Bad Breath - Halitosis

Bad Breath (Halitosis)

Halitosis — or bad breath — may be due to poor oral hygiene, but this isn’t always the case. It can also occur due to a number of health conditions, including dry mouth, heartburn, or even disease in another part of your body. Treatment for halitosis depends on the underlying cause.

• Halitosis is formed by volatile molecules which are caused because of pathological or nonpathological reasons and it originates from an oral or a non-oral source. It is very common in the general population and nearly more than 50% of the general population has halitosis. Although halitosis has multifactorial origins, the source of 90% of cases is the oral cavity such as poor oral hygiene, periodontal disease, tongue coat, food impaction, unclean dentures, faulty restorations, oral carcinomas, and throat infections. Halitosis affects a person's daily life negatively, most of the people who complain about halitosis refer to the clinic for treatment but in some of the people who can suffer from halitosis, there is no measurable halitosis.
• There are several methods to determine halitosis. Halitosis can be treated if its etiology can be detected rightly. The most important issue for the treatment of halitosis is the detection of etiology or determination of its source by detailed clinical examination. Management may include simple measures such as scaling and root planning, instructions for oral hygiene, tongue cleaning, and mouth rinsing. The aim of this review was to describe the etiological factors, prevalence data, diagnosis, and therapeutic mechanical and chemical approaches related to halitosis.

Halitosis originates from the oral cavity

• Although halitosis has multifactorial origins, the source of 90% of cases is the oral cavity. In the oral cavity, temperatures may be reached up to 37°C (and changed between 34 and 37°C). During exhaling also humidity may be reached up to 96% (and changed between 91% and 96%) in oral exhalations. These conditions may provide a suitable environment for bacterial growth. The number of bacterial species, which are found in the oral cavity, is over 500, and most of them are capable to produce odorous compounds which can cause halitosis. In these conditions,
• oral hygiene plays a key factor in the multiplication of halitosis-causative bacteria and causes an increase in halitosis. These bacteria include especially Gr-negative species and proteolytic obligate anaerobes and they are mainly retained in tongue coating and periodontal pockets. Among healthy individuals, with no history of halitosis and no periodontal diseases, some show halitosis because of the retention of bacteria on the tongue surface.[These bacteria degrade organic substrates (such as glucose, mucins, peptides, and proteins present in saliva, crevicular fluid, oral soft tissues, and retained debris) and produce odorous compounds.
• To poor oral hygiene, food debris and dental bacterial plaque accumulate on the teeth and tongue and cause caries and periodontal diseases like gingivitis and periodontitis. The inflammation of gingival and periodontal tissues creates typical sources for oral malodors, and plaque-related periodontal disease can increase the severity of halitosis. However, the other forms of periodontal disease, especially acute and aggressive forms such as acute necrotizing ulcerative gingivitis, pericoronitis, and Vincent's disease, or aggressive forms of periodontitis, can increase unpleasant breath odor. The type of gingival enlargement which is dependent on inflammation or drugs (such as phenytoin, cyclosporine, or calcium channel blockers) may increase the risk of bad odor.
• The severity of halitosis is affected from periodontal conditions, also periodontal conditions are affected by halitosis. The previous studies showed a relationship between oral halitosis and periodontal disease. Periodontal diseases may be developed by the volatile sulfur-containing compound transition to periodontal tissues. However, is still not well understood what is the relationship between periodontal health and oral malodors.
• Besides periodontal conditions, untreated deep carious lesions also create a retention area for food debris and dental bacterial plaque and may cause halitosis. Another important factor in halitosis is the flow of saliva. The intensity of sulfur compounds is increased because of salivary flow reduction or xerostomia.
• Saliva functions as a buffering or a cleaning agent and keeps bacteria at a manageable level in the mouth. Reduction of the salivary flow has negative effects on self-cleaning of the mouth and inadequate cleaning of the mouth causes halitosis. Reduction of Salivary flow may be affected by many reasons such as medications (e.g., antidepressants, antipsychotics, diuretics, and antihypertensives), salivary gland diseases (e.g., diabetes, Sjogren's syndrome), chemotherapy, or radiotherapy.
• Other factors that contribute to halitosis are endodontic, surgical, and pathologic factors such as exposed tooth pulps and non-vital tooth with fistula draining into the mouth, oral cavity pathologies, oral cancer and ulcerations, extractions/healing wounds or prosthetics or dentition factors such as orthodontic fixed appliances, keeping at night or not regularly cleaning dentures, restorative crowns which are not well adapted, non-cleaning the bridge body, and interdental food impaction.
• All these factors cause food or plaque retention area, raising bacterial amount, tissue breakdown, putrefaction of amino acids, and decrease of saliva flow. All these conditions result in the release of volatile compounds and cause halitosis.

