Halitosis (Bad Breath)

Introduction:

Bacteria and how they produce bad breath

The role of Anaerobic bacteria in Fetor Oris

80% 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 chemicals 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 odor) and dimethyl sulfide (smells like decayed vegetables). There are over 400 types of bacteria found in the average mouth. Several dozen of these can cause bad breath when allowed to flourish. They metabolize proteins such as dead tissue cells, blood and mucous. Proteins are made from building blocks called amino acids, and the digestion of these amino acids supply the bacteria with energy. Some of the amino acids contain sulfur, and these sulfur compounds are converted to VSC's as a waste product.

A healthy mouth contains many different kinds of bacteria. In any given part of the mouth, they establish a sort of balance between the competing species of bacteria depending on the conditions there. A healthy mouth does not smell bad because the conditions in all parts of it encourage a balance of bacteria that does not cause odors. We call a healthy balance of bacteria a normal flora, or a "normal floral pattern". There is a very wide range of floral patterns which are healthy. Everyone has a slightly different floral pattern. But when conditions in any area of the mouth change due to disease or other factors such as dehydration or the presence of fermentable substances such as blood, dead cells and shreds of food, the balance of bacterial species shifts, allowing the overgrowth of anaerobic bacteria at the expense of the rest of the normal floral organisms. Thus odors begin to emanate from that area due to the productuon of VSC's.

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 Sorgren'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 my page dedicated to Xerostomia after reading this one. There, you will find actual suggestions for treating this serious problem.

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.

Prescription and over-the-counter drugs that cause dry mouth include, but are not limited to:

antihistamines (the older types like Benedryl)

antidepressants (old style types like Elavil, Flexaryl etc)

anticholinergics (often used as decongestants as well as surgical drying agents like atropine and scopolamine )

anorexiants (diet pills)

antihypertensives (blood pressure meds),

antipsychotics (psychiatric drugs)

anti-Parkinson agents

diuretics ("water pills")

sedatives (sleeping pills)

Some drugs actually cause Halitosis (not originating in the mouth). Recovery room and operating room personnel can all attest to the incredibly bad breath (originating from the lungs) exhaled by patients recovering from general anesthetic agents after operations. Phenergan is an antihistamine used as a sedative and to control nausea and vomiting in patients recovering from the DT's (Delirium Tremens caused by chronic alcohol addiction). Patients on this drug have a halitosis which can permeate entire hospital wards.

Illegal recreational drugs may also cause chronic dry mouth and thus are a source of bad breath.

Illegal drugs have the added liability of lifestyle issues which interact with the dry mouth and make the bad breath much worse. Addicts and other recreational users often neglect their oral hygiene and use huge amounts of sugar leading to massive tooth decay. In addition, poor oral hygiene combined with poor nutrition causes gum disease. Both of these conditions are major causes of bad breath.

The drugs most likely to cause problems in this category are the metabolic stimulants: Cocaine, Crack, Ecstasy and Methamphetamines.

Heroine and Marijuana are not metabolic stimulants, however they predispose users to high sugar use and thus are associated with bad breath due to tooth decay. For much more on the way drugs effect your mouth, click here.

Bad breath caused by structures in the mouth (Fetor Oris)

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 odor 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.

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.

When a patient is suffering from any of a number of febrile diseases, he/she may develop an overgrowth of filliform papillae on the tongue. This is the "coating" on the tongue that old fashioned doctors used to talk about when the patient developed a fever. The technical name for this condition is white hairy tongue, or, if the coating is stained by food debris, black hairy tongue (see image at right).   When this condition develops, anaerobic bacteria can thrive over the entire dorsum of the tongue producing more serious odor problems. Click on the image to see more.

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. In effect, you are not only removing the mucous layer, but are giving your tongue a "haircut". It is necessary to scrape the top surface of the tongue very vigorously, almost as far back as the circumvallate papillae located at the very back of the tongue. (Note: there are numerous types of tongue scrapers. The type pictured on this site is probably the most popular because it was the first on the market. Other types are acceptable as well.)

