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“Do you mind and sit back a little? Because your breath is awful, it stinks” extooth advises you 100% effective ways to get rid of bad breath.

“How to knock bad breath?”

Try telling someone their breath smells without outraging.

Well, instead of being embarrassed or humiliating someone, let’s go-to brush our teeth and beat bad breath.

Halitosis, bad breath, fetor oris or oral malodor all are the same thing.

People socialize with each other every day. 

A foul or bad breath has a bad influence on a person’s social life.

A person with bad breath or halitosis may not be aware of this situation as he/she may have developed tolerance or olfactory disturbance.

Due to this reason, the individual generally cannot identify his/her halitosis and is usually pointed out the problem by his/her partner, family member, or friends.

Bad breath causes a distressing effect on a person’s life, and so the affected person may avoid socializing and tends to shun public life.

 The extooth team wants a smile on everyone’s face.

The Morning Breath

Some lousy breath like “morning mouth” is quite reasonable as changes occur in your mouth while you sleep. 

During the day, saliva, rinsing, and mouthwash cleanses away, spoiling food and smells.

The body forms less saliva during night time. 

Your mouth becomes dehydrated, and dead cells hold your tongue and cheeks. When bacteria utilize these cells for meals, they create a foul odor.

Do infections cause Bad Breath?

Yes, you heard me, right! An infection can be a reason for your Bad Breath. Moreover, halitosis can be an indicator of any systemic disease.

 10% of ear-nose-throat or 5% of gastrointestinal/ endocrinological disorders may contribute to it.

 We recommend you to consult a physician if it lasts even with mouthwashes and chewing gums.

Nearly 25% of the population seems to suffer from bad breath regularly.

Men and women seem to suffer in the same proportions, whereas women seem to seek faster professional help than men.

Why do we have bad breath?

Certain microbes fart and release volatile sulfur compounds (VSCs).

The most essential VSCs involved in bad breath (halitosis) are hydrogen sulfide (H2S), methyl mercaptan (CH3SH) and dimethyl sulfide (CH3)2S.

These sulfur compounds are principally generated by Gram-negative anaerobic oral bacteria including Treponema denticola, Porphyromonas gingivalis, Porphyromonas endodontalis, Prevotella intermedia, Bacteroides loescheii, Enterobacteriaceae, Tannerella forsythensis, Centipeda periodontii, Eikenella corrodens, Fusobacterium nucleatum.

 The proteolytic degradation process of peptides produces these components. The most powerful products in this sulfur compound production are cysteine, cystine, and methionine.

Bad breath in Smokers

You will be startled to know that the common cause of “smokers” breath “ is the tobacco itself.

Chemicals remain in the mouth even after a cigarette has been extinguished and produces bad breath. 

Remnants of the smoke remain in the lungs too well after the cigarette is extinguished. The lungs keep on emitting out the smoke-laden breath way beyond the last puff.     

Poor hygiene favors halitosis

Bad oral health, dental plaque, dental caries, aggregation and degeneration of food trash and dirty acrylic dentures. Dentures worn at night or not frequently cleaned or with rough surfaces add to bad breath.

Most of the engaged microorganisms in halitosis are associated with periodontitis(gum disease).

There is a positive association among bad breath and periodontitis: the extent of the periodontal pockets (feeling of digging in gums) is directly linked to the height of the VSC collections in the mouth.

Gingivitis and periodontitis are the principal elements of the problem.

Bleeding gums produces bad breath.

There is a positive correlation between the depth of the pockets and the concentration of the sulfur components.

 Necrotizing gingivitis or periodontitis causes extremely soiled odors.

This infection is caused by opportunistic bacterial infections happening in individuals with anxiety, starvation, faulty oral cleanliness, smoking, or systemic diseases.

How tongue coating induces bad breath?

The dorsum or uppermost covering of the tongue, which is unusual and has a coating of 25 cm2 is a perfect corner for oral bacteria.

Tongue covering houses bacteria, food wreck which on putrefaction produces bad breath.

So, the tongue surface appears to be an important reserve in the recolonization of tooth surfaces. The tongue coating is not easy to liquidate.

Regular scraping or brushing of the tongue can support to overcome the substrata for putrefaction, rather than to reduce the bacterial load. Furthermore, tongue cleaning enhances taste response.

How dry mouth induces bad breath?

Patients with a dry mouth usually show an enhanced amount of plaque on teeth and tongue.

As saliva has powerful antimicrobial properties, the absence of flow leads to the dissolution of the antimicrobial action of the saliva and the shift from Gram-positive bacteria to Gram-negative species.

