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Inside Dentistry
May 2008
Volume 4, Issue 5

Self-Reported Halitosis And Gastro-Esophageal Reflux Disease In The General Population.

Struch F, Schwahn C, Wallaschofski H, Grabe HJ et al. J Gen Intern Med. 2008;Jan 15 (Epub ahead of print).


OBJECTIVES: It is unclear whether gastroesophageal reflux disease (GERD) is a risk factor for halitosis. DESIGN AND PATIENTS/PARTICIPANTS: We studied this possible relationship in the general population using the cross-sectional Study of Health in Pomerania (SHIP). Employing structured interviews, self-reported halitosis was assessed among 417 edentulous (toothless) subjects aged 40 to 81 years and among 2,588 dentate subjects aged 20 to 59 years. The presence of heartburn or acid regurgitation (GERD-related symptoms) at 4 levels (absent, mild, moderate, severe) was taken as exposure and used for logistic regression. Analyses were adjusted for relevant confounders, such as age, sex, depressive symptoms, history of chronic gastritis, history of gastric or duodenal ulcer, smoking, school education, and dental status. MEASUREMENTS AND MAIN RESULTS: We found a strong positive association between GERD-related symptoms and halitosis (odds ratio 12.94, 95% confidence interval (CI) 2.66-63.09, P = .002 for severe compared to no GERD-related symptoms) in denture-wearing subjects and a moderate, positive association between GERD-related symptoms and halitosis (odds ratio 2.24, 95% CI 1.27-3.92, P = .005) in dentate subjects with a clear dose-effect relationship. CONCLUSIONS: The present study provides clear evidence for an association between GERD and halitosis. As there are effective treatments for GERD, these results suggest treatment options, such as proton pump inhibitors, for halitosis. These should be studied in randomized controlled trials.

Halitosis is caused mainly by tongue coating and periodontal disease. Bacterial metabolism of amino acids leads to metabolites including many compounds, such as indole, skatole, and VSCs, hydrogen sulphide, methyl mercaptan, and dimethyl sulphide. They are claimed to be the main etiological agents for halitosis. Gastrointestinal diseases are also generally believed to cause halitosis. This study provides further evidence that besides the dental conditions that contribute to halitosis, dentists and dental hygienists need to look at all possible sources of bad breath. While oral conditions contribute significantly to bad breath, acid regurgitation (GERD) can produce oral malodor. It is important that once oral conditions such as periodontal disease and defective restorations are treated and oral malodor persists, other medical conditions be considered to relieve the patient’s symptoms of bad breath. If GERD is contributing to halitosis, the use of treatment options such as proton pump inhibitors and other acid-reflux disease medications be considered by referring the patient to their physician for diagnosis and treatment.

Howard E. Strassler, DMD
Howard E. Strassler, DMD
Professor and Director of Operative Dentistry
Department of Endodontics, Prosthodontics and Operative Dentistry
University of Maryland Dental School, Baltimore, Maryland

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