Halitosis (Bad Breath)
by Dr. Christopher Chang, last modified on
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Halitosis (also known as bad breath) most often is caused by volatile sulfur compound (VSC) producing bacteria in the oral cavity (85%). Such bacteria exist on the gums, teeth, tonsils, adenoids, and tongue. Other (less common) causes of bad breath also include reflux, sinus infections, pneumonia, bronchitis, kidney failure, metabolic dysfunction, cancer, etc. The most recalcitrant cause of halitosis (in people with excellent oral hygiene) is due to bacterial overgrowth in the back part of the tongue (lingual tonsils). Adenoids is another location often neglected as a cause of halitosis.
If you are too embarrassed to ask others if you have bad breath, there are devices that can measure the total amount of foul-smelling VSC in your breath. Such breath checker devices are now available for purchase for around $50. Please note that such devices only measure for the presence of VSC... and not where the bad breath is coming from exactly. These devices essentially detect for the presence of:
• Hydrogen Sulfide: VSC associated with poor oral hygiene and the presence of organic debris on the tongue,
• Methyl Mercaptan: VSC associated with periodontal disease
Be aware that Dimethyl Sulfide, which is VSC associated with systemic (blood-borne), metabolic (blood-borne), or respiratory conditions, including otolaryngological (ENT) problems, is NOT detected by these devices.
To treat benign halitosis, there are some things one can do at home to resolve the issue before seeing a physician and/or dentist.
The first thing to do in order to save time and money to treat the bad breath is to first figure out WHERE the bad breath is coming from.
Here are some general rules of thumb:
• If the bad breath can be smelled coming out from both the nose AND mouth, the source is probably the throat
• If the bad breath can be smelled coming out from the nose but NOT the mouth, the source is probably the nose
• If the bad breath can be smelled coming out the mouth but NOT the nose, the source is probably the mouth
To further pinpoint the location of the bad breath, although disgusting, this entails scraping various surfaces and than smelling the material to see if it correlates with the bad breath. This means, squeezing the tonsils with a finger and than smelling the material that collects onto the finger, or scraping the tongue with a fingernail and smelling the fingernail, or using dental floss and than smelling the dental floss, etc.
Once you determine where the bad smell is coming from , you focus your treatments towards that anatomic region. Such treatment may include:
- Use mouthwashes, but avoid mouthwashes that contain alcohol. I typically suggest Listerine Zero or 1-2% Hydrogen Peroxide (you can make this using 1-2 parts of 3% hydrogen peroxide mixed with water). Some find Therabreath helpful as well.
- Brush your teeth daily! Poor dental hygiene leads to caries as well as gingivitis which both lead to halitosis.
- Floss your teeth daily! To understand the benefit in flossing, smell the floss after flossing your teeth.
- Brush your tongue daily, not just in the front, but in the back! Use a tongue brush or scraper. Toothbrush works, but not as well.
- Not only rinse, but GARGLE your mouth twice a day. When gargling, try to focus the gargle on the back part of the tongue where it curves down into your throat (stick your tongue out while gargling). Rinsing and gargling before bedtime works best as the residue from the mouthwash remains in the mouth for a longer period of time.
- Saline flushes (not sprays) to the nose twice a day (ie, Neilmed sold over the counter in many pharmacies is what we generally recommend) address nasal/sinus/adenoid sources of halitosis.
- Maintain proper hydration as dry mouth can exacerbate bacterial overgrowth.
- Researchers found that eating 6 ounces of yogurt a day containing live Streptococcus thermophilus and Lactobacillus bulgaricus reduced levels of odor-causing compounds, such as hydrogen sulfide, in the mouth. I usually suggest Activia yogurt which should be both rinsed and gargled before swallowing.
- Treat reflux if silent reflux suspected.
- Use a chinstrap if you mouth-breath causing the saliva to dry up in the mouth from mouth-breathing. Or treat the nasal obstruction if that is causing the mouth-breathing.
These are some suggested ingredients in toothpaste (based on reference below):
- Tin fluoride, sodium fluoride
- 20-65% bicarbonate and Zinc salts
- Hydrogen peroxide
These are some suggested ingredients for mouth rinses (based on reference below):
- Zinc chloride
- 1-2% Hydrogen Peroxide
- Listerine Zero
- Chlorine Dioxide
- Cetylpyridinium Chloride
What can our physicians provide beyond these measures?
- Endoscopic evaluation of the adenoids and lingual tonsils.
- Surgical procedures to remove the tonsils (lingual or palatine) and/or adenoids if they are contributing to the halitosis.
- If you have problems with tonsil stones, tonsil cryptolysis may be an option.
- Evaluate for more sinister causes of halitosis (ie, cancer, infection, tumors, etc).
If halitosis is affecting your quality of life, please contact our office for an appointment.
The relationship between oral malodor and volatile sulfur compound-producing bacteria. Otolaryngol Head Neck Surg. 2006 Nov;135(5):671-6. Link
Coblation lingual tonsillectomy. Otolaryngol Head Neck Surg. 2006 Nov;135(3):487-8. Link
Lingual tonsillectomy using bipolar radiofrequency plasma excision. Otolaryngol Head Neck Surg. 2006 Nov;134(2):328-30. Link
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