Bad breath, also called halitosis is defined as the offensive scent of the air exhaled. The most common description is that it stinks like rotten eggs or decaying cabbage. Bad breath nixes good rapport socially and professionally – you can practically kiss your self-image good-bye.
The overwhelming breath that turns people off is embarrassing and frustrating especially if you brush teeth and tongue three times a day, floss after every meal, experiment with all sorts of mouthwashes and chew gums that promise fresh breath. Regular dental care is not enough for this universal health problem. A close look into the symptoms, causes, lifestyle changes and novel modes of treatment is the strategic first move to banning bad breath for life.
Your mouth, the direct cause of 90% of bad breath cases is home to 50 million good and bad bacteria, belonging to 800 species constantly engaged in germ warfare. Some of these normal flora are aerobic (requires oxygen) while others are anaerobic (dies in the presence of oxygen). In healthy mouth conditions these two groups exist in balance; the good bacteria are able to secrete enough natural microbial to neutralize the offensive odor caused by the bad anaerobic bacteria and its metabolites.
Bad breath is a universal health problem and occurs when this delicate balance is tipped by a number of causes such as infections, stress, underlying medical conditions, extreme dieting and of course, poor oral hygiene among others. Statistics vary from affecting 1 out of every 3 adults to 50% of the adult population in varying degrees. No wonder store shelves are overflowing with gum, mints, mouthwashes and other products designed to combat this condition. Many of these are temporary cosmetic measures; fortunately, science hand-in-hand with Mother Nature has come up with effective weapons guaranteed to keep bad breath at bay.
Some people are not aware that they have foul breath; others can “smell” their own breath even when others can’t. Others have a pretty good idea because friends reflexively lean back whenever they whisper something up close and personal. There is a stigma surrounding it because of the unfair assumption of poor hygiene. This is a myth, as is the belief that those with scrupulous oral habits and sparkling teeth automatically have “baby’s breath”.
Those with tooth decay and gum disease can smell the odor of decay and blood even if they don’t cup their hand over their mouth and inhale. The mouth, nose and throat are actually contiguous chambers so any odor, even from beyond the gag reflex area in the oral cavity reaches the nose easily. Biofilm (similar to sludge) in the oral cavity is composed of mucus, cells, saliva, blood and bacteria-encrusted plaque. Bacteria in the biofilm eat whatever food debris is available and consequently release VSC (volatile sulfur compound), the substance that reeks of rotten eggs. More food equals faster bacterial growth. Other agents like diamines and short chain fatty acids also cause bad breath but only VSCs are measurable in the clinical setting and laboratories. Laboratory results make diagnosis a breeze and gives clues to the culprits behind the offensive breath.
When to see a Dentist and What to Expect
When masking bad breath with alcohol-based mouthwash, flossing and vigorous brushing are ineffective – even after swearing off sweets, milk, alcohol and tobacco, it’s time to pay your dentist a visit. A thorough oral examination and history are usually enough to make the diagnosis. The truth is, even a whiff of the breath that figuratively “blows you away” should be enough to get you on the dental chair.
According to the Mayo Clinic, morning appointments are best. To avoid masking of odors, don’t brush your teeth, smoke, chew gum, eat, drink beverage other than water, use scent or lipstick/gloss for three hours prior to your appointment. It’s also best not to have taken antibiotics or dieted prior to your check-up. Extreme dieting can give you foul breath doctors call “ketone” breath. Some of the questions likely to be asked are:
- Oral hygiene practices (brushing, flossing)
- Food preferences
- Dental appliance (e.g. dentures, braces, retainers)
- Lifestyle issues: Cigarette smoking, alcohol intake, drugs
- Associated or coexisting medical conditions (e.g. diabetes, allergies, frequent throat infections)
- Medications (some may cause drying of the mouth; antibiotics alter the normal flora balance)
- History of mouth breathing, snoring
The simplest and cheapest way to assess whether or not you have bad breath is to see a dentist who sniffs your breath and tries to localize whether the bad smell is from the mouth or nose. Scraping from the back of your tongue near the throat will be taken as well. This initial evaluation will be rated from a scale of 0-5 with 0 as none or minimal odor, and 5 as extremely foul-smelling. History of tongue coating and tonsil stones are diagnostic as well. This coating can be from fungal or bacterial overgrowth. Mouth sores though initially of viral origin, may be secondarily infected by bacteria. Prolonged use of antibiotics kills off not just the bad but the good bacteria in the mouth and shifts the balance towards fungal overgrowth. Apart from the factors localized in the mouth area, the dentist will check for any significant medical history (e.g. digestive system, diabetes) and drug use that can cause or contribute to oral dryness.
