal diseases rou-
tinely present a worse tongue-­coating smell (Bollen & Beikler, 2012;
Yaegaki, 1995).
Dental hygiene and health issues can also lead to halitosis (Bollen &
Beikler, 2012; Kapoor et al., 2016; Madhushankari et al., 2015; Ongole
& Shenoy, 2010; Rosenberg, 1990). For example, microbial plaques
create new dental pockets in which bacteria develop, then putrefaction
occurs, eventually increasing the overall foul odor (Rosenberg, 1990).
In a study exploring incubated dental plaque scrapings from patients
with periodontitis, for example, a wide range of bacterial strains was
identified, including P. gingivalis (Loesche, Syed, Schmidt, & Morrison,
1985) and T. denticola (Moore et al., 1985; Simonson, Goodman, Bial,
& Morton, 1988), which are major contributors to VSCs production
(Persson, Edlund, Claesson, & Carlsson, 1990). In another study, 101
subjects were classified into three groups: halitosis with probing depth
≥4 mm, halitosis without probing depth, and controls. The analysis in-
dicated that the exhaled VSCs concentrations in periodontitis patients
were greater and correlated with the presence of Bacteroides forsythus,
P. gingivalis and Prevotella intermedia (Awano et al., 2002). Similarly,
increased production of VSCs contributing to the presence or exac-
erbation of halitosis has been widely described in oral cavity diseases
(van den Broek et al., 2007), including but not limited to gingivitis
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| 687
(Zhou, McCombs, Darby, & Marinak, 2004), periodontitis (Tsai et al.,
2008), xerostomia (Bollen & Beikler, 2012), mucosal ulcerations, and
deep dental lesions (van den Broek et al., 2007; Cortelli, Barbosa, &
Westphal, 2008). These findings strongly suggest that identifying ex-
haled VSCs and monitoring their levels could serve as a simple non-­
invasive diagnostic tool for oral halitosis. Examples of different sources
of VSCs originating in the oral cavity are presented in Figure 1.
2.3 | Assessment of VSCs: from observation
to method
As previously mentioned, the diagnosis of halitosis relies heav-
ily on organoleptic assessment, in which the exhaled breath smell is
ranked from 0 (undetectable) to 5 (heavy foul odor) according to the
Rosenberg scale (Rosenberg et al., 1991). Considered the gold standard
method nowadays, inexpensive and easy to perform, it remains sub-
jective and lacks reliability and reproducibility (Hatt, 2004). Therefore,
several analytical methods and devices have been suggested and
tested as alternatives. These can be categorized into two main ap-
proaches: (i) in vitro assays and (ii) exhaled breath analysis. Among
the in vitro methods, the benzoyl-­DL-­arginine-­naphthylamide (BANA)
test, for example, is based on assessing the enzymatic activity of
Gram-­negative bacteria. In the saliva incubation test, the samples are
assessed by organoleptic measurement. Polymerase chain reaction
(PCR) is also used, in some case, allowing the bacterial strains present
in the oral cavity to be identified. On the other hand, chromatography
is used to assess β-­galactosidase activity. Polyamine concentrations
are also measured in saliva samples using the ninhydrin test (van den
Broek et al., 2007). However, these methods remain not suitable for
all cases of halitosis, and many of them have low sensitivity (Aydin
et al., 2016; Petrini, Trentini, Ferrante, D’Alessandro, & Spoto, 2012;
Sterer, Greenstein, & Rosenberg, 2002).
The second approach is based on assessment of exhaled volatile
compounds, namely VSCs produced in the oral cavity. Although GC-­
MS analysis is highly accurate and can measure very low concentra-
tions of VSCs, it is expensive and requires highly skilled operators,
making it less appropriate for routine diagnosis (Hakim et al., 2012;
Nakhleh, Broza, & Haick, 2014). Therefore, several portable and
easier-­to-­use devices for selective and specific assessment of VSCs
in the breath have been introduced during the past three decades
(Laleman et al., 2014).
First, in 1991, Rosenberg and colleagues developed the Halimeter®
(Interscan, Chatsworth, CA). It is based on a volumetric non-­selective
gas sensor for measuring the total sulfur-­containing compounds in a
given sample (Rosenberg et al., 1991). Easy to use and with satisfying
reproducibility, the system has been in use ever since. However, differ-
ent studies assessing the feasibility of the Halimeter® resulted in dis-
agreements about the diagnostic threshold to be used (ranging from
75 to 150 ppb), and the correlation with organoleptic scoring was also
inconsistent (Vandekerckhove et al., 2009; Yaegaki & Sanada, 1992a).
However, the main drawback of the system is its inability to discrimi-
nate between the different VSCs, and the fact is that it is insensitive to
non-­sulfuric volatile compounds (Laleman et al., 2014).
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688 | NAKHLEH et al.

