Bad breath, professionally known as halitosis, is a phenomenon found throughout the world. The results of various studies indicate that almost half of the population has bad breath at least occasionally, if not continuously. When we enter terms such as halitosis into internet search engines, they return almost nine million results or entries devoted to this problem, which shows how great the need for this type of information is. Awareness of the phenomenon is relatively old. Greek mythology tells us that Aphrodite punished disobedient women with bad breath. The self-proclaimed Sun King Louis XIV was known for extremely bad breath, but no one at court dared to tell him. Even today, unpleasant breath remains a taboo subject for many people, since it is an undesirable, offensive symptom that can lead to personal and psychosocial conflict.
Bad breath is caused by bacteria that obtain energy by breaking down proteins into smaller components (amino acids). During the breakdown of some of these, volatile sulfur compounds are released, causing an unpleasant odor. These bacteria live more easily without oxygen and in an alkaline environment. If they have suitable conditions for life and activity in the oral cavity and its immediate surroundings (nose, paranasal sinuses, pharynx and larynx), bad breath develops.
Bad breath is not an independent disease, but rather an indicator of another disease or disorder in the mouth or its immediate surroundings. We distinguish true halitosis originating from the mouth or nose, which can also be objectively demonstrated (devices, etc.), from false halitosis or pseudohalitosis, in which the disorder cannot be demonstrated or objectively measured. In the latter, it is also necessary to distinguish halitophobia, literally the fear of bad breath. These patients complain of bad breath that cannot be demonstrated, but they also do not accept explanations that they do not have it. The causes of bad breath are located in the oral cavity in almost 90% of cases. They most commonly involve the tongue and, to a considerably lesser extent, periodontal disease or disease of the tissues supporting the teeth. Two thirds of all microorganisms remain on the tongue, where they have the most favorable conditions for reproduction. The micro- and macro-roughness of the tongue provides bacteria, especially those living without oxygen, with additional conditions for growth. A pronounced association has been demonstrated between the amount of tongue coating (which serves as food for bacteria) and the presence of bad breath. Patients with tongue coating also have up to 25 times higher concentrations of bacteria per unit surface area. Formation of coating is additionally stimulated by smoking, stress, excessive coffee consumption, mouth breathing, one-sided chewing and insufficient fluid intake. Tongue coating consists of food debris, bacteria, remnants of epithelial and blood cells, and saliva. The amount of coating on the tongue depends largely on oral hygiene, although certain anatomical and other conditions increase the likelihood of its occurrence. A fissured tongue (lingua plicata) usually retains larger amounts of coating and therefore a greater quantity of bacteria responsible for bad breath. Abnormal elongation of the filiform papillae (tongue papillae), like deep fissures, allows a greater accumulation of bacteria and their nutrients on the surface of the tongue. The color of the tongue is most often altered, ranging from black through yellow to white. Because of the elongated papillae, such people may experience a feeling of choking. Despite the clinical picture described, the condition usually returns to normal with regular and thorough hygiene alone.
Diseases of the periodontal tissues also contribute their share (10%) to bad breath. Studies have shown a close relationship between the severity of periodontal disease and the amount of sulfur compounds (which cause bad breath), as well as an association between periodontal treatment and a reduction in oral malodor.
Carious lesions account for a smaller proportion of the causes of bad breath. Caries even lowers the pH value in the oral cavity and thereby, to some extent, compensates for the alkalinity that occurs with bad breath.
Some patients who wear dentures can also develop bad breath. The cause is usually poor denture hygiene and the resulting infection of the soft tissues beneath it. Cleaning the denture and removing it from the mouth during the night is usually sufficient to improve the condition.
Fortunately, malignant diseases in the mouth are very rare, but they can nevertheless alter oral odor, which strongly supports the above-mentioned fact that halitosis is not an independent phenomenon but only a symptom whose cause may lie elsewhere and may also be potentially dangerous. Treatment of malignant diseases in the mouth or its immediate surroundings can also cause bad breath. Radiotherapy for cancers in the head and neck region, and to a lesser extent certain chemotherapies, can cause irreversible damage to the salivary glands and thus the symptom of dry mouth or xerostomia. Dry mouth, in addition to a burning tongue and other undesirable disorders, is also accompanied by bad breath. Saliva plays an important role in maintaining the balance between potentially harmful and harmless bacteria. If there is not enough of it, bacteria proliferate and, among other problems, also cause bad breath.
In addition to the diseases described, dry mouth and its consequences can also be caused by taking certain medications (for lowering blood pressure, medicines that affect heart function, medicines for Parkinson's disease) and by certain systemic diseases such as the autoimmune Sjögren's syndrome. As a rule, the disease is also accompanied by pronounced bad breath, which can be treated relatively unsuccessfully with saliva substitutes. In some patients, salivary gland activity can be increased with medication (pilocarpine, cevimeline, Evoxac), but these medicines also usually do not achieve the desired results.
