Approach

The management of halitosis depends on the cause. In most patients, halitosis has an oral cause. Treatment is therefore directed towards reducing the accumulation of food debris and odour-producing oral bacteria.

Healthy patients with transient mild halitosis should improve their oral hygiene procedure, including gentle tongue scraping and use of antibacterial mouthwashes. Transient halitosis due to ingestion of food that causes excretion of sulfur-containing volatile agents from the lungs (e.g., garlic) cannot benefit from oral hygiene alone. In these cases, reduction of the breath concentration of these gases requires modification of the diet.[33]

Individuals with persistent halitosis due to dental disease need appropriate dental treatment. This may include restorative and surgical interventions.

Halitosis associated with disease of the nasopharynx, upper respiratory tract, and gastrointestinal tract benefit from adequate treatment of the underlying disorder.

Oral hygiene procedures (mechanical)

Effective physical removal of dental plaque is obtained via tooth cleaning, including brushing and interdental flossing. Similarly, dentures should be cleaned effectively, although there remains no specific cleaning method that will reduce halitosis associated with denture use.[34]

Oral hygiene procedures (chemical)

Mouthwashes suggested for the treatment of oral malodour act by reducing either the bacterial load or the associated odoriferous compounds.[3][35] Unfortunately, there are few RCTs of the effectiveness of these mouthwashes. 

  • Chlorhexidine gluconate produces a fall in bacteria that generate volatile sulfur compounds (VSCs) and used as a mouthrinse or spray can be more effective than improving oral hygiene alone at reducing oral malodour for several hours.[36][37] A combined chlorhexidine/zinc mouthwash was reported to be effective for halitosis in one study, but a Cochrane review concluded the evidence was very uncertain.[5][38] A mouthwash of chlorhexidine/cetylpyridinium chloride and zinc lactate also reduces oral malodour.[39] Patients may, however, be reluctant to use chlorhexidine long term as it has an unpleasant taste, can give rise to a burning sensation of the oral mucosa if used too frequently, and can cause (reversible) staining of the teeth.

  • Triclosan has both a direct anti-VSC action and an antibacterial effect. It is used in mouthrinses and toothpastes and may reduce oral malodour, but the evidence is uncertain.[5] The anti-VSC action seems to depend mainly upon the solubilising agent with which triclosan is delivered.[40] A formulation of triclosan/copolymer/sodium fluoride seems to be particularly effective in reducing VSCs, oral bacteria, and oral malodour.[41][42]

  • A 2-phase oil-water rinse can reduce oral malodour for several hours, without adverse effects.[43]

  • Other preparations that can reduce oral malodour for several hours include rinses containing cetylpyridinium chloride, chlorine dioxide, and zinc chloride, and stabilised stannous fluoride sodium hexametaphosphate dentifrice (0.454%).[44][45][46] The addition of zinc to chlorhexidine mouthwash can increase the reductions of the microbiota of the tongue and VSCs compared with chlorhexidine alone.[47] It may also enhance the masking effects of mouthwashes.[48] The use of sugar-free sweets containing zinc gluconate plus propolis was found to reduce VSCs (as determined by halimeter).[49]

  • A previous finding that metronidazole mouthrinse may be of benefit has never been confirmed by others.[50]

Tongue scraping

If oral malodour persists, the tongue may be the likely source of the odour, and hence gentle and regular tongue scraping is indicated.[47][51] This is aimed at dislodging trapped food, dead cells, and bacteria from between the filiform papillae, thus decreasing the concentration of VSCs.[3]

Tongue scraping should be done at night using either a hard toothbrush and cold water, but no toothpaste, or a tongue scraper. The benefits of tongue scraping seem to be short term.[3] Tongue scraping does not always reduce the intra-oral bacterial counts of bacteria supposedly associated with oral malodour and there is no evidence as to the most appropriate frequency, duration, or method of tongue scraping to reduce oral malodour.[47][52] A Cochrane review found very low-quality evidence that mechanical tongue cleaning may reduce organoleptic test scores.[5] The results of some studies suggest that the addition of gels such as Meridol™ (amine fluoride/stannous fluoride/zinc lactate) may reduce short-term oral malodour (as assessed by the organoleptic method) and VSCs.[53][54]

Cosmetic methods

Cosmetic methods, such as chewing gum, mints, flavoured sprays, and some mouthrinses, merely provide a competing and temporary smell that may mask the unpleasant odour. A herbal muco-adhesive tablet has been reported to reduce the subjective mouth odour and levels of VSC, at least in the short term.[55] A gum containing magnolia bark extract may lessen the oral bacteria associated with halitosis.[56]

Treatment of underlying conditions

Dental/periodontal disease

  • Appropriate management of dental and periodontal disease can control halitosis that results from the accumulation of bacteria on dental surfaces and periodontal tissues. Dental disease is usually managed with restorative and prosthetic measures, while in a significant number of individuals periodontal disease requires surgical intervention.

Oral and oropharyngeal disease

  • Includes infectious, inflammatory, and malignant disorders of the oral, nasal, and oropharyngeal mucosa, as well as surrounding soft and hard tissues. The therapeutic approach depends on relevant aetiopathogenesis.

Disease of upper respiratory and gastrointestinal tracts

  • Includes infectious, inflammatory, and malignant disorders. The therapeutic approach depends on relevant aetiopathogenesis.

Systemic disorders causing blood-borne halitosis

  • The therapeutic approach depends on relevant aetiopathogenesis.

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