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Consultant oral physician at the University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu State, Dr Otakhoigbogie Uwaila, tells EMMANUEL OJO the causes, management and social effects of halitosis, commonly known as bad breath
What is halitosis?
Halitosis, popularly known as bad breath, is an offensive odour from the mouth when someone speaks or the breath that individuals exhale. Simply put, it is bad breath or odour from the mouth or oral cavity. It is what people generally refer to as smelly mouth. That’s what halitosis is all about.
How common is it?

It is common. It’s one of the commonest reasons people visit the dental clinic. Apart from toothache and maybe bleeding gum, the next reason why many people visit the dental clinic is because of bad breath or odour coming out of their mouth.
How is it identified?
Well, like we earlier said in the definition of what it is, it is through breath. When people talk, some other persons around them find it difficult to stay around because of the odour oozing out of their mouth. That’s one of the commonest ways to determine that someone has halitosis or bad breath. In other words, to really say someone has halitosis or bad breath, someone else must be able to at least perceive and affirm the person’s breath has an unpleasant smell. You can’t really say someone has bad breath or halitosis if someone else doesn’t say they had smelly mouth. Meanwhile, the person who has bad breath may not know.

Are there degrees or types of bad breath or halitosis?
There are different types of bad breath. There are basically two categories. For the first case, the people around the sufferer will be the ones to affirm that the person has bad breath, especially people that are close and trusted. The sufferer might not know. For the second category, the individual complains about the bad breath but people around cannot really confirm. They are usually more distressed about the situation.
What are the causes?
Bad breath has two major origins. It is either intra-oral (within the mouth) or extra-oral (outside the mouth). About 90 per cent of the cases are intra-oral and there are lots of things that can cause it. Poor oral hygiene is the commonest cause of bad breath. Other causes include faulty dentition, such as misalignment of the teeth, leading to retention of leftover food particles between the teeth. Bad breath results when these leftover food particles are broken down by normal micro-organisms that are resident in the mouth, which are called the normal flora of the mouth. These micro-oragnisms are always there in the mouth to act on leftover food substances or debris, especially, protein-rich food substances. When these micro-organisms act on these protein-rich materials, they release gases, sulphur-containing gases mainly, which are basically responsible for bad breath or halitosis. These are the common causes of halitosis or bad breath.
For extra-oral halitosis, the cause might be systemic, for instance, uncontrolled diabetes, problems of the liver and lungs. For there to be extra-oral halitosis, originating from systemic problem, the person must be really sick; most times, they are hospitalised. Extra-oral halitosis can also result from an infection of the throat. And that’s why the management of halitosis is multi-disciplinary.
Can you speak more on the systemic causes of halitosis?
Basically, this results from gases that eventually end up in the bloodstream based on the abnormal breakdown of things in the body. From the blood, these offensive gases eventually end up in the lungs and are exhaled and perceived by others as mouth odour. Nasal drips can also cause halitosis.

It is also said that dry mouth or fast can bring about halitosis. How does that come about?
That’s very true. Usually, saliva has a way of cleaning the mouth. If there are no food particles in the mouth, if these particles are constantly being washed away by saliva, there will be nothing for the micro-organisms to work on or break down, so there won’t be release of odoriferous gases. But during fast, there is a form of dehydration, which also affects the volume of saliva in the mouth. With reduced saliva to cleanse the mouth, there is less cleansing of the mouth.
Conversely, when one is not fasting, he’s either taking eating or drinking and salivary production is high, which helps to cleanse the mouth of food particles. In summary, saliva cleanses the mouth and helps to minimise bad breath. However, for someone who is fasting, especially the dry one that’s done without water, there will be less saliva and the cleansing effect is not there, so the micro-organisms will have time to work on those proteinaceous materials and release foul gas, resulting in bad breath.
When people are fasting, they also rarely talk or they talk less and that also gives enough time for the build-up of these gases.
Is halitosis hereditary?
The issue of heredity in halitosis is a recent discovery. As I said earlier, 90 per of halitosis cases are intra-oral while 10 per cent are extra-oral or systemic. However, searchlight is recently being beamed on the hereditary nature of some forms of halitosis. Though the percentage is low and in the genetic halitosis, when such a case is handled, we make findings of the family history on such matters. Of course, for it to be genetic, there must be a close family member that would have complained of the same kind of thing. Some scientists have found out that there are some genes that may be mutated that causes this sulphur compound not to be eliminated from the body, which eventually present as bad breath.
There’s a gene that is supposed to work on some sulphur compounds being produced in the body but those genes were mutated. These are recent findings and research is ongoing in that regard. So, to answer your question, yes, there is a possibility of genetic halitosis but it is very rare and researches are still ongoing in that respect.