Emotional stress also noticeably reduces salivary secretion, as confirmed by many studies that have shown a markedly lower amount of saliva in more than 40% of people considered to be under stress.
During meals, salivary secretion increases greatly, so bad breath after meals is substantially less pronounced than before them.
During sleep, the situation is exactly the opposite. Reduced salivary secretion leads to the well-known and unpleasant morning breath. The phenomenon is more pronounced when breathing through the nose is not possible during sleep.
As already stated, most causes of bad breath lie in the oral cavity. In approximately ten percent of cases, however, they can be found in the nose, paranasal sinuses, pharynx and larynx. Most causes can therefore be diagnosed by a dentist, and only after all of these have been excluded is the patient referred to an otorhinolaryngologist, who will continue searching for the causes. In a very small proportion of cases, the causes of bad breath are found in the esophagus or stomach, so investigations of these organs usually do not produce the desired results. Inflammation of the palatine tonsils is among the more common causes of bad breath located outside the oral cavity. The surface of this lymphatic organ is highly fissured and provides ideal conditions for bacterial colonization, causing inflammation and bad breath. Acute inflammation (tonsillitis) causes severe bad breath, which disappears spontaneously once the disease has healed. In chronic inflammation (chronic tonsillitis), large numbers of anaerobic bacteria accumulate in the deep crypts of the tonsils and produce purulent discharge. During speaking, chewing or yawning, this appears on the surface of the tonsils in the form of purulent plugs, which are the cause of bad breath. In extreme cases, such diseased tonsils must be surgically removed. Enlargement of the tonsils alone, most commonly observed in children, can also cause bad breath because it prevents normal nasal breathing, leading to drying of the oral cavity and the consequences described above (dry mouth). The tonsils can also cause bad breath when a sharp food particle (a fish bone) becomes embedded in their soft tissue, causing inflammation, bacterial accumulation and consequently bad breath. Inflammation of the pharynx, which may be felt only as a rough, burning sensation, and inflammation of the larynx with an increased amount of anaerobic bacteria on the mucosal surface can also be accompanied by bad breath. Halitosis originating from this region deserves attention because it may be the first sign of diseases that do not resolve on their own. In cancers of the pharyngeal region, pain on swallowing and enlarged, swollen lymph nodes are relatively late signs of disease that should have been detected earlier.
Diseases of the mucosa of the nasal cavity and paranasal sinuses can cause unpleasant odor from the nose or oral cavity, which in practice is relatively difficult to distinguish; in both cases we can speak of halitosis, regardless of which cavity the odor originates from. Dried secretions of the nasal mucosa in chronic inflammation (chronic rhinosinusitis), as a consequence of surgery, radiation or deviations of the nasal septum, are common causes of the problem. The mucosa of a paranasal sinus can become inflamed because of disease of the teeth in the upper jaw, depending mainly on the anatomy of the sinus floor and the position of the affected teeth.
From the dental point of view, prevention and treatment of oral malodor actually means treating the diseases that cause it. For a long time, the problem of bad breath was understood as an "aesthetic" problem and was addressed by masking the symptom itself with products having a stronger and more pleasant smell. Given the frequency of causes (90% in the oral cavity), the first person an affected individual should speak to about the problem is the dentist. From a professional point of view, treatment therefore primarily involves professional cleaning of deposits, including scaling and root planing (periodontal treatment). Because prevention of bad breath is easier in this way, the most widespread form of therapy today uses solutions containing substances that reduce the number of bacteria in the oral cavity, which, as stated above, are the main cause of the problem. Chlorhexidine is considered the gold standard because it rapidly reduces the number of bacteria, especially anaerobic bacteria, and consequently lowers the concentration of sulfur gases that are actually the basis of the unpleasant smell. It is most commonly used as a 0.1% solution, sometimes in combination with cetylpyridinium chloride, which has an antiseptic effect. Mouthwashes usually also contain essential oils and alcohol, but their long-term use may reduce the oral cavity's own defense against bacteria. Chlorine dioxide is a somewhat less commonly used ingredient in preparations, acting as an oxidizing agent. It reduces the number of bacteria, inactivates bacterial enzymes involved in producing sulfur gases and at the same time destroys gases that have already formed. The substance is otherwise used much more commonly in the preparation of drinking water, but professionals are still not unanimous regarding the assumption that chlorine can accumulate in the body.