F I G U R E 1 The exhaled volatolome is a mixture of oral volatile sulfuric compounds (VSCs) and distal volatile organic compounds (VOCs).
The exhaled breath contains up to several hundreds of volatile compounds. VSCs (blue) are mainly produced in the oral cavity under normal
physiological conditions and accumulate in the oral diseases leading to halitosis. Alterations in exhaled VOCs (green), on the other hand, are due
to distal pathophysiologies, including but not limited to diabetes or to respiratory, gastrointestinal (GIT), liver and kidney diseases, eventually
leading to extra-­oral halitosis

Also designed for global measurement of sulfur compounds, the
Breathtron® was introduced in 1996 by Shimura et al. It is based on a
zinc oxide membrane semiconductor sensor that is highly sensitive to
VSCs (Shimura et al., 1996). The measurement is considered more spe-
cific than the Halimeter because exhaled non-­sulfuric compounds are
first trapped and eliminated from the sample, reducing the likelihood
of confounding effects (Laleman et al., 2014). Like the Halimeter, the
diagnostic threshold has been debated and different studies have used
a wide range of cutoffs, ranging between 250 and 400 ppb (Tanda
et al., 2007). However, the correlation between the results achieved
by the Breathtron® and the organoleptic scoring were higher and more
®
consistent than with the Halimeter. The Breathtron retains several of
the Halimeter’s advantages, being portable, easy to use, reproducible,
and providing immediate results. However, once again, it lacks the ca-
pacity to discriminate among different sulfuric compounds and takes
no account of potentially informative non-­sulfuric volatile compounds
(Laleman et al., 2014; Shimura et al., 1996).
Last, and most recent, is the OralChroma™, which, in fact, a porta-
ble and compact gas chromatography device coupled with an indium
oxide semiconductor gas sensor (Hanada et al., 2003). In contrast to
the previous devices, the OralChroma™ measures the absolute con-
centrations of each of hydrogen sulfide, methyl mercaptan, and di-
methyl sulfide within 10 min (Hanada et al., 2003). The device has
proved highly accurate even for very low concentrations of the mea-
sured compounds, and it discriminates among the main three VSCs
associated with halitosis, which could contribute not only to diagnosis
but also to better subclassification of halitosis. However, it is expen-
sive, and the use of room air as a carrier gas might lead to impurities
and contamination of the sample (Laleman et al., 2014).
All in all, the available devices take account only of exhaled VSCs
that could contribute to the diagnosis and monitoring of oral halitosis.
Nevertheless, correlation with organoleptic scoring indicates moder-
ate accuracy. Moreover, the absence of exhaled sulfuric compounds
does not rule out halitosis (Laleman et al., 2014; Van den Velde et al.,
2007a). Finally, all three devices entirely neglect the dozens of VOCs
in exhaled breath that are potential informative biomarkers in hali-
tosis, mainly in extra-­oral cases, as will be discussed in the following
sections.
3 | NON-­S ULFURIC VOCS CONTRIBUTING
TO HALITOSIS
In up to 15% of pathological halitosis cases, the source of the malodor
is not the mouth cavity and there is no relationship to oral disease.
In these cases, the unpleasant odor is a symptom of a distal systemic
disease (Bollen & Beikler, 2012; Kapoor et al., 2016; Madhushankari
et al., 2015; Ongole & Shenoy, 2010). Very old medical practice and
recent scientific corroboration suggest that VOCs emitted by the pe-
ripheral microenvironment of a given disease circulate in the local
and/or peripheral blood system and are excreted via exhaled breath.
Some remarkable shifts in the exhaled volatolome could impose

