Chapter 12- Bad breath.

Bad breath is also known as Oral Malodour or Halitosis [this last term according to QI is a made up word and I’ve never liked it but made up or not it is widely used so I have included it].

Common causes.

Food- the most obvious which we all know about, eating certain foods; – garlic, spices, onions, cabbage, brussel sprouts, cheese and onion crisps etc. This is obviously easy to manage by avoiding such foods in certain social situations.

‘Morning breath’- most people have breath that is ‘less than fresh’ first thing in the morning, thankfully the only people around at the time are our nearest and dearest who are, hopefully, forgiving until we have brushed our teeth. This is usually caused by reduced salivary flow during the night washing away bacteria, old dead cells etc and will be exacerbated by mouth breathing while asleep which I think most people probably do judging by the number of patients who complain to me about their partners snoring. Saliva flow will be further reduced by other factors which cause a dry mouth; – alcohol, smoking, certain drugs etc [see chapter 11].

Less common causes.

1- Infection in your mouth [oral sepsis].

• Tooth decay [caries] caused by poor oral hygiene.
• Gum disease [periodontal disease] caused by poor oral hygiene.
• Infection around an erupting wisdom tooth [periocoronitis].
• Infected extraction sockets.
• Ulcers [next chapter].
• Some other mouth [oral] infections- come to those in a later chapter.
• Bacteria and fungi on the back of your tongue.
• Food trapping around;- ledges on fillings, bridges and implants not cleaned correctly, very misaligned teeth etc.
• Dentures not cleaned thoroughly, regularly and disinfected on a regular basis.

Rotting bits of food smell just like something you have left in the back of the fridge too long and some bacteria give of nasty gasses as they metabolise. The bacteria most implicated in this are Gram-negative anaerobes of various types. Anaerobe bacteria survive in the absence of oxygen so are found in the bottom of periodontal pockets [see chapter 5], under gum flaps on erupting wisdom teeth and in extraction sockets that have not been kept clean according to ‘post-operative instructions’. The smell that you will most recognise is that of ‘volatile sulphur compounds [VSCs]’ ie rotten eggs.

2- Dry mouth. [see chapter 11].

3- Smoking, alcohol and some drugs.

4- Respiratory [breathing system]/ ENT problems;- infection in nasal passages, tonsillitis, sinusitis, lower respiratory tract infections.

5- Diseases in the rest of your body [Systemic diseases], some of which are;-

• Diabetes- when the patient becomes ketotic and the breath smells of acetone [pear drops, nail varnish remover].
• Stomach and intestines [Gastro-intestinal].
• Liver [hepatic] failure.
• Kidney [renal] failure.
• Lung [pulmonary] disease.
• Other metabolic disorders.

These causes are rare but obviously very important and need to be thoroughly investigated.

If you can get a willing partner or friend to help you, try and decide if the smell is coming from your nose, your mouth or both.

As a rough rule of thumb if it’s coming from your mouth it is likely to be infection of one sort or another in your mouth or your throat. If it’s coming from your nose it’s probably your sinuses or your nasal [nose] passages. If it’s coming from both it’s probably due to systemic [whole body] disease.

Little kids quiet often shove things up their noses;- beads, little nuts, peas seem to be a particular favorite, tiny lego, your pills- don’t leave them lying around etc. This leads to infection and malodour.

What to do.

• Avoid foods that make your breath smell; – onions, garlic, spices etc in a situation when you want to have fresh breath.
• Avoid habits that worsen breath; – alcohol and tobacco.
• Thorough oral hygiene as in chapters 6, 7 and 8. When you have that down to a fine art a mouthwash may help but ask your dentist which one first.
• Visit your dentist. He or she will identify any dental problems and together you can solve and treat those.
• Eat a good breakfast and regular meals. See the ‘eat well plate’, don’t forget your 5 a day. Make it 7 if you can, more if poss. interestingly pineapple contains an enzyme which helps clean your mouth.
• Brush your teeth after meals.
• Brush your tongue before going to bed. You can use a manual toothbrush, your electric toothbrush but not too fiercely, a teaspoon with the bowl facing down, or a tongue scraper. I never find these much use myself though some peoples swear by them. They are of very little help if you are a person who has a big furrow up the middle of their tongue. If you do have a furrow clean it thoroughly with a toothbrush, it’s like a little micro climate for bugs. You need to clean your tongue as far back as you can get to, as most of the bugs live ‘over the hill’. When you start looking at your tongue in detail don’t be alarmed if you see what looks like a ‘V’ of Darlic’s heads across the back of your tongue, this is normal anatomy these are your Circum Valate papillae.
• Keep your mouth as moist as possible 1.5 litres of water a day for a woman, 2 litres for a man. Use sugar free gum [xylitol containing] after a meal.
• Your dentist may recommend one of the new ’fresh breath’ products.
• If you have dentures, clean them very thoroughly at the end of the day, clean or at least rinse them after every meal, leave them out at night so you don’t get bacteria breeding under them. Ask your dentist for advice as to an overnight soak.

When you have seen your dentist for any treatment required together with an ongoing plan of action [care plan] and you have followed the above advice to the letter, if the problem appears to be no better your dentist will refer you to a specialist in Oral Medicine for their opinion. The specialist will probably also liaise with ENT and a physician to rule out other systemic causes.

If this is you please seek help, start with the ordinary things you can do yourself then go and see your dentist. A lot of patients who come to me for the first time have put off coming for a long time because they are embarrassed about their breath and the state of their mouths. Please don’t be, we are here to help.

There is nothing that saps your confidence more than feeling that your breath smells, that other people are avoiding getting to close to you or that you need to cover your mouth when talking. It makes you nervous in social situations meaning you either avoid them altogether or are constantly on edge.

Please seek help, the solution may be very simple and will make a big difference to your life.

The dental profession is here to help, we have seen it all before, you won’t be the first and you won’t be the last!

Please take my advice and good luck.