Bad breath can be an embarrassing problem for children, as well as parents. Bad
breath, or halitosis, can be a symptom of various conditions including:
postnasal drip, dry mouth, dental problems, and sinusitis. Halitosis in children
is often due to the decomposition of mucus secretions and debris which
accumulate on the tongue, in the nose, and between the teeth.
Halitosis is an offensive odor which comes from the mouth, nose, or airway. It
is also defined as exhaled air containing more than 75 parts per billion of
odor-producing volatile sulfur compounds.
WHAT ARE THE SOURCES OF HALITOSIS IN CHILDREN?
Halitosis can be caused by oral sources, non-oral sources, and
The source of halitosis is the oral cavity in up to 85% of affected
individuals. The most common odor-causing sites in the mouth are: the dorsum
(back) of the tongue, the area between the teeth, and under the gum line.
The coating on the tongue usually consists of desquamated (shed)
epithelial cells, blood cells, and bacteria. It is possible for more than
100 bacteria to attach to just one oral epithelial cell. The worst oral odor
occurs when many desquamating oral epithelial cells are trapped in the
plaque and crevices on the dorsum of the tongue.
Halitosis results from the action of specific bacteria (gram-negative
anaerobes) on oral debris and dental plaque. Sulfur-containing substrates
are eagerly devoured by these bacteria. The bacterial breakdown of
methionine and cysteine molecules yields hydrogen sulfide and
methylmercaptan – both of which produce bad breath. These volatile sulfur
compounds (VSCs) have a “rotten egg” smell.
The oral conditions which predispose to the production of bad breath are:
a decrease in the flow of saliva, stagnation of saliva, a predominance of
gram-negative anaerobes, an increase in the relative amount of protein in
the diet, a reduction in the relative amount of carbohydrate in the diet, a
rise in the oral pH to a more alkaline environment, and an increase in the
number of dead or necrotic oral epithelial cells in the mouth.
ORAL SOURCES OF HALITOSIS:
Dry mouth (xerostomia):
Dry mouth is an important factor in the production of bad breath. Xerostomia
may be due to: mouth breathing, a decrease in salivary flow, sleeping,
dehydration, salivary gland disease, chemotherapy, diabetes, and certain
medications. Saliva is very important because it cleanses the teeth and
mouth, and destroys oral microorganisms.
The most common source of bad breath is the back (dorsum) of the tongue.
An abscessed tooth or dental caries can cause halitosis. In the case of
dental caries, food debris gets stuck between the teeth and can cause
putrefaction. Faulty dental restorations or poorly fitting crowns allow food
and bacteria to accumulate – producing a foul odor.
Oral fungal infection:
Children who take antibiotics for a long time may develop a Candida
infection in the mouth. Children undergoing chemotherapy, or who are
immunosuppressed, are prone to develop oral fungal infections. Such oral
yeast infections produce a characteristic sweet odor.
Gingivitis and periodontitis are the most common inflammatory diseases which
cause halitosis. The resulting foul odor is very distinct. Gram-negative
bacteria such as Veillonella, Fusobacterium nucleatum, and Porphyromonas
gingivalis hide in diseased periodontal tissues, and produce foul gases.
Oral cancer and its treatment causes tissue destruction, bleeding, and
necrosis. The resulting oral debris is an ideal substrate for the anaerobic
bacteria which produce the offensive gases.
NONORAL SOURCES OF HALITOSIS:
Bad breath can also be caused by systemic (medical) problems such as:
Liver problems, respiratory and sinus conditions, tonsils, kidney problems, Helibactor
pylori infection, diabetes mellitus, timethylaminuria, medications, and
Liver failure and cirrhosis are associated with a sulfur or “rotten egg”
smell from the mouth.
Timethylaminuria, a metabolic disorder of the liver, causes the buildup of
trimethylamine in exhaled air.
Respiratory and sinus conditions:
Postnasal drip is probably the most common cause of halitosis in children.
Secretions from a sinus infection, runny nose, or nasal allergy drip down
the back of the throat and onto the tongue. Odor-causing bacteria thrive on
these secretions, and produce volatile sulfur compounds (VSCs). VSCs are the
gases which cause bad breath.
Asthmatic children who use corticosteroids may develop bad breath due to the
development of oropharyngeal candidiasis.
Enlarged adenoids may lead to mouth breathing.
Foreign bodies in the nose and respiratory tract will produce an
inflammatory response, a discharge, and eventually a foul odor.
If a child’s tonsils have deep crypts, food and debris will accumulate in
them, producing some halitosis. Sometimes tonsilloliths form in the crypts.
These tonsilloliths are small, soft, whitish-yellow secretions which produce
a foul odor as they break up.
Kidney failure causes uremia, which produces an ammonia smell in the breath.
Helibactor pylori infection:
This gastric infection can cause inflammatory changes in the stomach.
Achalasia of the esophagus also can result in halitosis.
Uncontrolled diabetes mellitus eventually results in ketoacidosis, causing
the breath to have an acetone smell.