Given that two thirds of all bacteria remain on the tongue and their quantity depends mainly on tongue coating, removing this coating is most often the best treatment for bad breath. It is removed with special brushes and pastes for tongue cleaning, two to three times a day, as an addition to normal dental hygiene. The tongue should be brushed as far back as possible, to the most distal point, which is in fact the highest part of the tongue when it is extended from the mouth as far as possible. Many patients complain that cleaning triggers gagging. This sensation is greatly reduced with regular cleaning and by closing the eyes during cleaning.
Bad breath is caused by bacteria that obtain energy by breaking down proteins into smaller components (amino acids). During the breakdown of some of these, volatile sulfur compounds are released, causing an unpleasant odor. These bacteria live more easily without oxygen and in an alkaline environment. If they have suitable conditions for life and activity in the oral cavity and its immediate surroundings (nose, paranasal sinuses, pharynx and larynx), bad breath develops.
Bad breath is not an independent disease, but rather an indicator of another disease or disorder in the mouth or its immediate surroundings. We distinguish true halitosis originating from the mouth or nose, which can also be objectively demonstrated (devices, etc.), from false halitosis or pseudohalitosis, in which the disorder cannot be demonstrated or objectively measured. In the latter, it is also necessary to distinguish halitophobia, literally the fear of bad breath. These patients complain of bad breath that cannot be demonstrated, but they also do not accept explanations that they do not have it. The causes of bad breath are located in the oral cavity in almost 90% of cases. They most commonly involve the tongue and, to a considerably lesser extent, periodontal disease or disease of the tissues supporting the teeth. Two thirds of all microorganisms remain on the tongue, where they have the most favorable conditions for reproduction. The micro- and macro-roughness of the tongue provides bacteria, especially those living without oxygen, with additional conditions for growth. A pronounced association has been demonstrated between the amount of tongue coating (which serves as food for bacteria) and the presence of bad breath. Patients with tongue coating also have up to 25 times higher concentrations of bacteria per unit surface area. Formation of coating is additionally stimulated by smoking, stress, excessive coffee consumption, mouth breathing, one-sided chewing and insufficient fluid intake. Tongue coating consists of food debris, bacteria, remnants of epithelial and blood cells, and saliva. The amount of coating on the tongue depends largely on oral hygiene, although certain anatomical and other conditions increase the likelihood of its occurrence. A fissured tongue (lingua plicata) usually retains larger amounts of coating and therefore a greater quantity of bacteria responsible for bad breath. Abnormal elongation of the filiform papillae (tongue papillae), like deep fissures, allows a greater accumulation of bacteria and their nutrients on the surface of the tongue. The color of the tongue is most often altered, ranging from black through yellow to white. Because of the elongated papillae, such people may experience a feeling of choking. Despite the clinical picture described, the condition usually returns to normal with regular and thorough hygiene alone.Diseases of the periodontal tissues also contribute their share (10%) to bad breath. Studies have shown a close relationship between the severity of periodontal disease and the amount of sulfur compounds (which cause bad breath), as well as an association between periodontal treatment and a reduction in oral malodor.
Carious lesions account for a smaller proportion of the causes of bad breath. Caries even lowers the pH value in the oral cavity and thereby, to some extent, compensates for the alkalinity that occurs with bad breath.
Some patients who wear dentures can also develop bad breath. The cause is usually poor denture hygiene and the resulting infection of the soft tissues beneath it. Cleaning the denture and removing it from the mouth during the night is usually sufficient to improve the condition.
Fortunately, malignant diseases in the mouth are very rare, but they can nevertheless alter oral odor, which strongly supports the above-mentioned fact that halitosis is not an independent phenomenon but only a symptom whose cause may lie elsewhere and may also be potentially dangerous. Treatment of malignant diseases in the mouth or its immediate surroundings can also cause bad breath. Radiotherapy for cancers in the head and neck region, and to a lesser extent certain chemotherapies, can cause irreversible damage to the salivary glands and thus the symptom of dry mouth or xerostomia. Dry mouth, in addition to a burning tongue and other undesirable disorders, is also accompanied by bad breath. Saliva plays an important role in maintaining the balance between potentially harmful and harmless bacteria. If there is not enough of it, bacteria proliferate and, among other problems, also cause bad breath.
In addition to the diseases described, dry mouth and its consequences can also be caused by taking certain medications (for lowering blood pressure, medicines that affect heart function, medicines for Parkinson's disease) and by certain systemic diseases such as the autoimmune Sjögren's syndrome. As a rule, the disease is also accompanied by pronounced bad breath, which can be treated relatively unsuccessfully with saliva substitutes. In some patients, salivary gland activity can be increased with medication (pilocarpine, cevimeline, Evoxac), but these medicines also usually do not achieve the desired results.
Emotional stress also noticeably reduces salivary secretion, as confirmed by many studies that have shown a markedly lower amount of saliva in more than 40% of people considered to be under stress.
