Banishing bad breath – includes related information on related disorders that cause bad breath, along with how to treat it
Dentists and physicians refer to it as “fetor ex oris,” “halitosis” or “oral malodour,” but friends and relatives probably just call it “bad breath.” Whatever name it goes by, malodorous breath can be very distressing and a social handicap; it’s been known to ruin many a love affair. Over half the population has occasionally bad-smelling breath, often on first awakening — especially after a heavy garlic- or onion-laden meal, or following an evening of alcoholic partying. In efforts to freshen the breath, millions are spent each year on over-the-counter gums, sprays and mouthwashes — most of which do little good. Since bad breath is mostly due to bacterial putrefaction in an unclean mouth, it can often be remedied by better mouth cleaning. But for some, the malodour is a tenacious problem that’s hard to control. It can arise from periodontal (gum) disease, lung infections and occasionally from systemic diseases such as diabetes, liver or kidney disorders.
Sufferers often unaware of having bad breath
According to television commercials, the scary or worst thing about bad breath is “not knowing you have it.” In many cases, people remain oblivious to their offensive breath through a phenomenon called “adaptation.” The cells in the nose responsible for smell become unresponsive to the continuous stream of bad odour. Halitosis sufferers may only get the message from the body language of others — who recoil at the smell as they speak — or they may realize they have bad breath only when friends or colleagues mention it. People may need to be tactfully told they have bad breath by a concerned friend or relative, or by their dentist. (You can do a “self-check,” by licking your wrist, letting it dry for a few seconds and smelling the area, or by cupping the hands over the mouth and sniffing your own breath). Owing to the stigma, people with bad breath may go to bizarre lengths — CAT scans, enemas, root canal jobs, even total tooth removal — to eliminate the malodour. “I’ve treated people who have altered career paths because of halitosis,” says one periodontist. “For example, one woman passed up medical school because she was aft-aid of offending patients.”
Mouth problems usually to blame
Over 90 per cent of bad breath originates in the mouth, due to bacterial activity. Causes include poor tooth and tongue-cleaning, periodontal disease, mouth or throat infections, unclean dentures or poorly fitting dental restorations. The primary cause of bad breath is uncontrolled growth of so-called Gram negative or anaerobic bacteria — which grow “without oxygen” — on protein-rich food remnants and waste matter stuck between the teeth or on the tongue. As the debris rots, the bacterial breakdown of proteins containing sulphur gives off foul-smelling gases, mainly methylmercaptan and hydrogen sulphide. When exhaled, these sulphurous gases have the familiar smell of bad breath. It is simple to check whether poor mouth care is to blame: don’t brush your teeth for a day or two and se what happens — the bad smell is due to bacterial putrefaction. But many people with immaculately clean mouths still have foul-smelling breath — so while it can help, oral hygiene isn’t the whole answer.
Saliva also plays a role
Besides the type and number of bacteria in the mouth, breath odour also varies according to the amount of saliva and its “pH” (acidity or alkalinity). Lack of saliva (which allows bacteria to colonize the teeth and tongue) and an alkaline environment increase the production of offensive mouth gases. Saliva irrigates the mouth, flushing out sulphur compounds, so anything that dries the mouth can create a bad odour. A condition called “dry mouth” reduces saliva and causes bad breath. Talking also dries the mouth. Many teachers, for instance, have dry mouths because they talk all day — which can also happen to those who chat endlessly on the phone. Other factors that contribute to mouth dryness are prolonged exercise, throat or sinus infections, mouth breathing (perhaps because of a cold or inflamed tonsils), stress and dehydrating medications. Anything that gets the saliva flowing and moistens the mouth can help to abolish bad breath — for example, eating citrus fruits, sucking lemon drops or eating celery or other high-fibre foods. (See Health News, October 1995 issue for more on dry mouth.
Food choices and hunger can produce bad breath
Bad breath is notoriously caused by certain foods — for instance, garlic, onions and some fish — and by diets rich in fat and meat. When these foods are digested, the smelly metabolites pass to the lungs where they are exhaled. In one study, even rubbing garlic on the feet led to bad breath! Missing meals, hunger fasting, starvation and low-calorie diets can also cause malodorous “hunger breath,” as the breakdown products of body proteins used for energy are exhaled.
