Bad breath

and Sabine Schrör, medical journalist and Martina Feichter, medical editor and biologist

Hanna Rutkowski is a freelance writer for the medical team.

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Sabine Schrör is a freelance writer for the medical team. She studied business administration and public relations in Cologne. As a freelance editor, she has been at home in a wide variety of industries for more than 15 years. Health is one of her favorite subjects.

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Martina Feichter studied biology with an elective subject pharmacy in Innsbruck and also immersed herself in the world of medicinal plants. From there it was not far to other medical topics that still captivate her to this day. She trained as a journalist at the Axel Springer Academy in Hamburg and has been working for since 2007 - first as an editor and since 2012 as a freelance writer.

More about the experts All content is checked by medical journalists.

Bad breath (med .: halitosis, foetor ex ore) rarely indicates a serious health problem, but it is extremely unpleasant for those affected. Often other people avoid their proximity, which can lead to social isolation. Initially incomprehensible for many of those affected, as they themselves often do not even notice the bad smell. Bad breath is usually caused by inadequate oral hygiene. Then the bacteria that are responsible for the bad breath multiply. Read here how bad breath develops, what causes it and what you can do about it.

Brief overview

Description: Unpleasant smelling odor of the exhaled air
Causes: Usually inadequate oral hygiene and its various consequences (food residue between the teeth, plaque, plaque on the tongue, tooth decay, inflammation of the gums, periodontal disease, etc.). Other causes are, for example, reduced salivation (e.g. when snoring, fasting or in old age), inflammation of the oral mucosa and tonsils, nasal polyps, chronic sinusitis, heartburn or reflux disease, esophageal diseases, bronchitis, pneumonia, tumors in the mouth or throat, diabetes that has not been set (diabetic coma), hormone fluctuations (in women), kidney failure, poisoning, medication.
When to the doctor If the bad breath persists for a long time and cannot be eliminated by brushing your teeth thoroughly or rinsing your mouth.
Tips: e.g. brush your teeth thoroughly and regularly, scrape your tongue, have dental problems (bad fillings, tooth decay, etc.) treated by the dentist, chew coffee beans (if you have bad breath from your stomach), chew anise or fennel seeds, chew parsley (if you smell garlic), lemon juice (with reduced salivation).

Bad breath: description

Breath from the oral cavity that smells unpleasant is commonly referred to as bad breath. It is seldom caused by serious causes. In return, social problems are often associated with it. Because those afflicted with bad breath usually have no idea that they are forcing their fellow human beings to distance themselves as soon as they literally open their mouths. In addition, many do not dare to speak to those affected about their bad breath. Most of the causes can be eliminated quickly.

Bad breath is not just bad breath

Strictly speaking, a distinction is made in medicine between halitosis and foetor ex ore.

Foetor ex ore is the bad smell when you exhale, which is therefore only noticeable when speaking or with your mouth open. The cause of bad breath lies in adjacent areas such as the oral cavity or tonsils.
Halitosis differs in that the foul smell can also be smelled when exhaling through the nose. Only about ten percent of all those affected suffer from this form. The causes are not only to be found in the oral cavity, but especially in the nasopharynx.

Development of bad breath

Foetor is mainly caused by bacteria. And there are many of them in our mouth - around 800 to 1000 different types of bacteria are at home there. Food components and cell residues offer them optimal living conditions. As so-called plaque, the microorganisms sit noticeably on the tooth surfaces, where they usually fall victim to the toothbrush. They thrive particularly well in places that are easily overlooked during daily oral care: the spaces between the teeth and especially the tongue with its large, deep surface offer the bacteria perfect refuge.

Some types of bacteria release volatile sulfur compounds, fatty acids and polyamines when they digest food. These substances cause bad breath. The volatile sulfur compounds in particular are odor-active. They are produced by microorganisms that are more common in diseases of the oral cavity such as periodontal disease. Diseases of the tooth supporting system are therefore often accompanied by unpleasant halitosis.

Our saliva works against bad breath. It washes around the teeth and loosens food residues along with bacteria, fungal spores and viruses, which are then swallowed. In addition, the saliva contains antibacterial substances and thus protects the tooth enamel.

Too little saliva explains the typical bad breath after waking up in the morning. When we sleep, we produce less saliva and swallow less. Strict diets and snoring also dry out the mouth and make it easier for bacteria to grow.

Frequency of bad breath

Many people avoid foods containing onions and garlic because they cause strong bad breath that can last up to 72 hours. But the bad breath after eating certain foods is usually only temporary.

It is different with permanent bad breath. It is estimated that around 25 percent of the population suffer from it. With increasing age, the number of those affected increases again. The reason for this lies in the teeth: many older people have restored teeth or wear dentures. Both offer the bacteria a larger target area. Every second person over 60 suffers from bad breath.

Imaginary bad breath

A quarter of all patients who are convinced that they suffer from bad breath cannot be detected. This mostly psychological phenomenon is called pseudohalitosis or halitophobia.

