Why does my breath stink?

Few things are as embarrassing as a person opening his mouth and having people around him cringe or squeeze their noses because of offensive odour from the mouth.  While some are aware that they suffer this medico-social problem, others are either in a state of complete ignorance or sometimes denial.

According to Dr Clement Chinedu Azodo of the department of Periodontics, University of Benin Teaching Hospital, Benin, Edo State, “it is a universal problem affecting 50 to 65 per cent of the adult population amounting to millions of people worldwide. It is also a common reason for dentist consultation as it raises a lot of concern among sufferers. It negatively impacts on daily life activities like communication with other persons, self-esteem, self-confidence, social and intimate relationship like dating and marriage, employability, and career aspirations. It causes embarrassment, inhibits social interaction, and also decreases quality of life among afflicted individuals.

“The effect of halitosis extends beyond the afflicted individuals, as it is also a source of embarrassment for relatives and friends of individuals afflicted with this condition. The concern can also trigger behavioural reaction namely self-consciousness, social isolation, suicide attempts, and suicide, mostly because of social, psychological, and relationship impediments.” In fact, in some societies it has earned the title “a social life killer.”

Given the many ways it can affect a person, it is no wonder that a smelly mouth is increasingly becoming a major health issue.

Known in medical terms as halitosis, Dr. Ezi Akaji of the Department of Preventive Dentistry, College of Medicine, University of Nigeria, Enugu, Enugu State, describes it as “an offensive or disagreeable odour emanating from the mouth or hollow cavities of the nose, sinuses or pharynx.”

Bad breath: Real or imagined?

Bad breath is one of such conditions where the sufferer may, most times on his/her own, not know he/she is suffering from. This can lead to a situation of self-consciousness which may or may not be founded. Dental experts say sometimes, bad breath may not be detectable by others but a person may strongly believe his breath smells. This is termed delusional halitosis.

According to Dr Akaji, halitosis can be classified into genuine halitosis, delusional halitosis or halitophobia. “Genuine halitosis is either physiological or pathological in origin, while pseudo-halitosis is the claim that halitosis exists when no objective evidence can be found,” she said.

The diagnosis of delusional halitosis is one that is usually taken with caution and treatment includes evaluation of the psychological predisposition of such patients.

Where does the foul odour emanate from?

Researchers have detected over 600 species of microorganisms in the mouth. Dr Akaji says, “various sites in the oral cavity serve as niches for these bacteria, but the dorsum of the tongue with its characteristic fissures and grooves is their primary location. In genuine halitosis, bacterial activities in the oral cavity are implicated in 80 per cent to 90 per cent of cases.”

Causes of bad breath

Bad breath could arise from oral or non-oral causes. “Oral causes include poor oral hygiene, periodontal diseases, tongue coat, unclean dentures, faulty restorations, oral carcinomas and throat infections. Gingivitis, periodontitis and tongue coating, are the most frequent oral causes of halitosis,” Dr Emeka Danielson Odai of the Department of Oral and Maxillofacial Surgery, University of Benin Teaching Hospital, Benin, Edo State, said. Dry mouth, food impaction areas in between teeth, oral ulcerations, oral malignance are other oral causes.

Although majority of halitosis cases are caused by oral and dental issues, other non-oral causes include those of sinonasal, pulmonary, and gastroenterological origins.  According to Dr Akaji this can be broken into “Ear Nose and Throat infections (acute pharyngitis, purulent sinusitis, and postnasal drip); bronchial and lung disease (chronic bronchitis, bronchiectasis, bronchial carcinoma), liver diseases (cirrhosis), kidney disorders (chronic renal failure), metabolic disorders (diabetes/diabetic ketoacidosis), GIT disorders, e.g. GERD.

“Foods: Certain foods have also been implicated to cause bad breath. Onions, garlic, coffee, alcohol and cigarettes among others.

“Drugs: Certain medications can cause bad breath because of their ability to cause dry mouth. Some of these include anti-depressants, diuretics, anti-hypertensives, analgesics and anti-histamines.

“Other conditions linked with bad breath are dehydration, old age, anaemia, hypovitaminosis, emotional stress, inflammatory autoimmune diseases and obstruction of salivary glands, malignancy and irradiation for head and neck cancers, multiple sclerosis, menopause.”

Treatment

As a result of the fact that the cause of bad breath can stem from numerous sources, it is important to get medical advice which would proffer treatment for the specific cause. The treatment options could range from changes in oral hygiene and diet to other treatments such as professional cleaning e.g scaling. In the case of non-oral sources, specific treatments can also be suggested. For instance, it has been discovered that tonsillectomy is a significantly effective procedure for the treatment of halitosis caused by chronic tonsillitis.

“Each case is treated differently depending on its origin thus making a holistic approach necessary. Before a treatment plan can be developed for any patient, an accurate diagnosis based on the patient’s history, physical examination, organoleptic assessment and evaluation of any laboratory tests must be made. Also, a review of significant aspects of the patient’s family and social history (such as dietary and smoking habits), drug histories, illnesses, hospitalisations and surgeries are invaluable in reaching an appropriate diagnosis,” Dr Akaji said.

However, some simple steps can be taken to tackle the condition. “In most instances, halitosis stems from putrefactive microbial activity within the oral cavity itself and can be alleviated by proper oral hygiene and dental care. Mechanical cleaning of teeth in the form of tooth brushing and flossing is essential mechanical means of oral hygiene that leads to reduced amount of oral bacteria and substrates and presumably reducing halitosis. However, mechanical methods can be ineffective in reaching and removing certain bacteria from all areas of the oral cavity. Mouth washes and rinses are considered more effective in reaching the less accessible parts of the oral cavity,” Dr Odai stated.

Sometimes, the cause could be traced to the tongue in which case it has been recommended that tongue-scraping should be adopted.

For halitosis from non-oral sources, a multi-disciplinary approach is necessary, experts say. Referrals to specialists such as otolaryngologists, gastroenterologists or mental health specialists should be done once possible the oral angle is handled.