Bad Breath (Halitosis): Causes

Pathogenesis (development of disease)

The causes of physiological halitosis are found directly in the mouth (about 90% of cases). The foul odor comes from the back of the tongue or from consumed foods and stimulants such as garlic or alcohol.Pathologic halitosis can have both oral – affecting the mouth – and extraoral – outside the mouth – causes. In less than 0.1% of cases, there is a gastrointestinal cause, such as esophageal diverticula (protrusions of the wall (diverticula) of the esophagus (esophagus)), cardia insufficiency (insufficient closure function of the cardia; Cardia closes the upper part of the stomach), gastroesophageal reflux (abnormally increased reflux of acidic stomach contents into the esophagus; GER, gastroesophageal reflux), or pyloric stenosis (narrowing (stenosis) in the area of the stomach outlet).

Etiology (causes)

Oral causes (approximately 90% of cases).

  • Candidiasis (thrush)
  • Infections – gingivitis (inflammation of the gums), stomatitis (inflammation of the oral mucosa), periodontitis (disease of the periodontium).
  • Caries (tooth decay)
  • Mouth breathing, snoring – leads to xerostomia (dry mouth).
  • Open root canals
  • Pathological processes within the oral cavity – e.g. tonsil stones (tonsil stones, tonsilloliths), abscesses, tumors.
  • Pemphigus – blistering skin disease.
  • Poor oral hygiene
  • Unkempt dentures
  • Xerostomia (dry mouth)
  • Gum changes – e.g. necrosis (death of tissue), gingival fibromatosis (benign proliferation of connective tissue).
  • Tongue coating

Extraoral causes

  • Bad breath from the respiratory tract
  • Bad breath from the throat, nose and ear area – e.g. chronic tonsillitis (tonsillitis), chronic sinusitis (sinusitis).
  • Bad breath from the gastrointestinal tract (digestive tract) – eg. prolonged fasting; esophageal diverticula (protrusions of the wall (diverticula) of the esophagus (esophagus)), cardia insufficiency (insufficient closure function of the cardia; Cardia closes the upper part of the stomach), gastroesophageal reflux (abnormally increased reflux of acidic gastric contents into the esophagus; GER, gastroesophageal reflux), or pyloric stenosis (narrowing (stenosis) in the area of the gastric outlet) (< 0.1% of cases)
  • Bad breath due to general diseases – e.g., diabetes mellitus, uremia (occurrence of urinary substances in the blood above normal values), liver cirrhosis (shrunken liver), purulent bronchitis, pneumonia (pneumonia), gastrointestinal diseases, tumors.

In about 90% of all cases, the cause of bad breath is the bacterial degradation of organic material in the oral cavity. The bacteria metabolize mainly proteins and excrete as a metabolic end product foul-smelling sulfur compounds – such as hydrogen sulfide (H2S), cadaverine and methyl mercaptan. Up to 41% of the cause of bad breath is found on the tongue, where up to 60% of all bacteria present in the oral cavity are located. The next most common cause is gingivitis (inflammation of the gums), with a frequency of 31%, and periodontitis, which is the cause of bad breath in 28% of patients. Smokers also exhibit a typical bad breath called smoker’s breath, which is caused by the components of tobacco.Furthermore, smokers have a high risk of developing periodontitis, which also causes bad breath. Behavioral causes

  • Diet
    • Malnutrition or undernourishment
    • Fasting cure especially under weight reduction with a diet high in protein and fat) or “starvation”.
  • Pleasure food consumption
  • Poor oral hygiene (poor dental hygiene).
  • Tongue coating

Disease-related causes

Respiratory system (J00-J99)

  • Bronchiectasis (synonym: bronchiectasis) – persistent irreversible saccular or cylindrical dilatation of the bronchi (medium-sized airways) that may be congenital or acquired; symptoms: chronic cough with “mouthladen expectoration” (large-volume triple-layered sputum: foam, mucus, and pus), fatigue, weight loss, and decreased exercise capacity
  • Lung abscess – encapsulated accumulation of pus in the lungs.
  • Pneumonia (pneumonia)
  • Sinusitis (sinusitis)
  • Tonsil stones (tonsil stones, tonsilloliths).

Endocrine, nutritional and metabolic diseases (E00-E90).

  • Coma diabeticum – comatose state due to hyperglycemia (high blood sugar) in diabetes mellitus.
  • Malnutrition / undernutrition
  • Trimethylaminuria (fish odor syndrome) – genetic disorder.

Skin and subcutaneous (L00-L99).

  • Pemphigus – refers to severe skin diseases associated with blistering.

Infectious and parasitic diseases (A00-B99).

