Halitosis – Bad breath

Background info on bad breath

Around 25% of the population suffers from chronic halitosis and the percentage is higher in older individuals than younger ones.  Halitosis, or bad breath, most often starts in the mouth (85%).   Gingivitis and periodontitis are the main causes of the problem.25  Poor oral hygiene allows food particles to collect on the surface of the tongue, between the teeth, or along the gum tissue that surrounds the teeth.  Naturally occurring bacteria in your mouth then break down those food particles, releasing chemicals that have a strong odor.

Microbial degradation of food particles produce volatile sulphur compounds (VSCs).  The most important VSCs involved in halitosis are hydrogen sulphide (H2S), methyl mercaptan (CH3SH) and dimethyl sulphide (CH3)2S.  Other molecules involved in this bacterial degradation process are: diamines (indole and skatole) or polyamines (cadverin and putrescin).  They seem play a less important role in the expression of bad breath.

oral malodor compounds

Periodontal disease and the tongue

There is a positive correlation between bad breath and periodontitis: the depth of the periodontal pockets is positively correlated to the height of the VSC concentrations in the mouth.14  A positive correlation between the depth of the pockets and the concentration of the sulphur components has also been shown.15  When tongue coating is taken into account, the correlation is even more significant.15,16 

Studies suggest bad breath is caused by tongue coating in the younger generation and by periodontitis with tongue coating in older individuals.  A clinical evaluation of malodour on 2 000 patients in Belgium, showed that 76% of these patients had oral causes: tongue coating (43%), gingivitis/periodontitis (11%) or a combination of the two (18%).18 


What causes bad breath?

Odor arises from food ingestion, smoking , alcohol consumption, extraoral sources and/or psychological conditions.  80-90% of the causes are mouth related.  Infections in the mouth, such as dental caries (tooth decay), periodontal disease or mouth sores related to other conditions may contribute to bad breath.  5% are sinus or gastrointestinal and 5% are considered other Zalewska 2012 Acta Gastroenterol  Systemic conditions, such as diabetes mellitus, uremia and kidney diseases, and hepatic diseases also cause.  It may result from infections in the nose, throat or lungs; chronic sinusitis; postnasal drip; chronic bronchitis; or disturbances in your digestive system.  The main food culprits are garlic, coffee, and onions, but excessive dairy and carbs can cause problems too.

Saliva helps wash food particles from your mouth; thus, people with a dry mouth are at an increased risk of experiencing bad breath.  Some medications, mouth breathing, allergies, and smoking all can contribute to dry mouth and thus bad breath.

It is always easy to recognize halitosis, but identifying the exact cause is more complex.  Bollen and Beikler article is great on breakdown of possible causes.  Int J Oral Sciences 2012

bad breath

How to eliminate bad breath

Since most bad breath comes from issues in the mouth your best weapon is good oral hygiene.  Cleaning your mouth reduces food residue and plaque as well as reduces the risk of developing cavities and periodontal disease.  There are not a lot of short cuts to eliminating bad breath and most of the ways to prevent and eliminate it are things you have likely heard before.

  • Get professional cleanings on a regular basis, possibly every 3 months.
  • Scrape or brush the back of your tongue.  The tongue is full of bacteria, especially in the back.  The tongue is the primary source of bad breath statistically and few clean it.
  • A tongue brush with tongue zinc paste is far more effective than a tongue scraper, which can only remove the upper surface layer of the biofilm
  • Use a mouth rinse 2-3 times a day.  Something with essential oils, chlorhexidine, chlorine dioxide, hydrogen peroxide, or cetylpyridinium chloride with zinc.  The chlorhexidine is the best but it stains teeth, especially with smokers.  Hydrogen peroxide and zinc solutions are arguably at the top as well.  Halita has several of the chemicals.
  • Clean between your teeth once a day by using an interdental cleaner such as floss
  • Brush your teeth 2-3 times day with a fluoride-containing toothpaste.  Triclosan also helps.
  • If you have dentures, take them out at night, clean them thoroughly, and use a disinfecting soak.
  • If your problem seems to stem from a dry mouth, check out my blog on dry mouth care.
  • Chew sugar free gum.  This stimulates bodies saliva production, which is our natural way of cleaning our teeth.
  • Drink lots of water
  • Using a weak whitening material at night may also help – it’s basically hydrogen peroxide which kills bacteria.
  • Taking a chlorophyll product may help
  • Probiotics can also help


How is bad breath detected and measured?

It is very important to first determine if bad breath is caused by something in the mouth (majority) or something non-oral.  This is accomplished very easily by comparing mouth breathing to nose breathing.  The majority of patients with non-oral halitosis have blood-borne halitosis, frequently caused by the VSC dimethyl sulfide.  This may be a sign of a serious disease.    Tangerman 2012

There are three methods of analyzing oral malodour.  Organoleptic measurement is a sensory test scored on the basis of the examiner’s perception of a subject’s oral malodour.  The problem is the testing methods are far from standardized. Aydin 2016 Comp  Gas chromatography (GC) is specific for detecting volatile sulphur compounds (VSC).  However, the GC equipment is not compact, and the procedure requires a skillful operator; therefore, it is impractical for practitioners to equip their offices for GC.  However, OralChroma advertises as a compact version and as being operating freindly.  Sulphide monitors analyze for total sulphur content of the subject’s mouth air, but most are not specific for VSC.

Yaegaki CDA


Gas chromatography and sulphide monitors (both known as halitometers)

  • OralChroma
  • Halimeter
  • Breathtron
  • TwinBreasor
  • Probe Perio
  • B/B Checker
  • BreathTracker
  • FF-2A
  • Cyranose 320

Chlorine dioxide

Shinada Trials 2010


vanSteenberghe J Perio 2001

Cetylpyridinium chloride with zinc

vanSteenberghe J Perio 2001


Dadamio J Perio 2013

Winkel J Perio 2003



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