Other tests may include:
1. B-galactosidase test identifies the presence of Actinomycetaceae and other associated bacteria largely responsible for periodontal disease and dental caries.
The BANA-test is a very sensitive, simple, user-friendly and inexpensive test for bad breath and gum disease whose basis is the presence of three anaerobic species found in plaque and associated with periodontal disease Trepobena denticola, Porphyronomas gingivalis and Bacteroides forsythus are capable of hydrolyzing benzoyl-DL-arginine-naphthylamide (BANA). A sample placed on a BANA strip turns blue within 24 hours if positive.
3. Portable Electronic and Gas Chromatography Breath Checker
The over-the-counter breath checker is a multi-tasking electronic gadget which is convenient and discreet to use. You simply blow into it and the LED lights up with results ranging from 1-6, with 1 as fresh breath and 6 as offensive. It can detect alcohol levels as well. Clinic-based breath analysis machines using gas chromatography techniques similar to those you see on CSI (Crime Scene Investigation television series) are extremely sensitive and can actually measure sulfur emissions as low as 1 parts per billion. Researchers studying the effects of periodontal disease or periodontitis at the Aristotle University of Thessaloniki classify patients as halitosis+ when readings are over 140 parts per billion. In a manner of speaking, this machine acts like a Geiger machine that reacts to gas emissions instead of radiation – odor quality and location in the mouth points to the likely bacterial cause.
Other qualitative indicators:
Scraping the back of the tongue with a tongue depressor and smelling it is a good test. You can also lick a strip of paper and smell it after it dries out. Bad taste described as metallic, bitter or sour is from protein breakdown caused by the bacteria. Tonsil stones are coagulated mass of mucus and bacteria that are lodged in the throat and get coughed out. These indicate nasal secretions and usually a good indicator of bad breath. To rule out the presence of medical diseases as the primary cause of halitosis, a physician can perform the following based on the history:
- Blood Tests
- Chest and Abdominal X-Ray
Causes of Bad Breath
In the germ war between the good probiotics source such as Streptococcus salivarius K12 and the breath foulers Trepobena denticola, Porphyronomas gingivalis, Bacteroides forsythus among others, bad breath results when the bad bacteria wins. Bad breath can also be a sign of other respiratory and gastric diseases.
Poor Oral Hygiene, Gingivitis and Dental Caries
Bad breath can be a function of anatomy – tiny left-over food particles composed of proteins, fats and partially digested carbohydrates, can lodge between the teeth and gums as well as on the surface, back and sides of the tongue. These particles congealing with mucus and saliva encrust the rims of the teeth with plaque. Plaque is initially curd-like but hardens to cement-like consistency. The entrapped bacteria continue to feed on the debris and in the breakdown process, release sulfur-based gases (VSC). Poor oral hygiene can be remedied by brushing teeth and tongue frequently, flossing after every meal, using probiotic dental products, gargling and cleaning dental appliances thoroughly. However the germ pockets that collect between the gum and teeth and dental caries should be treated by a professional because the gums are inflamed and bleed easily even when flossing or brushing teeth.
The tongue poses a particular problem because it’s not one smooth surface. The tongue surface is composed of villi (tiny fingerlike protrusions) whose tips slough off with contact from normal activities like talking and eating. Portions at the back part near the pharynx are not sloughed off as readily and house millions of bad-breath causing anaerobic bacteria. This area is oxygen poor which makes a great environment for proliferation of these bad breath-causing microbes. There are practical explanations for morning breath:
- Saliva has some antibacterial property aside from containing amylase for the partial, chemical breakdown of carbohydrates. However, at night production of saliva is reduced, hence increasing the chances for bad breath;
- While asleep, the mouth is closed, creating the perfect incubation medium for bad-breath producing anaerobic bacteria which thrive well in an oxygen-poor, nutrient-rich, warm and moist environment;
- Sleeping with your mouth open is worse because air dries out the oral cavity.