Halitosis originates from non-oral sources

• Nearly 8% of halitosis cases are caused by an extraoral source. This type of halitosis has many sources, but it is rarely seen. Respiratory system problems, gastrointestinal disease, hepatic disease, hematological or endocrine system disorders, and metabolic conditions can all be the causes of halitosis.
• Respiratory system problems can be divided into upper and lower respiratory tract problems. They are sinusitis, antral malignancy, cleft palate, foreign bodies in the nose or lung, nasal malignancy, subphrenic abscess, nasal sepsis, tonsilloliths, tonsillitis, pharyngeal malignancy, lung infections, bronchitis, and bronchiectasis lung malignancy. Bacterial activity in this pathology causes halitosis which leads to putrefaction of the tissues or causes tissue necrosis and ulcerations and the production of malodorous gases, which are expired causing halitosis.
• Gastrointestinal diseases cause halitosis. Pyloric stenosis, duodenal obstruction, Porto-enteric anastomosis, pharyngeal pouches, zenker's diverticulum, and hiatal hernia cause food retention. Reflux esophagitis, achalasia, steatorrhea, or other malabsorption syndromes may cause excessive flatulence or?Helicobacter pylori?infection causes gastric ulcers and VSC levels increase in an oral breath. Levels of VCS's in oral breath may be higher in patients with erosive than non-erosive oesophagogastric-duodenal mucosal disease although VSC levels are not influenced by the degree of mucosal damage.
• Also, hepatic or hematological diseases which are a hepatic failure (foetorhepaticus) and leukemia, renal failure (usually end-stage renal failure), endocrine system disorders which are diabetic ketoacidosis or menstruation (menstrual breath), metabolic disorders which are trimethylaminuria and hypermethioninemia may cause halitosis

Other causes of halitosis

• Dietary products such as garlic, onions, and spiced foods cause transient unpleasant odor or halitosis. Therewithal drugs such as alcohol, tobacco, betel, solvent abuse, chloral hydrate, nitrites and nitrates, dimethyl sulfoxide, disulphiram, somecytotoxics, phenothiazines, amphetamines, suplatast tosilate, paraldehyde may create the same effect

ASSESSMENT OF HALITOSIS

• Halitosis affects a person's daily life negatively, most people who complain about halitosis refer to the clinic for treatment but in some of the people who can suffer from halitosis, there is no measurable halitosis. Assessment methods of halitosis ensure discrimination of pseudo-halitosis and halitophobia. For these reasons, diagnosis of halitosis, and assessment of its severity (conditions that patients have, is it genuine halitosis or pseudo-halitosis or halitophobia) are very important. Therefore, the diagnostic way and tools were developed. Organoleptic measurement, gas chromatography, sulfide monitoring, the BANA test, and chemical sensors have most commonly used than the other methods such as quantifying β-galactosidase activity, salivary incubation test, ammonia monitoring, or ninhydrin method.

Organoleptic measurement

The oldest way for unpleasant odor detection is by smelling with the nose. Measurement of unpleasant odors by smelling the exhaled air of the mouth and nose is called organoleptic measurement. It is a simple way the detection of halitosis.

