Halitosis or bad breath is a commonly encountered problem by an ENT (Ear, Nose and Throat) doctor, and there are many factors that can produce it. The more you know about the condition, the more you understand how to prevent it.

Bad breath can be a source of embarrassment for some individuals. What’s odd is that most people who have chronic problems with bad breath do not know they have it. People often get used to their own smell and do not tend to notice their own bad breath. The only way they’ll know about it is if another person comments on it. However, most people are too polite to comment on another person’s bad breath. You may have to rely on a family member or a close friend to be honest and tell you if you have bad breath. A crude but quick test to find out if you are suffering from bad reath, is to lick the back of your hand or wrist, gave it for five minutes and smell the area.

According to Mayazaki et al, in the treatment of halitosis, one can classify the condition as genuine halitosis, pseudo-halitosis and halitophobia. Genuine halitosis is further be classified into physiologic halitosis and athologic halitosis. The focus of this article to discuss more on the causes and treatment of this condition.

Pseudo-halitosis is found in patients who perceive that a malodor exists when chnically it does not. While halitophobic atients interpret other people’s behavior, such as covering the nose, averting the face or stepping back, as an indication of their own bad breath, and such behaviors convince the patients that they have the offensive oral malodor. Because these conditions are caused by psychosomatic factors, clinicians should focus more on the treatment of the psychological state rather than the physical condition.

What are the causes of physiologic halitosis?
The origin of physiological halitosis is mainly found at the back surface of the tongue, and the malodor is derived from the tongue coating. This coating comprises of shed epithelial cells, blood cells and bacteria. Hence, cleaning the tongue is more important than rinsing the mouth.

There are more than 100 bacteria in the oral cavity that may be attached to a single epithelial cell on the tongue. The bad odor comes from the breakdown of anaerobic bacteria, producing these sulfur compounds in the form of hydrogen sulfides, otherwise known as volatile sulfur compounds.

An important factor in bacterial growth is the pH or acidity of the mouth. Bacteria reproduce faster in a more acid environment, so coffee and acidic foods increase acidity. Hormonal changes have even been implicated with bad breath. During menstruation, estrogen causes sloughing of body lining tissue including that of the mouth. This gives additional nutrition for anaerobic bacteria.

Another factor of physiological halitosis is anything that contributes to the decrease in the flow of saliva. Saliva irrigates the mouth and stimulates swallowing thereby flushing away debris. As saliva contains oxygen, the dryer your mouth and the thicker your saliva, the less the washing action and the lower the oxygen level become, creating a more anaerobic environment for bacteria to produce sulfur compounds. This oral stagnation is more pronounced in mouth breathers and those who snore.

Also considered a factor is eating food that causes foul breath. Among these are meats, garlic, onion, cheese, durian, century egg, anchovies, fish-paste, etc. These food particles find their way in between the teeth, which causes them to rot and emit a putrid smell. Management of this form of halitosis is usually by proper brushing and flossing of teeth making the condition easy to manage.

Certain medications for high blood pressure, antihistamines and depression can decrease saliva flow. Dehydration and stress also reduce the flow of saliva. Morning breath occurs due to decreased salivary flow during sleep.

Physiologic halitosis is generally considered as transient bad breath, often disappearing after the withdrawal of the offending agent or proper oral hygiene such as brushing of teeth, flossing, and use of mouthwashes.

What are the causes of pathologic halitosis?
Pathologic halitosis is usually persistent (chronic bad breath), which is a more serious condition. It is often more difficult to manage and may require a multidisciplinary approach as it involves different organs of the digestive tract. Patients usually find themselves under the care of a dentist, an ENT specialist, a gastroenterologist or an internist. There are a variety of diseases that can cause pathologic halitosis; they can be local or systemic. The following are some of the common causes of bad breath:

Gingivitis
Proliferation of pathologic bacteria in the oral cavity is the major contributor of most dental pathologies. It may begin with the build up of plaque around the teeth, which starts out as a sticky film of live bacteria. If it is not removed at this stage, it starts growing on the sugar and minerals and hardensto become calculus which may lead to gum irritation, gingivitis and eventually to periodontal disease causing halitosis.

