History and exam
Key diagnostic factors
common
malodorous breath
The physician can perform a variety of organoleptic tests to judge for bad breath.
consumption of onions, garlic, or spiced food
This supports a diagnosis of temporary blood-borne halitosis related to foodstuffs containing allium.
evidence of dental and/or periodontal disease
Dental and periodontal disease (e.g., acute necrotizing ulcerative gingivitis, acute gingivitis, aggressive periodontitis, pericoronitis) triggers accumulation of bacteria on oral surfaces.
evidence of disease of the oral mucosa
Mucosal disease (e.g., ulceration, lichen planus, pemphigus) and mucosal fenestration with bone exposure (e.g., dry socket, osteonecrosis) can trigger accumulation of bacteria.
evidence of nasopharyngeal disease
Nasopharyngeal disease (e.g., malignancy, sinusitis, tonsillitis, tonsilloliths, cleft palate) can trigger accumulation of bacteria.
Other diagnostic factors
uncommon
evidence of upper respiratory tract or gastrointestinal disease
Upper respiratory tract (e.g., infections, bronchiectasis, lung abscess) or gastrointestinal disease (e.g., esophageal diverticulum, gastroesophageal reflux disease) can trigger accumulation of bacteria.
evidence of upper respiratory tract and gastrointestinal malignancy
Malignancy of the upper respiratory and gastrointestinal tracts can cause halitosis, although this is a rare occurrence. Halitosis due to malignancy comes from superficial necrosis, ulceration, and secondary infection.
evidence of endocrine, metabolic, hepatic, or renal disease
Some endocrine (e.g., diabetic ketoacidosis), metabolic (e.g., trimethylaminuria, hypermethioninemia), hepatic failure, and renal diseases can cause blood-borne halitosis.
Risk factors
strong
oral disease
Several diseases of the soft (gingivae and mucosa) and hard tissues (teeth, jawbones) of the mouth, as well as ill-fitting or unclean dental prostheses, can lead to accumulation of food debris and consequent microbial putrefaction.
These diseases include food impaction (among teeth, underneath prostheses), acute necrotizing ulcerative gingivitis, acute gingivitis, adult and aggressive periodontitis, pericoronitis, dry socket, xerostomia, oral ulceration, and oral malignancy.[3]
weak
respiratory disease
Some respiratory diseases can cause increased microbial accumulation/activity on epithelial surfaces of the respiratory tract. This can lead to production of volatile sulfur compounds (VSCs), diamines, and short-chain fatty acids in the exhaled air.
These diseases include foreign body, sinusitis, tonsillitis, malignancy (upper and lower airways), bronchiectasis, lung abscess, and subphrenic abscess.[3][11]
gastrointestinal disease
Some GI diseases can cause increased microbial accumulation/activity on epithelial surfaces of the respiratory tract. This can lead to production of volatile sulfur compounds (VSCs), diamines, and short-chain fatty acids in the exhaled air.
These diseases include gastric Helicobacter pylori infection, pharyngoesophageal diverticulum, gastroesophageal reflux disease (GERD), pyloric stenosis or duodenal obstruction, aortoenteric anastomosis, and malignancy.[3][10]
hepatic disease
The normal demethylating processes of methionine is inhibited in individuals with significant liver damage (e.g., fetor hepaticus), leading to accumulation of methyl mercaptan and dimethyl disulfide, which can be exhaled in the breath.
renal disease
Uremia is a clinical syndrome associated with fluid, electrolyte, and hormone imbalances and metabolic abnormalities, which develop in parallel with deterioration of renal function. Excessive blood concentration of urea nitrogen due to renal failure can be exhaled in the breath and cause a typical ammonia odor.
endocrine disease or hormonal changes
The presence of excess ketones in the bloodstream characterizes diabetic ketoacidosis. Ketones can be exhaled in the breath. Menstrual hormonal changes can lead to excessive trimethylamine blood levels due to reduced enzyme (flavin monoxygenase) activity.
metabolic disease
Trimethylaminuria is a rare metabolic disorder caused by excessive blood levels of trimethylamine. This is excreted into body fluids and breath, leading to a persistent oral and body malodor similar to that of rotten fish. The causal factor of excessive free trimethylamine is substrate overload or reduced enzyme (flavin monoxygenase) capacity as a result of an inherited deficiency, drug interaction, liver damage, and/or hormonal modulation.[16]
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