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Rapid Responses: Rapid Responses published:
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GORD and Halitosis
- Deepak Kejariwal (25 September 2006)
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halitosis and lung abscess
- gordon j archer (27 September 2006)
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Halitosis
- Sureyya Cross (28 September 2006)
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Re: GORD and Halitosis
- Stephen R Porter, Crispian Scully (3 October 2006)
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Re: halitosis and lung abscess
- Stephen R Porter, Crispian Scully (3 October 2006)
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Re: Halitosis
- Stephen R Porter, Crispian Scully (3 October 2006)
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Halitosis: don’t forget to examine the hypopharynx
- Shahram Anari, Helen C. Richardson (8 October 2006)
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Re: Halitosis: don’t forget to examine the hypopharynx
- Stephen R Porter, Crispian Scully (9 October 2006)
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Deepak Kejariwal, SpR, Gastroenterology Norfolk & Norwich University Hospital, Norwich NR4 7UY
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In their clinical review on halitosis Porter and Scully mentions Gastro-oesophageal reflux disease (GORD) as one of the systemic causes of oral malodour. Bad breath almost never arises from the oesophagus, stomach, or intestines. The oesophagus is normally collapsed and closed; an occasional belch may carry odour up from the stomach, but the possibility of air escaping continuously is remote. Thus, gastroscopy should never be performed solely for the complaint of bad breath in an otherwise healthy ambulatory patient.(1) Although recent studies suggest that GORD may contribute frequently to ear, nose and throat (ENT) diseases, the cause-and-effect relationship is far from proven.(2) Establishing a correlation between GORD and airway (ENT and pulmonary) disorders has been hampered by the fact that both commonly occur in the general population and by the suggestion that the majority of patients with reflux related ENT manifestations do not report classical reflux symptoms such as heartburn and regurgitation.(3) The author’s suggestion thus may lead to unnecessary gastroscopies for halitosis. 1.Rosenberg M. Clinical assessment of bad breath: current concepts. J Am Dent Assoc 1996 Apr; 127(4):475-82. 2.Richter JE. Ear, nose and throat and respiratory manifestations of gastro-esophageal reflux disease: an increasing conundrum. Eur J Gastroenterol Hepatol. 2004 Sep; 16(9):837-45. 3.Poelmans J, Feenstra L, Demedts I et al. The yield of upper gastrointestinal endoscopy in patients with suspected reflux-related chronic ear, nose and throat symptoms. Am J Gastroenterol 2004; 99:1419- 26. Competing interests: None declared |
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gordon j archer, consultant physician alexandra hospital cheadle stockport
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I was surprised to see that this review of halitosis did not mention lung abscess. Most chest physicians(particulary the more senior} are well aware of the very pronounced and foul smelling halitosis associated with lung abscess to the extent it was almost regarded as a diagnostic sign. Gordon Archer
Competing interests: None declared |
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Sureyya Cross, GP Norway
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Very good article, but, I get quite often a test result from microbiology dpt as Candida albicans from patients who complain about halitosis. I am surprised its not mentioned here. Competing interests: None declared |
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Stephen R Porter, Professor of Oral Medicine UCL Eastman Dental Institute, 256 Grays Inn Road, London WC1X 8LD, Crispian Scully
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Authors’ response Dr Kejariwal raises an interesting point concerning gastro- oesophageal reflux disease (GORD) as a potential cause of oral malodour. He is correct that this is a very unlikely cause of this symptom, hence why we only mention this within a table of possible causes of oral malodour. As detailed in our review, oral malodour predominantly arises from the mouth, usually as a consequence of oral disease, and hence investigation should be focused upon the oral cavity. We did not suggest that detailed systemic investigation was warranted, and indeed without sufficient clinical evidence we would not consider investigation of the gastro-intestinal tract to be justifiable in a patient with oral malodour. SR Porter
Competing interests: None declared |
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Stephen R Porter, Professor of Oral Medicine UCL Eastman Dental Institute, Crispian Scully
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Authors’ response Dr Archer is of course correct, although oral malodour is not always cited as a feature of lung abcess, presumably as the other clinical features predominate and/or are more relevant to appropriate diagnosis. While lung infection may give rise to oral symptoms such as oral malodour it is interesting to note that oral infection may give rise to pulmonary infection – indeed some antimicrobial therapies for oral malodour (e.g. chlorhexidine) may lessen the risk of ventilator-associated pneumonia (1) 1. Koeman M, van der Ven JAM, Hay, E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006; 173:1348-55 SR Porter C Scully Competing interests: None declared |