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. Another alternative is to use one of the commercial products you may see advertised in the Google ads on this page instead of hydrogen peroxide.

Bad breath caused by structures in the upper respiratory system (Ozostomia)

Sinusitis and post nasal drip

Sinusitis does not directly cause bad breath. However, chronically inflamed sinuses do produce large amounts of mucous of varying thickness, which tends to drip down the back of the throat, coating both the throat and the back of the tongue. This condition is called post nasal drip. Mucus is made up of interlinked strands of protein, and anaerobic bacteria have a field day breaking down these proteins into foul smelling and sour tasting sulfur compounds. In addition, the thick secretions cling to the back of the throat causing the patient to want to swallow. Unfortunately, the mucous remains attached to the back of the throat leaving the patient feeling obsessed with swallowing.

The cure for post nasal drip is to treat the condition causing it.

The common cold, flu or allergy often cause post nasal drip. Ultimately, the cure for post nasal drip due to these conditions is to wait them out and when the condition cures itself, the post nasal drip stops as well. There are, however measures that a patient can take to reduce or eliminate post nasal drip while these conditions persist. General measures to reduce the discomfort and bad breath involve taking three drugs in combination:

Sudafed is a decongestant that is available over the counter. It can be purchased in timed release capsules, and it opens the sinuses while reducing the amount of mucous secreted.

Guaifenesin is a fairly safe drug that thins out the mucous that is produced and makes it easier to swallow. Guaifenesin is available over the counter in Robitussin® or a generic equivalent. Mucinex is another great source for large doses of this safe drug and it is now available over the counter.

An antihistamine like Benedryl® is a good antihistamine for nighttime use since it makes the patient sleepy. One of the newer non-drowsy antihistamines like Allegra® and Claritin® is appropriate for daytime use. Antihistamines help to relieve itchy, watery eyes and the tendency to sneeze. They also reduce the irritation in the sinuses which may be causing the post nasal drip in the first place.

One additional suggestion: The feeling that you always want to swallow the mucous in the back of your throat is quite irritating and distracting. It is possible to remove the mucous at the back of the throat simply by eating a piece of bread, a stalk of celery, or any other bulky food. The mucous will be swept down the esophagus when you swallow the food. If you have chronic problems with this condition, keeping a stalk of celery on the bedside table can make the night more peaceful.

Sinus infections cause the sinuses to produce thick, infected mucous which has a bad odor even before it is metabolized by the bacteria in the mouth. Sinus infections are best cured using an appropriate antibiotic. The standard antibiotic used for upper respiratory infections of all sorts in patients who are not allergic to penicillin is amoxicillin. If the patient is allergic to penicillin, then clindamycin, Biaxin® or Zithromax® are the drugs of choice. While the patient is under treatment for the sinus infection, it is advisable for him/her to take sudafed and guaifenesin to keep the sinuses open and to create enough thin mucous to help keep them clear.

Tonsillitis and Tonsilloliths
- Tonsillitis means an infection of the tonsils. Infections of the tonsils are generally caused by streptococcus (as in strep throat). The tonsils become red and inflamed while small white colonies of the strep organism are found in the tonsillar crypts, which are little indentations found on the surface of the tonsils (Click the image at the right for a closer look). Patients with strep throat or tonsillitis tend to have bad breath (ozostomia) until the infection is cleared up. The drug of choice for patients who are not allergic to it is penicillin. For patients who are allergic to penicillin, clindamycin, Zithromax® or Biaxin® are the drugs of choice.
- People with chronic sinusitis and post nasal drip may develop tonsilloliths which are tiny, white, foul smelling stones which lodge in the tonsillar crypts. Sometimes a tonsillolith can be pried out of the surface of the tonsil with a pencil or other small pointed instrument leaving what looks like a little "hole", but is, in fact, simply the tonsillar crypt in which it formed originally. Tonsilloliths sometimes give the feeling of something lodged in the throat. They can also contribute to bad breath. Some people have chronic problems with tonsilloliths. The only sure treatment for chronic tonsilloliths is removal of the tonsils. The operation is performed by an ear, nose and throat specialist (ENT) and is fairly simple and safe. The operation causes a very serious sore throat for two weeks post-op, but the benefit is that the patient suffers no more tonsillitis or tonsilloliths. Short of removing the tonsils, the bad breath can be treated by gargling with a 3% solution of hydrogen peroxide or Peridex® mouth wash which is available by prescription from your dentist or physician. The use of guaifenesin and pseudafed to lessen the post nasal drip is also effective.

