Bad Breath, Bad Tastes, and other Unpleasantness FAQ.

Or: It'll take more than RETSYN® this time...

The demand for products to deodorize and mask oral odors has never been greater; just witness the profusion of products on store shelves and advertisements for them in the media. While the need not to offend is a valid objective, the fact should not be lost that some odor is normal, while some may be a sign of something more significant. Below are reproduced a smattering of the many questions we receive on this topic.

Q: I often have a bad taste in my mouth and it seems to originate from the tongue. Whenever I brush it thoroughly it is okay for a short while. However, after a while or shortly after eating, my tongue seems to perhaps build up something on it. I don't often get a visible white coating, and often if I scrape my tongue, nothing will come off. It is at its worst in the morning when I wake up and late at night. In the morning I sometimes do have a residue on my tongue and have an unpleasant feeling/taste.

I maintain good dental hygiene - I brush teeth and tongue regularly and I floss. What can you recommend? I've tried various mouthwashes, but they don't seem to do anything. Particularly the ones with alcohol in. Is it possible that my saliva doesn't contain certain enzymes that normally destroy some of the bacteria on the tongue. Or could it be that my saliva just doesn't contain enough? Or perhaps there is something wrong with my tongue.

I would appreciate it if you could help me on this.

A: The source of oral malodor can be anywhere in the path of the airway, although the mouth is often the area first to garner suspicion.

One thing we have found is that a person is ill equipped to determine the presence or absence of his own bad breath. We have often encountered patients unaware of their own severe halitosis, and conversely, we have frequently encountered patients complaining of bad breath that we found to be undetectable.

The mouth is a warm, moist environment with a sufficient supply of organic nutrients to keep oral bacteria healthy, happy, and proliferating. We think that an instrument (toothbrush, dental floss, tooth pick, etc.) that is used and then thrust under the nose will always yield a detectable scent. Happily, this is not a common social activity!

What we are saying is that you may not have the problem that you think. "Morning mouth" is a common condition caused by the slowing of salivary flow during sleep. This permits the accumulation of desquamated epithelial cells, organic debris, and bacteria, which would otherwise be cleared from the mouth and swallowed. Everyone has this to an extent. Antimicrobial factors in saliva (enzymes and antibodies) are thought to be irrelevant to bad breath; it is more related to the volume of salivary flow.

You should discuss this issue with your dentist. He will be able to determine the extent of your oral malodor, and whether there is a dental basis for it. Be warned, though, that we have seen patients obsessively consult dentists, otolaryngologists, gastroenterologists, and endocrinologists in a vain attempt to find a cure for this problem which, in their case, did not exist in our opinion.

Q: For several years now, I have had small white formations appearing on my tonsils. After they have been there a few days, they eventually break free from the tonsil and I am able to spit them out. They smell absolutely foul! Can you explain what they are, why they form and any treatment available to stop them forming. I think they are referred to as "tonsilloliths"

I'm 25 and a non-smoker (if that helps).

A: Tonsils are collections of lymphoid tissue, usually located in their conventional locations (adenoids in the nasopharynx, lingual tonsils on the root of the tongue just anterior to the epiglottis, and the palatine tonsils between the anterior and posterior faucial pillars. Occasionally, tonsillar tissue occurs ectopically (in areas where they are usually not found).

Technically, the tonsils are not situated within the oral cavity, so a dentist is on shaky ground recommending treatment, but we'll tell you what we know...

The following applies to tonsils in general, but the issue is most noticeable on the palatine tonsils, since these are the only ones that are easily viewed. The tonsils are covered by the same type of tissue that lines the oropharynx and most of the mouth-- a layered epithelium that is renewed by growth of new tissue in the deeper layers and maturing as it is pushed up to the more superficial layers. The surface layers are of non-vital keratin, and continually slough, carrying with them any adherent bacteria and other organic material. Unlike other tissues, the surface contours of the tonsils are punctuated by deep pits and crypts that tend to retain and trap this exfoliated tissue, which is the mechanism by which these "tonsilloliths" develop. When the volume of this material exceeds the capacity of the crypt in which it is contained, it tends to be expelled. This material tends to have a fetid odor, since the presence of bacteria, moisture, and organic substrate provides perfect conditions for putrefaction. This material is not generally thought to contribute to oral malodor, since it is sequestered in its crypt away from the airway until it is expelled, after which it is cleared from the mouth quickly.

The only way to keep tonsilloliths from forming (that we know of) is to surgically remove the tonsils-- a rather aggressive approach, to be sure...

Q: What is that white or yellow stuff on my tongue? How do I avoid it?

