Table 20

Investigation and management of halitosis

InvestigationsPotential resultsClinical management plan
Actions from history, medication and dietary assessment
History findingsSmokingSmoking cessation advice.
Absence of salivaFollow guidelines for dry mouth (p. 11).
Medication findingsNitrates
Consider possible alternative options.
Dietary findingsStrong smelling foodEncourage dental hygiene.
Reduce dietary foods containing hydrogen sulphide.
First line
Visual inspection of mouthGum disease
Tooth decay
Hairy tongue
Encourage patient to visit a dentist.
Candida infectionAntifungal therapy.
Dry mouthSee page 11.
Second line
OGD and SI aspirate (p. 25)Gastric dysmotilityConsider a prokinetic (p. 26).
UlcerationBenign: 6 weeks PPI then reassess.
Malignant: as below.
Malignancy/tumour recurrenceDiscuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
Duodenal obstructionDiscuss with the supervising clinician and refer as clinically appropriate to a GI surgeon/gastroenterologist/oncology team within 24 hours.
Glucose hydrogen methane breath testSIBOManagement of SIBO (p. 27).
Third line
Contrast swallowPharyngeal pouchRefer to the ENT/oesophageal surgeon.
Fourth line
If normal investigations/no response to interventionRefer 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.