Related Terms

• Antibiotics, artificial saliva, bacteria, chewing gum, dental exam, dental floss, dentist, dry mouth, floss, flossing, fluoride toothpaste, mouth rinse, mouthwash, odor-causing bacteria, oral hygiene, scaling, root planning, toothbrush, toothpaste, xerostomia.

Background

• Halitosis is the medical name for bad breath. The foul odor may occur periodically or be persistent, depending on the cause.

• Some types of bad breath, including morning breath, are considered normal and are not causes for concern. This type of bad breath typically occurs because the mouth becomes dry at night, and dead cells stick to the tongue and inside of the cheeks. Bacteria eat these dead cells, and expel compounds that cause foul odors.

• There are many other potential causes of halitosis, including poor oral hygiene and certain foods, such as garlic. Bad breath may also be a sign of an underlying medical condition.

• Treatment for bad breath depends on the underlying cause. For instance, if poor oral hygiene is causing symptoms, the individual's breath will improve once he/she starts brushing and flossing the teeth regularly. In contrast, bad breath caused by chronic sinusitis may come back frequently because it stems from a structural abnormality in the sinuses.

Causes

• Poor hygiene: Individuals who do not take proper care of their mouths may develop halitosis (bad breath). This is because brushing and flossing the teeth every day removes food particles from the mouth. If these food particles are not removed each day, it promotes the growth of bacteria between the teeth, around the gums, inside the cheeks, and on the tongue. These bacteria expel compounds that cause a foul odor to develop.

• Tobacco: Smoking or chewing tobacco-based products may also cause bad breath. These products can also stain the teeth and irritate the tissues inside the mouth.

• Certain foods: All foods can lead to bad breath if the mouth is not properly cleaned each day. In addition, once food is digested and absorbed into the blood, it eventually reaches the lungs where it may cause bad breath when the person exhales. Certain foods, such as garlic or onions, are especially pungent. Brushing the teeth or using a mouthwash only temporarily eliminates the smell. The foods must completely pass through the body in order for the odor to be eliminated.

• Underlying medical problems: Bad breath can also be a sign of many different underlying medical problems. For instance, individuals who have gum disease, a condition that occurs when plaque buildup on the teeth spreads to the gums, often have bad breath. Plaque is a sticky film that contains bacteria, cholesterol, and fatty substances.

• Another common cause of bad breath is dry mouth, also called xerostomia. This occurs because there is less saliva to help remove dead cells that build up inside the mouth. When people have dry mouths, bacteria eat these dead cells and release compounds that cause foul odors. Dry mouth may occur as a side effect of various medications. It may also occur if a person has salivary gland problems or continuously breathes through the mouth.

• In addition, poorly fitting dental appliances, lung infections (such as pneumonia or bronchitis), chronic sinus infections, postnasal drip, diabetes, liver problems, kidney problems, yeast infections of the mouth (also called thrush or oral candidiasis), and gastroesophageal reflux disease (GERD), may also lead to bad breath.

Signs and Symptoms

• Halitosis (bad breath) occurs when the mouth emits a foul odor. This may occur periodically, or it may be a long-term condition, depending on the underlying cause. People are not always aware that they have bad breath because the nerve cells in the nose may become accustomed to the odor.

• Depending on the underlying cause, additional symptoms may also be present. For instance, if poor oral hygiene is causing the condition, the teeth may become coated with plaque, the gums may be pale or swollen, and tiny food particles may become trapped in between the teeth. If an infection of the mouth is causing bad breath, the gums may be swollen, red, sore, and/or bleed easily (especially after brushing or flossing).

Diagnosis

• Some types of halitosis (bad breath), such as morning breath, do not require a diagnosis because they are normal and are not causes for concern. However, if poor hygiene or an underlying medical condition is causing symptoms, a diagnosis is necessary to treat the patient.

• The healthcare professional will ask about oral hygiene and personal habits that may lead to bad breath (such as smoking). A dentist or physician may notice bad breath during a routine examination. Sometimes, the type of odor may suggest a particular cause. For instance, a urine-like smell may indicate kidney failure, while a fruity smell may indicate uncontrolled diabetes. If the patient has plaque buildup on the teeth or pale or swollen gums, gum disease may be suspected.

• In order to definitively determine the underlying cause, tests may need to be performed in addition to a physical examination. Commonly performed tests include X-rays of the chest or sinuses, blood tests, urine tests, and sputum tests.

