15/06/2015

What is halitosis?
Sandra Hipsz
Earl Marriott Secondary
Every morning across the world people wake up with bad breath. Most do not
know that there are cures and preventatives to this disease and that learning what it is and
how it is caused can be beneficial to your health. To begin, what is halitosis? Halitosis is
derived from the Latin halitus meaning breath and the Greek suffix osis meaning an
increase in volume. (Marawar, Pramod P et al. 2012) Halitosis is synonymous with bad
breath. Once the meaning of halitosis is understood it is essential to look into these three
questions:
1. What causes halitosis?
2. What tests are used to detect halitosis?
3. What are preventatives and treatments for halitosis?

What causes halitosis?

There are around 150 molecular components of human exhalations and many of
them smell terrible. Volatile sulfur compounds (VSCs) caused by bacteria are the main
molecular component that emit this malodor. Above the gum line there are gram positive
bacteria that dont smell too bad (not a big contributor of VSCs) but below the gum line
and on the back of the tongue there are gram negative bacteria that produce much more
gas (VSCs) and are therefore smellier. (Franklin, Deborah. 2013) There are two main
ways to differentiate the malodor, intra-oral and extra-oral.
Intra-oral
In 85% of genuine halitosis patients the halitosis is caused by intra-oral causes.
(Marawar, Pramod P et al. 2012) This includes tooth decay and gum disease caused by
plaque, using tobacco products and mouth infections. Halitosis is also caused by having a
dry mouth caused by medicines, salivary gland problems, or always breathing through the
mouth. (Aberdore, S. 2011). An intra-oral cause is malodor that originates in the mouth.
Specifically caused by microorganisms, which is the interaction between several oral
bacterial species. (Mainly gram negative anaerobic flora) (Marawar, Pramod P et al.
2012) The bacteria in the mouth feed off of mucus, food remnants and dead tissue cells.
To absorb the nutrients from this food through their cell walls, the bacteria has to break
down the organic matter into smaller molecules. For example theyll break proteins down
into their component amino acids and break those down even further, into various
compounds. Some of the malodorous bi products of these chemical reactions (VSCs) are
released in the form of a gas which is halitosis. (Rosenberg, M. 2015)

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Extra-oral
Extra-oral causes are conditions and diseases that do not primarily affect the oral
cavity. These include tonsillitis, the common cold and diabetes. Some metabolic disorders
cause halitosis through odiferous agents circulating in the blood stream and can be
exhaled, through alveolar gas exchange into the breath and cause halitosis (Alveolar gas
exchange is gas exchange between blood and the air so that oxygen can get to your
tissues). Also known as bloodborne halitosis. (Marawar, Pramod P et al. 2012)

What tests are used to detect halitosis?

Individuals are not good at determining whether are not they have genuine
halitosis. There is a simple home test where the patient suspecting halitosis licks the side
of their finger and then lets the saliva dry for a minute or so. They then smell the spot and
theyll have an idea what their breath smells like. (Aberdore, S. 2011) However this test
is inaccurate as patients tend to rate the smell on how bad they thought it was going to be
not the actual smell. (Rosenberg, M. 2015) That is why there are several tests in place to
determine whether the malodor is real. Tests include directly sniffing the bad breath and
the determination of odiferous sulfur containing substances. There are two main types of
testing.
Indirect testing
Indirect testing are methods that assess products produced by microorganisms in
vitro or identify odor producing microorganisms. Tests incude the BANA test,
bacteriologic analysis, ammonia monitoring, and cry osmoscopy. The BANA test is used
to determine proteolytic activity of certain oral anaerobes that contribute to malodor and
are considered as active hydrogen sulfide producers. Any active hydrogen sulfide
producers get hydrolyzed and if the hydrogen sulfide turns blue from the embedded dye
then the test is positive. Bacteriologic analysis is a polymerase chain reaction. It is the
favoured form of detection because it is cheap, simple and produces large numbers of
DNA copies even if the DNA is poor quality (from the saliva or tongue coating).
(Marawar, Pramod P et al. 2012)
Direct Testing
Direct testing is done through organoleptic and iedonic assessment. The two most
common kinds of direct testing are direct sniffing and gas chromatography. Direct
sniffing of the expired air is the simplest and most common method to evaluate oral
malodor. It is done when the patient with suspecting halitosis goes to the dentist. The
dentist asses the odor at a range of distances from the patient. However, there is a risk of
disease transmission through the expelled air. (fig. 1) (Marawar, Pramod P et al. 2012)

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Fig 1 (Marawar, Paramod P et al. 2012)

Levels are according to the severity of malodor.

Gas chromatography is the preferred method of detecting halitosis if

measurements of specific gases are required. Gas chromatography involves an apparatus
equipped with a flame photometric detector (specific to detecting sulfur in the mouth).
Its considered the best form of detection however, it requires inert column carrier gas
and technicians with adequate training which makes it costly and significantly more
difficult. There are many more forms of direct testing including sulfide monitoring, tanita
breath alert, halitox and the tongue sulfide probe. (Marawar, Pramod P et al. 2012)

What are preventatives and treatments for halitosis?

