Halitosis

Halitosis describes any breath odor that’s unpleasant, disagreeable, or offensive. This common sign is usually easy to detect, but an embarrassed patient may take measures to hide it. The patient may be unaware that he has halitosis, even though he may complain of a bad taste in his mouth, or he may believe that he has halitosis but that no one else can detect it (psychogenic halitosis).

Certain types of halitosis characterize specific disorders—for example, a fruity breath odor typifies ketoacidosis. (See “Breath with ammonia odor,” page 136; “Breath with fecal odor,” page 137; “Breath with fruity odor,” page 139; and “Fetor hepaticus,” page 336.) Other types of halitosis include putrid, foul, fetid, and musty breath odors.

Halitosis may result from a disorder of the oral cavity, nasal passages, sinuses, respiratory tract, or esophageal diverticula. It may also stem from a GI disorder associated with belching, regurgitation, or vomiting, or it may be an adverse effect of an oral or inhaled drug.

Other causes of halitosis include cigarette smoking, ingestion of alcohol and certain foods (such as garlic and onions), and poor oral hygiene—especially in patients with an orthodontic device, dentures, or dental caries. In addition, offensive skin odors—for example, from foot perspiration—may be absorbed locally and later expelled by the lungs, resulting in halitosis.

History and physical examination

If you detect halitosis, try to characterize the odor. Does it smell fruity, fecal, or musty? If the patient is aware of it, find out how long he has had it. Does he also have a bad taste in his mouth? Does he have difficulty swallowing or chewing? Does he have reflux or regurgitation? Does he have pain or tenderness? Ask the patient if he has a problem with flatus. Also ask him to describe the frequency of his bowel movements and the size and consistency of his stools.

Find out if the patient smokes or chews tobacco. Have him describe his diet and daily oral hygiene. Does he wear dentures? Complete the history by asking about chronic disorders and recent respiratory tract infection. If the patient reports a cough, find out if it’s productive.

Begin the physical examination by examining the patient’s mouth, throat, and nose. Look for lesions, bleeding, drainage, obstruction, and signs of infection, such as redness and swelling. Check for tenderness by percussing and palpating over the sinuses. Then auscultate the lungs for abnormal breath sounds. Auscultate the abdomen for bowel sounds, and percuss it, noting any tympany. Finally, take vital signs.

Medical causes

Bowel obstruction

Halitosis is a late sign in both small- and large-bowel obstructions, resulting from vomiting of bilious and later fecal material. Other findings in a small-bowel obstruction include constipation, abdominal distention, and intermittent periumbilical cramping pain. In a large-bowel obstruction, abdominal pain is milder and more constant than that associated with a small-bowel obstruction and is usually located lower in the abdomen.

Bronchiectasis

Bronchiectasis usually produces foul or putrid halitosis, but some patients may have a sickeningly sweet breath odor. The patient typically also has a chronic productive cough with copious, foul-smelling, mucopurulent sputum. The cough is aggravated by lying down and is most productive in the morning. Associated findings commonly include exertional dyspnea, fatigue, malaise, weakness, and weight loss. Auscultation reveals coarse or moist crackles over the affected lung areas during inspiration. Digital clubbing is a late sign.

Common cold

A musty breath odor may accompany a common cold, which usually also causes a dry, hacking cough with sore throat, sneezing, nasal congestion, rhinorrhea, headache, malaise, fatigue, arthralgia, and myalgia.

Esophageal cancer

In esophageal cancer, halitosis may accompany classic findings of dysphagia, hoarseness, chest pain, and weight loss. Nocturnal regurgitation and cachexia are late signs.

Gastric cancer

Halitosis is a late sign in gastric cancer. Accompanying findings include chronic dyspepsia unrelieved by antacids, a vague feeling of fullness, nausea, anorexia, fatigue, pallor, weakness, altered bowel habits, weight loss, and muscle wasting. Hematemesis and melena are signs of associated gastric bleeding.

Gastrocolic fistula

In this disorder, fecal vomiting is responsible for fecal breath odor, which is typically preceded by intermittent diarrhea.

Gingivitis

Characterized by red, edematous gums, gingivitis may also cause halitosis. The gingivae between the teeth become bulbous and bleed easily with slight trauma.

Acute necrotizing ulcerative gingivitis also causes fetid breath, a bad taste in the mouth, and ulcers—especially between the teeth—that may become covered with a gray exudate. Severe ulceration may occur with fever, cervical adenopathy, headache, and malaise.

