“My spouse tells me that I have terrible breath but I brush everyday and think I do a pretty good job! What can I do??”
Eric G. Jackson, DDS, MAGD, FICOI, FICD, FADI
One of the primary reasons I started the OHCP quarterly newsletter several years ago was to create a platform that could address a variety of dental topics in a non-invasive and anonymous manner. Much like the field of medicine, dentistry is filled with patients that have questions or concerns that never get asked because they consider them too embarrassing to bring up when I sit with them face to face. I first ventured into this “embarrassing” arena early last year with the article “HPV and Your Oral Health.” It was a timely article considering only weeks before actor Michael Douglas brought his battle with HPV induced throat cancer to the forefront. This quarter I’d like to write about a much less deadly, but much more common ailment…halitosis (commonly called bad breath). Halitosis is not confined to one gender or age group and can afflict each of us without proper oral health care techniques. Halitosis occurs primarily from two major sources: bacteria and food particles. As with any medical condition or disease, to treat and ideally eradicate it we must snuff out the root causes. Let’s review a few techniques and topics that will certainly help in your “Battle of the Breath.”
The first technique may seem overly simplistic…but it’s what dentists have been preaching for hundreds (thousands?) of years…MAINTAIN EXCELLENT ORAL HYGIENE AT HOME! Not only will this tactic combat halitosis but most other dental ailments as well. Cavities, gum disease, halitosis, tooth sensitivity, and even cardiac issues all cower in the presence of a well maintained oral cavity. Just brushing “everyday” and thinking you do a “pretty good job” likely isn’t cutting the mustard. Here’s what I recommend you consider for your four step home care regimen:
- Floss: Start by flossing. This removes the larger chunks of food from between the teeth which allows the bristles of your toothbrush better access resulting in more efficient brushing. Floss your entire mouth once or twice per day and specific sites as needed after meals.
- Toothbrush: Pick up your toothbrush next. Everyone owns one…but there’s a lot more to the story. Are you brushing 2-3 times per day for two minutes each time with a toothpaste (non-whitening please and if you don’t know why ask me!) approved by the American Dental Association? Don’t forget, not all toothbrushes are created equal! Think of doing dishes by hand vs. using a dishwasher. Sure for a small timeframe or just a few dishes, doing them by hand is no problem and quite easy. But what about ALL your dishes, 3x/day, every day, for life? I’ll take the dishwasher. Perhaps a silly analogy, but I do feel that strongly about appropriate use of dental technology! In this analogy, I’m obviously comparing a manual toothbrush vs. a mechanical toothbrush. Mechanical toothbrushes are tremendously more effective than their manual counterparts. Don’t believe me? Ask a Sonicare toothbrush user how clean their teeth and gums feel if they ever forgot it when they went on vacation and had to use a manual brush. It’s amazing how effective mechanical toothbrushes are. Remember, regardless of what type of toothbrush used, you must change it every 3 months or else the bristles become worn out and ineffective. Finally, if you do use a manual brush, be sure to select one that has Soft or Extra Soft bristles. Anything harder can irritate your gums and slowly cause gum recession…which exposes the soft root surface to bacteria...which leads to increased cavities and gum disease. Take any medium or hard bristle brush in your possession and reassign them to grout duty when you next clean the shower.
- patients (and even some dental professionals) limit their oral hygiene focus to just the teeth and gums. What about the bacteria covering the rest of the mouth? One of the main bacterial breeding grounds is the surface of your tongue. The grooves and fissures in the tongue harbor all sorts of odorous bacteria and need to be cleaned regularly. A tongue scraper is the dental tool for this job. Found in every pharmacy dental isle for about 5 bucks, tongue scrapers aren’t high tech devices, but they are very effective in reducing the bacterial count on your tongue…which combats a root cause of halitosis. Use the scraper at least once per day and please be gentle!
- Mouthwash: Finish your hygiene regimen with a minute rinse of mouthwash. The mouthwash will destroy any remaining bacteria on the teeth, gums, tongue, as well as any other area of the mouth (cheeks, roof of mouth, etc). Like all dental technology, not all mouthwashes are created equal either. At present, the only mouthwash I use and recommend to patients is Listerine Total Care Zero. It’s far and away my favorite because it combines the well known bacteria killing prowess of Listerine with a fluoride rinse aspect that, according to several studies, provides ~3-4 times the fluoride uptake of the well known fluoride rinse ACT. All this in a formula that contains zero alcohol. If you’re interested in a more in-depth discussion about mouthwash, you might consider reading my 1st Quarter 2013 OHCP Newsletter article titled “Mouthwash, Alcohol, and Oral Cancer.” I post each past edition of the OHCP newsletter on the office website. Simply click on the “Newsletters” tab on the home page and download a .pdf of the issue you’re interested in.
