Vol.3, # 45
December 2, 2006

Q: I suffer from bad breath-what natural treatments can help? - Layperson

A: Bad Breath, Halitosis (medical term), oral malodor (scientific term), and breath odor,  are terms used to describe noticeably unpleasant odors exhaled in breathing.

Types

Transient bad breath is a very common temporary condition caused by such things as oral dryness, stress, hunger (ketosis), eating certain foods such as garlic and onions, smoking, or poor oral hygiene. "Morning breath" is a common example of transient bad breath. Transient bad breath gradually disappears on its own, with the aid of chewing gum or brushing one's teeth. Chronic bad breath is a more serious and persistent condition affecting up to 25% of the population in varying degrees. It can negatively impact the individual's personal and business relationships, leading to poor self-esteem and increased stress. This condition is usually caused by persistent overpopulation of certain types of oral bacteria, primarily streptococcus mutans, and requires specialized treatment. Xerostomia (dry mouth syndrome) will increase bad breath problems.

Fetor hepaticus is a type of severely bad breath caused by chronic liver failure.

Treatment

Currently, chronic halitosis is not very well understood or even recognized as a treatable condition by most doctors and dentists, so effective treatment is difficult to find. There are a growing number of bad breath clinics responding to this endemic problem; unfortunately, most are simply outlets for one breath product or another. As with all general-purpose formulations, any one particular product may be effective for some, partly effective for a few, and not at all helpful for others. A very small number of clinics use a detailed assessment process including microbiology to determine the specific type or types of odor-causing bacteria. The specific bacteria are then controlled by individualized treatments. This procedure results in a very high success rate. Some who take a more holistic view of the body, including naturopaths and alternative nutritionists, believe that halitosis can be cured or greatly diminished by improving the overall health of the digestive tract, especially the small and large intestines. This process usually requires a change in eating style, lifestyle, and diet.

Check list

Product ratings for halitosis

Rating Nutritional Supplements Herbs
2Stars Coenzyme Q10 (if gum disease)
Folic acid (if gum disease)
Zinc chloride (rinse or toothpaste)
 
1Star 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)
3Stars 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 An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

Lifestyle

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 odor-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. 

A reduced saliva flow increases the concentration of bacteria in the mouth and worsens bad breath.  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. 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 sulfur-containing amino acids will enhance the production of sulfur gases that are responsible for bad breath. This effect was demonstrated in a study in which concentrations of these sulfur gases in the mouth were increased after subjects used a mouth rinse containing the amino acid cysteine.  Cleaning the mouth after eating sulfur-rich foods, such as dairy, fish, and meat, may help remove the food sources for these bacteria.

Supplements

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 stabilized chlorine dioxide appear to help eliminate bad breath by directly breaking down sulfur compounds in the mouth. One study showed reductions in mouth odor for at least four hours following the use of a mouthrinse containing this substance. 

Preliminary research has also demonstrated the ability of zinc to reduce the concentration of volatile sulfur 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.  A mouthrinse containing zinc chloride was seen in another study to neutralize the damaging effect of methyl mercaptan on periodontal tissue in the mouth. 

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

Herbs

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 ListerineĀ®, which contains thymol and eukalyptol. Thymol alone has been shown in research to inhibit the growth of bacteria found in the mouth.  Because of their antibacterial properties, other volatile oils made from tea tree,  clove, caraway, peppermint, and sage, as well as the herbs myrrh and bloodroot,  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.

Causes

Though the causes of breath odor are not entirely understood, most unpleasant odors are known to arise from food debris trapped in the mouth which is processed by normal mouth flora; there are over 600 types of bacteria found in the average mouth. Several dozen of these can cause trouble when allowed to flourish or are genetically disposed to overpopulate. Large quantities of these naturally occurring bacteria are often found on the posterior of the tongue, where they are undisturbed by normal activity. The rough surface of the tongue dorsum provides an ideal habitat for anaerobic bacteria, which flourish under a continually-forming tongue coating of food debris, dead cells, and hundreds of thousands of bacteria, living and dead. When left on the tongue, the anaerobic respiration of such bacteria can yield either the putrescent smell of polyamines, or the "rotten egg" smell of volatile sulfur compounds (VSCs) such as hydrogen sulfide, methyl mercaptan and dimethyl sulfide, depending on the bacteria type. It is generally these compounds which, when mixed with mouth air and exhaled, produce unpleasant breath. Other causes of chronic bad breath may be periodontitis (gum disease), helminthiasis (intestinal parasitic infections), diabetes, kidney failure, sinusitis, tonsilloliths, gastroesophageal reflux disorder (GERD), trimethylaminuria (TMAU), hormonal changes, and a wide variety of prescription drugs (especially when taken on a longterm basis).