How is halitosis diagnosed?
There are instruments that are used in the hospital for diagnosis. When someone comes to the hospital with complaints, we subject the person to some tests and we use a halimeter, which is the volatile sulphur compound monitor. Apart from that, there are some other tests that can be done for those that are largely academic but when they come to the hospital, diagnosis will be made.
How can it be managed?
Management is a holistic thing. You look at the individual specifically. Managing halitosis is a multi-disciplinary thing. When the person presents at the hospital, different parts of dentistry will have to evaluate the person. There are some conditions that are as a result of gum diseases, like periodontal problems. The periodontist will handle such a case. If the problem is coming from an impacted tooth, the oral maxillofacial surgeon is there to attend to it. So, there are many parts of dentistry that can handle the case of halitosis for the patient to be fine. If we also need to do referrals to ENT (Ear, Nose and Throat) surgeons, we do so. If it’s something that’s more systemic or has to do with the gastrointestinal tract, endocrine system or whatever it is, we employ the right experts to address the issue. But usually, we make sure that first of all, the oral hygiene of this patient is good because the majority of the cause of halitosis is poor oral hygiene. So, management of the condition requires a multidisciplinary approach, depending on what is causing it.
What are the preventive measures?
Poor oral hygiene is one of the major causes of halitosis, as I said earlier. Therefore, patients should keep a good oral hygiene. A regular visit to the dental clinic is also very important. We advocate that people should visit the dentists at least twice a year so that the dentist can do a general check-up. Then, regular brushing of the teeth, at least twice a day, particularly morning and night before going to bed, is recommended.
The most important thing is that we are able to remove these food particles that micro-organisms might act on, especially overnight. So, it is advisable to brush properly morning and night with fluoride-containing toothpaste and a toothbrush, medium and neck bristle brush, using the proper technique. How to know the proper technique also depends on you if you visit the dentist regularly because they usually demonstrate the techniques.

Again, majority of these micro-organisms that break down these food substances are usually on the tongue. The surface of the tongue looks like a towel or velvet material. Micro-organisms will always hide there. So, when one brushes, it is also good to clean the tongue. Apart from using a tongue cleaner, many people don’t even know that the back of their tooth brushes are normally used. If you check the back of a good toothbrush, you will find out that they are usually rough. That rough aspect is meant to clean the tongue but many people don’t know. The bristle of the tooth brush can also be used, it’s not bad, but then, you can use the back of the brush to clean the tongue, that way, to a very large extent, the micro-organisms will be reduced and they won’t be able to act on the food substances to produce those gases that produce mouth odour.
How soon should a toothbrush be changed?
Usually, a period of three months or when the bristles begin spreading away and looking scattered. That is when a toothbrush is due for change.
Again, most good toothbrushes are colour-coded. When the colour starts fading away, it’s time to change the toothbrush but many people don’t know this too.
Are there diets that aid halitosis?
Yes, there are some that are common. If you notice, I have repeatedly used the word proteinaceous. But there are other diets that contain some sulphur compounds like garlic, ginger, raw onions and so on. What we advocate most times is that if you want to use garlic, you could just swallow rather than chew. Though, it’s not really a big deal when you know that that is the cause of the smell, you can brush to minimise the odour but it might not be totally eliminated. Just have it in mind that garlic can lead to halitosis.
Does chewing gum help to prevent or reduce mouth odour?

Many chewing gums are minted and this can help to counter mouth odour. Chewing gum also stimulates the flow of saliva which also helps in the cleansing of the mouth.
Can babies have halitosis?
Yes. The main food for babies is milk and milk is a proteinaceous material and of course the micro-organisms are also in their mouth. The micro-organism will break down the materials from the milk. If you check the baby’s mouth, there’s this lining of whitish material, so, they can also release these gases. If you are bothered as a parent, there’s always a way to clean their mouth using cotton wool and water. There are even baby tongue cleaners that are sold in supermarkets. To answer your question, yes it is possible for halitosis to occur in children and newborns.
Does halitosis have any psychological effect on sufferers?
Yes, it does. Loss of self-esteem is a major consequence of this. When the sufferers know that they have halitosis, they withdraw into their shell and social interaction becomes a problem. They tend to be withdrawn. The earlier they get help, the better, so that the quality of life of these persons can be restored.
We are all social beings, we all love to be appreciated but when people start despising you because bad odour is oozing out of your mouth, it reduces your self-esteem. Health is actually a state of physical, mental and social well-being and not merely the absence of an infirmity. If one is not accepted socially, it’s an ailment. It’s a disease.

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