Fear of Bad Breath

That is a fourteen-fold range in a figure that decides whether somebody needs a dentist or a conversation, and it is the central fact of this entry. Halitophobia is what the upper end of that estimate is made of, and nobody knows where in the range the truth sits.

Why the line is so hard to draw

Bad breath is judged by other people, and the judgement is not something a person can make about themselves reliably. Someone convinced they have it cannot verify the belief, and reassurance is exactly what the belief predicts other people would offer.

The complaint also arrives in a setting that takes it seriously. Concern about bad breath is the third most common reason people seek dental care, after tooth decay and gum disease, and people in the United States spend more than a billion dollars a year on mouthwash. A person presenting with a complaint that has an entire retail category behind it is not obviously behaving unusually.

What genuine halitosis actually is

Between eighty-five and ninety per cent of genuine cases originate inside the mouth, and the specific location is the back of the tongue.

The posterior dorsum of the tongue is dry, poorly cleansed and convolutedly structured, which makes it an ideal habitat for anaerobic bacteria under a continually forming coating of food debris, dead epithelial cells, postnasal drip and bacteria both living and dead. Tongue bacteria account for eighty to ninety per cent of all mouth-related cases.

The odours are produced by breaking proteins into amino acids and certain amino acids further into detectable gases: the putrescent smell of indole, skatole and polyamines, or the rotten-egg smell of volatile sulfur compounds including hydrogen sulfide, methyl mercaptan and dimethyl sulfide.

A visible white coating on the tongue is not the same thing as the bacteria, which are invisible, and degrees of white coating are present in most people with and without halitosis.

The remaining genuine cases come from the nose, sinuses, throat, lungs, oesophagus or stomach, and rarely from a serious underlying condition such as liver failure or ketoacidosis.

Why the halitosis figures make the worry plausible

Estimated rates of bad breath in the population run from six to fifty per cent, and chronic bad breath is said to affect around twenty-five per cent to varying degrees. Intensity varies through the day with food, smoking and alcohol, and is usually worst on waking because the mouth has been inactive and low in oxygen overnight.

Someone worried about their breath is worried about something that fluctuates, that most people have to some degree at some point, that they cannot smell on themselves, and that is treated as a social taboo carrying stigma, the same ground the fear of body odour grows in. Every condition for a self-sustaining worry is present before any pathology is involved.

What the association with other conditions shows

Bad breath is associated with anxiety among those affected, and also with depression and with symptoms of obsessive-compulsive disorder.

The direction is not established in the material, and both readings are plausible. A person with a genuine and stigmatised symptom may become anxious and low. A person with obsessive-compulsive symptoms, or with social anxiety, may fix on breath as the object. Where the complaint is non-genuine, the second reading is the one that fits.

Why treatment splits genuine from non-genuine halitosis

Initial efforts for genuine cases are three, none of them decisive:

• tongue cleaning
• mouthwash
• flossing

The evidence behind them is tentative, with tentative evidence supporting mouthwash containing chlorhexidine or cetylpyridinium chloride, and evidence for tongue cleaners insufficient to draw clear conclusions. Treating gum disease, tooth decay, tonsil stones or reflux may help.

And then one sentence that belongs to this entry rather than to dentistry:

Counselling may be useful for those who falsely believe that they have bad breath.

That is the whole of the clinical guidance on halitophobia in the material. A condition estimated to account for anywhere between a twentieth and seven tenths of all complaints receives a single clause about counselling, with no instrument, no prevalence figure of its own and no study named.