Halitosis is More Than Bad Breath
This article begins a series exploring the health of your intestinal tract.  Consider the  strongest contact with the world around you is through your food, processed and absorbed by your intestine. 

Halitosis, also known as oral malodor and bad breath, is a common and distressing condition in which objectionable odors are present in mouth air. Between 50% and 60% of the people in Western countries suffer from this chronic condition.  It is usually due to bacteria decomposing proteins in the mouth and the large intestine, a process called microbial putrefaction, generating malodorous gaseous sulfur compounds, which contain dihydrogen sulphide (H₂S) and methyl mercaptan (CH₃SH). These sulfur compounds are major members of a family of gases known to be offensive in very low concentrations.¹  Although most patients perceive this condition as primarily a cosmetic problem, an increasing amount of evidence shows that extremely low concentrations of many of these compounds are highly toxic to tissues. These sulfur gases, especially methyl mercaptan, play a role in causing inflammatory conditions such as periodontitis (inflammation of the tissues surrounding and supporting the teeth).²  Periodontal disease has been associated with other serious illness, including heart disease.³ These sulfur gases are also involved in inflammation of other cells lining the intestional tract causing colitis, and occasionally, a life-threatening condition, known as ulcerative colitis. ⁴

The Source of Stinking Sulfur
So what is the primary source of all of these gaseous sulfur compounds generated from decomposing proteins?  They come from our food -- and primarily foods of animal origin. Of the 20 amino acids that make up all the proteins in nature, only two contain sulfur: methionine and cysteine.  Proteins with the highest content of sulfur-containing amino acids are found in red meats, poultry, cheeses and all other animal-derived foods.  For example, based on calories, beef provides 4 times more methionine than pinto beans, eggs have 4 times more than corn, cheddar cheese has 5 times more than white potatoes, and chicken provides 7 times more than rice.⁵  If you want to drastically cut down on your sulfur intake and improve your breath odor, then the most basic step for you to take is to change your diet to one based on starches, vegetables and fruits (without garlic and onions) – and minimize your intake of animal proteins.


Classification and Causes of Halitosis
Bodily origins of breath odor are classified as being from either the mouth and nose, or other parts of the body, referred to as a systemic origin. 

Further classifications of halitosis include: genuine halitosis, sub-classified as physiologic halitosis (found in healthy people) or pathologic halitosis (the result of a disease). Physiologic halitosis may be due to food and beverage consumption, alcohol and tobacco use, unclean dentures, or from bacteria found in the mouth and other parts of the intestinal tract. Many foods can cause bad breath, especially garlic, onions, and certain spices (like curry and chili powders that contain onion and garlic).

Causes of pathologic halitosis in the mouth and nose areas are: sinusitis, gum disease (gingivitis, peridontitis), an abscessed tooth, food impaction, or a foreign body in the nose (in the case of a child).  Causes of halitosis from diseases that affect the rest of the system include: kidney failure, liver failure, bowel obstruction, diabetes, and a metabolic condition known as fish-odor syndrome (trimethylaminuria).

If halitosis does not exist but the patient believes that he or she has oral malodor, the diagnosis would be pseudo-halitosis. 

Diagnosing Halitosis
Testing for sulfur gases in the mouth using a gas chromatography is the most accurate method to make the diagnosis of halitosis.  This is a large and expensive machine found in clinical and research laboratories. There is also a portable sulfide monitor, called a Halimeter, that some dentists use in their office practice to measure the levels of sulfur compounds in a patient’s breath.  More commonly the diagnosis is made by the unsophisticated method of the doctor or dentist smelling the person’s exhaled breath.  An informal diagnosis might also be made by close friends.  However, it is difficult for a person to smell his or her own breath because we become used to our own personal odors.

Origin of the Mouth-Produced Odors
In the mouth, bacteria feeding on various substances release airborne compounds that cause bad breath.  These are primarily anaerobic bacteria, which means they prefer to live without oxygen. The greatest concentration of these bacteria is on the back part of the top of the tongue.

Another common breeding ground for these anaerobic odor-producing bacteria is in the infection and inflammation of the gums and tissues surrounding the teeth -- conditions known as gingivitis and periodontitis (pyorrhea). These diseases are usually painless but swelling, bleeding, halitosis and foul taste are common.  Pus and debris can be expressed from the pockets and the teeth may be loose.

Treatment of Mouth-Produced Odors
Because much of the malodor comes from the tongue’s surface, cleaning the tongue is more important than rinsing the mouth. The tongue coating consists of dead and dying epithelial cells, blood cells and bacteria. More than 100 bacteria may be attached to a single epithelial cell on the top of the tongue, whereas only about 25 bacteria are attached to each cell in other areas of the oral cavity.⁶  Hence, cleaning the tongue is a very effective measure for improving physiologic halitosis.⁶ An infant toothbrush or a tongue scraper works best for this purpose. 

You can buy tongue scrapers for $2 to $23.  Here are some sites where you can look for tongue scrapers:

http://toothandgum.com/

http://www.sakool.com/products.htm

http://www.orasweet.com/scraper.html

http://www.orasweet.com/scraper.html

Mouthwashes mostly cover up odor and result in a temporary solution at best.  Most products have only the manufacturer’s claim to support their efficacy. Research suggests mouthwashes containing zinc, chlorhexidine, and hydrogen peroxide are effective in reducing mouth odor. However, the side effects of chlorhexidine mouthwash include tooth stains and allergic reactions, and the oxidative activity of hydrogen peroxide might be harmful to the mouth’s soft tissues.  Therefore, a mouthwash containing zinc would be preferable.⁶ Zinc inhibits odor by attaching to and neutralizing sulfur compounds.