In addition to an excellent oral hygiene regimen, keeping your mouth moist/hydrated will also help prevent halitosis. Ever wonder why your breath is extra stinky when you wake up in the morning? It’s because when sleeping the body greatly slows its production of saliva. Combine this with some mouth breathing /snoring while sleeping and you’ve got a perfect dry environment for stinky “Morning Breath.” Saliva not only lubricates the mouth but kills oral bacteria via its antiseptic enzymes. Low saliva = higher bacteria. For most of us, even if we wake with morning breath daily, it’s still considered an acute (short term) condition because our body ramps up saliva production once it wakes. For some people however, saliva production does not increase and the mouth is dry all day and all night. Chronic dry mouth like this is termed Xerostomia and like its acute counterpart Morning Breath, is a cause of halitosis. Xerostomia is a common side effect to a vast number of medications (both prescription and non-prescription). The level of dryness/Xerostomia in these situations varies from patient to patient so your experience may not be the same as others. I always recommend Xerostomia patients discuss their specific prescriptions with their medical doctor since there are sometimes alternate drugs that accomplish the same medical goal that may affect the patient’s saliva production less. Other great techniques to combat all severities of dry mouth include:
- Water: I recommend patients with dry mouth carry a water bottle and take small sips every 5 minutes to supplement their low salivary production. Water, like saliva, serves to balance the pH in the mouth and buffers against the acid produced by bacteria. A dry, improperly pH balanced oral cavity routinely yields a dramatic increase in negative dental conditions, especially tooth decay (caused by the high levels of acid).
- The Biotene line of products: Biotene is an excellent alternative of supplemental oral hydration to replace diminished saliva volume. Commonly available at most pharmacies, the Biotene line of products includes rinses, gels, toothpaste, and other items designed for people with dry mouth. The Biotene website (www.biotene.com) is an excellent informational resource about not only their product, but also Xerostomia and Sjogren’s Syndrome (a disease of the immune system that attacks the body’s moisture creating tear and salivary glands).
- Chew some sugarfree Xylitol gum (in moderation): The act of chewing naturally increases saliva production due to the body’s innate autonomic response. In the past, dentists would recommend dry mouth patients chew on small chunk of wax between meals. The wax went the way of the dinosaurs with the advent of sugar free gum containing Xylitol. I do caution patients about this method however, for fear of aggravating/overworking one or both of their Tempromandibular Joints (TMJ). TMJ disorders are not fun, so do all gum chewing in moderation and watch for negative/painful symptoms to arise. If they do, cut back the gum chewing or discontinue altogether. Also, please use caution: Xylitol can be quite toxic to dogs. Store any Xylitol product in a location away from Fido!
Halitosis can also have dietary origins so it is important to examine, and possibly augment, both your diet and dietary habits. Low carbohydrate/ketogenic diets have become a popular method of weight loss in recent years. While most people are familiar with low carb dieting made famous by Robert Atkins’ book(s), the term “ketogenic” is sometimes unfamiliar. Textbooks are literally written about this subject to I’ll keep the following biology/physiology discussion very brief and broad. The initial stage of the Atkins Diet is referred to as the induction phase and is considered a ketogenic diet. During this stage limited, if any, carbohydrates are consumed by the dieter. Because low carbohydrate meals yield low blood glucose levels, the body must seek an alternate fuel source to fulfill its metabolic needs. In response, the body produces additional ketones for use in the energy producing Krebs Cycle. Additionally, the body’s low glucose/ketosis causes cells to rely on glucose production from conversion of either protein (amino acids) or stored fat, thus resulting in overall weight loss. Phew!
Low carbohydrate/ketogenic diets are generally considered safe when used in moderation over a short period of time but misuse can have severe consequences. Both extreme &/or uncontrolled ketosis, as well as the condition Anorexia Nervosa, can yield a pathologic state termed ketoacidosis. In this condition, the excessive accumulation of ketones significantly decreases the pH of the blood and can be fatal. Ketoacidosis can be smelled on a person’s breath due to one type of ketone called acetone. One a person’s breath, this compound is classically described as smelling “fruity” or like nail polish remover. Ketoacidosis can be divided into two primary types: diabetic and alcoholic. If you detect or suspect ketoacidosis, speak with your medical doctor immediately and examine both your blood sugar and alcohol consumption.
