What causes halitosis? Is there any association between Helicobacter pylori and chronic bad breath? Will eradication of H. pylori eliminate chronic halitosis?
—Felix N. Chien, DO, Newport Beach, Calif.

The exact incidence of halitosis is not known, but a preliminary report of a study that measured oral malodor in 88 adults before breakfast and morning toothbrushing, etc., concluded that 20%-40% of adults suffer from morning bad breath (Oral Dis. 2005;11 Suppl 1:105-106). Bad breath originates in the mouth in 85%-90% of ambulatory patients (Lancet. 1997;350:187) and is thought to be largely due to volatile sulfur compounds that probably arise from bacterial accumulation between the teeth and from the posterior part of the tongue. Less frequently, halitosis originates in the nose (secondary to sinusitis or polyps obstructing mucus drainage) or tonsils (from tonsillolith collections) or results from other causes.

Some data suggest that H. pylori may be associated with halitosis, but it is not clear whether treatment-related improvement in halitosis resulted from eradicating the H. pylori per se or whether antibiotics nonspecifically improved bacterial overgrowth in the oral cavity. In a recent study, 148 H. pylori-positive patients with endoscopically confirmed non-ulcer dyspepsia halitosis (identified by self report and confirmed by family members) significantly improved after eradication of the bacteria (61.5% of patients to 2.7%, P <.001) (Eur J Intern Med. 2003;14:45-48). A more recent study from Argentina also found an association between H. pylori and halitosis (Helicobacter. 2005;10:312-317). In this study, 87% (40/46) of patients with burning, halitosis (measured by a Halimeter), and lingual hyperplasia had biopsy-proven H. pylori in the oral cavity compared with only 2.6% (2/78) in the control group (P <.001). Whether correlation implies causation here is not yet known.
—Daniel G. Tobin, MD (109-11)

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