Halitosis

Also indexed as: Bad Breath

Fresh breath can lead to more enjoyable interactions with others. According to research or other evidence, the following self-care steps may help halt your halitosis:

Control the sulphur
Routinely use a toothpaste or mouthwash containing zinc compounds or stabilised chlorine dioxide to help break down odour-causing sulphur chemicals

Keep an eye on hygiene
Brush and floss regularly to keep your teeth free of food particles that can lead to halitosis

Scrub the tongue
Brush your tongue or use a commercial tongue scraper regularly to remove odour-causing agents and keep bacteria in check

Get a dental check-up
Visit your dentist to find out if problems associated with oral health are contributing to your halitosis

These recommendations are not comprehensive and are not intended to replace the advice of your doctor or chemist. Continue reading the full halitosis article for more in-depth, fully-referenced information on medicines, vitamins, herbs, and dietary and lifestyle changes that may be helpful.

Halitosis is the technical term for bad breath, a condition estimated to affect 50 to 65% of the population.¹

Up to 90% of cases are thought to originate from sources in the mouth, including poor oral hygiene, periodontal disease, coating on the tongue, impacted food, faulty dental restorations, and throat infections.² ³ ⁴ The remaining 10% are due to systemic disorders, such as peptic ulcer (when associated with infection),⁵ ⁶ lung infections (bad breath can be the first sign in some cases),⁷ liver or kidney disease,⁸ ⁹ diabetes mellitus, cancer,¹⁰ or even a person’s imagination (healthy individuals sometimes complain of bad breath that cannot be smelled by anyone else and is not linked to any clinical disorder).¹¹

In most cases, bad breath in the mouth can be traced to sulphur gases produced by bacteria in the mouth.¹² ¹³ Factors that support the growth of these bacteria will predispose a person to halitosis. Examples include accumulation of food within pockets around the teeth,¹⁴ among the bumps at the back of the tongue,¹⁵ or in small pockets in the tonsils; sloughed cells from the mouth; and diminished saliva flow. Mucus in the throat or sinuses can also serve as a breeding ground for bacteria. Conditions are most favourable for odour production during the night and between meals.¹⁶

Although bad breath primarily represents a source of embarrassment or annoyance, research has shown that the sulphur gases most responsible for halitosis (hydrogen sulfide and methyl mercaptan) are also potentially damaging to the tissues in the mouth, and can lead to periodontitis (inflammation of the gums and ligaments supporting the teeth).¹⁷ ¹⁸ As periodontal disease progresses, so may the halitosis, as bacteria accumulate in the pockets that form next to the teeth.

Product ratings for halitosis

Science Ratings

Nutritional Supplements

Herbs

Coenzyme Q10 (if gum disease)

Folic acid (if gum disease)

Zinc chloride (rinse or toothpaste)

Selenium (if gum disease)

Vitamin C (if gum disease and deficient)

Vitamin E (if gum disease and deficient)

Bloodroot (rinse)

Caraway

Clove oil (rinse or toothpaste)

Eucalyptus

Myrrh (rinse)

Peppermint

Sage

Tea tree oil (rinse or toothpaste)

Thyme oil (rinse)

Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars

Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star

For a herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

Medical options

Improved oral hygiene and and treatment of underlying infections may be effective in some cases. Mouthwashes might help to control oral bacteria. Persistent halitosis requires professional dental care.

Lifestyle changes that may be helpful

Home oral hygiene is probably the most effective way to reduce accumulations of debris and bacteria that lead to halitosis. This includes regular tooth brushing and flossing, and/or the use of mechanical irrigators to remove accumulations of food after eating. Brushing the tongue or using a commercial tongue scraper, especially over the bumpiest region of the tongue, may help remove the odour-causing agents as well as lower the overall bacteria count in the mouth.

Because of the role of gum disease in halitosis, regular dental care is recommended to prevent or treat gum disease. Treatment for a person with periodontal pockets might include scaling of the teeth to remove tartar.¹⁹

A reduced saliva flow increases the concentration of bacteria in the mouth and worsens bad breath.²⁰ One of the most common causes of dry mouth is medication, such as antihistamines, some antidepressants, and diuretics; however, chronic mouth breathing, radiation therapy, dehydration, and various diseases can also contribute.²¹ Measures that help increase saliva production (e.g., chewing sugarless gum and drinking adequate water) may improve halitosis associated with poor saliva flow. Avoiding alcohol (ironically found in many commercial mouthwashes) may also help, because alcohol is drying to the mouth.

