COMMON CAUSES 

Oral cavity: Although halitosis has multifactorial origins, the most noticeable source of cases (90%) is oral cavity. According to Dr Bahadır Uğur Aylıkçı (Research Assistant, Kırıkkale University Dental Faculty, Department of Periodontology), temperatures in the oral cavity may reach up to 37°C. “When patients exhale, humidity may reach up to 96%. These conditions may provide a suitable environment for bacterial growth.” Over 500 bacterial species can be found in the oral cavity, most of which are capable of producing odorous compounds which may cause halitosis. “In these conditions, poor oral hygiene is a contributing factor for multiplication of halitosis causative bacteria and causing an increase in halitosis.” 

Gingivitis & periodontitis: Almost 10% of the population with severe periodontitis are accompanied by bad breath. According to Dr GS Madhushankari et.al. in Journal of pharmacy & bio allied sciences Research Journal of Pharmacy and Technology (Volume 7, Issue 2) the reasons for this are: 

• The spaces between the teeth and gums entrap food in patients with periodontitis and eventually the bacteria act on these enclosed food substances, producing odoriferous substances. 
• Also, the bleeding tendency of gums in gingivitis and periodontitis worsens halitosis. Initially, it will impart an iron or metallic smell and later, as the blood decomposes, a more profound smell is produced. 

Other oral cavity pathologies that can cause halitosis include dental cavities, tongue coating, exposed tooth pulps, extractions/healing wounds, dentures worn at night or not regularly cleaned, restorative crowns which are not well adapted, cysts with fistula draining into the mouth, oral cancer, and ulcerations. This according to Dr US Mahadeva Rao et.al. in Volume 8, Issue 2 of Research Journal of Pharmacy and Technology. “Most of these factors cause halitosis due to tissue breakdown, putrefaction of amino acids, and decreasing of saliva flow. 

Dry mouth: Saliva is an important part of dental health and breath. The American Dental Association explains that saliva rinses and removes unwanted leftovers from the mouth, helps break down food when eating, and provides disease-fighting substances to help prevent cavities and infections. “If you don’t make enough saliva, one sign may be halitosis. Dry mouth can be caused by medications, certain medical conditions, alcohol use, tobacco use, or excessive caffeine.” 

Medical conditions or medications: “Tonsillitis, respiratory infections such as sinusitis or bronchitis, and some gastrointestinal diseases may play a role in a small number of cases of halitosis,” said Dr Alessandro Villa (chief of the Sol Silverman Oral Medicine Clinic at University of California San Francisco). “Advanced liver or kidney disease and uncontrolled diabetes can also lead to unpleasant breath. In these cases, a patient is likely to experience significant symptoms beyond bad breath and should seek medical attention. 

Diet: According to the American Dental Association, diet is a common source of unpleasant breath. Foods such as garlic and onions can cause foul breath. After food has been digested, chemicals that cause odour can be absorbed into the bloodstream and from there into the lungs where these chemicals are then exhaled. Diets high in protein and sugar also have been associated with halitosis. 

Smoking and tobacco: Tobacco products have a negative impact on the body and breath. Not only do many tobacco products leave their own odour on the breath but as mentioned previously, they can also cause dry mouth. Smokers are also more likely to develop gum disease, which can also add to halitosis. 

PREVENTION & MANAGEMENT 

Encourage patients to practice proper oral hygiene which includes brushing at least twice a day using a fluoride-containing toothpaste, daily flossing, and regular (generally twice a year) dental visits. Gentle cleaning of the tongue twice daily with a tongue brush, scraper, or cleaner, to help wipe off bacteria, debris, and mucus is also advised. Unless otherwise advised by their dental professional, patients with dentures should clean and soak them in an antibacterial solution overnight. Drinking enough water during the day may help prevent dry mouth. 

“Chewing sugar-free gum may help to remove food debris from around the teeth and stimulate saliva production,” said Professor of Dentistry at King's College London Dental Institute, Dr Nairn Wilson. “These two efforts can help reduce halitosis, particularly if the chewing gum has a strong flavour.” Advise patients to make changes to their diets and cut out foods that can cause bad breath. Limiting sugary foods, which have been linked to bad breath, can also be beneficial. Patients should change toothbrushes every 3-4 months and opt for soft-bristled toothbrushes. 

Mouthwashes: 

Fortunately, a variety of mouthwashes are available for controlling halitosis. A review of mouthwashes and their use in different oral conditions published in the Scholars Journal of Dental Sciences, listed the usual active ingredients in these mouthwashes as antimicrobial compounds like Chlorhexidine, Cetylpyridinium chloride, chlorine dioxide, hydrogen peroxide, essential oils, and Triclosan. Author Dr Amit Parashar reported that mouthwashes containing essential oils are effective in reducing oral malodour and gingivitis. “Mouthwashes based on essential oils contain thymol, eucalyptol, and menthol in an alcohol solvent are broad spectrum antimicrobial agents which decrease bacterial multiplication, aggregation, and pathogenicity.” 

A separate review, published by Cochrane concluded that mouth rinses containing Chlorhexidine and Cetylpyridinium chloride could inhibit production of volatile sulphur compounds, while Dr Hunny Sharma et al. said in the International Journal of Oral Health and Medical Research that Chlorhexidine-containing mouth rinses have been shown to be successful in reducing antibacterial activity in supragingival plaque and the bacterial load on the tongue. “As such, they are considered as possibly effective agents in controlling halitosis.” According to specialist in periodontics, Dr George Jacob, “Chlorhexidine and zinc mouth rinses have a strong effect on volatile sulphur-containing compounds and are effective for at least nine hours.”