An important and very vital aspects in cosmetic dentistry is controlling bad breath.  More than 90 million people suffer from chronic halitosis or bad breath. In most cases it originates from the gums and tongue. The odor is caused by bacteria from the decay of food particles, other debris in your mouth, and poor oral hygiene. The decay and debris produce a sulfur compound that causes the unpleasant odor.

Anaerobic Bacteria

Studies have shown that about 85% patients suffering from halitosis have an oral condition as the source. If a person has healthy teeth and gums (i.e. no cavities, periodontitis, or abscesses), the next most common source of oral malodour is the tongue. Bacteria which produce volatile sulfur compounds (VSCs) have been found to congregate on the tongue, especially the posterior one third.These bacteria can be found on the surface of the tongue, throat, teeth, and periodontal pockets in the gums.

Tongue and Throat Collect Bacteria

Saliva from nearby glands drips down on the posterior region of the tongue, which is full of irregularities where bacteria love to hide. The anaerobic bacteria (bacteria which thrive without oxygen) break down specific components (amino acids) of the saliva, creating certain gases or VSCs. These VSCs have been implicated as a major contributing factor to halitosis or bad breath. If your Tongue has a white coating, this is evidence of excessive anaerobic bacteria buildup.

Medications

One of the most common side effects of thousands of medications is dry mouth (xerostomia).  Bacteria tend to thrive in this environment.

Dry Mouth / Mouth Breathing

Mouth breathing during sleep dries the mouth, creating the dreaded 'morning breath'.  Other causes of dry mouth include medications, exercise, dieting, alcohol or alcohol based mouth rinses, smoking. Other contributing oral factors of halitosis include inflammatory conditions, oral cancer, oral candidiasis,etc.

While the oral cavity is by far the most common source of bad breath, systemic conditions can also be responsible for this condition. Nasal and sinus problems, including foreign bodies inserted in the nose and neglected for a period of time, can be a cause. Repetitive tonsillar infections, infections of the oropharynx, pulmonary diseases (such as bronchitis and pneumonia), and gastrointestinal problems are all possible contributing factors. Certain systemic diseases produce particular odours. A few of these relationships include liver failure producing a rotten egg smell, diabetes producing a sweet smell, intestinal dysfunction producing heavy sour breath, and scarlet or typhoid fever producing a musty smell.

Diet

Many foods (ie: Dairy) contribute to the ability of bacteria to create VLCs. Very spicy foods, such as onions and garlic, and coffee may be detected on a person's breath for up to 72 hours after digestion. Onions, for example, are absorbed by the stomach and the odor is then excreted through the lungs. Studies even have shown that garlic rubbed on the soles of the feet can show up on the breath. Acids in foods such as coffee decrease oxygenation and can cause this bacteria to thrive.

DETECTION

While most of the population has transient halitosis, chronic malodor is less common. Regardless of the type of halitosis, proper diagnosis is important. The difficulty in determining whether an individual has halitosis and its possible causes arises because there are no convenient methods to measure this condition. Some self-monitoring tests and in-office tests are available to aid in the diagnosis, although they are either awkward or still need research to ensure their viability.

Self-monitoring tests generally involve obtaining feedback from a spouse or friend. Individuals may have difficulty detecting halitosis themselves because the brain has the ability to suppress odours stemming from ourselves. While procuring an odour judge may be embarrassing, it is the best method for at-home breath testing. If the odour judge does not wish to smell the patient's breath directly, the patient can scrape the posterior region of the tongue with a spoon or place saliva on the wrist by licking it. The spoon or wrist can then be smelled and assessed by the odour judge. The spoon test is better in case the saliva is not a good carrier of the potential odorant. There is also a home microbial test which is comprised of cotton-tipped applicators and test tubes containing a specific medium. After the applicators are placed on the tongue, they are inserted in the test tubes. If the color in the test tube changes within a certain time period, this is an indication that you have chronic bad breath.

In-office testing can include odour judge testing, microbial and fungal testing, the salivary incubation test, volatile sulfur detection testing, and, in the future, artificial noses. Among other problems, the current tests lack specificity, i.e. it is difficult to determine either the existence or the cause of chronic halitosis. The most recent machine on the market for detecting halitosis, a portable sulfide monitor, also has its proponents and critics. The machine is designed to measure sulfur content in the breath, but it can be inaccurate. At this point, the machine is better for monitoring a patient's progress than in obtaining an initial diagnosis. Most dental offices do not have the capability yet to perform these tests.