NAKHLEH et al.
specific smells in the exhaled breath that in certain cases are recog-
nizable even by the unaided nose (Buszewski, Kesy, Ligor, & Amann,
2007; Haick et al., 2014; Miekisch et al., 2004; Sinues et al., 2013).
In diabetic ketoacidosis (DKA), for example, the decarboxylation of
excess acetyl-­CoA under starvation-­like circumstances produces an
excess of ketone bodies such as acetone, and the sweet flavor of
the exhaled breath is well recognized by physicians (Amann et al.,
2010; Buszewski et al., 2007; Miekisch et al., 2004). Similarly, dis-
tinctive and decipherable smells in kidney and liver diseases have
been repeatedly reported by physicians (Ongole & Shenoy, 2010).
Therefore, it is highly important to recognize VOCs that are impli-
cated in extra-­oral halitosis and related to systemic diseases, and to
refer the patient to a designated specialist for treatment (Bollen &
Beikler, 2012; Madhushankari et al., 2015; Ongole & Shenoy, 2010).
However, although shifts in the exhaled volatolome can occur in a
wide spectrum of systemic diseases, the volatolomic alterations are
very delicate in the vast majority of cases; thus, the human sense of
smell cannot distinguish them (Nakhleh, Amal et al., 2017). Figure 1 is
a schematic representation of the different sources of exhaled non-­
sulfuric VOCs.
3.1 | Respiratory disease-­induced VOCs contributing
to halitosis
Owing to the proximity of the oral cavity to the airways, there is an
acutely increased concentration of VOCs in the exhaled breath dur-
ing airway and/or respiratory pathophysiology (Nakhleh, Haick et al.,
2017). For example, a distinctive smell is well recognized in cases of
increased bacterial activity such as sinus-­related illness and tonsillitis
(Ferguson, Aydin, & Mickel, 2014). In adults, both acute and chronic
respiratory diseases result in significant shifts in the exhaled vola-
tolome (Haick & Cohen-­Kaminsky, 2015). Respiratory diseases can
induce an unpleasant odor described as “acidic” or “cheesy” in the
exhaled breath (Bollen & Beikler, 2012). Indeed, dozens of exhaled
VOCs have been reported in increased concentrations in respira-
tory and airway diseases. In active tuberculosis, for instance, tride-
cane, 2-­butyl-­1-­octanol, and 4-­methyl-­dodecane accumulate in the
exhaled breath of patients and in sputum cultures (Nakhleh, Jeries
et al., 2014; Phillips et al., 2010), while in patients diagnosed with
pneumonia, levels of butane, 2-­methyl, ethanol, dodecane, heptane,
1-­undecene, nonanal, decanal, and 2,6,10-­trimethyl-­dodecane are
augmented (Gao et al., 2016; Schnabel et al., 2015). Exhaled acetic
acid has been suggested as a volatile biomarker of cystic fibrosis in
view of its significantly greater level in patients than in healthy con-
trols (Smith et al., 2016). Clinical investigations in pulmonary hyper-
tension (PH) revealed that diverse VOCs are increased in patients
and are often correlated with severity of the disease. Compounds
such as 2-­nonene, 2-­propanol, acetaldehyde, ammonia, ethanol,
pentane (Cikach et al., 2014), and 1-­methyl-­4-­(1-­methylethnyl)-­ben
zene (Mansoor et al., 2014) have been reported in PH. Likewise, over
50 different VOCs were correlated with asthma and COPD (Allers
et al., 2016; Christiansen, Davidsen, Titlestad, Vestbo, & Baumbach,
2016; Tomasiak-­Lozowska et al., 2012), lung cancer (Amann et al.,
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| 689
2011; Barash et al., 2009; Hakim et al., 2012; Mazzone et al., 2007;
Peled et al., 2012; Phillips et al., 1999), and other acute and chronic
respiratory diseases. Together, these observations indicate that ir-
regular or unpleasant breath odor could be present and taken as
halitosis.
3.2 | Gastrointestinal and liver pathology-­
related VOCs
Gastrointestinal (GIT) diseases could induce exhaled volatolome
alterations via two main pathways: (i) esophageal release of VOCs
through the upper gastric sphincter to the oral cavity, and/or (ii)
adsorption of VOCs from the GIT tract into the blood stream and
subsequent diffusion via the lungs into the exhaled breath (Carlini &
Ligabue-­Braun, 2016; Di Lena, Porcelli, & Altomare, 2016). Searches
for non-­invasive biomarkers in GIT diseases have repeatedly iden-
tified distinctive volatolomic profiles in exhaled breath. Isobutane,
2-­butanone and ethyl acetate, for example, are increased in the
breath of individuals with gastric H. pylori and in the gaseous mix-
ture released by the bacterial strain (Ulanowska, Kowalkowski,
Hrynkiewicz, Jackowski, & Buszewski, 2011). VOCs associated with
elevated oxidative stress and inflammation have been reported in
inflammatory bowel diseases (IBD), including Crohn’s disease and
ulcerative colitis. For example, we have previously reported that
ethanol, 2-­butanone, tetrachloroethylene, 2,4-­dimethyl-­1-­heptene,
5-­ethyl-­2-­methyl-­octane, and dodecane are significantly elevated
in patients with IBD (Karban et al., 2016). Exhaled 2-­propenenitrile,
furfural, 2-­butoxy-­ethanol, hexadecane, 4-methyl-octane,
1,2,3-­tri-­methylbenzene, α-­methyl-­styrene, and others are associ-
ated with malignant and benign gastric and colon cancer (Amal et al.,
2015, 2016; ). Alcoholic liver states, cirrhosis, and hepatic cancer
are also associated with alterations in different spectra of exhaled
VOCs, including but not limited to propanoic acid, isopropyl alcohol,
1-­hexadecanol, and octane (Pijls et al., 2016).
3.3 | The uremic smell of kidney diseases
It has been long recognized that kidney diseases are associated
with an ammoniacal breath odor, usually termed “uremic fetor”
(Madhushankari et al., 2015; Ongole & Shenoy, 2010). While previ-
ously this was often interpreted as an oral hygiene problem, quan-
titative analysis of exhaled VOCs in chronic kidney diseases (CKD)
patients eventually revealed otherwise. Several studies have explored
the volatile metabolites in exhaled breath in kidney diseases, and the
vast majority of these studies have reported similar results. Levels of
exhaled ammonia, urea (the end product of detoxification of ammo-
nia), isoprene, and several hydrocarbons were significantly elevated in
most cases with acute and chronic kidney failure (Assady et al., 2014;
Marom et al., 2012; Nakhleh, Amal et al., 2014). Some of these com-
pounds were also correlated with different stages of the diseases and/
or to dialysis management. In one study, it was shown that the exhaled
ammonia concentrations decreased more than 10-­fold after circa 3 h
of dialysis (Davies, Spanel, & Smith, 1997).
 16010825, 2018, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/odi.12699 by Nat Prov Indonesia, Wiley Online Library on [30/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
690 | NAKHLEH et al.