The measurement method is the organoleptic test; the patient takes breathe deeply by inspiring the air by nostrils and holding awhile, then expiring by the mouth directly or via a pipette, while the examiner sniffs the odor at a distance of 20 cm (the purpose of using a pipette is to lessen the intensity of expiring air) and the severity of odor is classified into various scales, such as a 0- to 5-point scale (0: no odor, 1: barely noticeable, 2: slight but clearly noticeable, 3: moderate, 4: strong, and 5: extremely strong) or more widely point scale from 0 to10 point.

• This measurement is considered to be the gold standard for measuring and assessing bad breath because of no-cost, and being practical and simple. However, it has some difficulties. It may be difficult to calibrate the practitioner and to gain the correct result; in clinical practice, the patient should avoid eating odiferous foods for 48 h before the assessment, and both the patient and the examiner should refrain from drinking coffee, tea or juice, smoking and using scented cosmetics before the assessment. Also, the other problem is the way of measurement, it is an unlikeable situation for the examiner because of smelling unpleasant odor and inconvenient conditions for the patient. To lessen unpleasant situations instead of expiring air to examiners, the patient can breathe the air inside the bag for a while, then the examiner sniffs this odor from the bag and classifies its severity. In this way, the unpleasant side of organoleptic measurement becomes a more acceptable one.

Gas chromatography

• Measurement with the gas chromatography method is considered to be highly objective, reproducible, and reliable. Using gas chromatography we can measure VSCs. It separates and analyzes compounds that can be vaporized without decomposition; samples are collected from saliva, tongue coating, or expired breath. In this method, measurements are performed and equipped with a flame photometric detector or producing mass spectra. The concentration of each VSC (ng/10 mL mouth air) was determined based on a standard of hydrogen sulfide and methyl mercaptan gas prepared with a permeate.
• In the gas chromatography method, the patient closes the mouth and holds air for 30 s, then mouth air (10 mL) is aspirated using a gas-tight syringe. After the collection of samples, it is injected into the gas chromatograph column at 70°C. The results are precise and reliable, but this method takes a long time to run. Moreover, it is expensive and not used commonly in chairside, and requires a skilled operator. Mostly, the results of the gas chromatography method show a high correlation to organoleptic measurements but gas chromatography has high sensitivity and it can detect low-concentration molecules. Therefore, sometimes we may see a low correlation between gas chromatography and organoleptic measurements.

Sulfide monitoring

• Gas chromatography has high accuracy and sensitivity, but the application method on the chairside is difficult and expensive. In order to avoid these disadvantages, a new portable device which is a sulfide monitor was developed to measure VSCs.
• In this method before taking measurements, patients should close their mouths and refrain from talking about food for 5 min prior to measurement, then a disposable tube of the sulfide monitor is inserted into the patient's mouth to collect mouth air. Meanwhile, the patient is breathing through the nose and the disposable tube is connected to the monitor. Sulfur-containing compounds in the breath can generate an electrochemical reaction. This reaction is related directly to levels of volatile sulfur-containing compounds.
• The sensitivity and specificity of the sulfide monitor are less than the gas chromatography but correlations of measurements are highly significant. On the other hand, the sulfide monitor and organoleptic measurements show a low correlation because of volatile compounds such as alcohols, phenyl compounds, alkenes, ketones, and polyamines. Short-chain fatty acids can be detected by organoleptic measurements, but cannot be detected by the sulfide monitor so the correlations between measurements may be inconsistent.

Chemical sensors

• Because of the difficulties of gas chromatography and the less sensitivity of sulfide monitors, a more sensitive and easy device was made. Chemical sensors have an integrated probe to measure sulfur compounds from periodontal pockets and on the tongue surface. The working principle of chemical sensors is similar to sulfide monitors. Through the sulfide-sensing probe, sulfide compounds generate an electrochemical voltage and this voltage is meadevice's screen as a digital score.
• Using the new chemical sensors, ammonia, and methyl mercaptan compounds can be measured from breath air and some new types of sensors measure each volatile sulfur-containing compound separately. The sensitivity is similar to gas chromatography and the results of the measures are highly close to organoleptic scores so chemical sensors are called?the electronic nose.

