Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – oral hygiene

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1st line – 

oral hygiene

In most patients, halitosis has an oral cause. Treatment is therefore directed toward reducing the accumulation of food debris and odor-producing oral bacteria.

Healthy patients with transient mild halitosis need to improve their oral hygiene procedure. This can be achieved by effective physical removal of dental plaque via tooth cleaning, including brushing and interdental flossing, gentle tongue scraping, and use of antibacterial mouthwashes.[47][51]

Similarly, dentures should be cleaned effectively, although there remains no specific cleaning method that will reduce halitosis associated with denture use.[34]

Tongue scraping is aimed at dislodging trapped food, dead cells, and bacteria from between the filiform papillae, thus decreasing the concentration of volatile sulfur compounds.[3] It 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 malodor and there is no evidence as to the most appropriate frequency, duration, or method of tongue scraping to reduce oral malodor.[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 malodor (as assessed by the organoleptic method) and VSCs.[53][54]

There is a range of mouthwashes suggested for the treatment of oral malodor; examples include chlorhexidine gluconate, triclosan, and 2-phase oil-water rinse. They act by reducing either the bacterial load or the associated odoriferous compounds.[3] 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 candy containing zinc gluconate plus propolis was found to reduce VSCs (as determined by halimeter).[49]

Other preparations that can reduce oral malodor for several hours include rinses containing cetylpyridinium chloride, chlorine dioxide, and zinc chloride, and stabilized stannous fluoride sodium hexametaphosphate dentifrice (0.454%),[44][45][46]

Unfortunately, there are few randomized controlled trials of the effectiveness of these mouthwashes.

Consider – modification of diet

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Consider – 

modification of diet

Treatment recommended for SOME patients in selected patient group

Transient halitosis due to ingestion of foods that cause the excretion of sulfur-containing volatile agents from the lungs (e.g., garlic) cannot benefit from oral hygiene only. In these cases, reduction of the breath concentration of these gases requires modification of the diet.[33]

Consider – treatment of underlying disorder

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Consider – 

treatment of underlying disorder

Treatment recommended for SOME patients in selected patient group

Halitosis associated with disease of nasopharynx and upper respiratory and gastrointestinal tracts benefits from adequate treatment of underlying disorder. These diseases usually include infectious, inflammatory, and malignant disorders of the affected organs, as well as of the surrounding soft and hard tissues.

Consider – restorative and surgical intervention

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Consider – 

restorative and surgical intervention

Treatment recommended for SOME patients in selected patient group

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.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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