TREATMENT

Brush and Floss Your Teeth Properly

Bacteria thrive on food particles on our teeth to create Volatile Sulfur Compounds (VLCs), which cause bad breath. At least 2 minutes of brushing is necessary to properly clean all tooth surfaces.  In addition 30% of the surfaces of our teeth is not cleanable with a brush.  This makes flossing absolutely critical!

Use Bad Breath Relief Products

Halitosis Toothpaste, Non-alcoholic Sulfur reducing mouth rinses, sugar free chewing gum and breath mints.

Clean Your Tongue

Anaerobic bacteria thrive in the fissures and mucous layer of the tongue, sometimes creating a visible whitish layer.  They live safe from oxygen under a protective layer of mucous, food particles and proteins . Tongue cleaners can remove this layer and much of the bacteria which resides on your tongue. One of the easiest and most efficient treatments for halitosis is mechanical debridement. This means thorough, regular flossing and brushing of your teeth and your tongue. A tongue scraper can be very helpful as well. When using a tongue scraper, it is best to clean as far back on the tongue as possible, starting from the back and moving toward the front. This scraping motion is done several times in row.

Drink Plenty of Water

Keeping hydrated allows proper salivary flow to help rinse and flush out unwanted bacteria.

Effective oral rinses must eliminate the problematic bacteria while maintaining the balance of normal bacteria in the oral environment. The assorted types of rinses being developed and marketed contain quaternary ammonium, zinc, chlorhexidine (already in use to help treat periodontitis), chlorine dioxide, or triclosan. Chlorhexidine and chlorine dioxide rinses have received the most press lately. Because chlorhexidine is such a strong antimicrobial rinse, it is advised to only use this type of rinse as a short-term adjunct for treatment. At present, chlorine dioxide can be used on a long-term basis, although some researchers do question its safety. In lab experiments, chlorine dioxide has been shown to be effective by breaking the sulfide bonds in VSCs, but this finding has not yet been substantiated using live subjects. Chlorine dioxide neutralizes the sulfur compounds which cause bad breath.  A majority of mouth rinses contain alcohol, which actually dries out the mouth and can end up contributing to halitosis.

Chewing stimulates saliva and aids in cleaning out noxious bacteria.

Periodontal disease is a bacterial infection of the gums and ligaments which support the teeth. This leads to bone loss and deep pockets between the teeth and gums which are not easily cleanable.  Extremely high amounts of bacteria can live in these pockets and need aggressive cleaning therapies to reduce   bad breath.  Signs of periodontitis include red or swollen gums, loose teeth, bleeding gums, pus, pain on chewing.

Other management tools include antibiotics, nasal mucous control methods, avoidance of certain foods and medications, salivary substitutes, and management of systemic diseases.

Twice yearly dental check-ups are a good idea for all adults. This is because people often do not become aware of dental problems until considerable damage has occurred. A dentist can recognize potentially damaging problems early. In addition, the dentist can diagnose other problems which cause bad breath including abscesses, periodontal disease, cavities, and impacted teeth.

The causes and treatment of bad breath or halitosis is a popular area in cosmetic dentistry today. Some research has been done, but more needs to be accomplished, especially regarding treatments.

There are actually several different sources of oral malodour. These include mouth and tongue sources, nasal and sinus sources, lower respiratory tract and lung sources, gastrointestinal diseases and disorders, systemic diseases, and ingestion of certain foods, fluids, and medications as detailed above. The major challenge is first determining if a patient does have chronic bad breath. Then the source/s can be investigated. This may require a team approach of dentist and physician(s) to determine if it is an oral problem or not.

If it is determined to be orally-related, the two main oral problems which cause halitosis are either tooth decay and/or periodontal disease. Other oral problems, such as xerostomia (dry mouth), oral candiasis (fungal infection), and oral cancer, can also contribute to oral malodour. If these problems are ruled out, the main causative agent in the oral cavity are certain bacteria which emit volatile sulfur compounds (VSCs). The main source of these bacteria is generally the tongue.

First, advise to avoid bad breath is to brush not only their teeth, but also their tongue and their palate (gently). Tongue scrapers/cleaners help reduce problems associated with halitosis! If scrupulous oral hygiene, which includes brushing, flossing, and tongue scraping, does not help alleviate the problem, other items can be tried. Salivary stimulants may help if the problem is related to dry mouth. Some newly formulated mouthwashes, which include various ingredients such as zinc and chlorine dioxide, are being developed to combat bad breath. While there seems to be some value in these new agents, further research still needs to be conducted.

My first advise would be to have a complete and thorough examination by your dentist, including radiographs and an oral cancer exam. If no obvious dental cause is discovered, see your physician to rule out another medical cause. In the meantime, your best defense is to practice excellent oral hygiene, including regular brushing, flossing, and tongue-scraping.