F I G U R E 2 Volatile organic compounds (VOCs) and volatile sulfuric compounds (VSCs) in systemic and oral diseases. (a) Heat map of
quantitative GC-­MS analysis of breath samples obtained from 731 patients, diagnosed with one of 16 different systemic diseases. The
abundance of each VOC is given on the color scale. While at the individual VOC level, it is almost impossible to distinguish between different
diseases (each row in the heat map), the overall VOC pattern (each column in the color map) is quite distinctive. The VOCs are VOC-­01,
2-­ethylhexanol, VOC-­02, 3-­methylhexane, VOC-­03, 5-­ethyl-­3-­methyl-octane, VOC-­04, acetone, VOC-­05, ethanol, VOC-­06, ethyl acetate,
VOC-­07, ethylbenzene, VOC-­08, isononane, VOC-­09, isoprene, VOC-­10, nonanal, VOC-­11, styrene, VOC-­12, toluene, and VOC-­13, undecane.
(b) Comparison between simulated halitosis breath and healthy human breath by a pattern recognition algorithm applied to the responses of
array of sensors based on functionalized nanofibers. (a) Reprinted with permission from: Nakhleh et al. (2017) https://doi.org/pubs.acs.org/doi/
full/10.1021/acsnano.6b04930. (b) Reprinted with permission from: Kim et al. (2017) https://doi.org/10.1021/acs.accounts.7b00047. Copyright
(2017) American Chemical Society