Bad breath: causes and triggers

Around 95 percent of all causes of bad breath are local in the mouth or throat and are the result of inadequate oral hygiene:

Foetor ex ore: causes

Dental plaque: Bacteria that can cause bad breath accumulate in hard-to-reach places or in the spaces between the teeth.
Tongue coating: Most bacteria live on the tongue. Cleansing them is a good cure for bad breath.
Bad denture cleaning: Removable dentures should also be cleaned thoroughly every day to prevent bad smells.
Food and luxury foods: onions, garlic, alcohol, smoking and coffee cause bad breath.
Food residues in the mouth: Often undetected and small, food residues can get caught between the teeth or even on the tonsils or in the throat and lead to bad breath.
Reduced salivation: Snoring, breathing with your mouth open, but also with increasing age or when fasting, the mouth dries out. Salivary gland diseases such as Sjogren's syndrome also reduce saliva production. In addition to an uncomfortably dry mouth and problems eating or speaking, bad breath often occurs.
Oral mucosal inflammation: Especially in children, a herpes infection occasionally spreads into the oral cavity and causes what is known as gingivostomatitis herpetic (oral rot).
Changes in the oral mucous membrane: Sexually transmitted diseases such as syphilis also show up through wounds in the oral mucous membrane, which are ideal sites for bacteria to adhere to.
Tonsillitis: Especially with chronic tonsillitis, deposits form that cause an unpleasant odor.
Tumors in the mouth and throat (squamous cell carcinoma) can also cause bad breath.
Fungal infection: An infection with Candida albicans leads to coverings with bad breath.
Caries (tooth decay): Holes in the teeth and in the tooth enamel offer bacteria ideal places to nestle. The bad breath usually occurs again and again, even a few hours after brushing your teeth.
Gingivitis: A slight inflammation of the gums can be reversed with regular oral hygiene.
Periodontitis: Due to predisposition, negligent brushing of teeth or diseases such as diabetes, the teeth supporting structures can become inflamed. Then bacteria collect in the enlarged gingival pockets, which can cause bad breath.
Abscesses and fistulas: Teeth with inflamed root canals often cause pain and accumulations of pus, which in turn can lead to bad breath.

Halitosis

If the breath from the nose also smells unpleasant, the cause of bad breath is often in the sinuses or in the throat. Sometimes the cause is serious physical illness (systemic disease). Common causes include:

Diets and fasts
Nasal polyps
Foreign bodies in the nose - this should be borne in mind, especially with small children
chronic sinus infection
chronic runny nose, for example as a result of nose operations, frequent drug use or radiation treatment of cancers of the face
Tumors in the nasopharynx
Respiratory diseases: bronchitis, pneumonia, bronchiectasis (sac-shaped expansions of the bronchi), lung abscess
Poisoning: With phosphorus or selenium the breath smells like garlic, with hydrogen cyanide like bitter almond.
Medicines: Certain medicinal substances promote the colonization of the oral mucosa with fungi or bacteria or dry out the mouth.

Bad breath comes from the stomach much less often than previously thought:

Heartburn, reflux disease: a sour halitosis is more typical here.
Esophageal diseases: In the rare Zenker's diverticulum (protrusion of the esophageal mucous membrane), leftover food can spread a strong bad breath. Such complaints are also possible due to tumors, inflammation and movement disorders of the esophagus (achalasia).

Systemic diseases are a rare cause of bad breath:

Cirrhosis of the liver
Kidney failure
Uncontrolled diabetes mellitus: diabetic coma with breath that smells like acetone (smell of rotting fruit)
acute rheumatic fever

In women, the hormones can also affect the breath - for example during menstruation, pregnancy or menopause.

What helps against bad breath?

Prevent instead of fighting: Don't let bad breath develop in the first place - daily brushing of your teeth removes leftover food and odor-active bacteria.
Off to the dentist: Most of the time, superficial causes in the area of the teeth are the basis of the bad breath. Caries, old fillings, leaky crowns or bridges are ideal breeding grounds for bacteria. Since these areas cannot be reached with a toothbrush, the bad breath persists, but it can be remedied with new restorations.
Tongue scraping: Deep folds in the tongue are the mouth's reservoir of bacteria. Special tongue scrapers gently remove the tongue coating. Brushing the tongue with an ordinary toothbrush also gives good results.
Chewing coffee beans: If you have bad breath caused by the stomach, chewing coffee beans can help.
Nature between the teeth: chewing anise or fennel seeds also cleanses the breath. Fresh parsley is said to help against the smell of garlic.
Lemon against dry mouth: If you suffer from dry mouth and bad breath due to reduced salivation, lemon juice stimulates the salivary glands in most cases.
Mouthwash: Especially antibacterial mouthwashes with chlorhexidine can prevent the growth of microorganisms and briefly freshen the breath. But even simple sage tea has a disinfectant effect as a mouth rinse and is a tried and tested home remedy for bad breath.

Caution: Mints and chewing gum containing sugar are not suitable for bad breath! Rather, the carbohydrates they contain promote bacterial growth and thus the development of bad breath.

Bad breath: when do you need to see a doctor?

Bad breath has mostly harmless causes that can be eliminated with thorough oral care. However, if your symptoms persist over a longer period of time and cannot be controlled by brushing your teeth or rinsing your mouth, you should see your doctor or dentist.

Bad breath: what does the doctor do?

The family doctor or dentist will first examine the mouth and throat. Usually the cause of halitosis or foetor ex ore can be found here - whether inflamed tonsils, a runny nose with a sinus infection or diseases of the teeth or gums.

The doctor's most important tool is his nose. He can assess the intensity of the smell at different distances. In addition, various smells indicate possible diseases: For example, the breath smells slightly like urine in the case of kidney failure, purulent infections are also unmistakable. Technical methods such as sulfur detectors are rarely used, but can convince doubting pseudohalitosis patients.

A detailed physical examination should not be missing in order to rule out diseases of the kidney, liver, stomach or metabolism (e.g. diabetes mellitus) as the cause of the bad breath. For this it may be necessary to involve doctors from other specialties.

Treatment of bad breath

If the cause is in the mouth, the fetus can be eliminated with simple means:

Professional teeth cleaning removes plaque in places that are difficult to reach yourself.
The removal of tooth decay, damaged fillings, crowns or bridges eliminates nesting sites for further bacteria.
Diseases of the periodontium or gums may have to be treated with antibiotics.

For all other causes of bad breath, the doctor will also suggest a suitable therapy. For example, surgical removal of nasal polyps can be useful.

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