Hepatic encephalopathy

A characteristic late sign of hepatic encephalopathy is fetor hepaticus, a musty, sweet, or mousy (new-mown hay) breath odor. Other late effects include coma, asterixis (flapping tremor), and hyperactive deep tendon reflexes.

Ketoacidosis

Alcohol-induced, diabetic, and starvation forms of ketoacidosis produce a fruity breath odor. Alcohol-induced ketoacidosis is usually seen in poorly nourished alcoholics who have eaten very little over several days. Symptoms include sudden Kussmaul’s respirations with vomiting for several days, light dehydration, abdominal pain and distention, and absent bowel sounds. The patient is alert and has a normal or slightly decreased blood glucose level.

Life-threatening diabetic ketoacidosis produces a rapid, thready pulse; marked hypovolemia; nausea and vomiting; and, in its early stages, the triad of polydipsia, polyphagia, and polyuria.

Also life-threatening, starvation ketoacidosis produces Kussmaul’s respirations; weight loss; bradycardia; dry, scaly skin; sore tongue; muscle and tissue wasting; abdominal distention; and signs of dehydration, such as oliguria and poor skin turgor.

Other common effects of diabetic and starvation ketoacidosis include orthostatic hypotension, generalized weakness, anorexia, abdominal pain, and altered level of consciousness.

Lung abscess

Lung abscess typically causes putrid halitosis, but its cardinal sign is a productive cough with copious, purulent, often bloody sputum. Other findings include fever with chills, dyspnea, headache, anorexia, weight loss, malaise, pleuritic chest pain, asymmetrical chest movement, and temporary clubbing.

Necrotizing ulcerative mucositis (acute)

A strong, putrid breath odor is characteristic of this uncommon disorder, which initially causes slight cheek inflammation that’s rapidly followed by tooth loss and extensive bone sloughing in the mandible or maxilla.

Ozena

This severe, chronic form of rhinitis causes a musty or fetid breath odor as well as thick green mucus and progressive anosmia.

Periodontal disease

Periodontal disease causes halitosis and an unpleasant taste. Typically, the patient’s gums bleed spontaneously or with slight trauma and are marked by pus-filled pockets around the teeth. Related findings include facial pain, headache, and loose teeth covered by calculi and plaque.

Pharyngitis (gangrenous)

Halitosis is a chief sign of gangrenous pharyngitis. The patient also complains of a foul taste in the mouth, an extremely sore throat, and a choking sensation. Examination reveals a swollen, red, ulcerated pharynx, possibly with a grayish membrane. Fever and cervical lymphadenopathy are also common.

Renal failure (chronic)

Renal failure produces a urinous or ammonia breath odor. Among its widespread effects are anemia, emotional lability, lethargy, irritability, decreased mental acuity, coarse muscular twitching, peripheral neuropathies, muscle wasting, anorexia, signs of GI bleeding, ecchymosis, yellow-brown or bronze skin, pruritus, anuria, and increased blood pressure.

Sinusitis

Acute sinusitis causes a purulent nasal discharge that leads to halitosis. Besides a characteristic postnasal drip, the patient may exhibit nasal congestion, sore throat, cough, malaise, headache, facial pain and tenderness, and fever.

Chronic sinusitis causes a continuous mucopurulent discharge that leads to a musty breath odor, postnasal drip, nasal congestion, and a chronic nonproductive cough.

Zenker’s diverticulum

This esophageal disorder causes halitosis and a bad taste in the mouth associated with regurgitation. The patient may also report a chronic cough that’s most pronounced at night, hoarseness, odynophagia, neck pain, and “gurgling” sounds in the throat when he swallows liquids.

Other causes

Drugs

Drugs that can cause halitosis include triamterene, inhaled anesthetics, and any drugs known to cause metabolic acidosis such as nitroprusside.

Herb Alert

Special considerations

If examination of the mouth and sinuses doesn’t reveal the cause of halitosis, prepare the patient for upper GI and chest X-rays or endoscopy.

Pediatric pointers

In children, halitosis commonly results from physiologic causes, such as continual mouth breathing and thumb or blanket sucking. Phenylketonuria—a metabolic disorder that affects infants—may produce a musty or mousy breath odor.

Geriatric pointers

Extensive dental caries, mouth dryness, and poor oral hygiene can cause halitosis in elderly patients.

Patient counseling

To help control halitosis, encourage good oral hygiene. If halitosis is drug induced, reassure the patient that it will disappear as soon as his body completely eliminates the drug.

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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