Halitosis

Probability diagnosis

• Dietary habits

• Poor oral hygiene

• Oro-dental disease (esp. gingivitis, discharging abscess)

• Dry mouth (e.g. on waking)

• Smoking/alcohol

Serious disorders not to be missed

Malignancy

• lung, oropharynx, larynx, stomach, nose, leukaemia

Pulmonary tuberculosis

Quinsy

Lung abscess

Blood dyscrasias/leukaemia

Uraemia

Hepatic failure

Pitfalls (often missed)

Nasal and sinus infection

Tonsillitis

Mouth breathing

Systemic infection

Appendicitis

Bronchiectasis

GORD/Hiatus hernia

Rarities:

• pharyngeal and oesophageal diverticula

• Sjögren syndrome

• scurvy

Masquerades checklist

Depression

Diabetes (acetone)

Drugs (e.g. antidepressants, isosorbide)

Is the patient trying to tell me something?

Possible manifestation of psychogenic disorder (e.g. depression).

Key history

• General health

• Respiratory history

• Gastrointestinal history including dry mouth and reflux

• Dental history

• Drug history including OTC preparations, alcohol and smoking

• Dietary history: ask about onions, garlic, peppers, curries, spicy salami and similar meats, strong cheeses and water intake

• Psychosocial history

Key examination

• Orodental inspection, also oropharynx, nose and sinuses

• Respiratory system

• Abdominal examination

Key investigations

• FBE

• ESR/CRP

• Urine analysis

• Blood sugar

• Kidney function tests

• Liver function tests

• X-ray of sinuses

• Consider CT scan sinuses

Diagnostic tips

• If cause is unknown refer to a dental surgeon; consider an ENT opinion.

• Bacterial putrefaction of dental and food debris plus inflammation of the gums are largely responsible for oral malodour.

• Smoking, alcohol and a dry mouth all aggravate the problem.

• One survey indicated that 87% had an oral cause, 8% ENT and 5% an unidentified cause.