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Bad breath: still a taboo and a problem

Date: December 01, 2021

Author: Louise Sinclair

Halitosis, or bad breath, is thought to affect as many as one in two U.S. adults. It is universally regarded as socially undesirable, causing sufferers to experience shame, anxiety, low self-esteem, and loss of confidence. In this article, we’ll discuss how dental students can discuss this sensitive topic with their patients, identify the root cause, and help them to find freedom from halitosis.

What causes halitosis?

De Geest et al. (2000) categorized halitosis as either originating in the oral cavity or systemic in origin (such as sinusitis, diabetes, liver cirrhosis, renal failure). Transient halitosis may be due to pungent foods, alcohol, smoking, recreational drug use, high-protein diets (such as keto or Atkins) and severe food restriction.

The vast majority (80-90%) of halitosis cases are of intra-oral origin, most often arising from volatile sulfur compounds released during the bacterial breakdown of certain amino acids. Gram negative anaerobic bacteria present intra-orally produce these volatile sulfur compounds. While these bacteria are frequently found on the posterior surface of the tongue, they can also proliferate in or around:

  • Interdental spaces

  • Deep carious lesions

  • Periodontal pockets

  • Defective dental restorations

Other intra-oral causes include poor oral hygiene and oral pathologies such as abscesses, pericoronitis, xerostomia and candidiasis.

How to help your patients with halitosis

1. Don’t shy away from the topic

While some people are painfully aware of their halitosis, others can be oblivious to the problem. In either case, it is a sensitive topic that can feel difficult for dental students to raise.

It may help to initiate the conversation as part of a bigger oral health discussion. For example, you may say:

“One of the possible side effects of periodontitis is bad breath. I did notice a slight odor during your examination, it’s very common and we can address it.”

You could also incorporate questions about halitosis into the patient’s pre-screening or medical history. If the patient volunteers that they think they have halitosis, you can use this as a jumping-off point to safely raise the topic without causing offence. If patients with halitosis have a medical condition that can cause it, you could also explain that this can happen and ask if they currently have any concerns or have ever noticed this.

2. Identify the source

The best course of action will depend on the cause. A thorough oral examination can help to identify intra-oral causes like dental caries, periodontitis, or abscesses, in which case treating the root cause may also eliminate halitosis.

However, it’s worth keeping in mind that there may be interplay between several different causes. Conduct a thorough medical history to identify any extra-oral factors, and enquire about smoking, alcohol, dietary and oral hygiene habits.

3. Help patients establish a good oral care routine

Good oral hygiene is a key factor in managing many oral health conditions, and halitosis is no exception. In addition to twice-daily brushing and daily interdental cleaning, encourage your patient to incorporate tongue cleaning into their routine.

The tongue can develop a whitish coating due to various factors, like smoking, periodontal disease, and diet. This coating provides the perfect environment for the bacteria that cause bad breath, particularly on the posterior surface of the tongue. Removing it with a tongue scraper, or a toothbrush with a textured head, lowers the oral bacterial load and reduces the production of volatile sulfur compounds.

4. Recommend an antimicrobial mouth rinse

An antimicrobial mouth rinse can help to control bacterial growth in the oral cavity. For example, Colgate PerioGard, which is indicated as part of the treatment of gingivitis, has been shown to significantly reduce the level of bacteria, including anaerobic bacteria. Another option is a hydrogen peroxide rinse, such as Colgate Peroxyl. This rinse's oxygenating action helps to remove debris, and as an antiseptic rinse has been shown to lower the bioburden (during procedures).