BANA test

• The BANA test is practical for chair-side usage. It is a test strip composed of benzoyl-DL-arginine-a-naphthylamide and detects short-chain fatty acids and proteolytic obligate gram-negative anaerobes, which hydrolyze the synthetic trypsin substrate and cause halitosis. It detects especially?Treponema denticola,?P. gingivalis, and?T. forsythensis?that are associated with periodontal disease. By using the BANA test, we can detect not only halitosis but also periodontal risk assessment.

To detect halitosis, the tongue is wiped with a cotton swab. For periodontal risk assessment, the subgingival plaque is obtained with a curette. To evaluate, the samples are placed on the BANA test strip, which is then inserted into a slot on a small toaster-sized incubator. The incubator automatically heats the sample to 55° for 5 min. If?T. denticola, P. gingivalis, or?B. forsythias?are present, the test strip turns blue or bluer. The deepening of the blue color shows the existence of a higher concentration and a greater number of organisms.

• Close relationships are found between the BANA test and organoleptic measurements, but the relationship between the BANA test and sulfur monitor measurements is poor. Performing multiple-regression analysis with organoleptic measurements and the BANA score as the dependent variable, both peak VSC levels and BANA scores factored into the regression, yielding highly significant associations. This result may be caused by BANA-positive microorganisms which contribute halitosis?via?non-sulfur odorants, such as cadaverine
• The BANA test results demonstrate a significant positive correlation with the increasing pocket depth. Periodontal conditions can be assessed by this way, but periodontal conditions can be changed by BANA-negative microorganisms or the percentage of BANA-positive microorganisms may be below the detection limit of the BANA test. Comparing the sensitivity of the BANA test and of ELISA a 9% rate of false-positive results was found. The BANA test results reflect periodontal disease activity which may cause halitosis by bleeding gums.

Quantifying?β-galactosidase activity

• Deglycosylation is the removed link of glycosyl groups from glycoproteins. Deglycosylation of glycoproteins is the initial step in oral malodor production. By deglycosylation of glycoproteins, proteolytic bacteria degrade proteins which are especially salivary glycoproteins, and cause halitosis. Proteolysis of glycoprotein depends on the initial removal of the carbohydrate side-chains which are O- and N-linked carbohydrates. β-Galactosidase is one of the important enzymes which are responsible for the removal of both O- and N-linked carbohydrate side-chains.
• β-Galactosidase activity can be easily determined by the use of chromogenic substrates absorbed onto a chromatography paper disc. In order to measure β-galactosidase activity, saliva was taken in a paper disc and discoloring of the paper disc changes based on β-galactosidase activity, and these changes are recorded; no color: 0, faint blue color: 1, moderate to dark blue color: Sterer?et al. found a positive correlation between organoleptic scores and β-galactosidase.

Salivary incubation test

• Salivary incubation is one of the assessment methods to measure halitosis indirectly. The first time, Marc Quirynen?et al. carried out a study to evaluate salivary incubation and halitosis. To measure halitosis with the salivary incubation test, saliva was collected in a glass tube and then incubating the tube at 37°C in an anaerobic chamber under an atmosphere of 80% nitrogen, 10% carbon dioxide, and 10% hydrogen for 3-6 h. After incubation, an examiner evaluates the odor. Although this method has some similarities with the organoleptic measurements, it has some advantages over them. The most important advantage is that the salivary incubation test has much less influenced by external parameters such as smoking, drinking coffee, eating garlic, onion, spicy food, and scented cosmetics. However, in organoleptic measurements, external parameters have negative effects on the result so the patient and examiner should avoid some odiferous food and drink before 48 h. The other advantages are unpleasant conditions of these measurements compared to organoleptic methods. The results of the salivary incubation test are shown a strong correlation with the organoleptic measurement. If the hardness of the incubation process does not be counted, the salivary incubation test could be one of the valuable tests for halitosis measurements.

