Halitosis (bad breath)

The culprits for bad breath are what's known as aromatic chemicals. These are smelly compounds released either by the food itself or bacteria. This can be your mouth bacteria, helping to break down small particles of food as part of digestion, or bacteria from an underlying health condition.

To help understand the causes of bad breath further, they can be split into three main categories: physiological, pathological, and psychogenic.

Physiological halitosis

This is normal and means there is no underlying condition causing the bad breath. It only lasts a short time and can be improved with simple steps such as good oral hygiene. The causes of physiological halitosis are:

• Dry mouth: Saliva plays a crucial role in washing food particles from your mouth down the digestive tract. Saliva also has powerful antimicrobial properties against bacteria in the form of hydrogen peroxide, lysozymes, and lactoferrin. If you are not producing much saliva, more particles get left behind, and bacteria can grow unchecked, releasing aromatic compounds into your breath. This is the cause of morning breath as you release less saliva overnight. It is also why dehydration, alcohol, and caffeine can cause bad breath, as they all lead to a dry mouth.
• Strong-smelling foods: Onion and garlic can cause short-term bad breath. They release strong-smelling aromatic compounds that can linger long after you have eaten them.
• Fasting or a diet low in carbohydrates: Fasting or a low carbohydrate diet can cause bad breath because the body produces a chemical called ketones, which has a distinctive smell and is released when fat is broken down.
• Smoking: Cigarette chemicals can stay on the surface of your mouth and gums. They are then released into your breath resulting in a distinctive smell. Smoking can also dry out your mouth and increase the chance of developing gum disease, another risk factor for bad breath.

Pathological halitosis

This is bad breath caused by an underlying condition. This can be something within the mouth. These tend to be dental issues such as cavities and gum disease. Conditions outside of the mouth can also cause it. Digestive problems may cause an incomplete breakdown of food in the stomach. You may have an imbalance of your gut microbiome (friendly gut bacteria), and acid reflux (heartburn) can also cause halitosis. Bacterial infections in the nose, sinuses, or throat, such as tonsilitis or abscess, may release aromatic chemicals. Mouth and throat cancer are rare, and smoking puts you at particular risk, but this can be the cause of bad breath for some. Rarely some conditions cause a dry mouth, such as Sjogren's syndrome, and some medications, such as antimuscarinics, antihistamines, tricyclic antidepressants like amitriptyline, and some diuretics.

Psychogenic halitosis

Also known as subjective halitosis, someone believes they have bad breath, but it's not detectable by anyone else.

Oral hygiene: The best way to prevent bad breath is through good oral hygiene. This sweeps away all food particles from the mouth to avoid the build-up of bacteria and remnants of your dinner. It also lowers the risk of plaque build-up, tooth decay, and gum disease, which can all increase halitosis in the longer term.

You probably learned early in life to brush your teeth morning and evening, but let's go through the rules to ensure you're doing everything to keep your mouth, teeth, and gums healthy:

• Brush your teeth morning and night with fluoride toothpaste for at least 2 minutes (as long as a song on the radio).
• Invest in an electric toothbrush, as they remove plaque build-up more efficiently from your teeth than a normal toothbrush, giving you better oral hygiene and a lower risk of gum disease.
• Brush your tongue with a gentle toothbrush that has a specific tongue cleaner on the back.
• Use floss or interdental picks twice a day to get rid of any food stuck between your teeth.
• Clean any dentures thoroughly to remove bacteria and food on them in the same way you would look after your teeth.

Chewing gum encourages the release of saliva to wash away food particles and fight unwanted bacteria. It can also help freshen your breath up with a minty scent. Make sure to choose the sugar-free type. Avoid things like sugary mints as they may help with bad breath in the short term but can cause longer-term issues. Stimulating saliva with ice cubes or sugar-free fruit pastilles will also help.

Hydration: Keeping well hydrated will also help maintain a good amount of saliva, avoiding a dry mouth, and saliva can be stimulated with frequent sips of cold, unsweetened drinks.

Alcohol and caffeine: In a similar vein, avoiding alcohol and caffeine avoids the dry mouth that can lead to bad breath.

Stopping smoking will improve halitosis and reduce the risk of serious mouth and gum problems, along with all the other health benefits your body can look forward to.

Treatments for bad breath aim to improve oral hygiene and deodorize the mouth.

Many flavored toothpastes can help to remove plaque and prevent tartar build-up on the teeth, which, in turn, prevents bad breath.

Gum disease, including gingivitis and periodontitis, can lead to swollen and bleeding gums. This leaves growth pockets for bacteria to settle in between the gums and around the teeth. These bacteria feed on remnants of food and debris around the teeth, growing in number and leading to infection, inflammation, and bad breath.

Untreated gum disease can lead to avoidable problems like premature tooth loss and inflammation in the mouth that can spread to other parts of the body. Long-term consequences of this include cardiovascular disease and diabetes. For bleeding gums and gingivitis, your dentist can prescribe a 30-day course of a chlorhexidine 0.2% based mouthwash such as Peridex, rinsed twice daily, to help reduce harmful mouth bacteria.

Most dentists and hygienists recommend cleaning twice daily with a good electric toothbrush for at least 2 minutes and not putting excessive pressure on the gum line. Particular importance should be placed on cleaning between the teeth with dental floss or interdental brushes. If this is tricky due to the angle of the teeth, an electric water flosser or water pick can help to remove a build-up of plaque and tartar between the teeth. Brushing your tongue with a gentler setting on your electric toothbrush or with a specific tongue cleaner can also help improve oral hygiene. If you wear dentures, make sure they're cleaned properly and regularly.

Other products, such as CB12 mouthwash and CB12 chewing gum, can neutralize and deter substances that encourage bad breath. They are widely available in pharmacies and healthcare stores.

If you have tried these simple measures for at least two weeks and are still suffering from bad breath, or your symptoms are severe and causing you distress, the best next step is to see your dentist. They will check your mouth or gums for any dental issues causing symptoms.

If you think the bad breath is due to an underlying health issue, book an appointment to discuss this with your doctor. They will ask about other symptoms and examine your mouth and other relevant areas. They may consider further investigations or refer you to a specialist team.