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Stephen R Porter, Professor of Oral Medicine UCL Eastman Dental Institute, 256 Grays Inn Road, London, WC1X 8LD, Crispian Scully
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Authors’ response: Dr Cross raises an interesting notion, but there is no evidence that candidal infection predisposes to oral malodour. For example patients with dentures, some of whom may have candida-associated denture associated stomatitis (1,2), do not seem to have an increased frequency of halitosis. Likewise Chronic mucocutaneous candidosis, which gives rise to a spectrum of acute and chronic candidal infection of the mouth, is not known to give rise to oral malodour (3). Of course persons with oral candidal infection, particularly pseudomembranous candidosis (thrush) may have oral malodour as a consequence of any underlying disease (e.g. xerostomia). 1. Verran, J. Malodour in denture wearers: an ill-defined problem. Oral Dis 2005; 11 (suppl 1): 24-8 2. Lamfon, H, Al-Karaawi, Z, McCullough, M, Porter SR, Pratten J. Composition of in vitro denture plaque biofilms and susceptibility to antifungals. FEMS Microbiol Lett. 2005; 242:345-51. 3. Porter, SR, Scully, C. Orofacial manifestations in primary immunodeficiencies: T lymphocyte defects. J Oral Pathol Med. 1993; 22:308-9. SR Porter
Competing interests: None declared |
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Shahram Anari, Specialist registrar in Otolaryngology The James Cook University Hospital, Middlesbrough, TS4 3BW, Helen C. Richardson
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Sir, We read with interest the review article on halitosis by Porter and colleagues(1) where authors presented a useful overview of the aetiology, diagnosis and management of this condition. However, we feel that examination of the larynx and hypopharynx has been largely ignored. The importance of ruling out oro-pharyngeal malignancy in halitosis was raised previously(2) in a response to the authors’ earlier editorial on halitosis in this journal(3). Although malignancies of the larynx and hypopharynx do not solely present with halitosis, they must not be overlooked(4). A thorough examination of the hypopharynx and larynx (preferably by fibreoptic laryngoscope) is an important step in the investigation of halitosis; failure to identify an otherwise asymptomatic malignancy might occur otherwise. Laryngopharyngeal reflux has been associated with halitosis(5) and certain non-pathognomonic laryngeal and hypopharyngeal signs have been attributed to this condition(6). Fiberoptic examination of the larynx/hypopharynx can easily detect hypertrophied lingual tonsils which are a known consequence of the laryngopharyngeal reflux(7). Food residue trapped in vallecula because of hypertrophied lingual tonsils could be a possible source of halitosis. There is no doubt that oral and dental problems play a major role in halitosis but a multidisciplinary approach involving periodontologists, internalists, otolaryngologists and psychologists is the ideal way forward(8,9). This is especially helpful in cases where no obvious oro- dental causes are discovered. Shahram Anari MD, MRCS; Helen C. Richardson FRCS (ORL-HNS), Dipl Clin Ed Department of ENT, The James Cook University Hospital, Middlesbrough, UK 1. Porter SR, Scully C. Oral malodour (halitosis). BMJ. 2006; 333: 632-5 (23 September) 2. Richardson H, Prichard AJN. Managing halitosis through history and examination are important. BMJ. 1994; 308: 652 3. Scully C, Porter S, Greenman J. What to do about halitosis. BMJ. 1994; 308: 217-8 4. Mesolla M, Motta G, Galli V. Chondrosarcoma of epiglottis: report of a case treated with CO2 laser epiglottectomy. Acta Oto-Rhino-Laryngologica Belgica. 2004; 58(1): 73-8 5. Karkos PD, Thomas L, Temple RH, Issing WJ. Awareness of general practitioners towards treatment of laryngopharyngeal reflux: a British survery. Otolaryngology-Head & Neck Surgery. 2005; 133(4): 505-8 6. Hicks DM, Ours TM, Abelson TI, Vaezi MF, Richer JE. The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers. J Voice. 2002; 16(4): 564-579 7. Mamede RC, de Mello-Filho FR, Vigaro LC, Dantas RO. Effect of gastroesophageal reflux on hypertrophy of the base of the tongue. Otolaryngol. Head Neck Surg. 2000; 122: 607-10 8. Bollen CM, Rompen EH, Demanez JP. Halitosis: a multidisciplinary problem. Revue Medicale de Liege. 1999; 54(1): 32-6 9. Delanghe G, Ghyselen J, Feenstra L, van Steenberghe D. Experiences of a Belgian multidisciplinary breath odour clinic. Acta Oto-Rhino- Laryngologica Belgica. 1997; 51(1): 43-8 Competing interests: None declared |
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Stephen R Porter, Professor of Oral Medicine Oral Medicine, UCL Eastman Dental Institute, 256 Grays Inn Road, London, WC1X 8LD, UK, Crispian Scully
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Authors' response: We would agree completely that appropriate additional specialist advice/investigations be undertaken where no obvious oro-dental cause is established for objective oral malodour that. As noted by Anarai and Richardson a variety of malignant and non-malignant laryngeal and hypopharyngeal lesions may be sources of malodour and that appropriate investigation may be warranted. SR Porter
Competing interests: None declared |
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