Ammonia monitoring

• Besides VSCs, ammonia is another important factor in halitosis. Sulfur compounds can be detected by a portable sulfide monitor, but unfortunately, ammonia cannot be measured using this method. Ammonia is the major basic gas in a variety of important sample matrixes, for example, the ambient atmosphere, indoor air, and human breath. Comparatively, breath contains high levels of ammonia; it is 1 ppmv in the breath of a healthy individual or may be higher in individuals with renal failure.

To perform measuring halitosis, a newly portable monitor has been developed. This monitor detects ammonia quantity which is produced by oral bacteria. At least 2 h before measurements, the patients should refrain from eating and drinking activities. Then patients use a special mouth rinse for 30 s and close their mouths for 5 min. This rinse includes a urea solution and the bacteria produce ammonia from urea. To measure the concentration of ammonia a disposable mouthpiece which is part of the device is placed inside a patient's mouth. This disposable part is connected to an ammonia gas detector which contained a pump that drew 50 mL of air through a tube and the concentration of ammonia is noted directly from the scale on the detector tube.

• There is no correlation between the organoleptic score and the ammonia level measured with ammonia monitoring, but measurements of the ammonia level with ammonia monitoring show a significant correlation with the total level of VSCs measured with gas chromatography.

Ninhydrin method

• Gases which are components of halitosis were produced from the breakdown of peptides and glycopeptides by bacterial putrefaction in the oral cavity. During this process, peptides are hydrolyzed to amino acids which further are metabolized to amines or polyamines. These molecules cannot be measured by sulfide monitoring. Hence, the ninhydrin method was used for the examination of amino acids and low-molecular-weight amines.
• Levels of low-molecular-weight amines may give information for halitosis caused by bacterial putrefaction of low-molecular-weight amines. The ninhydrin method is simple, rapid, and inexpensive. This method is a kind of colorimetric reaction. The collected saliva is mixed with isopropanol and centrifuged. The supernatant was diluted with isopropanol, buffer solution (pH 5), and ninhydrin reagent. The mixture was refluxed in a water bath for 30 min, cooled to 21 8°C, and diluted with isopropanol. Light absorbance readings were determined using a spectrometer. The results of ninhydrin methods show a significant correlation with organoleptic scores and sulfide monitor measurements.

Impact of daily life

• People interact with each other every day, and halitosis has a negative effect on a person's social life. The person who has halitosis may not be aware of this situation because this person may have developed tolerance or olfactory disturbance. Due to this cause, the patient generally cannot identify his/her halitosis and it is identified by his/her partner, family member, or friends. This condition causes a distressing effect on persons who have halitosis and so the affected person may avoid socializing.

Self-care products

• Halitosis interferes with normal social interactions. For these reasons, self-care products are used by halitosis patients for preventing unpleasant odors. However, these products direct treatment of halitosis is not possible; these products such as chewing gum and mints, toothpaste, mouth rinses, and sprays decrease the odor and attempt to mask halitosis with pleasant fragrances. The use of chewing gum may decrease halitosis, especially through increasing salivary secretion. Mouth rinses containing chlorine dioxide and zinc salts have a substantial effect on masking halitosis, not allowing the volatilization of the unpleasant odor. Especially dietary caused halitosis such as onion, garlic, or cigarette can be masked by these approaches. These approaches should be only used as a temporary solution to relieve and improve the satisfaction of the patient. Professional treatment of real halitosis has crucial severity.

