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Halitosis most often results from fermentation of food particles by anaerobic gram-negative bacteria in the mouth, producing volatile sulfur compounds such as hydrogen sulfide and methyl mercaptan. Causative bacteria may be present in areas of periodontal disease, particularly when ulceration or necrosis is present. The causative organisms reside deep in periodontal pockets around teeth. In patients with healthy periodontal tissue, these bacteria may proliferate on the dorsal posterior tongue.

Factors contributing to the overgrowth of causative bacteria include decreased salivary flow (eg, due to parotid disease, Sjögren syndrome, or use of anticholinergic drugs), salivary stagnation, and increased salivary pH.

Certain foods or spices, after digestion, release the odor of that substance to the lungs; the exhaled odor may be unpleasant to others. For example, the odor of garlic is noted on the breath by others 2 or 3 h after consumption, long after it is gone from the mouth.

About 85% of cases result from oral conditions. A variety of systemic and extraoral conditions account for the remainder (see table Some Causes of Halitosis).

The most common causes overall are the following:

• Gingival disorders or periodontal disease

• Smoking

• Ingested foods that have a volatile component

GI disorders rarely cause halitosis because the esophagus is normally collapsed. It is a fallacy that breath odor reflects the state of digestion and bowel function.