Trimethylaminuria is another condition that warrants a brief discussion as it’s another possible cause of bad breath. Generally considered rare and more common in women, this condition has also been referred to as Fish Odor Syndrome. Trimethylaminuria is a condition when your body cannot break down a chemical called trimethylamine. The excess trimethylamine is released in the person’s saliva and breath as well as most other bodily secretions (sweat, urine, reproductive fluids, etc). Some people with trimethylaminura produce a strong odor all the time, but most have a moderate smell that varies in intensity. Individuals with this condition generally do not have any other physical symptoms and typically appear healthy. The odor produced varies depending on many known factors, including diet, hormonal changes, stress level, amount of sweat, other odors in the space, and individual sense of smell.
Tonsilloliths (aka Tonsil stones) are another possible cause of persistent bad breath. People who have chronic inflammation in their tonsils or suffer repeated bouts of tonsillitis are quite prone to tonsil stones. While not always visible to the naked eye, if they grow large enough, tonsil stones can often be mistaken for a throat infection/strep throat. Your tonsils are filled with nooks and crannies called crypts where bacteria and other materials, including dead cells and mucous, can become trapped. When this happens, the debris can become concentrated in white formations that occur in the pockets. Because of their foul composition, tonsil stones are often linked with halitosis and may produce pain when swallowing if large enough. Other symptoms frequently reported include a metallic taste, throat closing or tightening, coughing fits, and choking. These symptoms, including halitosis, are temporarily resolved by removal of the tonsil stone. There are quite a few methods of removal that typically depend on the size of the stone. A few methods to remove smaller stones are rinsing them out with oral irrigators (like a WaterPik), pushing them out with the tongue or a cotton swab, or gargling with warm salt water. Larger stones are more difficult to remove and may require more invasive methods of removal including: curettage, laser resurfacing of the tonsillar crypts, and complete surgical removal of the tonsils (tonsillectomy).
The final potential cause of halitosis that I would like to discuss is one we dental professionals unfortunately still see all too often: Periodontal (Gum) Disease. Persistent bad breath is often an indicator that something is amiss with a patient’s gums. Gum disease is caused by the buildup of plaque on teeth and in the pocket surrounding each tooth called the sulcus. Essentially these bacteria eat sugars and excrete acid as waste. This acid is quite toxic to its surroundings. Acid contacting sound tooth structure will slowly dissolve the tooth surface to form a cavity. Acid contacting the sulcular gums causes irritation and bleeding, and if untreated, will slowly dissolve the bone surrounding the tooth. The secret to gum disease is PREVENTION. Maintaining excellent oral hygiene at home using the before mentioned four step regimen and visiting our office for regular dental hygiene appointments are essential.
I will end with a brief word of caution. In today’s digital age, it is quite easy to be swept up by the next popular Pinterest Pin containing a new dental tip or trick. Please be careful. For example, let’s take a look at the classic Pinterest recommendation that you should rinse with lemon juice or vinegar to kill or diminish the bad breath of halitosis. Please think about this objectively for a moment! Lemon juice and vinegar are both extremely acidic...nearly the pH of battery acid. Rinsing with something that acidic may mask the halitosis...but it will most certainly cause an exponential increase in tooth decalcification and cavity formation. Do not do it! Perhaps this example was too obvious for you...but there is a reason there are so many dental tips/tricks being passed around the internet...people believe all their outrageous claims (oil pulling anyone??) Patients are not thinking objectively and scientifically about the recommendations because they unfortunately do not have the academic knowledge of a dental professional. Well, that’s the essence of why I write these newsletter articles: To increase the dental knowledge base of my patients and “deputize” you as honorary dental professionals.
I hope the information and techniques discussed in this quarter’s article will shed light on the often experienced, but rarely discussed topic of halitosis/bad breath. If you would like to speak about Halitosis (Chronic Bad Breath), or any other topic, please feel free to call the office and schedule a complimentary appointment with me. Email and Twitter are also available options. I am extremely passionate about modern dentistry and love discussing it with patients, so don’t hesitate to contact me.
Eric G. Jackson, DDS, MAGD, FICOI, FICD, FADI