Has anyone ever asked to share a piece of gum or a mint with you? Did you wonder if they were doing this out of the goodness of their heart or did it cross your mind that they were trying to tell you something about your breath? Bad breath or halitosis can be both embarrassing and cause those around you to avoid being in close proximity. As a dentist, I am frequently asked what causes halitosis (aka bad breath) and how to fix it?
What causes bad breath?
Halitosis, the medical term for bad breath, has multiple etiologies. Occasional bad breath can be caused by specific foods that we eat: onions, garlic, spices, etc. Persistent oral malodor can be due to poor oral hygiene, post nasal drip, acid reflux or systemic conditions such as cancer or diabetes.
Approximately 90% of bad breath symptoms originate in the oral cavity. The main culprit being the bacteria on the dorsum of the tongue that produce volatile sulfur compounds (also known as VSCs), a byproduct of their metabolism. Most halitosis is an imbalance of the natural bacterial inhabitants of the mouth. Addressing these properly will reverse the signs and symptoms of bad breath. If you don’t experience relief from the following interventions, it is possible a systemic condition is to blame and further medical intervention would be warranted.
Step #1 Tongue Hygiene
The tongue is the proverbial elephant in the room. With a surface that mimics the shag carpets so popular in the last century, the tongue has a tremendous amount of surface area to harbor bacteria that contribute to bad breath. As I have discussed in prior newsletters, it is important to use a quality tongue scraper on a daily basis to reduce debris and bacteria collecting on this surface.
I would advise using a tongue scraper every time you brush your teeth. It is not recommended to clean your tongue using a toothbrush, even if it is one dedicated for tongue use only. Tongue cleaners have a specific curved design to help follow the natural anatomy and they are used in a sweeping fashion to pull debris from back to front.
Cleaning the posterior portion of the tongue can stimulate the gag reflex in some individuals. To combat this be sure to engage your core muscles, tightening them as if to protect your body from impact. This will help to distract and discourage the gag reflex. Swipe back to front (about 5 to 10 swipes) , rinsing your tongue scraper between each swipe.
One quick test to check for fresh breath is to swipe the posterior contents from your tongue, wait five seconds and then use your own nose to evaluate for malodor holding the tongue scraper about two inches from your nose.
Step #2 Floss Your Teeth
The pathogens responsible for gingivitis and periodontal disease also play a role in halitosis. One of the best ways to minimize the colonization and formation of the biofilm responsible for bad breath is to practice regular and purposeful flossing. Ideal floss selection would be one that is textured or fuzzy. These do well to capture and remove debris unlike smooth thin flosses that essentially just move plaque from one area of the tooth to another. Unfortunately, the thicker flosses can be more challenging for some patients to use because the floss shreds and breaks between the tight contacts. If you’re one of these patients, you may find step #3 to be helpful.
Step #3 Use a Water Flosser Daily
I have previously written and recommended the daily use of a water flosser. Research points to a more effective removal of biofilm with this habit when compared to daily flossing. If you’re new to this concept, be patient. My best advice is to only use the device over a sink and your head should be parallel to the drain allowing the water to drain from your mouth directly into the sink.
Step #4 Brush for Two Minutes Twice Daily
My hygiene staff and I highly recommend using an electric toothbrush. My personal favorite is the Sonicare base model. It is reasonably priced and highly effective at cutting down on plaque accumulation. Perhaps the most important feature of a quality electric toothbrush is the timer function. Not only does it encourage the two minute recommended brushing time but it also beeps to remind you to move your toothbrush so each area receives equal attention. We can all attest to brushing our teeth and having our minds elsewhere. The electric toothbrush helps to encourage mindfulness when brushing.
Step #5 Combat Xerostomia
Xerostomia, the clinical term for dry mouth, is one of the most common conditions we see in our aging population. As we mature, our bodies produce less saliva which can lead to trouble eating and even speaking. Additionally, age often comes with an increasing prescription medicine list and a common side effect of pharmaceuticals is dry mouth. Most patients will complain that they are most bothered at night with severe dryness that disrupts their comfort while sleeping.