Figure 1 schematically summarizes the composition of exhaled
breath and the different sources of sulfuric and non-­sulfuric volatile
compounds that could lead to halitosis.
4 | VOC PATTERNS IN SYSTEMIC DISEASES
The arguments described above, supported by hundreds of other
scientific reports, present a clear consensus: different local or sys-
temic pathophysiological processes or diseases cause substantial
alterations in the exhaled volatolome (Amal et al., 2015; Amann
et al., 2011; Haick et al., 2014; Hakim et al., 2012; Miekisch et al.,
2004; Nakhleh, Broza et al., 2014; Peled et al., 2012; Phillips et al.,
2010). However, it is noticeable in the scientific literature that in
systemic diseases, in contrast to oral halitosis, the dominant volatile
compounds in exhaled breath are non-­sulfur-­containing. Therefore,
while the assessment of VSCs alone can be informative and use-
ful in oral halitosis, it is insufficient for exploring extra-­oral halito-
sis. Consequently, it is very important in halitosis cases to assess
non-­sulfuric VOCs in the exhaled breath (Ongole & Shenoy, 2010).
Although in some cases the acquired smell of the exhaled breath is
sharp and well known to medical staff (the sweet acetone-­like odor
of DKA, the uremic smell in kidney failure), in most other cases the
odor is not clear, known or recognizable by physicians. This is partly
because the same volatile biomarkers are associated with different
diseases, and a given disease affects a spectrum of VOCs (Nakhleh,
Amal et al., 2017).
We have recently explored volatolomic alterations in 731 pa-
tients diagnosed with one of 16 different systemic diseases. We
found that the most powerful and distinctive VOCs for diagnosis
and/or classification of diseases were 13 compounds that were
common to all of them. It is notable that none of these 13 volatile
biomarkers were sulfur-­containing. Moreover, none of these com-
pounds was dominant enough to discriminate among the diseases
explored; nevertheless, these 13 compounds, considered jointly,
differed markedly among the healthy/disease states (Figure 2a)
(Nakhleh, Amal et al., 2017). In most cases, the variations in the
concentrations of these VOCs were in the range several to hun-
dreds of parts per billion by volume (PPBV), so it is highly doubt-
ful that such alterations could be identified and recognized by
the unaided nose, as in organoleptic assessment (Nakhleh, Amal
et al., 2017). This suggests that (i) VSCs are not indicative in cases
of extra-­oral halitosis and (ii) assessment of VOC patterns is more
informative for medical application than individual VOCs measure-
ments (Broza et al., 2015; Hakim et al., 2012; Nakhleh, Amal et al.,
2017) (Figure 2a).
 16010825, 2018, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/odi.12699 by Nat Prov Indonesia, Wiley Online Library on [30/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
NAKHLEH et al. | 691

F I G U R E 3 The concept of artificially intelligent olfaction in halitosis. In contrast to selective sensing, an array of sensors performs semi-­
selective and/or collective assessment of the exhaled breath composition. The array includes a subset of programmed sensors with higher
affinity to VSCs (bottom sensor panel) and another subset of sensors with acquired higher affinity to non-­sulfuric volatile organic compounds
(VOCs) (top sensor panel). All sensors are exposed and react to the sample simultaneously, and their responses are recorded and processed
toward pattern recognition application. Software will then compare the patterns calculated from the different sets of sensors and compare them
to the database of patterns obtained previously in the preclinical training phases. A tree-­of-­decision-­based classifier will then determine whether
a subject suffers from oral or extra-­oral halitosis; in the second case, it will also classify the volatolomic pattern according to the different
systemic diseases