During meals, salivary secretion increases greatly, so bad breath after meals is substantially less pronounced than before them.
During sleep, the situation is exactly the opposite. Reduced salivary secretion leads to the well-known and unpleasant morning breath. The phenomenon is more pronounced when breathing through the nose is not possible during sleep.
As already stated, most causes of bad breath lie in the oral cavity. In approximately ten percent of cases, however, they can be found in the nose, paranasal sinuses, pharynx and larynx. Most causes can therefore be diagnosed by a dentist, and only after all of these have been excluded is the patient referred to an otorhinolaryngologist, who will continue searching for the causes. In a very small proportion of cases, the causes of bad breath are found in the esophagus or stomach, so investigations of these organs usually do not produce the desired results. Inflammation of the palatine tonsils is among the more common causes of bad breath located outside the oral cavity. The surface of this lymphatic organ is highly fissured and provides ideal conditions for bacterial colonization, causing inflammation and bad breath. Acute inflammation (tonsillitis) causes severe bad breath, which disappears spontaneously once the disease has healed. In chronic inflammation (chronic tonsillitis), large numbers of anaerobic bacteria accumulate in the deep crypts of the tonsils and produce purulent discharge. During speaking, chewing or yawning, this appears on the surface of the tonsils in the form of purulent plugs, which are the cause of bad breath. In extreme cases, such diseased tonsils must be surgically removed. Enlargement of the tonsils alone, most commonly observed in children, can also cause bad breath because it prevents normal nasal breathing, leading to drying of the oral cavity and the consequences described above (dry mouth). The tonsils can also cause bad breath when a sharp food particle (a fish bone) becomes embedded in their soft tissue, causing inflammation, bacterial accumulation and consequently bad breath. Inflammation of the pharynx, which may be felt only as a rough, burning sensation, and inflammation of the larynx with an increased amount of anaerobic bacteria on the mucosal surface can also be accompanied by bad breath. Halitosis originating from this region deserves attention because it may be the first sign of diseases that do not resolve on their own. In cancers of the pharyngeal region, pain on swallowing and enlarged, swollen lymph nodes are relatively late signs of disease that should have been detected earlier.
Diseases of the mucosa of the nasal cavity and paranasal sinuses can cause unpleasant odor from the nose or oral cavity, which in practice is relatively difficult to distinguish; in both cases we can speak of halitosis, regardless of which cavity the odor originates from. Dried secretions of the nasal mucosa in chronic inflammation (chronic rhinosinusitis), as a consequence of surgery, radiation or deviations of the nasal septum, are common causes of the problem. The mucosa of a paranasal sinus can become inflamed because of disease of the teeth in the upper jaw, depending mainly on the anatomy of the sinus floor and the position of the affected teeth.
From the dental point of view, prevention and treatment of oral malodor actually means treating the diseases that cause it. For a long time, the problem of bad breath was understood as an "aesthetic" problem and was addressed by masking the symptom itself with products having a stronger and more pleasant smell. Given the frequency of causes (90% in the oral cavity), the first person an affected individual should speak to about the problem is the dentist. From a professional point of view, treatment therefore primarily involves professional cleaning of deposits, including scaling and root planing (periodontal treatment). Because prevention of bad breath is easier in this way, the most widespread form of therapy today uses solutions containing substances that reduce the number of bacteria in the oral cavity, which, as stated above, are the main cause of the problem. Chlorhexidine is considered the gold standard because it rapidly reduces the number of bacteria, especially anaerobic bacteria, and consequently lowers the concentration of sulfur gases that are actually the basis of the unpleasant smell. It is most commonly used as a 0.1% solution, sometimes in combination with cetylpyridinium chloride, which has an antiseptic effect. Mouthwashes usually also contain essential oils and alcohol, but their long-term use may reduce the oral cavity's own defense against bacteria. Chlorine dioxide is a somewhat less commonly used ingredient in preparations, acting as an oxidizing agent. It reduces the number of bacteria, inactivates bacterial enzymes involved in producing sulfur gases and at the same time destroys gases that have already formed. The substance is otherwise used much more commonly in the preparation of drinking water, but professionals are still not unanimous regarding the assumption that chlorine can accumulate in the body.
Given that two thirds of all bacteria remain on the tongue and their quantity depends mainly on tongue coating, removing this coating is most often the best treatment for bad breath. It is removed with special brushes and pastes for tongue cleaning, two to three times a day, as an addition to normal dental hygiene. The tongue should be brushed as far back as possible, to the most distal point, which is in fact the highest part of the tongue when it is extended from the mouth as far as possible. Many patients complain that cleaning triggers gagging. This sensation is greatly reduced with regular cleaning and by closing the eyes during cleaning.