These recommendations (including the management of people with suspected pseudo-halitosis or halitophobia) are based on published narrative reviews on halitosis or oral malodour [Rosenberg, 1996; Coventry et al, 2000; Morita and Wang, 2001; Messadi and Younai, 2003; Scully and Felix, 2005a; Porter and Scully, 2006; Lee et al, 2007; Hughes and McNab, 2008; Scully and Greenman, 2008; van den Broek et al, 2008].

Oral hygiene measures

• The recommendation for oral hygiene measures is based on expert opinion and aims to reduce the accumulation of debris and bacteria in the mouth.

Referral to a dentist for people with halitosis

• The recommendation to consider referring all people with halitosis (including people without pathological causes) is based on feedback from some CKS expert reviewers. This is because some oral diseases (such as periodontitis) may be difficult to diagnose by visual examination alone.

Treatments for halitosis that are not recommended

• Empirical antibiotic treatment
• In the absence of oral or dental infection, empirical antibiotic treatment (such as metronidazole 200 mg three times daily for 7 days) should only be initiated by a specialist; antibiotics may be used for recalcitrant cases of halitosis, to eliminate unidentified anaerobic infections [Coventry et al, 2000; Scully and Greenman, 2008].
• Helicobacter pylori eradication
• H. pylori has been implicated as a cause of halitosis, but the evidence for this is sparse [Scully and Felix, 2005a].
• Although evidence from two very small trials reported improvement in halitosis following H. pylori eradication therapy in people with dyspepsia, these results should be interpreted with caution, given that [van den Broek et al, 2008]:
• These trials generally did not examine the participants for oral causes of halitosis.
• The reduction or disappearance of halitosis after eradication therapy could be due to the simultaneous eradication of halitosis-producing bacteria in the oral cavity.