Penam Periodontics - Evidence based Personalized Periodontics

Halitosis (Bad Breath)

Halitosis or bad breath is potentially the result of a number of different causes. It can be embarrassing for some people, especially when interacting with family and friends. There are 3 main factors which contribute to Halitosis and these are:

  1. Poor oral hygiene in the presence of odour producing bacteria;
  2. Dietary factors;
  3. Tonsillitis and Tonsilloliths;
  4. Systemic disorders/problems.

1. Poor oral hygiene

Poor oral hygiene is not the basic cause of halitosis but poor oral hygiene in the presence of specific odour producing bacteria within the dental plaque is the major issue in subjects who have halitosis. However, good oral hygiene practice in those people that have the odour producing bacteria will result in a dramatic improvement in halitosis in many cases. These odour producing bacteria are not only found on the gums but most of them are found on the tongue. Therefore in these halitosis subjects oral hygiene should include cleaning of the tongue (tongue scraper or toothbrush). Brushing and interdental cleaning (most efficient being an interdental brush) are also essential.

2. Diet

Diet can be a source of Halitosis. Foods that contain esterified fatty acids or oils (Garlic and onions are classic examples) or sulphurous compounds are a major cause in some individuals. The body excretes a significant percentage of the esterified fatty acids though the breath. You exhale them out. Other foods that contain these esterified fatty acids, such as wine, may also contribute to Halitosis. The treatment in these cases should revolve around reduction of the food source.

3. Tonsillitis and Tonsilloliths.

Tonsillitis is associated with short term episodes of Halitosis. These are usually resolved by the medical treatment of the infection.

Tonsilloliths, also known as tonsil stones or tonsil calculi, are clusters of both soft and calcified material that form in the crypts (crevices) in the tonsils. While true tonsil stones are rare, small areas of calcification or bacterial concretions are relatively common and they may occur in ~10% of the population. Tonsilloliths occur more frequently in adults than in children and may not be noticed until the patient has an x-ray or scan.

A study (in 2007) found an association between Tonsilloliths and bad breath. Seventy-five percentage (75%) of those with bad breath had Tonsilloliths, compared with 6% of subjects with normal breath test results. The calculi are covered with odour producing bacteria in those subjects with bad breath.

Treatment of Tonsilloliths is usually performed by the Ear, Nose and Throat (ENT) surgeons. So referral to an ENT surgeon is usually expected. However a number of methods may be used:

  1. Oral irrigators.
  2. Manual removal of the material on a regular basis;
  3. Vigorous rinsing;
  4. Curettage by the ENT surgeon;
  5. Laser crypt lysis. Reduction of the tonsil using lasers.
  6. Surgical removal of the tonsil.

 4. Systemic disorders/Problems

Bacterial related causes of systemic associated halitosis include odour producing bacterial overgrowths in the maxillary or nasal sinuses, in the tonsils or the bowel. Certain systemic disease may also contribute to Halitosis. An example is the smell of acetone on the breath of Diabetics when they develop ketosis.

Treatment of Bad Breath The treatment of any condition should revolve around the elimination of the aetiological events or agents. Therefore just using a mouth freshening product, such as chewing gum, mouthwashes, sprays or lozenges is unlikely to address the aetiological events. The proper diagnosis of the aetiology of the condition is important as that should determine the treatment need. Treatments may vary from improved oral hygiene, to changing your diet, to surgical removal of the tonsils.

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