Investigation and management of halitosis
| Investigations | Potential results | Clinical management plan |
|---|---|---|
| Actions from history, medication and dietary assessment | ||
| History findings | Smoking | Smoking cessation advice. |
| Absence of saliva | Follow guidelines for dry mouth (p. 11). | |
| Medication findings | Nitrates Phenothiazines8 | Consider possible alternative options. |
| Dietary findings | Strong smelling food | Encourage dental hygiene. Reduce dietary foods containing hydrogen sulphide. |
| First line | ||
| Visual inspection of mouth | Gum disease Tooth decay Hairy tongue | Encourage patient to visit a dentist. |
| Candida infection | Antifungal therapy. | |
| Dry mouth | See page 11. | |
| Second line | ||
| OGD and SI aspirate (p. 25) | Gastric dysmotility | Consider a prokinetic (p. 26). |
| Ulceration | Benign: 6 weeks PPI then reassess. Malignant: as below. | |
| Malignancy/tumour recurrence | Discuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks. | |
| Duodenal obstruction | Discuss with the supervising clinician and refer as clinically appropriate to a GI surgeon/gastroenterologist/oncology team within 24 hours. | |
| Glucose hydrogen methane breath test | SIBO | Management of SIBO (p. 27). |
| Third line | ||
| Contrast swallow | Pharyngeal pouch | Refer to the ENT/oesophageal surgeon. |
| Fourth line | ||
| If normal investigations/no response to intervention | Refer to oral medicine. | |
ENT, ear, nose and throat; GI, gastrointestinal; MDT, multidisciplinary team; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PPI, proton pump inhibitor; SIBO, small intestinal bacterial overgrowth.