The most effective oral health care mouthwashes contain substances that have the ability to directly oxidize gaseous sulfur compounds to non-malodorous products.  Two such agents are chlorite anion and chlorine dioxide, and the latter is also a powerful killer of odor-producing bacteria.⁷.  Examples of this type of mouthwash are:

CloSYSII Mouthwash at $24.95 per bottle, which may be ordered at

http://www.saveyoursmile.com/products/fb/kit.html

or call (888) 309-1326, and

DioxiRinse Mouthwash at $16.95 a bottle at

http://frontierpharm.com/ushop/

or call (800) 767-3486.

Disease conditions in the mouth must also be treated to remove odors.  Leaking and broken fillings must be repaired (I recommend porcelain and plastic rather than mercury amalgams).  Periodontal disease needs to be cured with visits to the dental hygienist every 3 to 4 months, meticulous flossing and a healthy plant-based diet.  I have seen people change their pockets from 6mm to 2 mm depths in less than 4 months by using all three of these recommendations.

Morning breath is a particularly bothersome problem for most people.  This may be because the bacteria that cause the odors like to live without oxygen (anaerobic), so with the mouth closed during sleep, these bacteria thrive.  A recent study evaluated these techniques: no treatment, brushing the teeth with toothpaste, brushing the tongue, rinsing with 5 ml of 3% hydrogen peroxide, eating breakfast, or swallowing two BreathAsure capsules for morning breath.⁸ The breath air samples were analyzed for sulfur-containing gases with gas chromatography.  Brushing the teeth or ingestion of BreathAsure had no influence on the sulfur gases. Ingestion of breakfast and tongue brushing resulted in strong trends toward decreased sulfur gases. Hydrogen peroxide significantly reduced the sulfur gas concentrations for eight hours.

Large Intestine-Produced Mouth Odors:
Bad breath also comes from the putrefaction of food proteins into sulfur gases in your large intestine.⁹ These gases are absorbed through the intestinal wall into the blood stream where they circulate until they reach the lungs and are eliminated into the breath. An investigation of the “gut versus mouth” origin of odoriferous breath gases was recently performed utilizing the sulfur-containing gases of garlic to identify the source of these substances.¹⁰ Five individuals each ingested 6 grams of garlic, and sulfur gases in mouth, lung air, and urine samples were measured. They found that breath odor after garlic ingestion initially originates from the mouth and subsequently from the gut.

There is abundant evidence that gases produced by the microflora of the gut, such as hydrogen and methane, are efficiently absorbed into the blood flow that drains the intestine and are then excreted into the expired air.¹¹  Cleaning of the oral cavity would not be expected to reduce the breath concentration of gases derived from the gut.  The only way to reduce this source of sulfur gas is to decrease your intake of sulfur-containing amino acids, which means avoiding animal products and a few plant foods, like garlic and onions. (Garlic and onions do not produce the highly toxic methyl mercaptan, and would not be expected to cause tissue damage.¹⁰)

Eliminating Halitosis
Now you understand the causes of bad breath and you can remedy your situation by making changes which are free, easy, and without side-effects.

10 Steps to Fresher Breath:

1)      Change to a starch-based diet

2)      Minimize intake of animal products (high sulfur)

3)      Avoid garlic, onions and strong spices

4)      Avoid use of tobacco, coffee and alcohol

5)      Use a tongue brush or scraper daily

6)      Floss teeth at least daily

7)      Brush teeth frequently

8)      See your dentist to repair teeth

9)      See your hygienist every 3 to 6 months for a cleaning

10)  As a last resort, use a chlorine dioxide mouthwash

 References:

1. Suarez FL, Furne JK, Springfield J, Levitt MD. Morning breath odor: influence of treatments on sulfur gases. J Dent Res 2000 Oct;79(10):1773-7.

2. Ratcliff PA, Johnson PW.  The relationship between oral malodor, gingivitis, and periodontitis. A review.  J Periodontol. 1999 May;70(5):485-9.

3.  Katz J.  Inflammation, periodontitis, and coronary heart disease. Lancet 358:303, 2001.

4. Babidge W, Millard S, Roediger W.  Sulfides impair short chain fatty acid beta-oxidation at acyl-CoA dehydrogenase level in colonocytes: implications for ulcerative colitis. Mol Cell Biochem. 1998 Apr;181(1-2):117-24.

5.  Bowes & Church’s, Food Values of Portions Commonly Used. 17^th edition / revised by Jean A. T. Pennington.

6. Yaegaki K, Coil JM. Examination, classification, and treatment of halitosis; clinical perspectives. J Can Dent Assoc 2000; 66:257-61.

7.  Silwood CJ, Grootveld MC, Lynch E.  A multifactorial investigation of the ability of oral health care products (OHCPs) to alleviate oral malodour. J Clin Periodontol 2001 Jul; 28(7):634-41.

8. Suarez FL, Furne JK, Springfield J, Levitt MD.  Morning breath odor: influence of treatments on sulfur gases. J Dent Res 2000 Oct; 79(10):1773-7.

9. Cummings JH.  Fermentation in the human large intestine: evidence and implications for health.  Lancet 1:1206, 1983.

10. Suarez F, Springfield J, Furne J, Levitt M.  Differentiation of mouth versus gut as site of origin of odoriferous breath gases after garlic ingestion. Am J Physiol. 1999 Feb;276(2 Pt 1):G425-30.

11.  Human Colonic Bacteria: Role in Nutrition, Physiology, and Disease, edited by G. R. Gibson, and G. T. Macfarlane. Boca Raton, FL: CRC, 1995, p. 131-154.