Bad breath is a frequent or persistent unpleasant odor to the breath.
Other breath odors
Certain diseases produce substances that are detectable on the breath, but these odors are typically mild and not considered bad breath. For example,
Liver failure gives the breath a unique mousy (musty, sweet, and sometimes a faintly rotten egg-like [sulfurous] odor).
Kidney failure makes the breath smell like urine or ammonia.
Severe, uncontrolled diabetes makes the breath smell like nail polish remover (acetone).
Causes of Bad Breath
Most bad breath is caused by problems in the mouth. Causes that contribute to bad breath are listed in the table Some Causes and Features of Bad Breath.
Common causes
The most common causes of bad breath are
Odor-causing bacteria on the tongue
Certain foods and alcoholic beverages
Tobacco use
Bad breath is most often caused by the action of certain mouth bacteria on food particles in the mouth. These bacteria break down (degrade) the food particles into foul-smelling substances. These bacteria are more common among people with periodontal diseases (such as gingivitis and periodontitis) and poor oral hygiene.
Periodontal diseases inflame and destroy the structures surrounding and supporting the teeth, such as the gums and the outer layer of the tooth root, and are caused mainly by an accumulation of certain bacteria. These bacteria grow in deep pockets that surround the teeth. Such bacteria can also grow on the back of the tongue, even in people who do not have periodontal disease. These bacteria can also overgrow due to a decrease in the flow of saliva (caused by some diseases or the use of certain medications—see Dry Mouth) or a decrease in the acidity of saliva.
After digestion, odors caused by certain foods or spices, such as onions or garlic, pass from the bloodstream into the lungs. The odors are then exhaled and may be unpleasant to others. For example, the odor of garlic can be smelled on the breath by others 2 or 3 hours after it is eaten, long after it is gone from the mouth and stomach. Oral hygiene cannot remove these odors.
Bad breath is more common among people who smoke than people who do not smoke.
Less common causes
Less common causes of bad breath include
Infections in the sinuses (sinusitis) or lungs
Cancer of the nasal passages (see also Paranasal Sinus Cancer), mouth, or throat
Foreign object in the nose (typically in children)
Imagined halitosis (psychogenic halitosis)
Although people commonly think that gastrointestinal disorders cause bad breath, they rarely do because the muscular channel that connects the throat with the stomach (esophagus) is normally collapsed. Bad breath is not caused by poor digestion, nor does it indicate how a person’s digestive system or bowels are functioning. However, rarely, a pouch in the esophagus (Zenker diverticulum), present at birth in some people, can collect food particles. The food particles can decompose and create a foul odor. Gastroesophageal reflux disease (GERD) and stomach cancer also can cause bad breath.
Bad breath that is imagined is called psychogenic halitosis (pseudohalitosis). People believe that their breath smells bad when it actually does not. This problem may occur in people who tend to exaggerate normal body sensations or in people who have a serious mental disorder, such as schizophrenia. Some people with obsessive thoughts have an overwhelming sense of feeling dirty and believe that their breath smells bad.
Evaluation of Bad Breath
Bad breath rarely requires an immediate evaluation by a doctor or dentist. The following information can help people decide whether an evaluation is needed and help them know what to expect during the evaluation.
Warning signs
Certain symptoms and characteristics are cause for concern. They include
Fever
Pus-filled (purulent) sputum or discharge from the nose
Visible or touchable abnormal spots in the mouth
When to see a doctor
People who have fever or purulent sputum or nasal discharge or who may have inhaled a foreign object should see a doctor right away. People who discover an abnormal spot in their mouth should see a dentist within several days.
People with bad breath but no warning signs and who otherwise feel well should see a dentist when they are able.
What the doctor does
Dentists and doctors first ask questions about the person's symptoms and medical history. They then do a physical examination. What they find during the history and physical examination often suggests a cause of the bad breath and the tests that may need to be done (see table Some Causes and Features of Bad Breath).
The sniff test is a helpful part of the examination that can help tell whether the bad odor is coming from a nose or sinus disorder versus a mouth or lung disorder. The person exhales about 4 inches (about 10 centimeters) away from the doctor’s nose, first through the mouth with the nose pinched shut and then through the nose with the mouth closed. If the odor is worse through the mouth, the cause most likely originates in the mouth. If the odor is worse through the nose, the cause most likely originates in the nose or sinuses. If the odor is similar from both the nose and the mouth, the cause most likely originates from another part of the body or the lungs. If the examiner is unable to tell where the cause originates, the back of the tongue is scraped with a plastic spoon. After 5 seconds, the spoon is sniffed. A bad odor on the spoon shows that the likely problem is bacteria on the tongue.
Testing
The need for testing depends on what the doctor finds during the history and physical examination, particularly whether warning signs are present. Some specialists who focus on bad breath have unusual testing equipment, such as portable sulfur monitors, gas chromatography, and chemical tests for tongue scrapings. Such testing is rarely needed except for medical research.
The doctor may suggest that people whose symptoms seem to be related to ingested or inhaled substances avoid the suspected substances for a period of time to see whether the symptoms go away (trial of avoidance).
Treatment of Bad Breath
Treatment of the cause
Regular oral hygiene and dental care
Once diagnosed, any causes of bad breath are treated.
Physical causes can be removed or corrected. For example, people can stop eating garlic, onions, and other odor-producing food and stop smoking. If the cause is oral, people should see a dentist for professional cleaning and treatment of periodontal diseases and cavities. At home, people should improve their daily oral hygiene routine, including thorough flossing, toothbrushing, and brushing the top and back of the tongue with the toothbrush or a tongue scraper. Many deodorant mouthwashes and sprays are available, but these are of limited benefit. The effects of most of these products do not last more than 20 minutes. People recovering from alcohol use disorder should use alcohol-free mouthwashes.
People with psychogenic halitosis may need to have a psychiatric evaluation.
Essentials for Older Adults: Bad Breath
Older adults are more likely to take medications that cause dry mouth, which leads to difficulties with oral hygiene and hence to bad breath. Oral cancers, another cause of bad breath, also are more common with aging. Older adults are otherwise not more likely to have bad breath.
Key Points
Most bad breath is caused by the degradation of food particles by bacteria in the mouth.
Home treatment includes enhanced toothbrushing, flossing, and brushing or scraping the tongue.
The effects of mouthwashes do not last very long.
Disorders outside the mouth may cause bad breath but are often recognizable based on findings during a doctor's or dentist's examination.
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
MouthHealthy.org: Provides information on oral health, including nutrition and guidance on selecting products that carry the American Dental Association's seal of approval. There is also advice on finding a dentist and how and when to see one.
