Bad Breath (Halitosis) – Hidden Causes, Effective Treatments & Prevention

Abstract

Bad breath, or halitosis, is commonly due to poor oral hygiene, but the causes can vary. It can be acute or chronic. Acute halitosis is mostly due to poor oral hygiene, whereas chronic halitosis can be due to an underlying systemic health condition or an infection. The odour can range from sweet to unpleasant. Odour-causing bacteria are involved in the development of halitosis. Proper diagnosis is essential to identify the underlying cause, and the symptoms are managed accordingly. Dental examinations are conducted by the dentist. Regular checkups and professional cleaning can be helpful in managing halitosis.

Statistics for Halitosis

1. Globally, halitosis is prevalent in about 31.8% of the population.
2. The intraoral causes of halitosis affect about 85–90% of adults, whereas extraoral causes affect 5–10% of adults.
3. Less than 1% of people have blood-borne halitosis.
4. Smoking increases halitosis by up to 2.69 times.
5. Adults aged 30 years and above are more prone to halitosis.
6. Around 35–45% of people globally have halitosis at any given time.

Introduction

Bad breath is scientifically known as ‘halitosis’ or malodour. Bad breath can be common in most people at some point in their lives. However, if it persists all the time, it is mostly a chronic condition and may indicate an underlying health problem. It can impact individuals socially and psychologically. It can cause anxiety, depression, and OCD in some patients. It can also be an indicator of an underlying disease. The most common cause is bacterial biofilm containing odour-causing bacteria that break down proteins into amino acids. These further release volatile sulfur compounds.

Locations where these odour-causing bacteria thrive include

1. Interdental areas
2. Tongue
3. Tooth crevices
4. Gingival niche
5. Areas where food becomes impacted
6. Orthodontic wires or ill-fitted dentures
7. Areas with abscesses or pus formation

Common Signs and Symptoms of Halitosis

1. Metallic taste in the mouth
2. Rotten egg-like smell from the mouth
3. White coating on the tongue
4. Persistent bad taste
5. Social embarrassment, anxiety, and stress

The Mechanism of Action for Halitosis – Why Does Bad Odour Exist?

Understanding the cause is the most important step in treating halitosis, which involves bacterial metabolism in the majority of cases. Volatile sulfur compounds (VSCs) are produced by anaerobic bacteria. These compounds are the primary cause of bad odour. The bacteria break down proteins into amino acids from food metabolites or dead cells. Some odour-producing molecules include:

1. Hydrogen sulfide: It produces a rotten egg-like smell.
2. Dimethyl sulfide: It produces a sweet, unpleasant odour.
3. Methyl mercaptan: It gives off a pungent, rotten cabbage-like smell.

Hidden Causes of Halitosis

There are various causes that can be intraoral and extraoral. In most adults, the cause lies in the oral cavity itself. The intraoral causes include tongue and gum diseases, xerostomia, and dental appliances. Extraoral causes include systemic diseases like respiratory diseases, throat infections, GERD, cancers, or medications taken by the person. Let’s know more about the causes as explained below:

1. Oral hygiene: Good oral care involves brushing, flossing daily, and cleaning the tongue. It removes trapped food particles and the plaque layer from the tooth surface, thus reducing the bacterial load. The plaque layer can cause gum irritation and inflammation, so it needs to be removed properly. Plaque also contains numerous bacteria that can cause bad breath. Using an alcohol-free mouthwash is also recommended to help maintain fresh breath.
2. Xerostomia: Also referred to as dry mouth, it causes a reduction in salivary flow. Decreased salivary production can increase bacterial growth in the oral cavity. During mastication, food may get stuck in the tooth crevices, leading to bacterial accumulation. Xerostomia can be secondarily associated with an underlying disease. In all these cases, unpleasant odours can develop in the mouth.
3. Diet: Some food items like garlic or onion can cause bad breath. After digestion, the breakdown products enter the lungs via the bloodstream and cause bad odour. Fasting regularly and consuming low-carbohydrate foods can produce ketones upon their breakdown and cause bad breath.
4. Tobacco: Consumption of tobacco can lead to gum problems. When inflammation develops, bacterial growth increases and produces bad odour.
5. Medications: Certain drugs reduce salivary flow and produce bad odour or release chemical compounds in the breath. These drugs include nitrates (for patients with angina), chemotherapy drugs, and even some tranquilisers. Consumption of excessive vitamin supplements can also cause bad breath.
6. Ketoacidosis: In diabetic patients having low insulin stores, the body’s sugars are depleted, so the body uses fat reserves. The breakdown of fat produces ketones. Ketones build up in the body, which can be harmful and cause an unpleasant odour. Therefore, ketoacidosis is a serious and life-threatening condition.
7. Other medical conditions: Bad breath can be a symptom of cancers, metabolic disorders, liver failure, constipation, GERD, sinusitis, throat infections, and aspiration pneumonia.

Effective Treatment Options and Preventive Measures for Halitosis

Managing halitosis effectively requires proper oral care and treating the underlying cause. However, if it remains persistent, it is a sign that professional help is required. Optimal results depend on identifying the cause through proper examination and diagnosis. The treatments can be targeted or adjunctive, and in some cases, an interdisciplinary approach may be needed to manage halitosis.

Treatment options include

1. Treating the underlying cause (intraoral or extraoral): In cases of gum disease, the patient is referred to a periodontist (gum specialist), as gums may recede and pocket formation may occur, creating a niche for bacteria. Professional deep scaling and root planing are required in such cases. If the individual has any dental appliance in the mouth, it also requires regular cleaning. Systemic diseases can be managed with appropriate treatment for conditions such as diabetes, metabolic disorders, lung and throat infections, or gut disorders. Management of these health conditions can help reduce bad breath.
2. Mouthwashes and toothpastes: Plaque buildup on the tooth surfaces must be removed properly and effectively. Mouthwashes can help remove plaque and reduce bacterial growth, thereby improving breath freshness. An antibacterial toothpaste may be recommended by the dentist to prevent biofilm buildup in the oral cavity.

Preventive measures include

1. Drinking plenty of water: Staying hydrated is one of the best ways to prevent bad breath. The amount of water intake varies from person to person depending on age, activity level, and any underlying medical condition. Adequate water intake helps prevent dry mouth and dehydration.
2. Chewing sugar-free gum: This can increase salivary flow in the mouth and provide temporary relief from bad breath.
3. Dietary tips: Avoid consuming raw garlic and onions, as they can cause bad breath by releasing sulfur compounds.
4. Lifestyle tips: Quit smoking and avoid the consumption of alcohol and tobacco.
5. Use of an electric toothbrush: The electric motions and vibrations help remove plaque more easily and efficiently than a manual toothbrush. Plaque-causing bacteria are removed, leaving behind fresher breath.

Conclusion

Halitosis is a common problem faced by many people. It can impact individuals socially, which can leave them stressed and anxious. It is a multifactorial condition with both intraoral and extraoral causes. It can be secondarily linked to a disease and may be a symptom of underlying health problems. Gum diseases can also cause bad breath. Diet and lifestyle factors should be improved to help prevent bad breath. There are various treatment options for managing halitosis depending on the underlying cause. Regular dental visits and good oral hygiene can help prevent halitosis before it becomes persistent and stressful.