Treatment

• General: Treatment of halitosis (bad breath) depends on the underlying cause. Patients should tell their doctors if they are taking any drugs (prescription or over-the-counter), herbs, or supplements because these agents may result in dry mouth, a common cause of bad breath. In general, it is recommended that people practice good oral hygiene, regularly visit their dentists, and drink plenty of fluids to help prevent bad breath.

• Mouthwashes: Many over-the-counter mouthwashes can help treat bad breath that is not caused by underlying medical conditions. Some mouthwashes, such as Listerine®, contain antiseptics that eliminate odor-causing bacteria inside the mouth. Mouthwashes are typically used once or twice a day before or after brushing the teeth.

• Good oral hygiene: If poor oral hygiene is causing symptoms, regularly brushing and flossing the teeth each day will help reduce symptoms of bad breath. People should also visit their dentists every six months for checkup and cleanings. Good oral hygiene will help prevent infections and gum disease from developing.

• Artificial saliva: Artificial saliva products, such as Salivart®, may be used as often as needed to reduce symptoms of dry mouth, a common cause of bad breath. These products are available as solutions, mouthwashes, sprays, and swabs. They are also available in many flavors, such as mint. Some of these products are made with calcium or fluoride to help protect the teeth.

• Toothpaste and gum: Specially designed toothpastes (such as Biotene Antibacterial Dry Mouth toothpaste®) and chewing gums (such as Biotene Dry Mouth Gum®) are available for patients with dry mouths. These toothpastes may help limit the amount of bacteria in the mouth and reduce gum irritations caused by dry mouth. Specially designed chewing gums are made with enzymes similar to those found in saliva.

• Antibiotics: If an infection is causing symptoms, antibiotic medications may be prescribed. The exact type, dose, and length of treatment depend on the type and severity of the infection. These medications kill the bacteria that are causing the infection. Once the infection is treated, symptoms of bad breath go away.

• Scaling and root planning: Patients who have gum disease that is causing halitosis may benefit from noninvasive procedures, such as scaling and root planning. During scaling, a dentist removes plaque and tartar from below the gums to the bottom of each pocket. During root planning, the roots of the teeth are smoothed in order to allow the gums to reattach to their roots. Antibiotics may also be prescribed after these procedures to prevent infections from developing.

Integrative Therapies

• Unclear or conflicting scientific evidence:

• Peppermint: Peppermint is a flowering plant that grows throughout Europe and North America. Peppermint is most often grown for its fragrant oil. Early research suggests that cleaning the mouth with an essential oil mixture of diluted tea tree, peppermint, and lemon may improve bad breath in intensive care unit patients.

• Avoid if allergic or hypersensitive to peppermint or menthol. Peppermint is generally considered safe in non-allergic adults when taken in small doses. Use cautiously with G6PD deficiency or gallbladder disease. Menthol, a component of peppermint oil, is generally considered safe in non-allergic adults. However, doses of menthol greater than 1 gram per kilogram of body weight may be deadly in humans. Avoid if pregnant or breastfeeding.

• Tea tree oil: The tea tree (Melaleuca alternifolia) is a small tree with narrow, soft, alternate leaves and yellowish flowers the shape of bottlebrushes. It is one of more than 30 species of paperbark trees that are found throughout Australia. Tea tree oil is obtained by steam distillation of its leavesand is used in mouthwash for dental and oral health. However, there is currently insufficient evidence in humans to recommend for or against the use of tea tree for bad breath.

• Avoid if allergic to tea tree oil or plants of the Myrtle (Myrtaceae) family, Balsam of Peru, or banzoin. Use cautiously with a history of eczema. Avoid taking tea tree oil by mouth because reports of toxicity have been reported. Avoid if pregnant or breastfeeding.

• Zinc: Zinc formulations have been used since ancient Egyptian times to enhance wound healing. Preliminary research suggests that chewing gum containing zinc may reduce bad breath. The mechanism of action of zinc in reduction of halitosis has not been well reported in the available literature. However, some studies suggest potential anti-bacterial properties of zinc in combination with other ingredients. Additional research is needed before a firm conclusion can be made in this area.

• Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride because studies have not evaluated its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used because studies cannot rule out the possibility of harm to the fetus.