Xerostomia or dry mouth is a condition where there is decreased production of saliva. Saliva moistens food and contains the enzyme amylase which kicks off carbs digestion. Salivary glands ductal openings are located underneath the tongue. Do you notice how images of ice cream sundae topped with your favorite goodies cause your mouth to water instantaneously? When nervous, stressed, and in cases where the parotid glands are blocked, there is insufficient saliva to keep the mouth wet making it difficult to talk, eat, chew and swallow. Spit guards against tooth decay and prevents bad breath.
Some drugs like antihistaminics have a drying effect. Certain medical conditions like diabetes, Sjogren’s syndrome and Parkinson’s can also present with the same symptom. Sjogren’s syndrome is an autoimmune disease where tear and parotid glands are attacked and the tongue cracks from drying out. Since systemic diseases may be involved, you should always seek dental or medical consult when the dry mouth condition is prolonged. Management includes drinking lots of water, chewing on sugar-free gum and avoiding beverages that could worsen the condition like coffee and alcohol. Coffee can also cause staining which looks unattractive.
What is good for the goose is not necessarily good for the gander – so it is with food aroma which may smell offensive to us but mouth-watering to others. Garlic, onions, curry and even the exotic durian have oils that make their way into the respiratory system where is it is exhaled as an odor reminiscent of the food eaten. Onions and garlic contain mercaptans which when attacked by bacteria release sulfur from the protein in food debris. Technically, any food is suspect but there are four categories that have a stimulating effect on anaerobic, bad-breath causing bacteria:
- Drying agents (see Xerostomia)
- High Protein Food (e.g. dairy products, legumes)
- Acidic food like colas, coffee, juice
Mouth, Throat, Nasal and Sinus Conditions
Mucus, pus and phlegm are rich in amino acids which bad breath bugs thrive on. Dairy intake increases the amount of secretions and makes them more viscid, especially when there are respiratory tract infections like sinusitis, tonsillitis, peritonsillar abscess, and pharyngitis. Asthmatics also produce a lot of phlegm increasing the risk for developing bad breath.
Tonsil stones, arising from congealed post-nasal drips draining from sinuses entrap bacteria and since these are located beyond the gag reflex, are not within reach of regular brushing. Occasionally the cause of bad breath is from the lower respiratory tract. Miscellaneous oronasopharyngeal cavity conditions that can produce bad breath are
- mouth, buccal, tongue and gum sores (bacterial, viral, fungal),
- parotitis (infection of the parotid glands),
- malformations (e.g. cleft palate; bacteria can lodge in crevices),
- foreign object lodged in nasal cavity (especially in young children)
- ear infection (middle ear infection drips secretions through the Eustachian tube to the throat)
- poor dental appliance hygiene.
Cigarettes and tobacco smells are persistent and can stick to the teeth and gums. It can be belched from the gut or breathed out from the lungs. Nicotine, the active component of tobacco is actually a poison that can cause hyperacidity. Acid reflux which regurgitates acid from the stomach weakens the teeth and leaves them prone to damage and decay. People who forcibly vomit (anorexia nervosa-bulimia syndrome) and release gastric acids on a regular basis weaken their teeth in the same manner. In addition, the heat from smoking cigarettes can also cause mouth sores.
Some diseases increase the risk of developing bad breath. When the cause of bad breath cannot be readily determined but the expired breath is overwhelming systemic diseases should be ruled out:
- Diabetes (bacterial growth is faster in diabetics; oral thrush from the fungus Candida albicans can cause the white coating on the tongue)
- kidney disease
- liver disease (hepatitis, cirrhosis)
- ketoacidosis (ketone breath from excessive dieting)
- gastrointestinal conditions (ulcerative colitis, malabsorption syndromes, gastritis, ulcer, cancer)
- lung diseases (tuberculosis, bronchiectasis, cancer, lung abscess)
- fever, dehydration (this condition causes xerostomia)
Treatment of Bad Breath
Treatment naturally starts with pretty standard procedures like filling dental caries, mechanically removing plaque build-up, brushing tongue to remove film and deposits, protecting teeth with coating, ensuring proper fit of dental appliances and dosing with antibiotics to treat sores, gingivitis and other infections. See a doctor for proper management of any medical cause of bad breath.
