Q: No matter what I do, my breath smells. I floss and brush twice a day, use a tongue scraper and mouthwash, but no matter what, my breath still stinks. Someone mentioned it could be my tonsils or my stomach, what do you think? What can I do?
Dr Grant replies: Halitosis, or bad breath, is a common complaint with up to 25pc of people having normal breath but being excessively worried about bad breath. In fact, a lot of affected individuals are not aware they have bad breath. Oral causes of bad breath are thought to account for up to 90pc of cases. There is usually evidence of disease during a dental consultation. In your case, it sounds like you have excellent oral hygiene and presumably no untreated dental decay or gingivitis, so it is worth exploring other possible causes.
The majority of bad breath is caused by bacteria that live in your oral cavity acting on food material caught between the teeth and on the dorsum of the posterior, one third of the tongue. Temporary causes like eating raw garlic/onion/smoking cigarettes or acute causes like tonsillitis/peritonsillar abscess obviously don’t apply to your situation. People who suffer with persistent dry mouth, recurrent dental abscesses, defective dental restorations or failure to clean dentures/dental devices appropriately may also experience bad breath. The tonsils account for only a small amount of cases, typically when a white cheese-like material forms on the tonsillar crypts that can lead to tonsillar stones.
Two common conditions like rhinosinusitis and post-nasal drip can lead to bad breath. The odour is generally worse when breathing out through the nose. Some underlying lung conditions associated with bad breath include bronchitis, bronchiectasis or lung abscess. But you would need to have symptoms suggestive of chronic lung disease such as cough, sputum, fevers or weight loss.
A few rare causes include a Zenker’s diverticulum, when an abnormal outpouching occurs at the junction of the lower part of the throat and the upper part of the oesophagus causing food to collect. Even more rare is a gastrocolic fistula when an abnormal connection forms between the stomach and the colon, typically due to a cancer. Unfortunately cancers can form in the oral cavity, nasal cavity, pharynx, larynx, trachea, and oesophagus, potentially causing bad breath. Lastly, I mentioned psychological bad breath (paranoia), but there is also neurological bad breath which is a disorder of taste/smell resulting in the belief that bad breath is present when, really, it isn’t.
So let’s go back to the oral cavity and discuss what you can do to improve your bad breath. When you use mouthwash try to use it an hour or more after brushing teeth at night. Continue to use your tongue scraper as best you can but since so much bad breath is associated with the posterior tongue, it is important to gargle when using mouthwash.
Firstly, you should tilt your head back and stick your tongue out when you gargle as this helps get to that posterior tongue. Secondly, try a strong chlorhexidine gluconate mouthwash for two weeks then switch back to regular mouthwash. Also, ensure you drink two litres of water daily and limit caffeine/alcohol intake. Check in with your dentist or doctor if you have any concerns about anything mentioned above.