Bad Breath

Bad breath is no longer a laughing matter

Bad breath plagues just about everyone at one time or another. People snicker about it, but bad breath can be a devastating social disability. More than a few people have been denied employment, failed in business and relegated to low social status.

There are essentially four sources of bad breath :

1. The Mouth : This includes the teeth, the gums, and the top surface (dorsum) of the tongue, especially the very back of the tongue. Since this type of bad breath is the most common, its diagnosis and treatment will be covered extensively.

 The term for odours from the mouth is Fetor Oris (not halitosis)___Fetor means "a strong offensive smell" and is a generic term. Oris means "from the mouth". Fetor oris is a strong 0ffensive smell originating specifically from the mouth.

 Fetor Oris is the most common type of bad breath and accounts for about 8O% of all cases. If you are young and generally healthy, the chances are good that your problem falls into this category.

 The structures in the mouth that can harbor bad breath are :

 The Teeth

 The Gums

 The Tongue (especially the back of the tongue)

2. The Upper Respiratory Tract : This includes the nasal cavities, sinuses, throat, tonsils and the larynx (voice box).

  The term for bad breath from the upper respiratory tract is ozostomia.

 Ozostomia is the second most common type of bad breath, and is most commonly associated with post nasal drip, but can be associated with infections of the various organs in the upper respiratory tracts as well, including sinusitis, sore throat and laryngitis.

3. The Lungs : Bad breath originating from the lungs is either a temporary phenomenon caused by consuming certain foods or drugs, or it is a chronic problem caused by disease processes.

  Stomatodysodia is the term for bad breath caused by outright disease processes in the lungs, such as various infections, emphysema, bronchitis or lung cancer.

 Halitosis is the term for bad breath that results from physiologic processes elsewhere in the body and carried to the lungs by the bloodstream, or to the mouth by chronic vomiting.

4. The Stomach : Technically, this type of bad breath is a subcategory of halitosis, but one that does not originate from the lungs. Bad breath originating from the stomach is caused by disease processes which produce chronic vomiting.

Bacteria and how they produce bad breath

% of all bad breath originates from bacterial overgrowth within, or upon structures in the mouth. If you are young, healthy, and do not suffer chronic sinusitis, tonsillitis or laryngitis, chances are good that this section is the most relevant to your problem.

When someone has bad breath caused by structures in the mouth, the chemicals you actually smell are sulfur compounds created by anaerobic bacteria. Anaerobic bacteria grow in the absence of oxygen and they most easily colonize areas where there is some mechanism to limit exposure to oxygen. As a class, the chemical that these anaerobes produce are called Volatile Sulfur Compounds (VSC's), and they include such beauties as hydrogen sulfide (rotten egg smell), methyl mercaptan (smells like rotten cabbage, and is the chemical added to natural gas to give it a recognizable odours) and dimethyl sulfide (smells like decayed vegetables).

A Chronic and temporary oral conditions that cause fetor oris

Before discussing the actual structures of the mouth that must be treated in order to cure fetor oris, It is necessary to understand that there are several chronic or temporary conditions can shift the balance of microbial flora toward an overgrowth of the bacteria which produce VSC's:

 Xerostomia : This is the technical term for dry mouth. Dry mouth dehydrates and concentrates the layers of salivary protein and mucous that coat the structures of the mouth. This concentration of mucous, saliva and food detritus makes for overgrowth of all sorts of different bacteria in different parts of the mouth. In some areas of a dry mouth, anaerobic bacteria overgrow and produce serious amounts of volatile sulfur compounds. Other areas favor the overgrowth of aerobes which produce their own volatile waste products which can smell and taste nearly as bad as the vsc's produced by the anaerobes. The most common type of bad breath caused by dry mouth is morning breath, which is a result of breathing through the mouth while sleeping. Some people tend to develop chronic dry mouth due to conditions such as Sjogren's syndrome. Elderly people are also prone to dry mouth due partly to the ageing process, but mostly to the numerous drugs they consume which tend to cause dry mouth.

" Dry mouth is a separate problem with its own diagnostic and treatment protocols. Patients suffering from dry mouth may wish to consult a dentist and under go treatment "

 Drugs : Certain drugs tend to cause dry mouth and thus are a prime cause of chronic bad breath. These include both prescription and non prescription drugs as well as both legal and illegal drugs.

  The Teeth : In their healthy state, teeth are hard structures and are not prone to harbor bacteria that are associated with bad breath. On the other hand, people who use a lot of sugar will have areas of decay inside their teeth. Decay inside a tooth provides an anaerobic environment and is thus a great place to live if you are a sulfur metabolizing germ. Tooth decay is just what the name implies--dead, decayed matter. Dead stuff smells bad by itself, and since the decay is fairly soft, it absorbs juices from the foods you eat, and that decays as well. Every area of decay is a potential source of bad breath. You cannot hope to eliminate bad breath permanently without first having the decay repaired by a dentist.

In addition, even without decay, if the oral hygiene is poor, plaque, which is made of bacteria, along with food debris accumulates on and between the teeth. Bacteria in the plaque produce VSC's in local areas wherever oxygen is limited, thereby causing bad breath. In healthy individuals, this type of bad breath can generally be eliminated simply by brushing and flossing the teeth properly once a day. Flossing is essential since the area between the teeth is more likely to be free of oxygen than any other area of the mouth, and therefore is always a source of bad breath if not kept clean. If you have a problem with bad breath, try smelling a piece of floss after using it to clean between the teeth and see for yourself.