Psychiatric and neurological reasons
Psychiatric disorders such as depression or delusions, may appear to cause bad breath, but often are just imagination — or due to medications taken. Some people are unshakably convinced they have foul breath, although no one else, not even the examining physician notices it. Such people may have psychiatric problems which lead to olfactory hallucinations that make them think they are “emitting bad smells.” Such olfactory hallucinations may be caused by temporal lobe epilepsy or schizophrenia. People with hypochondriacal psychoses may be preoccupied with imagined bodily defects and think they give off offensive odours. Convinced they have unremitting bad breath — arising from sweat, intestinal gas or other causes — such people may try to guard others from the smell by avoiding all social contact. They may forever apply deodorants, wash their clothes or compulsively use mints, mouthwashes and oral sprays.
Diagnosis: Pinpointing causes can be a “stumper”
Everyone has occasionally foul-smelling breath, but for some it’s a persistent and devastating problem. While halitosis may be due to tooth, gum or other mouth problems — sometimes remedied by good oral care — tracing the causes can be baffling. A visit to the dentist is a first step in distinguishing oral from non-oral causes. Bad breath may be diagnosed in the old-fashioned way — organoleptically by the nose (smelling or “sniff”) test — describing a person’s breath, as sour, putrid, musty, garlicky, sweet or whatever. New devices, becoming common in dental offices, can analyze gases emanating from the mouth and may help trace the causes of bad breath. People breathe into a shoebox-sized device called a “halimeter,” and a read-out tells them the amount of sulphurous gases given off. But these devices have a narrow range and can only reliably detect hydrogen sulphide, not mercaptans — the more obnoxious gases — nor yeast odours, so their use can be misleading. Although a dentist might identify the source of halitosis, diagnosis may require a thorough medical work-up to trace its origins — perhaps a lung or throat infection, diabetes, digestive disturbance or liver disorder.
Treatment: getting rid of bad breath
Since the most common cause of bad breath in otherwise healthy people is overgrowth of bacteria and “mouth neglect,” the first step in remedying it is to locate its origins and improve mouth care. Dentists and dental hygienists can advise on oral hygiene (how to brush and floss the teeth), can detect and treat gingivitis, periodontitis and other mouth disorders, refit poorly fitting dentures and crowns, and refer people to other specialists. Dentists or hygienists can also advise on dental prophylaxis — the number and type of professional tooth cleanings and dental check-ups needed.
Management of bad breath includes attention to diet, avoiding anything known to cause the malodour. “Hunger breath” is avoided by eating regularly. Anything that promotes saliva flow, chewing and tongue action can reduce mouth malodour (even if it’s only gum or parsley). Strategies may include eating oranges or other citrus (acidic) fruits, chewing fibrous vegetables (such as celery), sucking lemon drops or chewing sugarless gum. One dentists notes that “rinsing with lots of tap water may not be helpful as it washes away the protective saliva and may worsen rather than diminish the odour.” Medications that are mouth-drying (such as antihistamines, antidepressants, anticoagulants) might be replaced with other, less drying forms. Persistent bad breath may require the attention of a periodontist, otolaryngologist, halitosis expert or other specialist.
How about mouthwashes and rinses?
Besides scrupulous oral hygiene, special mouthwashes, mints and gum-chewing can temporarily relieve bad breath, but most just mask the odour and last no more than 10-30 minutes. Chlorophyll-containing products don’t appear to be much help. While Scope mouthwash, for instance, claims to “kill the germs that cause bad breath,” it is not so simple, as plaque (a mixture of debris and bacteria) stakes out countless hideouts in the mouth that mouthwashes can’t reach. Regardless of why the bacteria are in the mouth, the smelly compounds they emit put up a tough fight against regular mouthwashes. A 1992 Consumer Reports test of 15 mouthwashes found that they masked odour only for 10 minutes to an hour at most. Alcoholic mouthwashes are best avoided because they dry the mouth.
Dentists recommend two bactericidal mouthwashes that “kill the bacteria that cause bad breath” (as the ads say). They are Listerine[TM] (available over the counter) and, for more serious cases, a prescription mouthwash, chlorhexidine gluconate, which can abolish bad breath for as long as eight hours, especially effective for periodontal disease. Recent studies show that 0.2 per cent aqueous chlorhexidine can dramatically reduce bad breath — judged both subjectively and by measuring sulphurous emissions. Some use it once a day, others twice daily. Side effects of chlorhexidine include a transiently bitter aftertaste, temporarily stained teeth, which may require regular cleanings by a dental expert, and — rarely — an allergic reaction.