  • Angina Plaut-Vincenti – relatively rare form of tonsillitis (tonsillitis). It is the best-known form of the so-called fusotreponematoses, which can also occur outside the tonsils (tonsils) on the pharyngeal mucosa and gums
  • Diphtheria (true croup) – infectious disease caused by infection of the upper respiratory tract with Gram-positive Corynebacterium diphtheriae.
  • Gingivostomatitis herpetica – inflammation of the gums, which has spread to the entire oral mucosa.
  • Mononucleosis (Pfeiffer’s glandular fever) – common viral disease (Epstein-Barr virus (EBV)), with benign disease of the lymphoid tissue.

Liver, gallbladder and bile ducts – pancreas (pancreas) (K70-K77; K80-K87).

  • Hepatic insufficiency/dysfunction of the liver with partial or complete failure of its metabolic functions (foetor hepaticus: intense, sweetish, and slightly fetid (“putrid”) odor reminiscent of fresh liver or even feces (feces)).

Mouth, esophagus (food pipe), stomach, and intestines (K00-K67; K90-K93).

  • Acute gingivitis (inflammation of the gums).
  • Acute necrotizing ulcerative gingivitis – severe gingivitis leading to the formation of ulcers.
  • Gastroesophageal reflux disease (synonyms: GERD, gastroesophageal reflux disease; gastroesophageal reflux disease (GERD); gastroesophageal reflux disease (reflux disease); gastroesophageal reflux; reflux esophagitis; reflux disease; Reflux esophagitis; peptic esophagitis) – inflammatory disease of the esophagus (esophagitis) caused by the pathological reflux (reflux) of acid gastric juice and other gastric contents.
  • Caries
  • Laryngopharyngeal reflux (LRP) – “silent reflux” in which the cardinal symptoms of gastroesophageal reflux, such as heartburn and regurgitation (backflow of food pulp from the esophagus into the mouth), are absent.
  • Oral abscesses – encapsulated collections of pus in the oral cavity.
  • Esophageal achalasia – dysfunction of the lower esophageal sphincter (esophageal muscles), with the inability to relax; it is a neurodegenerative disease in which nerve cells of the myenteric plexus die. In the final stage of the disease, the contractility of the esophageal muscles is irreversibly damaged, with the result that food particles are no longer transported into the stomach and lead to pulmonary dysfunction by passing into the trachea (windpipe). Up to 50% of patients suffer from pulmonary (“lung“) dysfunction as a result of chronic microaspiration (ingestion of small amounts of material, e.g., food particles, into the lungs). Typical symptoms of achalasia are: Dysphagia (dysphagia), regurgitation (regurgitation of food), cough, gastroesophageal reflux (reflux of gastric acid into the esophagus), dyspnea (shortness of breath), chest pain (chest pain), and weight loss; as secondary achalasia, it is usually the result of neoplasia (malignant neoplasm), e.g., cardiac carcinoma (cancer of the entrance of the stomach).
  • Esophageal diverticula – bulges in the muscular layer of the esophagus, in which esophageal debris can accumulate.
  • Periodontitis – inflammation of the periodontium (periodontium).
  • Stomatitis (inflammation of the oral mucosa)
  • Xerostomia – dry oral mucosa
  • Tongue coating

Neoplasms – tumor diseases (C00-D48)

  • Gastric carcinoma (stomach cancer)

Psyche – nervous system (F00-F99; G00-G99)

  • Halitophobia – sign of psychiatric disorders in which the patient has a fear of bad breath.
  • Pseudohalitosis – sign of psychiatric disorders in which the bad breath is perceived only by the affected person.

Symptoms and abnormal clinical and laboratory findings not elsewhere classified (R00-R99).

  • Cough (in case of productive cough or sputum/sputum).
  • Cachexia (emaciation)
  • Rhonchopathy (snoring)

Genitourinary system (kidneys, urinary tract – reproductive organs) (N00-N99).

  • Renal insufficiency (kidney weakness).

Injuries, poisoning, and other consequences of external causes (S00-T98).

  • Foreign body in the mouth/throat

Medications

Some medications cause bad breath directly or indirectly by producing xerostomia (dry mouth). The following medications can inhibit saliva production, leading to bad breath:

  • Antiadiposita, anorectics.
  • Antiarrhythmics
  • Antiepileptic drugs
  • Antidepressants
  • Antihistamines
  • Antihypertensives
  • Antiparkinsonian drugs
  • Antipsychotics (neuroleptics) – clozapine
  • Anxiolytics, ataractics
  • Diuretics
  • Hypnotics
  • Muscle relaxants
  • Sedatives
  • Spasmolytics

Furthermore, taking sulfur-containing drugs such as disulfiram or dimethyl sulfoxide (DMSO) can cause bad breath. Further