Further, other salivary factors can influence the progression of oral malodor (Bad Breath):

Addition of the salivary pH by the consumption of amino acids

A shift in the oxygen exhaustion (a cut arouses the metabolism of Gram-negative bacteria, held for greater VSC production).

Saliva shows to experience chemical transformations with aging. 

As the number of ptyalin drops and mucin raises, saliva becomes thick and viscous and confers difficulties for the aged. One of the most common reasons for xerostomia is medication. (anticholinergics, antihistamines, and diuretics). The other supporting constituent is poor fluid retention of aging tissues which dry the skin and oral mucosa.

 Massive mouth breathers, radiation therapy, dehydration and autoimmune diseases (as Sjögren’s syndrome) can also lessen salivation, as can systemic ailments such as diabetes mellitus, nephritis, and thyroid dysfunction.

Dry mouth symptoms are handled with hydration and sialogogues or with artificial saliva substitutes.

In people with Sjögren’s syndrome and in those who have encountered any radiation therapy, pilocarpine presents good results.

A convenient lifestyle with changing sleep habits results in altered saliva flow. This results in dry mouth or halitosis. Anxiety levels are cultivated to play in modern-day aims achievement. The resultant outcome is evident in the mouth; the foundation is by fetid odor. 

ENT Pathology and halitosis

Maximally 10% of the oral malodor cases begin from the ears, nose, and throat (ENT) region, from which 3% gains its origin at the tonsils.

Plaut-Vincent angina (caused by Fusobacterium Plaut-Vincenti and Borrelia Vincenti) is an added ENT reason for halitosis.

The presence of tonsilloliths depicts a 10-fold raised risk of unusual VSC levels.

Anaerobic bacteria tonsilloliths include the species of Eubacterium,  Fusobacterium, Porphyromonas,  Prevotella,  Selenomonas and Tanerella, all of which seem to be connected with the creation of VSCs.

Sinusitis and halitosis

Streptococcus pneumoniae and Haemophilus influenzae are the chief guilty bacteria.

A characteristic odor arises with the purulent mucus.

Because those bacteria can build VSCs, a formal agreement to halitosis is possible.

In chronic sinusitis, 50%–70% of the patients mourn of oral malodor.

Eventually, with the additional use of antibiotics reduces the anaerobic pathogens, yet as the odor problem.

GIT and halitosis

When Zenker’s diverticulum is present, a stubborn offensive odor develops.

Also, bleeding of the esophagus can provoke a musty odor. Bad breath with severe regurgitation is also observed.

In instances of intestinal obstruction, fecal mouth odor may be detectable.

Metabolic diseases and halitosis

Renal disease in the frame of chronic renal failure is connected with high blood urea nitrogen levels and low salivary flow rates.

The dispersed odor is a typical uremic odor in combination with a dry mouth.

Diabetic ketoacidosis leads to a typical breath odor. Diabetes type 2 reveals a distinctive sweet and fruity smell.

Many metabolic dysfunctions in the bowels, like trimethylaminuria create a particular fishy smell.

The liver is also associated with oral malodor.

Due to a weakened liver capacity, waste products are expelled by the lungs, producing the ‘fetor hepaticus’: a delightful, excremental odor (the breath of death).

How to check for halitosis?

There is two approaches – Intraoral and Extraoral examination.

Intraoral Examination

1. Tongue: scraping the tongue with a spoon, smelling the scraping, and analyzed with Tongue coat indices and tongue coat weight. Also, chair-side tests, such as HalitoxTM for VSCs and polyamines, which are based on its color changes, are useful. The intensity of hue change from colorless to yellow to yellowish-brown depicts the number of VSC producing bacteria.

      2.Saliva: Saliva is tested for tissue breakdown products by TOPASTM– toxicity pre-screening assay for hydrogen sulfide and methyl mercaptan along with polyamines.

• SSS System – Salivary supernatant sediment test for cysteine breakdown products in saliva.
• Swinnex filter test to determine the malodorous potential of stagnated saliva during nocturnal conditions contributing towards morning breath.
• Extraoral examination

Organoleptic Scoring

The gold standard is the organoleptic scoring, which is sniffing the odor of the patient.

The patient should avoid garlic or onions the day before the test.

At least 12 h before the consultation, do not be clean or rinse the teeth. Avoid perfumes for at least 6 hours before the examination, and the intake of food or liquids. Quit smoking for at least 24 h before any examination.