In sum, dentists and hygienists usually recommend a daily regimen of tooth brushing, flossing and tongue-scraping, and — for bad cases — rinsing with a chlorine mouthwash. Those with persistent mouth malodour should consult a specialist or bad breath clinic, if they can find one!
RELATED ARTICLE: “Early morning” bad breath common
In a healthy person’s mouth, the odour varies at different times of day, according to the foods consumed and when the last meal was eaten. One reason why many people experience “morning breath” is that the mouth dries out at night, the flow of saliva decreases and the mouth becomes more alkaline, allowing gases to build up. The reduction of saliva and cessation of chewing encourage bacterial putrefaction. By morning, the breath often smells bad. As people begin to eat, drink and talk, saliva flows again and the breath becomes fresher. Brushing the teeth and chewing gum during the day can also sweeten the breath.
RELATED ARTICLE: Disorders that cause halitosis include:
* gum diseases (such as gingivitis and periodontitis) — producing a characteristic “fetid” odour – a common cause;
* dry mouth or xerostomia;
* Sjogren’s syndrome (an autoimmune disease);
* chronic nose, throat and sinus infections;
* breathing through the mouth — perhaps because of enlarged tonsils or adenoids;
* foreign objects stuck in the nose, causing inflammation — as with children who stuff bits of toys, peanuts or other small objects into the nostrills’
* mouth infections (e.g., candidiasis — with a typically “fruity” smell);
* lung disorders, e.g., tuberculosis and bronchiectasis;
* mouth abscesses or cancer;
* general infections with fever, e.g., typhoid fever;
* starvation, fasting, hunger, skipping meals;
* vitamin or mineral deficiencies, e.g., lack of vitamins A or B12, or of dietary zinc or iron;
* leukemia — with an odour of decaying blood;
* diabetes mellitus — with a sweet or “acetone-like” smell;
* liver disease — producing breath smelling like “rotten eggs”;
* kidney disease — with a typically fishy mouth odour;
* gastrointestinal problems such as heartburn — rare cause;
* anxiety and stress;
* medications that reduce salivary flow such as antidepressants, antipsychotics, antihistamines, decongestants and some blood pressure drugs.
RELATED ARTICLE: Tips for banishing bad breath:
* Brush the teeth at least three times a day, and floss once daily;
* Clean the tongue before bedtime by scraping with a plastic tongue-cleaner or brushing gently;
* Eat regular meals to prevent “hunger breath:” and avoid fasting;
* Try the baking soda solution: brush the teeth with baking soda toothpaste (which can be abrasive to sensitive gums);
* Use a Water Pik[TM] — to help clean the mouth, perhaps with added baking soda, which changes the pH acidity) of the mouth and can be especially helpful for gingivitis;
* Keep the nose and sinuses clean;
* Stimulate saliva flow with acidic fruits — such as oranges and lemons, — or sugarless citric gums and candy;
* Use an oil-and-water mouthwash made with a mixture of Listerine[TM] or Cepacol[R] and olive oil, gargled and spat out three times a day;
* Try another mouthwash that is half hydrogen peroxide and half water, used as a rinse, not a gargle;
* Avoid certain foods such as onions, garlic, peppers, spicy salami and strong cheeses if they cause malodour;
* Chew fibrous vegetables such as parsley and wintergreen, to stimulate saliva flow (especially after eating onions or garlic);
* Know your medications — ask whether they dry the mouth (as happens with antidepressants, antihistamines, diuretics, decongestants and many blood pressure and heart medications); consider alternatives.
RELATED ARTICLE: Don’t forget to clean your tongue!
Many people neglect to clean the tongue although it is a common cause of halitosis. Tiny hairs on the tongue trap food debris and, although it appears smooth, its surface is etched with grooves and crevices in which plaque and bacteria can collect and give off foul-smelling gases. “Tongue-scraping is a key part of oral hygiene in some cultures,” says one dentist. “No Arab or Indian would think of leaving home without scraping the tongue.” One expert from Toronto’s Fresh Breath Clinic notes that “the tongue may naturally have a white coating, which is no cause for alarm, but as a general rule, the rosier or more pink it is, the healthier.” Brushing or scraping the tongue should be part of the daily mouth-care routine and may be as or more effective than toothbrushing in freshening the breath.
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