Saliva is the body’s natural cleansing agent and when the flow and quantity decrease one of the side effects can be noting an increase in bad breath or a foul taste in your mouth. Drinking water may bring temporary relief but there are other interventions that can bring a more lasting effect.
Due to the complex nature of xerostomia, I plan to write a separate newsletter covering this topic. In the meantime these products have received positive feedback from my patients who have used them:
Step #6 Shut Your Mouth
People who are chronic mouth breathers often experience halitosis. Breathing through the mouth dries out the oral tissues negating the benefit of a proper salivary flow. I have written on this topic previously and cannot emphasize enough that not only for your dental health but also for your systemic health, it is imperative to learn to breathe through your nose. If mouth breathing plagues you during the night, many people benefit from mouth taping.
Step #7 Avoid Harsh Mouthwashes
A growing interest and topic of research is the delicacy of the oral biome. We’ve been trained to think bacteria are bad and we need to treat the mouth in a fashion that sanitizes it from the critters that inhabit it. But a growing body of research is pointing to the harms of this mindset and it has caused me to retract mouthwash recommendations that I used to promote.
There are specifically formulated oral rinses that target the volatile sulfur compounds (VSCs) that contribute to bad breath by exposing them to a super oxygenated environment. One product that comes highly recommended is TheraBreath. This rinse is free of dyes, parabens, and sulfates. It uses sodium chlorite to harness the power of oxygen to combat the anaerobic bacteria that produce VSCs. Patients can experience up to 12 hours of relief using this product twice daily.
Step #8 Zinc
Zinc is an essential mineral to human health. It is essential for our bones, our muscles, our skin and our oral cavity. It plays a vital role in tooth development and is effective at helping to maintain healthy homeostasis in the mouth. Adequate zinc levels can help to reduce plaque formation and prevent calculus build up. Zinc also plays a key role in the prevention of halitosis. Some dental products feature zinc to help combat both bad breath and periodontal disease. Zinc supplementation has shown to help improve halitosis along with gingivitis and periodontal disease. Natural sources of zinc include lamb, liver, beef and oysters. Recommended daily allowance to prevent disease vary based on age and gender.
Step #9 Oral Probiotics
Halitosis is predominantly caused by a disruption of the oral biome. The Standard American Diet of overly processed foods that are high in sugar and additives does not help the ongoing fight to establish a healthy balance of the bacteria that inhabit our mouths. There is research that demonstrates beneficial evidence in subjects that utilized an oral probiotic. Specifically the strains of bacteria targeted were Lactobacillus reuteri, Lactobacillus salivarius, Weisserlla cibaria and Streptococcus salivarius. These bacteria play a role in a healthy mouth and help to inhibit the overgrowth of bacteria that lead to bad breath.
I am new to the idea of utilizing an oral probiotic. It seems the market is flooded with options. This one is available on Amazon with good reviews. The one that I have used and really like is from BOKA. This is a growing field in dentistry and I hope to be able to write more and have more recommendations in the future.
Step #10 EAT A HEALTHY DIET
I struggled with whether I should list this as ‘number one’ or ‘save the best for last’. No provider can adequately stress the need to consume a healthy diet. I recently listened to one of my dental school professors, Dr. Gary Slade, being interviewed on the Peoples’ Pharmacy via NPR. The topic was water fluoridation but at one point Dr. Slade was asked what are the three most important actions a person can take to have a healthy mouth. He listed eating a healthy diet as number one. I could not agree more (although I disagree with his position on water fluoridation). Yes, some foods like onions and garlic can contribute to temporary halitosis but a diet rich in whole, organic foods help to encourage a healthy mouth, a healthy biome and overall a healthy body.
If you’ve made it this far, thank you for reading. I am grateful for the opportunity to help you and your family. The topic for this newsletter came by request from a patient. Please feel free to reply to this email should you have suggestions for a future newsletter.
Sincerely,
Jessica