Professional treatment

• Halitosis can be treated if its etiology can be detected properly. Therefore, the most important issue for the treatment of halitosis is detecting etiology or determining its source by detailed clinical examination. Although most of the cases are caused by the oral cavity, sometimes other etiologies can contribute to oral halitosis. If it is not detected of the etiology accurately, the treatment can be unsuccessful therefore investigation and adequate diagnosis are crucial.
• In the event of an oral cavity caused by halitosis, reduction of the bacterial load is essential. Appropriate periodontal management is the first step. Necrotizing ulcerative gingivitis, gingivitis, adult and aggressive periodontitis, or periodontal pockets can increase the bacterial load so periodontal health has significant importance in controlling the amount of halitosis caused by bacteria. An initial periodontal treatment includes scaling and root planning which may alleviate the depth of the periodontal pockets and severity of gingival inflammation and it eliminates halitosis-causing bacteria. During periodontal therapy, the usage of antiseptic mouthwash relieves the reduction of bacterial load. Chlorhexidine can be used as a valuable antiseptic agent, but long-term uses of chlorhexidine can cause staining of teeth and mucosal surfaces.

Good oral hygiene instruction is another important issue for oral-caused halitosis. Proper brush, dental floss, and inter-dental brush usage are very important. However, sometimes even if periodontal health is perfect, tongue coating can be an important source of halitosis. The tongue dorsum can be a shelter for these bacteria. If a patient has a geographic or fissure tongue, the coating will be more. Due to these reasons, cleaning of tongue dorsum by brushing, tongue scraper or tongue cleaner is important. One of the studies showed the importance of tongue cleaning; reduction of VSC levels was found with the toothbrush at 33%, with the tongue scraper at 40%, and with the tongue cleaner at 42%.

• The existing and necessary restorative conditions of a patient must be reviewed. Unsuitable prosthetics and conservative restorations, such as causing food impactions, unclean areas, or food retention, create a reservoir area for bacteria. Replacement or renewal of old restorations with proper restoration provides prevention of these reservoir areas. Also existing in the nontreated cavity of decayed teeth, nonvital teeth with fistula or exposed tooth pulps may create a reservoir area for bacteria, so treatments of these teeth with proper restoration are important.
• The other conditions cause halitosis such as xerostomia, pericoronitis, oral ulceration, or malignancy which must be diagnosed and treated well. Mostly, xerostomia may be an oversight because of superficial clinical examination. This condition leads to patients being deprived of the protective and mechanical washing effects of saliva. The reasons for xerostomia must be examined in detail. If xerostomia is caused by head and neck radiotherapy or salivary glands pathology, artificial saliva products must be suggested to the patients.

Medical conditions or history can be illuminating information about the cause of halitosis. If halitosis originates from nonoral causes such as respiratory, gastrointestinal and hepatic, renal, endocrine, or hematological disease, consultation should be done with a specialist. If the actual disease is not properly diagnosed and treated, the effect of halitosis will affect a person's social life and becomes bothersome. Accordingly, the duties of a dentist in extra-oral cause halitosis are aware of the patient about the source of halitosis and send him/her to the specialist.

• As mentioned above, a detailed clinical examination of halitosis is crucial. Sometimes people can think have halitosis in spite of they have no measurable halitosis. This condition is called halitophobia and this condition can be a mono-symptomatic delusion (“delusional halitosis”) or manifestation of olfactory reference syndrome. Management of halitophobia may be more complex than management of real halitosis. Halitophobia persons avoid socializing and even avoiding talking with people; therefore, treatment of halitophobia is very important. Prior to treating people who have halitophobia, it must be proven that he/she has no measurable halitosis by measuring devices. If persons are obsessed with the idea of having bad breath, consultation with a hyua psychologist is required.

A note from Dr. Mansour Majed?

GP Dentist?- Master’s of Fixed Prosthodontics

Bad Breath (Halitosis)

Halitosis — or bad breath — may be due to poor oral hygiene, but this isn’t always the case. It can also occur due to a number of health conditions, including dry mouth, heartburn, or even disease in another part of your body. Treatment for halitosis depends on the underlying cause.

What is halitosis?

Halitosis is the medical term for bad breath. Everyone gets bad breath from time to time — especially after eating garlic, onions or other strong foods. But bad breath that doesn’t go away (chronic halitosis) could mean you have an oral health issue or a condition that’s affecting another part of your body.

