Causes of halitosis

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
Tonsillitis	Enlarged, erythematous tonsils; associated fever and enlarged anterior cervical lymph nodes
Peritonsillar abscess	Swollen, fluctuant tonsil, with deviation of the uvula; drooling; trismus
Chronic caseous tonsillitis with or without tonsilloliths	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

GERD: gastroesophageal reflux disease.
* Organoleptic testing is a subjective process in which the clinician scores the strength of the odor from the mouth (possibly including samples from the tongue, teeth, or dentures) and nose.
¶ The list of drugs that can cause dry mouth is extensive. Included are diuretics, antihistamines and decongestants, tricyclic antidepressants, and amphetamines.

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Causes of halitosis