- Good dental habits should be observed:
- Proper toothbrushing with a soft-bristled tooth brush that is changed regularly
- Tongue brushing (all surfaces)
- Flossing after meals; use of water pik
- Gargling with saline or cyclohexidene rinse
- Drinking lots of water frequently throughout the day
- Proper cleaning of dental fixtures and braces if applicable.
However, if those interventions are not 100% successful, then it’s time to call on Mother Nature; this time with a slight twist. Modern treatment of bad breath goes beyond masking it with the standard minty scent we all grew up with. In fact, dealing with bad is a whole new science – and it begins with identifying good bacteria.
Oral probiotics are based on Streptococcus salivarius K12, the good bacteria that secrete BLIS (bacteriocin like inhibitory substance) which is capable of destroying gram negative (anaerobic) bacteria responsible for releasing VSCs that cause bad breath. WHO (World Health Organization) defines probiotics as ‘live microorganisms which when administered in adequate amounts confer a health benefit on the host’.
Probiotics for dental care were discovered accidentally in the 80’s by Prof. John Tagg (microbiologist at the University of Otago in Dunedin) who was then in search for a microorganism that can fight bacteria responsible for strep throat, caused by Streptococcus pyogenes. He discovered that the BLIS-releasing Streptococcus salivarous K12 found in the throat of healthy children when cultured in the laboratory were effective in eliminating bad breath at its very source. Studies in New Zealand unequivocally showed that overgrowth of bad bacteria was arrested with regular use. This happy discovery of restored bacterial balance is the basis of oral care products that include toothpaste, mouthwash, lozenges and chewing gum. Mouthwash or gargles are slightly alkaline to counteract the acidic environment that bad bacteria prefer.
For effective treatment, dentists advice using this protocol:
- thorough mechanical cleaning of the gums and teeth,
- oral antibiotics as needed,
- three-day course of chlorhexidene gargle prior to starting probiotic treatment.
Chronic Sinus Conditions Treatment
If the cause of bad breath is due to sinus conditions, management is manifold:
- Limited oral antihistamine treatment to lessen mucus secretion and build-up
- Antibiotic treatment (if needed)
- Nasal irrigation to control post-nasal drip (may also use the neti pot)
Dietary and Lifestyle Tips
For long-lasting fresh breath, munching on a sprig of parsley or biting into an apple might not be enough to exorcise bad breath. Apart from seeking dental treatment and observing proper dental hygiene, the bad breath sufferer can:
- Eat nutritious fruits and vegetables rich in antioxidants
- Use chlorella or spirulina supplements which are considered natural deodorizers and anti-oxidants. Chlorella and spirulina are friends with benefits since these marine-based products contain effective anti-oxidants.
- Control carbohydrates, soda, caffeine and coffee in the dietØAdd a few drops of oregano oil to your morning mouthwash. Oregano possesses natural astringent and cleansing properties.
- Avoid cigarettes and alcohol.
The best advice? Mother’ wise words – brush your teeth three times a day; and we hasten to add – gargle and floss after every meal and watch that tongue!
- Horz, H. P. et. al (2007). Distribution and Persistence of Probiotic Streptococcus salivarius K12 in the Human Oral Cavity as Determined by Real-Time Quantitative Polymerase Chain Reaction. Oral Microbiology Immunology, (22), 126-130.
- Loesche, W. J. et. al (1992). Comparison of the Benzoyl-DL-Arginine-Naphthylamide (BANA) Test, DNA Probes, and Immunological Reagents for Ability to Detect Anaerobic Periodontal Infections Due to Porphyromonas gingivalis, Treponema denticola, and Bacteriodes forsythus. Journal of Clinical Microbiology, 30(2), 427-433.
- Tagg, J. R. et. al (2006). A Preliminary Study of the Effect of Probiotics Salivarius . Journal of Applied Microbiology, (100), 754-764.