Access by oral bacteria to sulphur-containing amino acids will enhance the production of sulphur gases that are responsible for bad breath. This effect was demonstrated in a study in which concentrations of these sulphur gases in the mouth were increased after subjects used a mouth rinse containing the amino acid cysteine.²² Cleaning the mouth after eating sulphur-rich foods, such as dairy, fish, and meat, may help remove the food sources for these bacteria.

Vitamins that may be helpful

Because most halitosis stems from bacterial production of odiferous compounds, general measures to diminish bacteria as well as measures targeted at prevention or treatment of periodontitis and gingivitis may be helpful. Mouthwashes or toothpastes containing a compound called stabilised chlorine dioxide appear to help eliminate bad breath by directly breaking down sulphur compounds in the mouth. One study showed reductions in mouth odour for at least four hours following the use of a mouthrinse containing this substance.²³

Preliminary research has also demonstrated the ability of zinc to reduce the concentration of volatile sulphur compounds in the mouth. One study found that the addition of zinc to a baking soda toothpaste lessened halitosis by lowering the levels of these compounds.²⁴ A mouthrinse containing zinc chloride was seen in another study to neutralize the damaging effect of methyl mercaptan on periodontal tissue in the mouth.²⁵ ²⁶

Nutritional supplements recommended by some doctors for prevention and treatment of periodontitis include vitamin C (people with periodontitis are often found to be deficient),²⁷ vitamin E, selenium, zinc, coenzyme Q10, and folic acid.²⁸ Folic acid has also been shown to reduce the severity of gingivitis when taken as a mouthwash.²⁹

Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful

The potent effects of some commercial mouthwashes may be due to the inclusion of thymol (from thyme) and eukalyptol (from eucalyptus)—volatile oils that have proven activity against bacteria. One report showed bacterial counts plummet in as little as 30 seconds following a mouthrinse with the commercial mouthwash Listerine™, which contains thymol and eukalyptol.³⁰ Thymol alone has been shown in research to inhibit the growth of bacteria found in the mouth.³¹ ³² Because of their antibacterial properties, other volatile oils made from tea tree,³³ clove, caraway, peppermint, and sage,³⁴ as well as the herbs myrrh³⁵ and bloodroot,³⁶ might be considered in a mouthwash or toothpaste. Due to potential allergic reactions and potential side effects if some of these oils are swallowed, it is best to consult with a qualified healthcare professional before pursuing self-treatment with volatile oils that are not in approved over-the-counter products for halitosis.

Are there any side effects or interactions?
Refer to the individual herb for information about any side effects or interactions.

References
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1. Bollen CM, Rompen EH, Demanez JP. Halitosis: a multidisciplinary problem. Rev Med Liege 1999;54:32–6 [in French].

2. Meningaud JP, Bado F, Favre E, et al. Halitosis in 1999. Rev Stomatol Chir Maxillofac 1999;100:240–4.

3. Spielman AI, Bivona P, Rifkin BR. Halitosis. A common oral problem. NY State Dent J 1996;62:36–42.

4. Touyz LZ. Oral malodor—a review. J Can Dent Assoc 1993;59:607–10.

5. Tiomny E, Arber N, Moshkowitz M, et al. Halitosis and Helicobacter pylori. A possible link? J Clin Gastroenterol 1992;15:236–7.

6. Ierardi E, Amoruso A, La Notte T, et al. Halitosis and Helicobacter pylori: a possible relationship. Dig Dis Sci 1998;43:2733–7.

7. Lorber B. “Bad breath”: presenting manifestation of anaerobic pulmonary infection. Am Rev Respir Dis 1975;112:875–7.

8. Touyz LZ. Oral malodor—a review. J Can Dent Assoc 1993;59:607–10.

9. Durham TM, Malloy T, Hodges ED. Halitosis: knowing when “bad breath” signals systems disease. Geriatrics 1993;48:55–9.

10. Spielman AI, Bivona P, Rifkin BR. Halitosis. A common oral problem. NY State Dent J 1996;62:36–42.

11. Iwakura M, Yasuno Y, Shimura M, Sakamoto S. Clinical characteristics of halitosis: differences in two patient groups with primary and secondary complaints of halitosis. J Dent Res 1994;73:1568–74.

