Types of halitosis | Comments/associated clinical features |
Physiologic | Common, worse in morning ("morning breath") |
Pathologic | |
Oral origin | Most common; odor largely confined to the mouth or stronger from the mouth than the nose with organoleptic testing* |
Gingivitis/periodontitis | Gingival erythema, swelling, bleeding, tooth mobility |
Excessive tongue coating | Positive tongue organoleptic testing |
Dry mouth | May be associated with drugs,¶ some medical conditions (eg, Sjögren's) |
Tonsillar pathology | |
| Enlarged, erythematous tonsils; associated fever and enlarged anterior cervical lymph nodes |
| Swollen, fluctuant tonsil, with deviation of the uvula; drooling; trismus |
| Tonsillar crypts containing caseous material, tonsilloliths |
Dental prosthesis | Strong odor from dental prosthesis with organoleptic testing* |
Nasal origin | Relatively uncommon; odor stronger from the nose than the mouth with organoleptic testing* |
Rhinosinusitis | May be associated with fever, sinus tenderness, purulent nasal discharge |
Postnasal drip | Drip need not be infected – odor results from action of the bacteria present on the tongue on the material in the drip |
Foreign body | More common in children |
Respiratory tract origin | Uncommon |
Bronchiectasis | May be associated with a chronic cough and/or purulent sputum |
Bronchitis | Generally an acute or subacute process |
Lung abscess | Often associated with fever, weight loss |
Gastrointestinal tract origin | Uncommon |
Zenker diverticulum | Most patients present over age 60; male predominance; may be associated dysphagia |
Gastrocolic fistula | Usually associated with colon cancer; abdominal pain and weight loss often present |
Helicobacter pylori (not well established as causative) | |
GERD (not well established as causative) | |
Upper aerodigestive tract origin | Uncommon |
Malignancy | A malignancy can arise anywhere along the upper aerodigestive tract, including the oral cavity, nasal cavity, oropharynx, nasopharynx, hypopharynx, larynx, trachea, and esophagus |
Systemic origin | Uncommon; odor with similar quality emanates from both the mouth and the nose with organoleptic testing* |
Trimethylaminuria | Genetic disorder causing a characteristic fishy odor |
Advanced renal disease | Elevated levels of urea can produce odor |
Diabetic ketoacidosis | Ketoacidosis can produce a characteristic fruity odor |
Advanced liver disease | Jaundice, ascites, edema |
Subjective | Relatively common |
Psychologic | The persistent belief that halitosis is present despite a negative evaluation is halitophobia |
Neurologic | Disorders of taste and smell can result in the belief that bad breath is present when, objectively, it is not |
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