Bad breath originating from the lungs (and stomach)

Stomatodysodia is bad breath caused by outright disease processes in the lungs. These include infections, bronchitis and pulmonary abscess, as well as chronic problems like tuberculosis, pneumonia, emphysema, and lung cancer. It also includes odors from stagnant mucous accumulated in the lungs due to prolonged bed rest, as well as stagnant cigarette smoke embedded in it. People with any of these conditions generally already know they have them, and their bad breath is at least partly from their disease condition.

Halitosis is a term invented in 1921 by the Listerine company. It means bad breath stemming from systemic metabolic conditions. Chemicals from systemic disease conditions are carried to the lungs via the bloodstream. In other words, the odor comes from chemicals excreted through the lungs. Halitosis is also the term used to describe mouth and throat odor due to vomiting. There are three types of halitosis:

Physiologic halitosis is of a temporary nature and happens when a patient eats certain aromatic foods such as herbs, spices, certain cold cuts, curries, onions, garlic, radishes, turnips and leeks, or drinks certain types of liquids such as wine, brandy, whisky, liqueurs, beer, tea and coffee. Foods such as these are the most common source of transient (temporary) bad breath, and the cure for physiologic halitosis is simply to avoid aromatic foods, or to wait out the effects.

Pathological halitosis originating in the lungs is caused by the release of chemicals from disease processes elsewhere in the body, and carried to the lungs by the bloodstream. This type of halitosis is not easily reversible and tends to persist without treatment. The best way to treat the bad breath caused by pathological halitosis is to treat the underlying condition. The most common conditions which cause pathological halitosis are as follows:

Diabetes--Uncontrolled diabetes causes the accumulation of abnormal metabolites in the bloodstream, and these are excreted through the lungs. They include ketones such as acetoacetic acid, hydroxybutyric acid and acetone.

Uremia--Urine in the bloodstream caused by kidney failure.

Gastritis--Inflammation of the lining of the stomach.

Gastric ulcer--actually localized bacterial infections in the lining of the stomach.

Liver disease, or Hepatitis--In particular, Fetor Hepaticus, which is bad breath caused by chronic liver failure. Also known as "breath of the dead," Fetor hepaticus is a condition seen in portal hypertension where an incompetent liver allows mercaptans to pass directly into the blood stream, and finally into the lungs where they are exhaled. It is a late sign in liver failure. The breath has a sweet, fecal smell.

Pathological halitosis originating in the stomach is caused by conditions which produce chronic vomiting. In this case, the origin of the bad breath is the stomach, but the real culprit is the vomit which coats the throat and oral structures and stagnates producing foul odors.

Acid Reflux Disease (ARD--Formerly known as GERD)--This is generally controlled using H2 blockers like Tagamet, Zantac or Pepsid.

Pyloric Stenosis--This is a developmental condition found in infants which causes vomiting, and is corrected surgically.

Any condition which causes chronic vomiting can potentially cause pathological halitosis. This includes migraine headaches, morning sickness, food poisoning, food allergies, bulimia, alcoholism, certain medications and chemotherapy in cancer patients.