A: Coatings on the tongue can come from any of a number of causes.

The surface of the tongue is studded with myriad bumps known as papillae. They come in three types: filliform, fungiform, and circumvallate. The fungiform and circumvallate contribute to taste perception; they are the larger bumps on the front or the back of the tongue respectively. The most numerous type are the small filliform papillae, which cover the majority of the dorsal (upper) surface of the tongue.

Sometimes the filliform papillae either hypertrophy (grow larger) or atrophy (grow smaller) as a result of chemical, endocrine, or microbiological factors. This will give rise to changes in the appearance of the tongue.

For instance, the habitual use of hydrogen peroxide-containing mouthrinses will cause the filliform papillae to grow, leading to a clinical condition elegantly known as "black hairy tongue."

Strep infection will sometimes take the form of scarlet fever (scarletina), which causes the filliform papillae to develop a white coating, allowing the fungiform papillae with their contrasting red color to create the characteristic "strawberry tongue" appearance.

A condition called benign migratory glossitis, also referred to as "geographic tongue", presents as islands of atrophied filliform papillae within areas of normal papillae, giving the tongue a map-like appearance.

Some people develop yeast infection (candida albicans) following administration of broad-spectrum antibiotics or if the immune system is depressed. This causes a white coating to appear on the tongue.

Sometimes the level of activity and/or salivary flow is not sufficient to remove exfoliated cells from the surface of the tongue, allowing them to accumulate and create a coating. This can sometimes be reduced by habitually brushing the tongue when you brush your teeth. Use caution to avoid gagging yourself, though!

As you can see, there are many things that match the description you present; the treatment must be tailored to your specific problem. If it persists, I'd advise a consultation with your dentist to clarify the nature of the condition.

Q: I got a bridge put in a month ago and I have this metallic taste in my mouth. I tried brushing my teeth, mouth wash--nothing seemed to work. Does any one have any advice on how to get of the metallic taste in my mouth?

A: Our patients sometimes complain of a taste with some base metal alloys used for bridges; this usually wears off within a few weeks.

The presence of a fixed bridge creates greater difficulty in proper oral hygiene, since floss cannot be introduced between the abutment teeth in the conventional way. Have your dentist or hygienist instruct you in how to use a floss threader or proxi-brush. This may help the problem. You might also ask your dentist to verify that all the excess hardened cement was properly removed from the margins of the crowns.

Q: I'm pretty attentive to matters relating to hygiene but I've become aware that I have bad breath. What can I do about it? I brush regularly and chew lots of gum. Thanks.

A: Bad breath can occur as the result of any malodorous condition within the respiratory tract, but as dentists, we realize this usually means a less than perfectly hygienic condition in the mouth. Good oral hygiene will not only include brushing regularly (the jury is out regarding gum chewing), but also regular flossing and professional cleaning. It may also involve the diagnosis and treatment of pathological conditions presently undisclosed, such as dental decay or periodontal (gum) disease, as these can contribute to oral malodor. We would also consider tobacco use as a common offender, both smoked and smokeless.

It is common knowledge that certain dietary practices will contribute to bad breath. Garlic consumption will add its distinctive bouquet both as a residue in the mouth and by distribution of its volatile constituents systemically through the bloodstream, thereby finding its way to the lungs and expired air. Coffee will create a disagreeable breath odor for some people.

Additionally, certain metabolic conditions will yield a characteristic smell: extreme hunger, uncontrolled diabetes, uremia, occult gastrointestinal bleeding all cause odor.

Even if the cause of oral odors is not certain, it is useful to remember that the mouth is warm and moist, with plenty of organic material available to putrefy. All mouths have some odor; sometimes the best that can be hoped for is to minimize it. My advice would be to get a thorough dental examination and cleaning, treat any decay or gum disease that is found, maintain scrupulous oral hygiene, and only after you've taken care of that should you look for some more exotic cause for the bad breath.

Q: How do I get rid of garlic breath?

Please help quick!

A: The only way to get rid of garlic breath is not to eat it; that's sometimes difficult to do, since it is not always obvious that what you're eating has garlic.

Sorry if this answer was not timely enough to help you out of your apparent predicament. In the future, you might insist whoever is in your company to consume a clove of garlic immediately; that person's garlic will cancel out your garlic--some kind of corollary of Newtonian physics or something like that ;-)

P.S. In some parts of the world, there are local culinary ingredients that present similar social problems; in Asia and the South Pacific, the durian fruit has a the same reputation as garlic does in Mediterranean cuisine. If you ever try a durian, you'll know what we mean!

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