Different samples are analyzed for:

• mouth odor (sniffed at 10 cm from the oral cavity: while the patient ordinarily breaths and while the patient counts loudly to 10)
• saliva odor ( wrist-lick test: the patient licks at the wrist, and after 10 s of drying, record the score)
• tongue coating (debris scraped from the dorsum of the tongue with a periodontal probe)
• interdental ‘floss’ (after flossing with dental tape, score the odor of the floss)
• when the patient is inhaling through the nose (mouth shut), a score is given to the exhaled air
• prosthesis odor (if the patient wears a partial or full removable denture, scoring of the odor of this prosthetic)

 A well-trained clinician performs organoleptic scoring.

If the odor samples smell bad or not, giving a score to the intensity. These scores go from 0 to 5.

The advantages of organoleptic scoring are: inexpensive, no equipment needed, and a wide range of odors is detectable.

Disadvantages include the extreme subjectivity of the test, the lack of quantification, the saturation of the nose.

Portable gas analysis

The Halimeter (Interscan corporation, Chatsworth, CA, USA) and OralChroma (Abimedical corporation, Miyamae-ku Kawasaki-shi, Kanagawa, Japan) are computerized machines open to catch some of the volatile sulfur components in expired breath.

The OralChroma is a compact gas chromatograph endeavoring more economical cost, more powerful performance, and more user-friendly services than standard gas chromatographs by restricting the target gases into three types: H2S, CH3SH, and (CH3)2S.

The Halimeter can only provide a notion of the total measure of VSCs, existing in a sample. In the Halimeter, we mark the total amount of ppb (parts per billion) of VSCs in the sample.

In normal situations, this value is less than 100 ppb. If we get some 300–400 ppb, it means a persistent oral odor.

These portable machines have a lot of advantages: easy handling, fast results, transportable, and reproducible.

Furthermore, even untrained staff can master it. They are somewhat economical.

Lately, the OralChroma may provide a more extensive estimation of VSC creation by oral microflora than the Halimeter. It would be advisable to select one machine as a gold standard to make several studies relative in the future.

Gas chromatography

The gas chromatography (GC) analysis can be conducted on the puff, saliva, and tongue trash. VSCs can be well distinguished, but the challenge will be to separate the other contributing elements of oral malodor.

GC has numerous benefits: an interpretation of almost all elements with high sensitivity and specificity.

The method is non-invasive, but costly and demands a well-trained team.

The succession of the process takes much more time, and the device cannot be used in daily application.

Treatment

Self-care products

Halitosis interferes with normal social interactions. For these reasons, people use self-care products to prevent unpleasant odor.

Few lifestyle changes and home remedies for bad breath include:

• Brush the teeth: Do certain to clean your teeth at least twice a day, preferably after every meal.
• Floss: Flossing decreases the build-up of food shreds and plaque from within the teeth. Brushing only wipes around 60 percent of the outside of the tooth.
• Clean dentures: Clean anything that goes into your mouth, including dentures, a bridge, or a mouth guard, on a daily basis. Cleaning stops the bacteria from growing up and being transported back into the mouth. Replacing toothbrush every 2 to 3 months is also necessary for similar reasons.
• Brush tongue: Bacteria, food, and dead cells usually build up on the tongue, particularly in smokers or those with a particularly dry mouth. A tongue scraper can sometimes be beneficial.
• Avoid dry mouth: Drink lots of water. Avoid alcohol and tobacco, both of which dessicate the mouth. Chewing gum or sucking a sweet, preferably sugar-free can assist stimulate the generation of saliva. If the mouth is constantly dry, a doctor may prescribe medication that stimulates the stream of saliva.
• Diet: Avoid onions, garlic, and spicy food. Sugary foods are also inducing to bad breath. Decrease coffee and alcohol consumption. Having a breakfast that includes rough foods can assist cleanse the back of the tongue.
• Quit smoking: While the most simple solution to stop bad breath following smoking is simply to beat the habit, we are well conscious of how hard this may be.
• Chewing gum, mints: chewing gum may reduce halitosis, particularly through enhancing the salivary flow.
• Mouth rinses: Mouth rinses carrying chlorine dioxide and zinc salts have a strong effect on hiding halitosis, not letting the volatilization of the offensive odor.

Nevertheless, by these products, a direct remedy of halitosis is unlikely. Apply these methods as a substitute solution to overcome and enhance the ease of the patient. The professional approach of real halitosis has critical severity.