After a positive diagnosis for halitosis has been made a treatment plan is
implemented. To do this there is a need to find the cause of why the halitosis is happening
and eliminate or correct it. This can be done mechanically or chemically.
In the mechanical method, doctors need to instill in patients good oral hygene
practices like tongue brushing, tongue scraping, healthy diet, chewing gum and keeping
hydrated.
Even with good oral hygene the bad breath can linger. In this case using the chemical
method might help. Patients can use an effective mouthwash (rinsing and gargling) is
advised because it decreases the amount of bacteria produced. Other ways include
masking the malodor, using probiotics or using natural herbs like thyme, eucalyptus or
peppermint. (Marawar, Pramod P et al. 2012)
For bad breath reduction, ingredients that provoke sulphide-reducing bacteria in the
oral cavity can be used with other compounds that neutralize vomit odors as sulphur
reducing bacteria are not the only contributors to bad breath. These ingredients include
botanical extracts, cetylpyridinium chloride, chlorhexidine, chlorine dioxide,

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dehydroascorbic acid, essential oils, hydrogen peroxide, sodium bicarbonate, triclosan
and zinc salts. (Lourith, N Kanlayavattanakul, M. 2009)
Botanical extracts
Methyl mercaptan is a common malodorous bi product caused by bacteria. It has been
found that betel leaves reduce the volatility of methyl mercaptan and are therefore used to
treat halitosis. Other botanical extracts that inhibit oral microbes and reduce bad breath
are catechin and resveratrol. They are extracted from licorice. In addition, a herbal
formulation that includes lavender and sage extracts has been found effective against oral
malodor. Not to mention the fact that their aromatic effects are appreciable for bad breath
neutralization and flavouring the treatment products. (Lourith, N Kanlayavattanakul, M.
2009)
Cetylpyridinium chloride
Cetylpyridinium chloride is an antimicrobial agent that reduces VSCs. It is used in
many products that are said to cure bad breath. These products include mouthrinses,
mouthsprays, dentrifices and oral gel. This antimicrobial agent can also be used on
animals which makes it the active ingredient most commonly used in the prevention and
curing of halitosis. (Lourith, N Kanlayavattanakul, M. 2009)
Chlorhexidine
Chlorhexidine can be found in most mouthrinses because it reduces VSCs with
efficacy and leaves no unpleasant taste or staining on teeth. (Lourith, N
Kanlayavattanakul, M. 2009)
Chlorine dioxide
This stable free radical has been used in mouthwashes, dentrifices, mouthsprays and
chewing gum. Mainly because it reduces VSCs and other malodors coming from the
mouth. In addition it was used with zinc ions to limit halitosis by complexing with sulfur.
However, it was deemed unsafe because the adverse effects resulting from the generated
chlorine ions remained unclear. (Lourith, N Kanlayavattanakul, M. 2009)
Dehydroascorbic acid
Dehydroascorbic acid has been found to prolong the suppression of halitosis for three
hours because it has an oxidizing effect. However, it is rarely used because the vitamin C
derivative is very unstable. (Lourith, N Kanlayavattanakul, M. 2009)
Essential oils
Essential oils have been included in mouthwashes because they inhibit bactericidal
activity against pathogenic microorganisms that accumulate in bad breath. Mint is used

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because it inhibits pathogens in the respiratory tract. Anise, fennel, basil and juniper berry
are used in mouthwash, toothpaste and mouthspray because they neutralize garlic odor in
breath. Furthermore, bay, caraway, cedar, cinnamon, citronella, clove, coriander, laurel,
lavender, lemon, marjoram, mustard, orange, orris, parley, pimento, pine, rosemary, sage,
sassafras, turpentine, thyme and witch hazel oils are used in several forms to reduce
halitosis.
Most mouthrinses contain alcohol for breath treatment. These mouthrinses may not be
the best purchase as it is possible for the alcohols to metabolize into odorous compounds
that would elevate bad breath. Concentrations of ethyl alcohol have therefore been
reduced. (Lourith, N Kanlayavattanakul, M. 2009)
Hydrogen peroxide
A drop of VSCs was noticed following treatment with hydrogen peroxide alone
but effective treatments have also been created with the addition of sodium bicarbonate.
(Lourith, N Kanlayavattanakul, M. 2009)
Sodium bicarbonate
Sodium bicarbonate (baking soda) with the addition of peroxide is a very effective
treatment against malodor especially at high concentration.
(Lourith, N Kanlayavattanakul, M. 2009)
Triclosan
This antibacterial is widely used in many oral care products mainly because it is
highly compatible with other ingredients and is stable in various products while still
helping with malodor. (Lourith, N Kanlayavattanakul, M. 2009)
Zinc salts
Zinc salts are used to control halitosis because they are non-toxic and they dont
stain teeth. Zinc salts suppress the production of VSCs and is mainly used in in
mouthrinses and dentrifices. However consumers have found it to have an unpleasant
taste. Companies are therefore masking the taste using other ingredients. Zinc can also be
used with other ingredients that control bad breath. (Lourith, N Kanlayavattanakul, M.
2009)

Conclusion
In summary, halitosis is a disease that is caused mainly by gram negative bacteria
that live in your mouth and create volatile sulfur compounds. Halitosis can be diagnosed,
treated and cured in various ways. However there are many preventatives that can stop
halitosis form ever happening in the first place. Just remember to maintain good oral
hygene and to eat a healthy diet.

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References
Franklin, Deborah Good bacteria for bad breath
Scientific American May 2013; 30-32 Retrieved from ebsco.com
Marawar, Pramod P et al. Halitosis: A silent affliction
Chronicles of Young Scientists Oct-Dec 2012; 251-257 Retrieved from ebsco,com
Aberdore, S Natural approaches to halitosis: Bad breath be gone
Alive: Canadas Natural Health and Wellness magazine Dec 2011; 43-45
Retrieved from ebsco.com
Lourith, N Kanlayavattanakul, M Oral malodor and active ingredients for treatment
International Journal of Cosmetic Science July 2009; 321-325 Retrieved from
ebsco.com
Rosenberg, M What causes bad breath?
Ted-ED March 2015; Video retrieved from youtube.com
Fig.1:
Marawar, Pramod P et al. Halitosis: A silent affliction
Chrinicles of Young Scientisits Oct-Dec 2012; 253 Retrieved from ebsco.com