12. Reiss M, Reiss G. Bad breath—etiological, diagnostic and therapeutic problems. Wien Med Wochenshchr 2000;150:98–100 [in German].

13. Tonzetich J. Production and origin of oral malodor: a review of mechanisms and methods of analysis. J Periodontol 1977;48:13–20.

14. Kleinberg I, Westbay G. Salivary and metabolic factors involved in oral malodor formation. J Periodontol 1992;63:768–75 [review].

15. Reiss M, Reiss G. Bad breath—etiological, diagnostic and therapeutic problems. Wien Med Wochenshchr 2000;150:98–100 [in German].

16. Waler SM. Bad breath from the oral cavity. Tidsskr Nor Laegeforen 1997;117:1618–21 [in Norwegian].

17. Ratcliff PA, Johnson PW. The relationship between oral malodor, gingivitis, and periodontitis. A review. J Periodontol 1999;7:485–9.

18. Waler SM. Bad breath from the oral cavity. Tidsskr Nor Laegeforen 1997;117:1618–21 [in Norwegian].

19. Bollen CM, Rompen EH, Demanez JP. Halitosis: a multidisciplinary problem. Rev Med Liege 1999;54:32–6 [in French].

20. Tonzetich J. Production and origin of oral malodor: a review of mechanisms and methods of analysis. J Periodontol 1977;48:13–20.

21. Astor FC, Hanft KL, Ciocon JO. Xerostomia: a prevalent condition in the elderly. Ear Nose Throat J 1999;78:476–9.

22. Waler SM. On the transformation of sulfur-containing amino acids and peptides to volatile sulfur compounds (VSC) in the human mouth. Eur J Oral Sci 1997;105:534–7.

23. Frascella J, Gilbert R, Fernandez P. Odor reduction potential of a chlorine dioxide mouthrinse. J Clin Dent 1998;9:39–42.

24. Brunette DM, Proskin HM, Nelson BJ. The effects of dentifrice systems on oral malodor. J Clin Dent 1998;9:76–82.

25. Ng W, Tonzetich J. Effect of hydrogen sulfide and methyl mercaptan on the permeability of oral mucosa. J Dent Res 1984;63:994–7.

26. Waler SM. The effect of some metal ions on volatile sulfur-containing compounds originating from the oral cavity. Acta Odontol Scand 1997;55:261–4.

27. Vaananen MK, Markkanen HA, Tuovinen VJ, et al. Periodontal health related to plasma ascorbic acid. Proc Finn Dent Soc 1993;89:51–9.

28. Murray M, Pizzorno J. Encyclopedia of Natural Medicine, rev2d ed. Rocklin, CA: Prima Publishing, 1998, 722–9.

29. Pack AR. Folate mouthwash: effects on established gingivitis in periodontal patients. J Clin Periodontol 1984;11:619–28.

30. Kato T, Iijima H, Ishihara K, et al. Antibacterial effects of Listerine on oral bacteria. Bull Tokyo Dent Coll 1990;31:301–7.

31. Cosentino S, Tuberoso CI, Pisano B, et al. In-vitro antimicrobial activity and chemical composition of Sardinian Thymus essential oils. Lett Appl Microbiol 1999;29:130–5.

32. Petersson LG, Edwardsson S, Arends J. Antimicrobial effect of a dental varnish, in vitro. Swed Dent J 1992;16:183–9.

33. Cox SD, Mann CM, Markham JL, et al. The mode of antimicrobial action of the essential oil of Melaleuca alternifolia (tea tree oil). J Appl Microbiol 2000;88:170–5.

34. Serfaty R, Itic J. Comparative trial with natural herbal mouthwash versus chlorhexidine in gingivitis. J Clin Dent 1988;1:A34–7.

35. Dolara P, Corte B, Ghelardini C, et al. Local anaesthetic, antibacterial and antifungal properties of sesquiterpenes from myrrh. Planta Med 2000;66:356–8.

36. Hannah JJ, Johnson JD, Kuftinec MM. Long-term clinical evaluation of toothpaste and oral rinse containing sanguinaria extract in controlling plaque, gingival inflammation, and sulcular bleeding during orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:199–207.

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The information presented in Healthnotes is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or chemist for any health problem and before using any supplements or before making any changes in prescribed medications. Information expires March 2007.

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