Antihistamines, antipsychotics, bronchodilators, antidepressants, and
antispasmodics cause dry mouth (xerostomia).
Children who have been taking antibiotics during the last month often have
halitosis which is bacterial in origin. This oral malodor is transient, and
usually disappears when antibiotic therapy has ceased.
Bad breath during menstruation may be caused by transient gingivitis.
PSYCHOLOGICAL CAUSES OF HALITOSIS:
Pseudo-halitosis occurs when bad breath does not actually exist, but the
child or parent believes it does. Some parents and patients can be convinced
that there is no malodor problem when a portable sulfide monitor (Halimeter)
proves the lack of halitosis.
If the child or parent still believes that bad breath exists after
successful treatment of genuine halitosis or pseudo-halitosis, the problem
is then diagnosed as halitaphobia. Children or parents with halitaphobia
should be referred to a psychologist for further assistance.
HOW IS HALITOSIS DIAGNOSED AND MEASURED?
Establishing a diagnosis of halitosis involves three steps:
Obtain a complete medical history, perform a thorough clinical examination
of the patient, and measure or evaluate the patient’s breath.
1) Medical history:
A complete medical history needs to be completed, including taking a
medication history. Detailed information about current and past medications
is very important. A detailed face-to-face interview with the patient and
parent is needed. A review of systems is performed. Questions that deal with
the patient’s and parent’s psychological health need to be included.
2) Clinical examination:
A physical examination is done, with special given attention to the
structures of the head and neck. A complete oral and dental examination is
mandatory, evaluating for potential periodontal disease, dry mouth, salivary
gland disease, tooth decay, poor dental restorations, orthodontic
appliances, and oral ulceration.
3) Measurement and evaluation of the breath:
The two practical methods of detecting and measuring halitosis are: sensory
(organoleptic) and instrumental.
a) The organoleptic technique is the most reliable, and is based on the
examiner’s perception of the patient’s breath. In the organoleptic
technique, the examiner smells the patient’s breath while positioned 4 to
6 inches away from the mouth. The odor level is scored on a five-point
scale. The tongue odor is measured by gently scraping the back of the tongue
with a plastic spoon and evaluating the odor on the spoon. The patient is
asked to refrain from ingesting food or drink, and to refrain from any oral
hygiene procedures two hours before the procedure. No garlic or spicy food
should be ingested within 48 hours before the evaluation procedure.
b) Instrumental measurement is performed using a portable sulfide monitoring
unit (Halimeter). This device is specific for hydrogen sulfide gas, but not
for methylmercaptan gas. A flexible straw is inserted into the partially
opened mouth, or into the nostrils, while the patient holds their breath.
The peak VSC level is measure in parts per billion. Any measurement over 75
ppb is diagnostic for halitosis.
WHAT IS THE TREATMENT FOR HALITOSIS?
The cause of halitosis is often the coating on the middle third of the
tongue. Therefore, gentle daily cleaning of the back (dorsum) of the tongue
is very important. A small, soft-bristled brush should be used to gently
clean the tongue surface.
Routine oral hygiene procedures such as brushing and flossing are very
important. Remember that children younger than 8 years of age are usually
not able to floss on their own. Mouth rinses can also be useful, but only
for children who have learned to expectorate.
When bad breath is due to dry mouth (xerostomia), treatment involves
having the child drink lots of sugar-free fluids. Sugarless gum may
stimulate salivary flow. In very severe cases, an artificial salivary
substitute such as carboxymethylcellulose may be needed.
If bad breath is due to periodontal disease, an important part of the
treatment is to improve oral hygiene at home. The dentist may need to
intervene with surgical or pharmacologic treatment.
If halitosis is due to dental disease, treatment will be needed to restore
dental caries or defective dental restorations. In case of a dental abscess,
endodontic or surgical treatment may be needed.
TIPS FOR PREVENTING HALITOSIS:
Children should brush their teeth three times a day with a soft-bristled
toothbrush. They should use dental floss every day to help reduce mouth
odor. Children younger than 8 years of age will need to have their parents
help them floss.
Children should gently brush the posterior part (dorsum) of the tongue
with a soft-bristled toothbrush every day.
Children should eat a good breakfast, as this will stimulate the flow of
saliva and reduce oral microbial levels. Eating fibrous foods is highly
Children with halitosis should rinse frequently with water, and drink
plenty of fluids to help reduce dry mouth. Chewing sugar-free gum will also
help stimulate salivary flow.
Children should always avoid alcohol-containing mouth rinses, as they dry
the oral tissues and may cause oral tissue sloughing. Remember that
mouthwashes can poison young children, and should be kept out of reach of
Children should visit their dentist and physician regularly.
An article in Contemporary Pediatrics reviews the topic of bad
breath in children. It presents some common clinical scenarios, discusses
some basic research on halitosis, reviews the main causes of bad breath in
children, presents steps for arriving at a diagnosis, and discusses