  The Gums : Another name for the gums is the periodontium. The periodontium is composed of bone as well as the pink, gummy tissue you can see. In its healthy state, the periodontium is not prone to harboring bacteria, and therefore does not contribute to bad breath. On the other hand, when the periodontium becomes diseased due to bad oral hygiene (especially when bacteria are allowed to accumulate between the teeth), bacteria begin to eat away at the attachment of the gums to the tooth, and the bone that holds the tooth starts to rot. This process is called periodontal disease. (Click the image to the right to learn all about periodontal disease.) The bacteria like to multiply within the newly created space between the root and the gums because of all the dead stuff that accumulates there. This space provides an oxygen restricted environment allowing a shift in the floral balance toward the anaerobic bacteria. The gums become red and inflamed, and are constantly bleeding. The anaerobic bacteria digest the blood and necrotic (dead) gum tissues producing lots of VSC's.

People with periodontal disease have a very characteristic bad odours to their breath which a dentist usually recognizes as soon as he approaches the patient. Most other people just recognize it as super bad breath!. Bad breath from periodontal disease is the worst bad breath there is. If you have bad breath, and you are not cleaning between your teeth on a regular basis, then the chances are good that you are suffering from at least minor periodontal disease. You must see a dentist to have your disease diagnosed and treated if you want any hope of curing your bad breath. If you are healthy and under the age of 35, a good professional cleaning will usually stop the disease, and with continued brushing and flossing on your part, neither the bad breath nor the gum disease will return. The treatment for more advanced cases of gum disease is well discussed on my page dedicated to the treatment of periodontal disease.

One form of periodontal disease which may cause fetor oris is partially impacted wisdom teeth. Teeth that are partially submerged below the gums have a built-in pocket between the gums and the crown of the tooth which tends toward anaerobic conditions allowing the overgrowth of anaerobic bacteria. Partially impacted wisdom teeth are prone to a condition called pericoronitis, which is an infection of the gums around the crown of an unerupted tooth. The cure for bad breath caused by impacted wisdom teeth is extraction of the offending tooth/teeth by an oral surgeon, although the condition can be temporarily treated by irrigating under the gums with hydrogen peroxide and placing the patient on an antibiotic.

 The Tongue : The top (dorsal) surface of the tongue is covered with structures called papillae. There are three types of papillae, but the ones that concern us here are called filliform papillae. They are the microscopic hairlike projections that produce the pink, velvety coating on the top surface of a healthy tongue. Filliform papillae are always growing, just like the hair on your head. Generally, these papillae grow to a certain length and then break off. This shedding happens more easily on the anterior part of the tongue because it is in constant motion and because it makes frequent contact with the teeth while talking and eating.

Shedding of the filliform papillae is slower on the back part of the tongue, so the papillae there tend to grow longer. These longer hairs are an ideal place for bacterial colonies to hang out. Anaerobic bacteria thrive within the continuously forming layer of mucous, food debris, dead cells and dead bacteria that is always present in this area. This bacterial layer is held in place by the longer filliform papillae.

Treatment for bad breath associated with the tongue

If you are in good general health, have healthy teeth and gums, and your oral hygiene is good, then the most likely cause of your bad breath is a bacterial coating on the back of the tongue. The following routine may be performed once a day, preferably in the morning, however performing this routine at night not only reduces morning breath, but will make your bed partner MUCH happier.

 The first step in the treatment of bad breath (fetor oris) caused by bacterial coatings on the tongue is simply vigorous scraping using either a tongue scraper or, probably just as good, an inverted spoon.

If you slide your finger over your tongue toward the back of your throat, you can feel the circumvallate papillae, which form a "V" shaped line across the posterior dorsum (top surface) of the tongue. It is important to scrape the top surface of the tongue nearly as far back as these papillae. Do not scrape the circumvallate papillae themselves. It is normal to gag during this process, however, persistence pays off, and the gagging subsides over time as you get used to it. Gagging has a huge psychological component, and you can learn to overcome it. Remember, the scraping must be vigorous enough to give your tongue a "haircut", but not so vigorous that you cause pain or bleeding. If you look at (or smell) the material that you scrape off the tongue, you will see why there is so much potential for bad breath from it.

 After you have scraped your tongue, the second step in the treatment of fetor oris is to disrupt the actual volatile sulfur compounds as well as the anaerobic bacteria that remain after scraping. This is easily accomplished by gargling or vigorously brushing the tongue with a 1.5 percent solution of hydrogen peroxide (available in any drug store). Hydrogen peroxide liberates oxygen. That is why it bubbles up when it comes into contact with bacteria or blood. The hydrogen peroxide you buy at the store is a 3 percent solution. It is generally wise to dilute the peroxide solution half and half with water in order to gargle with it, however you may prefer to apply 3% hydrogen peroxide directly to the tongue using a tooth brush. Vigorous brushing with hydrogen peroxide will help to further remove the bacterial layer while at the same time oxygenating the area. Use copious amounts of peroxide. The hydrogen peroxide solution accomplishes two simultaneous operations :

 The oxygen liberated by the hydrogen peroxide combines with the VSC's thus neutralizing them and effectively removing the chemical compounds immediately responsible for the bad breath.

 The oxygen liberated by the hydrogen peroxide kills the anaerobic bacteria responsible for producing the VSC's.

Hydrogen peroxide is cheap and very effective in both neutralizing VSC's, and in killing anaerobic bacteria, but it tastes terrible, which is why you may want to rinse your mouth afterwards with a commercial mouthwash, or use Peridex®, which is available by prescription, instead of peroxide. Listerine (the original type) is also effective in killing the anaerobes and neutralizing VSC's.