5 | ARTIFICIALLY INTELLIGENT
OLFACTION: FROM VISION TO PRACTICE
IN HALITOSIS
Exhaled breath samples are complex and contain up to several hun-
dreds of different volatile compounds from various sources. On the
one hand, VOCs are delivered to the lungs from the peripheral blood
system, while others such as VSCs originate mainly from the oral and
nasal cavities. In addition, exhaled breath usually contains volatile
compounds from exogenous sources such as volatile pollutants that
are absorbed to the body by inhalation, food intake, or even via the
skin (Van den Velde et al., 2007b).
However, in the field of halitosis, techniques that have been de-
veloped so far only assess VSCs levels, so they have limited capacity
to discriminate among diseases completely neglect extra-­oral cases
(Laleman et al., 2014). Unlike the selective measurement of individ-
ual volatile compounds, artificial olfaction, which is based on a non-­
selective sensor array, assesses the overall spectrum of exhaled volatile
compounds (Barash et al., 2009; Haick et al., 2014; Nakhleh, Broza
et al., 2014; Vishinkin & Haick, 2015). Bio-­inspired by the mammalian
sense of smell (so it is also known as “electronic nose”) and combined
with artificial intelligence, that is, machine-­learning techniques, it can
recognize specific patterns (“smells”) and use as reference for future
objective and independent recognition. On the one hand, the collec-
tive sensing of the exhaled volatolome by an array of sensors allows
high selectivity for pattern changes associated with variety of diseases
to be achieved; on the other, it can adjust for minor alterations pos-
sibly caused by confounding factors and/or intra-­individual variations
(Broza et al., 2015; Haick et al., 2014; Kahn, Lavie, Paz, Segev, & Haick,
2015; Konvalina & Haick, 2014; Vishinkin & Haick, 2015).
With the great advances in field of sensors for gases, mainly based
on nanomaterials, highly efficient and tailor-­made systems could be
designed for the diagnosis, classification, and monitoring of diseases
(Tisch et al., 2012; Vishinkin & Haick, 2015). We have previously pre-
sented an artificially intelligent sensor array composed of 20 func-
tionalized nanomaterials based sensors that we were able to develop
and train to discriminate successfully among 17 different systemic
diseases, with an overall accuracy of 86%, by the analysis of exhaled
breath (Nakhleh, Amal et al., 2017). Unlike a single sensing mechanism
(single detector/sensor), the array includes an assembly of nanosen-
sors, each subset of which is tailored and designated for a specific
mission. This can be achieved by manipulating the shape and size of
the nanoparticles, and/or by functionalizing the nanoparticle films
with various organic sensing layers (Kahn et al., 2015; Karban et al.,
2016; Peng et al., 2009). In addition, as a training phase, preclinical
experimental assessments could be made using artificial gas mixtures
composed of target VOCs/VSCs, which would allow the training the
sensors for increased sensitivity (Karban et al., 2016; Nakhleh et al.,
2016). For example, Kim et al. have recently reported an array of sen-
sors, based on functionalized nanofibers, that were sensitive to breath
 16010825, 2018, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/odi.12699 by Nat Prov Indonesia, Wiley Online Library on [30/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
692 | NAKHLEH et al.

samples from healthy subjects but deliberately injected with hydrogen

Artificially intelligent olfaction

sulfide (Kim, Choi, Jang, Cho, & Kim, 2017) (Figure 2b). This shows

Pattern recognition/”sulfuric
Array of nanomaterial-­based

conjugated with artificial

that a single qualitative analysis of exhaled breath could be informa-

sensors for gas sensing

Multiqualitative analysis
tive about several aspects of the content and the clues hidden therein.
This is highly important and relevant for halitosis patients, for whom,
as discussed previously, it is necessary to simultaneously identify and

signature”
intelligent
assess the spectra of the sulfur-­containing and non-­sulfur containing
volatile compounds for optimal detection and classification.

