Halitosis is not a minor problem, as it is estimated that approximately 30% of the adult population has it or has had it on occasion. Its appearance causes great worry among our patients, not only because of the possible health implications, but also because of the possible psychological aspects that may affect daily life and social, intimate and professional relationships.

Today we can classify halitosis cases into three main types:

• Genuine or true halitosis: the bad smell that is truly present and can be measured and objectified.

• Pseudo-halitosis: bad smell that cannot be objectified, but the patient believes he has halitosis.

• Halitophobia: if after treating the previous, the patient still persistently believes he has halitosis.

At the same time, true halitosis can be classified as:

• Genuine Physiologic Halitosis: an oral health problem exists and the origin of the problem is the tongue coating on the posterior tongue dorsum.

• Genuine Pathological Halitosis:

- Of oral origin: origin of the problem is the tongue coating on the back of the tongue, and it involves other pathological conditions of the oral cavity, mainly periodontal disease (gingivitis and periodontitis).

- Of extraoral origin: tends to be associated with ENT problems and, in a minimal percentage of cases, with systemic diseases.

In approximately 90% of all cases of genuine halitosis, the origin of the bad odour is in the mouth (approximately 60% are associated with periodontal disease). Which is why the role of dental professionals is key in controlling and treating these patients.

Its appearance

The appearance of halitosis is mainly due to the presence of volatile sulphur compounds (VSC) in the air exhaled from the oral cavity. Mainly hydrogen sulphide (H2S) and methyl mercaptan(CH3SH) in oral halitosis and dimethyl sulphide (CH3)2S in extraoral pathological halitosis. Although VSCs represent 90% of all foul-smelling compounds that contribute to bad breath, other components have been identified to contribute to a lesser extent. These include volatile aromatic compounds (indole and skatole), organic acids (acetic, propionic) and amines (putrescine and cadaverine). 

The mechanism of production of these VSCs is directly associated with the protein metabolism of anaerobic gram negative bacteria, mostly present in the biofilm on the tongue, but also in the subgingival area, saliva and other areas. Substrates are amino acids that contain sulphur such as cysteine, cystine and methionine, which are free floating in saliva, in crevicular fluid or that appear after proteolysis of protein substrates provided by desquamation of oral epithelium, pharyngeal mucus, leukocytes, blood cells and, to a lesser extent, nutrients from the diet.

Its treatment

The treatment of oral halitosis mainly aims to:

• Reduce the number of bacteria that produce bad odour.

• Reduce the protein substrates available that are involved in the metabolic process of these bacteria.

• Neutralise the volatilisation of these foul-smelling products.

This can be done:

• Genuine Physiologic Halitosis: by carrying out professional dental cleaning and polishing, by explaining and stressing the instructions for oral hygiene, including instructions for brushing, interdental cleaning with dental floss and/or interproximal brushes, depending on each individual’s needs, and performing gentle tongue cleaning with a tongue cleaner. Lastly, by gargling with specific mouthrinses (to reach the back part of the tongue).

• Genuine Oral Pathological Halitosis: Besides applying the above mentioned protocol, all oral diseases must be treated, and in particular, we must treat the existing periodontal disease.

Halitosis can potentially become a chronic condition, and patients must use specific mouthrinses on a regular basis, for long periods of time. Currently, other alternative therapeutic strategies are being studied, such as the use of probiotics.

Although the research published on this subject a priori is providing results that seem promising, more well-designed studies are needed, including a greater number of patients and with long term results both for safety as well as for efficacy of the products, before they may be applied to therapeutic protocols for this type of patients.

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