GPAtlas🧭 When to suspect
Halitosis is persistent, unpleasant breath odour – either noticed by the person themselves or reported by those around them. It is common, and is estimated to be the third most frequent reason people seek dental care, after tooth decay and gum disease.
The pivotal first step in primary care is to decide which of three problems you are dealing with, because management diverges completely depending on whether odour is genuinely present.
| Category | What it means | Broad approach |
|---|---|---|
| Genuine halitosis | Genuinely detectable malodour (physiological or pathological) | Identify and treat the source – usually oral |
| Pseudo-halitosis | The person complains of odour, but none is detectable by the clinician or by others | Reassurance, explanation and self-care – usually resolves |
| Halitophobia | Persistent fear or belief of malodour despite reassurance, examination and treatment | Acknowledge distress; consider psychological referral; avoid reinforcing the belief with more treatment |
Around 85–90% of genuine halitosis is intra-oral, caused by volatile sulphur compounds (VSCs) – chiefly hydrogen sulphide and methyl mercaptan – produced by Gram-negative anaerobic bacteria coating the posterior (back) of the tongue. Gingivitis and periodontal disease are the other main contributors. Extra-oral causes (sinonasal disease and, rarely, systemic or gastrointestinal disease) make up a small minority. Transient physiological halitosis – everyday “morning breath” – is normal and resolves with eating, drinking or brushing.
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🧠 Clinical pearl – it is the mouth, not the stomach Patients (and sometimes clinicians) instinctively blame “the stomach”, but isolated halitosis is rarely due to reflux or Helicobacter pylori, and true extra-oral causes are uncommon. Examine the posterior tongue and the gums first – that is where the answer almost always lies. |
Source: NICE · NICE NG12
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