• Traditional or theoretical uses lacking sufficient evidence:

• Arnica: Arnica is native to the meadows and mountainous regions of Europe and North America. The flowers of the plant are most often used for their medicinal benefit. Traditionally, arnica has been used to treat bad breath. However, the safety and effectiveness of this use has not been studied.

• Arnica should only be used if it is very diluted. Use cautiously if allergic to arnica, sunflowers, marigolds, or any related plants (such as daisies, ragweed, or asters). Avoid contact with open wounds or near the eyes or mouth. Use cautiously with a history of stroke. Use cautiously with diabetes drugs or if taking blood-thinners. Stop two weeks before and immediately after surgery or dental or diagnostic procedures with bleeding risks. Avoid if pregnant or breastfeeding.

• Detoxification therapy: Detoxification is a broad concept that encompasses many different modalities and substances used in cleansing the body's systems and organs. It has been suggested, but not proven, that detoxification may help treat bad breath. Until research is performed in this area, it remains unknown if this is an effective treatment.

• In cases of illness, the various forms of detoxification should be used under professional guidance. See specific monographs for precautions and warnings associated with modalities of detoxification.

• Lemongrass: Lemongrass oil is an essential oil used in deodorants, herbal teas, skin care products, fragrances, and insect repellents. It is also commonly used during aromatherapy. Theoretically, lemongrass may help treat bad breath. However, studies are lacking in this area, and a firm conclusion cannot be reached at this time.

• Avoid if allergic to lemongrass, its constituents, or any members of the Poaceae family. Use cautiously if taking diabetic or heart medications or medications that are broken down by the liver. Use cautiously with liver conditions. Avoid if pregnant or breastfeeding.

• Licorice: Licorice is harvested from the root and dried rhizomes of the low-growing shrub Glycyrrhiza glabra. It has been proposed that licorice may help treat individuals who have bad breath, but studies have not evaluated the safety or effectiveness of this therapy.

• Avoid if allergic to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid with congestive heart failure, coronary heart disease, kidney disease, liver disease, fluid retention, high blood pressure, or hormonal abnormalities. Avoid if taking diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.

• Sage: Sage has been used in Europe for centuries as a spice and a medicine. Laboratory research has evaluated the use of sage as a possible treatment for bad breath. Although this early research suggests sage has little effect on breath, additional research is needed to reach a firm conclusion.

• Avoid if allergic to sage species, their constituents, or to members of the Lamiaceae family. Use cautiously with high blood pressure. Use the essential oil or tinctures cautiously in patients with epilepsy. Avoid if pregnant or breastfeeding.

Prevention

• Regular checkups: Individuals should visit their dentists every six months for routine cleanings and checkups. During a checkup, a dentist will also look for signs of medical problems, such as gingivitis, cavities, and dry mouth. Many of these problems may lead to halitosis (bad breath).

• Practice good oral hygiene: Good oral hygiene can help prevent bad breath. It can also help prevent infections and gum disease from developing. Individuals should brush their teeth twice a day with fluoride toothpaste. The tongue should also be brushed to help remove dead cells and odor-causing bacteria. Toothbrushes should be replaced every two to three months. A floss or interdental cleaner should be used once a day to remove plaque and food particles between the teeth. Dentures should be removed at night, and thoroughly cleaned before they are placed into the mouth in the morning.

• Avoid smoking or chewing tobacco: Individuals are encouraged not to smoke or chew tobacco because it may lead to bad breath, as well as many other health problems.

• Drink plenty of fluids: Because a dry mouth may lead to bad breath, it is recommended that individuals drink plenty of fluids, especially water. In addition, chewing gum or eating hard candy also stimulates the production of saliva. However, individuals may wish to consider purchasing sugarless gum or candy because frequent consumption of sugar may have negative effects on the teeth.

• Avoid or limit foods that cause bad breath: Individuals who are concerned about bad breath may wish to limit or avoid certain foods that are known to cause bad breath. Garlic and onions are especially pungent. However, people react differently to different types of foods. Individuals may wish to consider keeping a log of the foods they eat and their symptoms. This may help people pinpoint specific foods that are contributing to bad breath.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

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6. National Dental Association (NDA). www.ndaonline.org.

7. National Institutes of Health (NIH). www.nih.gov.

8. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

9. Oklahoma Dental Association. Patient's page. Bad breath (halitosis) and your oral health-- what you should know. J Okla Dent Assoc. 2007 Jun;98(9):7. View Abstract