Sinusitis
Chronic sinus infections are among the most common forms of upper respiratory infections in children and adults. The symptoms include purulent nasal discharge, sensation of “fullness” on the face, nasal congestion, chronic coughing, chronic sore throat, and bad breath. It is important to recognize these symptoms of chronic sinusitis as these are often associated with more serious complications. The mainstay treatment is usually antibiotics, removal of the offending irritant, and treatment of allergy if it exists.

Postnasal drip
Postnasal drip refers to the sensation of thick phlegm in the throat, which can become infected. This is part of the mucous-nasal cilia system that defends us from disease. When the amount of liquid secreted by the nose and sinus is reduced, and the cilia of the nose and sinus slow down, the fluid thickens and patients become aware of its presence. This also gives a bad taste and smell in the mouth.

Chronic tonsillitis
Chronic tonsillitis and chronic pharyngitis is a common cause of halitosis. Tonsil stones (tonsilloliths) are caused by an accumulation of sulfur-producing bacteria and debris that become lodged in the tonsils. This debris putrefies in the back of your throat, and collects in the tonsil crypts (small divots or pockets which appear on the surface of the tonsils). When this debris combines with the volatile sulfur compounds produced by the anaerobic bacteria beneath the surface of your tongue, along with the tonsil stones it can also create chronic halitosis.

Gastroesophageal Reflux Disease
A condition commonly known as GERD is currently being considered as among the more common causes of bad breath. The reflux of putrid gases found in patients who constantly belch is among the areas of concern as the cause of halitosis. The management of this condition entails dietary restrictions, use of anti-motility drug and proton pump inhibitors.

Systemic diseases
There are also numerous conditions that lead to pathologic halitosis which are not directly related to the digestive tract, just to name a few are the following:

1. Diabetes mellitus
2. Chronic liver failure
3. Lower respiratory tract infection
4. Renal infection or chronic renal failure
5. Cancer
6. Other metabolic dysfunctions

Although these conditions are known to produce bad breath, it is unwise to assume that patients troubled by it, suffer from the above conditions.

Can diabetes cause halitosis?
Not all people suffering from diabetes will have halitosis, unless a diabetic person is in a state of very high blood sugar known as ketoacidosis. However, bad breath may be more prevalent in individuals with diabetes, simply because certain types of odor-causing bacteria tend to thrive in a high-sugar environment. Ketoacidosis refers to the presence of high concentrations of keto acids in the body. This results when a person’s body is burning stored fat at a high rate as a result of untreated type 1 diabetes mellitus.

This condition can be detected by checking the pH level of the individual’s blood. Additionally, diabetic individuals with ketoacidosis often suffer from dehydration, which can also cause oral dryness, another contributing factor to halitosis. The breath takes on a “fruity smell”, often described as sickly-sweet. Similarly, patients with diabetic nephritis or chronic kidney failure would also experience a change in breath odor, resulting in “fishy” bad breath.

How is bad breath treated?
By instituting proper oral hygiene, one can prevent or manage halitosis in general. Primary brushing technique and regular flossing of teeth ensure the removal of food debris and plaque build up. The correct way of cleaning the tongue is to gently clean it with a toothbrush or a tongue scraper at least twice a day. Application of mouth rinse or tongue gel may provide a useful adjunct. The use of sugarless chewing gum can also help by promoting salivary production, this is specially useful for patients with dry mouth. Gargling with commercially available mouth rinses containing betadine, chlorhexidine, xylitol, cetylpyridinium, zinc gluconate, etc. is also recommended. Other self-remedies include increased water intake, avoidance of smoking, alcoholic beverages, and spicy foods.

For the control of anaerobic infection, health professionals often resort to the combination of metronidazole and ciprofloxacin. It is also advisable to go to a dentist, an internist, or an ENT doctor for proper diagnosis and management. These professionals may be able to provide you with better care.

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