Diagnosis

One's own breath odor is often undetectable due to habituation, although many people will have an accompanying bad taste (metallic, sour, fecal, etc) depending on oral dryness and the degree of breath odor.

A somewhat effective home method to determine the presence of bad breath is to lick the back of the wrist, let the saliva dry for a minute or two, and smell the result. Another way would be to lightly scrape the posterior of the tongue with an inverted spoon or a piece of dental floss, and to smell the dried residue. A spouse, family member, or close friend may be willing to smell one's breath and provide honest feedback. Highly reliable home tests are now available which use a chemical reaction to test for the presence of polyamines and sulfur compounds on tongue swabs. Remember that breath odor changes in intensity throughout the day depending on many factors, so test several times.

If bad breath is persistent, and all other medical and dental factors have been ruled out, specialized testing and treatment is required.

Hundreds of dental offices and breath clinics now use a portable sulfide monitor called the Halimeter to test for levels of sulfur emissions (specifically, hydrogen sulfide) in the mouth air. When used properly this device can be very effective at determining levels of certain VSC-producing bacteria. However, it has drawbacks in clinical applications. For example, other common sulfides (such as mercaptan) are not recorded as easily and can be misrepresented in test results. Certain foods such as garlic and onions produce sulfur in the breath for as long as 48 hours and can result in false readings. The Halimeter is also very sensitive to alcohol, so one should avoid drinking alcohol or using alcohol-containing mouthwashes for at least 12 hours prior to being tested. This analog machine loses sensitivity over time and requires periodic recalibration to remain accurate.

New technology is now appearing in the form of portable gas chromatography machines such as the OralChroma, which is specifically designed to digitally measure molecular levels of the three major VSCs in a sample of mouth air (hydrogen sulfide, methyl mercaptan, and dimethyl sulfide). It is extremely accurate and produces visual results in graph form via computer interface.

Microbiological testing of swab samples of teeth and tongue residue remains the most accurate method of determining the specific bacterial causes of oral malodor.

Home care

Using commercial breath-freshening mouthwashes, mints, or lozenges gives only temporary relief at best, since these products only mask mouth odors for a few minutes. Rinses containing antibacterials such as chlorhexidine, zinc gluconate, or chlorine dioxide may provide better control depending on the individual. Avoid alcohol-containing rinses, since alcohol is a drying agent and will worsen the problem.

Bad breath may be temporarily reduced by using a hydrogen peroxide rinse. Hydrogen peroxide at a concentration of 1.5% can be taken as an oral antiseptic by gargling 10 ml, about two teaspoons. Hydrogen peroxide is commonly available at a concentration of 3% and should be diluted to 1.5% by mixing it with an equal volume of water. Hydrogen peroxide is a powerful oxidizer which kills most bacteria, including useful aerobic bacteria.

Brushing after meals and flossing at least once daily is necessary to remove rotting food debris from between the teeth, especially at the gumline. Gently cleaning the tongue surface twice daily with a tonguebrush, tongue scraper, or tongue cleaner will reduce this primary source of breath odor. An inverted teaspoon is also effective; a toothbrush less so, as the size and angle of the head do not allow it to reach as far as necessary. Be careful to avoid scraping the V-shaped row of taste buds found at the extreme back of the tongue. Brushing a small amount of antibacterial mouth rinse or tongue gel onto the tongue surface will further inhibit bacterial action.

Since dry mouth can increase bacterial buildup and cause or worsen bad breath, chewing sugarless gum can help with the production of saliva, and thereby help to reduce bad breath. Some gums, toothpastes, sprays, and gels which combat dry mouth for several hours have recently been marketed over the counter. Maintain water levels in the body by drinking several glasses of water a day. Adding lemon juice to your water is refreshing and also beneficial. Parsley is a natural breath freshener when chewed slowly, and is easy to grow at home.

Some studies have shown that eating yogurt, drinking green tea, or chewing cinnamon or sugarless cinnamon gum can reduce bad breath.

In short, bad breath has three causes- bacterial, metabolic (kidney, liver, and pancreas abnormalities), and extraneous causes (i.e.-alcohol consumption, foods, tobacco...). Correcting these will eliminate bad breath. Consult the appropriate healthcare professional familiar with the treatment of bad breath.



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DISCLAIMER:  The information in this column, is NOT intended to diagnose and/or treat any health related issues and is provided solely for informational purposes only. Consult the appropriate healthcare professional before making any changes to your healthcare regime. Even what may seem like simple changes in the diet for example, can interact with, and alter, the efficiency of medications and/or the body's response to the medications. Many herbs and supplements exert powerful medicinal effects. Neither the author, nor the website designers, assume any responsibility for the reader's use or misuse of this information.

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