Professional treatment

• Scaling and Root planing procedures: Primary periodontal treatment involves scaling and root planing, which may lighten the intensity of the periodontal pockets and cruelty of gingival inflammation, and it reduces halitosis breeding bacteria.
• During periodontal therapy, the practice of antiseptic mouthwash helps the decrease of the bacterial quantity. Chlorhexidine is a helpful antiseptic agent, just careful with the long-term usage of chlorhexidine as it can produce staining of teeth and mucosal surfaces.
• Maintaining oral hygiene: Daily oral hygiene instruction is another important concern for halitosis.
• Proper brush, dental floss, and inter-dental brush usage are extremely important. Yet, sometimes even if the periodontal health is comprehensive, tongue coating can be an important cause of halitosis.
• The tongue dorsum can be a house for these bacteria. If a patient has a geographic or fissure tongue, the film will be more.
• Due to these causes, scraping tongue dorsum by brushing, tongue scraper, or tongue cleaner is important.

One of the studies revealed the effect of tongue cleaning; there was a decline of VSC levels with the toothbrush 33%, with the tongue scraper 40%, and with the tongue cleaner 42%.

• Chlorhexidine (CHX) mouthwash: CHX is the most dynamic molecule against plaque. Flushing with 0.2% CHX causes a decline of 43% in VSCs and of 50% in the organoleptic counts on a day-long basis.
• Essential oils: these products deliver only a short-term and limited effect (25% reduction) for 3 hours — also, an insufficient compression in odor-producing bacteria.
• Chlordioxide: Chloordioxide is a strong oxidizing agent that can reduce 29% of oral malodor for up to 4 hours.
• Triclosan: Triclosan is powerful against the bulk of oral bacteria. An 84% decrease in VSCs after 3 hours.
• Aminefluoride/Tinfluoride: The mixture of AmF/SnF2can causes an 83% reduction in the morning halitosis.
• Peroxide(H2O2): a concentration of 3% of this product can result in a 90% VSC reduction after 8 hours.
• Chlorhexidine and zinc mouthwash: has a powerful effect on volatile sulfur-containing compounds and is effective for at least 9 hours.
• Cetylpyridinium and zinc mouthwash: have a real synergistic effect on volatile sulfur-containing compounds levels after 1 hour, but minimally above the effect of zinc alone.
• Chlorhexidine, cetylpyridinium chloride, and zinc-lactate mouthwash: Chlorhexidine is still the gold standard mouth rinse, but it does have some side effects.
• Due to these disadvantages, companies are coming up with new formulations. Since CHX and CPC are both antimicrobial agents, it seems reasonable to assume that the newly marketed mouthwash that contains CHX and CPC acts by reducing the number of VSC-producing bacteria on the dorsum of the tongue.
• Probiotics: probiotic bacterial strains, originally sourced from the indigenous oral microbiotas of healthy humans, may have potential applications as adjuncts for the prevention and treatment of halitosis.
• The oral regime of the probiotic lactobacilli not only showed to increase the physiologic halitosis but also recorded advantageous effects on bleeding on probing from the periodontal pockets.
• Treating Dental pathology: Dentists initially analyze any existing and needed restorative health. Improper prosthetics and conservative restorations, such as creating food impactions, uncleaned state, or food retention, generate a pool for bacteria. Replacement or renewing of old restorations with proper restoration provides the prevention of these reservoir areas. Also, the presence of the non treated cavity of decayed teeth, non-vital teeth with fistula or exposed tooth pulp may form a reservoir for bacteria, so treatments of these teeth with decent restoration are crucial.
• Treating Medical conditions: If halitosis origins from non-oral problems, consult with the specialist.
• You must understand the real disease and manage it. Otherwise, the outcome of halitosis will influence your social life. Hence, the responsibilities of a dentist in extra-oral cause halitosis are informed of the patient about the source of halitosis and sending him/her to the specialist.

Delusional halitosis

Sometimes people can believe they have halitosis in spite of them having no measurable halitosis. This condition is called a halitophobia, and this condition can be a monosymptomatic delusion (“delusional halitosis”) or demonstration of olfactory reference syndrome.

Management of halitophobia is complicated than the control of real halitosis.

Halitophobia persons withdraw socializing and even bypassing talking with people; hence, treatment of halitophobia is very important.

Before treating people who have halitophobia, verify if he/she has no measurable bad breath by measuring devices. If you are getting captivated with the thought of having bad breath, then ask a psychologist.

Do I have bad breath?

It’s not always obvious to say if you have bad breath. Other people may mention it first, but they could consider uncomfortable telling you.

A simple test to find out whether you have bad breath is to lick the inside of your wrist with the back of your tongue.

Wait a few seconds until the saliva evaporates.

If your wrist smells offensive, it’s possible your breath does, too.