Ask Dr James: My partner of 20 years has terrible breath. Help

Dear Dr James,

“For the 20 years we have been together my partner has always had terrible bad breath. Her dentist says her teeth, though a bit discoloured, are sound. But despite flossing twice a day and brushing after every meal, within an hour the smell is as pungent as ever. I suspect the malodour may be emanating from elsewhere – but what might account for it and is there anything that can be done?”

Dear reader,

Bad breath (or halitosis) is an ancient affliction whose adverse social consequences have been remarked on, variously, by the Roman poet Ovid (“those with strong breath don’t talk when you’re fasting and always keep your mouth a distance from your lover”); Jane Austen, who complained of her neighbours in a letter to her sister Cassandra (“I was as civil to them as their bad breath would allow”); and the philosopher Bertrand Russell, whose affair with Lady Ottoline Morrell, he acknowledged, was vitiated by his “offensive breath.”

The obvious culprit, then as now, would be the putrefaction of food debris by bacteria in the mouth resulting in caries and gum disease – the implication being it is the sufferer’s fault for failing to pay sufficient attention to their dental hygiene. But this is certainly not the whole story: those self-conscious about their bad breath are probably, as here, more assiduous teeth brushers than most – but are still unable to eradicate the antisocial odour. Nonetheless, bad breath is usually due to the presence of bacteria – and the volatile sulphur compounds they produce- though it can be difficult to locate where they are hanging out. The following possibilities should be considered.

Dental restoration

Bacteria can lurk in an amalgam-restored tooth as tellingly illustrated in the account by a London dentist of a patient whose odour persisted despite the usual measures. He re-attended when the cusp of an upper molar (that had an amalgam restoration) fractured, since the odour had vanished. “I suspect it was due to bacteria colonising a crack under the restoration”, he writes.

The tongue

The large pitted surface of the back of the tongue can retain large numbers of loose cells and microorganisms – the most likely source of malodour in those with otherwise good oral hygiene. This is most readily countered by an antiseptic mouthwash such as chlorohexidine or gently cleaning the tongue with a soft toothbrush or scraper.

The nose and sinuses

The postnasal drip of secretions from chronic infection of sinuses can taint the breath while in children the possibility of some foreign body stuffed up the nostril should be suspected. “My three-year-old granddaughter suffered from bad breath for almost a year” a reader reports. Having read an article on the subject she suggested to her daughter in law she take her to Casualty where a piece of folded cardboard was extracted from her left nostril. “The smell promptly disappeared and we are all greatly relieved”.

Gut infection

The intense acidity of the stomach destroys 99% of bacteria within a few seconds making it an unlikely source of bad breath, the exception being the bacterium helicobacter – implicated as a cause of gastritis and peptic ulcer – and readily diagnosed by a simple breath or stool test. Several reports follow the standard course of antibiotics to eliminate helicobacter, patients find their breath smells sweeter.

Threadworms 

Threadworms in children most commonly result in loss of appetite and itchiness around the anus. They may also however be a hidden cause of halitosis, curable with a single dose of the anti-parasitic drug Mebendazole.

Late onset halitosis

Very importantly, halitosis that develops for the first time in those who are 60 or over can be a potentially sinister early sign of malignancy in the mouth, sinuses or elsewhere. It warrants thorough investigation to identify its source.

Email queries and comments in confidence to Drjames@telegraph.co.uk