The next time a patient comes to see you complaining about persistent halitosis, consider this: the cause is likely to be oral pathogenic bacteria – even when there are no obvious signs of periodontal disease.
After an initial examination of a patient's mouth reveals there is no substantial plaque build up or gingival inflammation or bleeding, dental and medical professionals may conclude that the cause of breath odour is likely arising from some other medical condition.
Bacteria can be present in the mouth, however, in numbers substantial enough to cause odour – even when a patient practises good oral care and gums show no obvious signs of disease. Halitosis is therefore often attributed to other causes, such as the following, and so the sufferer may not receive appropriate treatment and the problem persists.
Misconception: Regular use of mouthwash will cure persistent bad breath
Dental and medical professionals will sometimes suggest that a patient with breath odour use a mouth rinse. However, mouthwashes that can be purchased over the counter are, at best, temporarily helpful in controlling halitosis. They simply flush away loose bacteria. They do not halt the growth of harmful plaque biofilm. In fact, many mouthwashes contain sugar and alcohol, which can aggravate oral infections.
Misconception: Stomach and digestive problems are a common source of breath odour
Since the esophagus is a closed tube, digestive problems in the stomach do not often contribute to bad breath. Occasionally, gases escape to the mouth when the lower esophageal sphincter does not close properly due to gastroesophageal reflux disease or a hiatal hernia. A Zenker's diverticulum may also result in halitosis due to aging food retained in the esophagus. These conditions, however, are all relatively uncommon.
Misconception: Tonsils are frequently involved in halitosis
In fact, only about 3% of cases of chronic oral malodour are related to the tonsils. Most of these involve tonsil stones, or tonsilloliths. These lumps of calcified food, mucous and bacteria can decay and cause breath odour. People who suffer from tonsillitis or dry mouth are more susceptible to tonsil stones.
Misconception: Postnasal drip often produces oral malodour
Most instances of postnasal drip, an accumulation of mucus in the postnasal space, are caused by allergies or hypersecretion from the paranasal sinuses. These types of postnasal drips do not contain volatile sulphur compounds in sufficient amounts to create an odour. It is generally only in cases of sinus infection, where bacteria proliferate in the sinus cavities and at the back of the throat, that postnasal drip causes breath odour.
About 15% of medical conditions such as the ones described above may cause chronic breath odour, however oral hygiene habits and gingivitis and periodontitis are by far the most common culprits. In the case of inadequate oral care, a visual inspection of the mouth often reveals plaque biofilm buildup. It's important to be aware, however, that obvious signs of infection, such as bleeding and inflammation of the gums, may not be present.
Thus an oral microbial analysis is the most effective diagnostic tool for determining the presence and status of disease and selecting appropriate antimicrobial treatment. If the analysis indicates the presence of bacteria that produce sulphur compounds, eliminating bad breath may require prescribing an antibiotic rinse or implementing another type of specialized periodontal treatment.
Ultimately, it's helpful to remind patients that proper care of the teeth and gums and regular dental checkups and cleanings are the most effective ways to prevent bad breath – and to protect their overall health.