Poor oral hygiene is the #1 risk factor for bad breath. In most cases, the cause can be traced to the mouth. The smell is mainly caused by volatile sulfur compounds (VSC) produced by bacteria.
The patient is often unaware of the problem and it can be worsened by mouth breathing. Transient oral malodour on awakening is a natural phenomenon.
Halitosis may cause significant social impairment, fear of social situations and social withdrawal. For most patients, halitosis may be more of a social vs medical problem.
Management of halitosis usually involves identifying and treating the specific cause. Oral hygiene should be recommended to every patient. Stimulation of salivary flow and use of refreshing mouthwashes or gargles may benefit certain patients
Causes of bad breath
Poor oral hygiene, dental caries, periodontal diseases, and difficulty in cleaning prostheses.
Reduced salivation and drying of the mouth often associated with Sjögren’s syndrome, Radiotherapy and post-operative conditions, Anticholinergic drugs
Bad-smelling nutrients, drugs, and stimulants and their degradation products e.g. Garlic, Tobacco, Alcohol, Isosorbide nitrate, Disulfiram
Infection and putrefaction involving salivary glands, tongue, ulcers and lesions of the oral mucosa
Infection of the tonsils, adenoids or lingual tonsil
Tonsillary plugs: whitish or yellowish foul-smelling grainy mass is accumulated in the tonsillary crypts and is shed by pressure on the crypt.
Retropharyngeal or nasopharyngeal accumulation of mucus and pus, adenoids (cause mouth breathing, particularly in children), maxillary sinusitis
Nasal tumours, foreign bodies, other causes increasing mouth breathing
Atrophic rhinitis and ozaena
Oesophageal diverticles, achalasia, reflux disease
Bronchitis, bronchiectasis, pulmonary empyema
Some systemic diseases namely diabetes, renal and hepatic failure
If no outside person has reported on the patient having oral malodour, the patient may suffer from a disturbance of the sense of smell or from olfactory hallucinations.
Treatment
Treatment is aetiology-specific. Severe tonsil-associated malodour problem may warrant tonsillectomy.
When no specific treatable cause is found, the management consists of attempts to increase salivary secretion, to decrease the amount of bacteria in the mouth and to mask the odour:
- Good oral hygiene, tongue brushing or scraping
- Stimulation of salivation using chewing gum or lozenges; artificial saliva
- Non-alcoholic antimicrobial mouthwashes and gargles. Mouthwashes and toothpastes containing e.g. chlorhexidine, cetylpyridinium or triclosan temporarily decrease the amount of odour-producing bacteria. Disadvantages of chlorhexidine include unpleasant taste and staining of teeth.
- Lozenges, mouthwashes and sprays intended for masking the odour have a momentary effect only.