What is the most common cause of bad breath?

The most common cause of halitosis is poor oral hygiene. Without proper?oral hygiene?— like brushing, flossing, and routine?dental cleanings?— harmful bacteria invade your?mouth?and multiply out of control. This can lead to several oral health issues like halitosis,?cavities,?and?gum disease. ?

What are other halitosis causes?

While poor oral hygiene is the most common cause of halitosis, it’s not the only one. There are several other conditions that can cause bad breath, including:

• Dry mouth:?Saliva helps to wash your mouth, so if your body isn’t making enough saliva, it can lead to halitosis.?Smoking?can cause dry mouth, and it also increases your risk for gum disease. Additionally, certain medications can cause dry mouth.
• Head and neck cancers:?Symptoms of oral or?oropharyngeal cancer?(your oropharynx is between your nose and mouth) include sores that don’t heal, mouth pain,?difficulty swallowing, a lump in your neck, and unexplained weight loss.
• Gastroesophageal reflux disease (GERD):?This is a digestive disorder in which stomach acid or fluid leaks back into your?esophagus, the tube that takes food from your mouth to your?stomach.
• Tonsil stones:?When food gets stuck in your tonsils (located in the back of your throat), it sometimes hardens into calcium deposits called tonsil stones or tonsilloliths.
• Gum disease:?Gingivitis?is an inflammation of your gums that can cause redness, swelling, and bleeding. It’s caused by?plaque, a sticky film that builds up on your teeth and can be removed by brushing and flossing. Untreated gingivitis can lead to?periodontitis, which damages gum tissue and can lead to tooth and bone loss around your teeth.?Trench mouth?is an advanced form of gum disease that can involve intense pain, bleeding,?fever,?and?fatigue. (It’s called “trench mouth” because it was a common illness for soldiers in the trenches during World War I.)
• Infections in your?nose,?throat,?or?lungs:?People with?pneumonia, for example, cough up liquid that smells bad.
• Diabetes:?People with diabetes have an increased risk of gum disease — and gum disease can make it harder to manage diabetes because it can increase blood sugar.
• Liver disease?or?kidney disease:?When your liver and kidneys are working properly, they filter toxins out of your body. But in people with liver or kidney disease, these toxic substances aren’t being cleared out. This can result in halitosis.
• Sj?gren’s syndrome:?This autoimmune disease can lead to muscle pain, dry eyes, dry skin, and dry mouth (which is often linked to halitosis).

How is halitosis treated?

Halitosis treatment depends on the root cause of the issue. For example, if bad breath is due to poor oral hygiene, a dental cleaning and improved oral hygiene at home will likely help.

But if halitosis is a symptom of another condition somewhere else in your body, your primary healthcare provider can help you with proper diagnosis and treatment.

Occasionally, your dentist may recommend special mouth rinses to combat certain bacteria in your mouth.

How can I permanently get rid of bad breath?

As mentioned above, treating the underlying condition is the only halitosis cure. Gum and breath mints only cover up the problem.

Once your healthcare provider determines what caused halitosis, they can create a treatment plan tailored to your specific needs.

How can I prevent halitosis?

Proper oral hygiene is the best way to keep your breath smelling clean and fresh. Here are some general guidelines:

• Brush twice a day, for at least two minutes each time, and floss once a day. Remember to clean your tongue with your brush or a tongue scraper, which you can buy in the oral health aisle.
• Use an alcohol-free antibacterial mouthwash.
• See your dentist regularly for check-ups and cleanings. For some people, this may be every six months. But others may need more frequent visits to keep their oral health in check.
• Drink a lot of water to help prevent dry mouth.
• Boost the production of saliva by using sugar-free chewing gum, sucking on sugar-free candy, or eating healthy foods that require a lot of chewing. Your dentist might recommend or prescribe products that can produce artificial saliva or help your body produce saliva.
• Avoid alcohol, caffeine, and tobacco products because they can dry out your mouth.

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