Yes
Yes
Yes
No
When the array is combined with analytical software and a da-
Main characteristics of the Halimeter®, Breathtron®, and OralChroma™, compared with the features of sensor array-­based artificially intelligent olfaction

tabase of breath patterns, the signals obtained from each subset of

Gas chromatography linked with a indium oxide

sensors as a response to newly introduced breath sample could be

Absolute concentrations of hydrogen sulfide,

analyzed and the recognition procedure made as a tree-­of-­decision
methyl mercaptan, and dimethyl sulfide algorithm (Cohen-­Kaminsky et al., 2013; Nakhleh, Amal et al., 2017).
Thus, while one subset of sensors could be informative regarding the
VSCs in a given sample, indicating the possibility of oral halitosis,
other subsets would assess the patterns of VOCs linked to differ-
semiconductor gas sensor

ent systemic diseases. Figure 3 schematically describes the different

stages of artificially intelligent olfaction analysis. Table 1 summarizes
the main features of the currently available devices for analyzing ex-
OralChroma™

Quantitative

haled breath in halitosis and the potential use of artificially intelligent

olfaction.
As described so far, cross-­reactive (semi-­selective) sensors are used
Yes

Yes
No
No

in such systems in order to analyze patterns qualitatively. This means

Semiconductor sensor-­based zinc

that the system is not capable of quantitative analysis or identifying

the exact VOCs/VSCs in a given sample. Therefore, prior to the clinical
phase, it is critical to study the identity of the targeted compounds in
vitro and in vivo, by chromatography and spectrometry, for example,
oxide membrane

in order to accomplish a training phase (Nakhleh, Haick et al., 2017). To

do so, in vitro VOCs/VSCs should be studied from a variety of gaseous
Quantitative
Breathtron®

and liquid phases, including the exhaled breath, the oral cavity, saliva
samples, and cell/bacterial cultures. Preclinical artificial samples (e.g.,
Yes

No

No
No
No

gas mixtures resembling the statistically validated VOCs) could then

be obtained and used to determine the characteristics of sensors to
be included in the array (Karban et al., 2016). In addition to this phase,
Volumetric non-­selective gas

a wide database of breath samples from oral and extra-­oral halitosis

patients should be used for clinical validation of the sensors, and for
use as a database of pattern references that the software would use
to match the pattern and classification of each newly obtained breath
sample (Nakhleh, Amal et al., 2017).
Quantitative
Halimeter®

sensor

Yes

No

No
No
No

6 | SUMMARY
Potential classification of oral halitosis
Global sulfuric-­containing compounds

Discrimination between specific VSCs

Pathological halitosis is much more than a social nuisance. Usually, it

Assessment of non-­sulfuric VOCs

is a symptom of oral cavity disorder, or it could be due to a systemic

Indication of extra-­oral halitosis/

and potentially serious disease, so it is highly important to detect and

classify each case correctly. Commercially available systems for VSCs
Qualitative/Quantitative

assessment are very useful, but they are still controversial and are
Sensing mechanism

systemic diseases

useless for extra-­oral halitosis. Artificially intelligent olfaction has

the potential to serve as a non-­invasive, inexpensive technique for
TABLE 1

detecting oral and extra-­oral halitosis. Designed with high sensitiv-

ity to both VSCs and VOCs patterns, once trained, the system could
detect and classify halitosis, and moreover indicate the distal systemic

NAKHLEH et al.
source of the malodor. Still, extensive fundamental, preclinical, and
translation studies will be required to translate this vision into clinical
reality.
ACKNOWLE DG E MEN TS
The authors acknowledge Dr. Orna Barash and Dr. Vladislav Dvoyris
for fruitful discussions and revision of the manuscript. The authors
also thank Dr. Viki Kloper for help with the figures and fruitful discus-
sions. No coauthor declares any conflict of interest.
AUT HOR CONTRI B UTI O N S
All three authors have contributed in writing this review.
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How to cite this article: Nakhleh MK, Quatredeniers M, Haick H.
Detection of halitosis in breath: Between the past, present, and
future. Oral Dis. 2018;24:685–695. https://doi.org/10.1111/
odi.12699