The Medical Consumer's Advocate
Q:
I have had bad breath for
many years. Last week I finally got the courage to visit
my ENT doctor to ask for help. She looked in my ears,
down my nose and down my throat. She suspected reflux or
sinus problems. I had a CT Scan on Monday and the results
were negative. Today I will begin a medication (I do not
know name as I have not picked it up yet) to treat
reflux. I questioned the nurse about reflux saying that I
do not have heart burn or any other symptom that I
recognized goes along with reflux. I was more inclined to
believe I had bacteria in my mouth and throat from excess
proteins and mucus as I seem to always be swallowing
something. Sometimes I can taste my bad breath. The nurse
indicated that the back of my throat appeared red and
swollen and that is more aligned with the symptoms of
reflux. She also indicated that many people do not even
know they have reflux and that bad breath is a symptom of
it. After searching the internet for additional
information, I have found no link to reflux and bad
breath. Most internet sites say it is a volatile sulfur
bacteria living in the tongue and back of throat. I have
purchased hundreds of dollars of bottles of rinse
containing different amounts of Chlorine Dioxide. Nothing
works.
My questions to you are: Is bad breath a symptom is
reflux? Can you have reflux with no symptoms other than
bad breath? Are there other questions or information I
can give my ENT to help her understand this problem? Will
taking chlorophyll help with the breath odor?
Since I have "come out of the closet" on
this, I am very anxious to begin to see a resolution. I
want to get the most of my visit with my ENT. She seems
to be eager to help. Thanks for your help.
A: I have heard it said many times that bad
breath is a symptom of reflux. This sounds plausible, but I
have to be honest and say I have not yet encountered a
patient who fit this picture. The usual symptoms of reflux
are quite variable, but may include any subset of the
following: dry cough, habitual throat clearing, hoarseness,
"lump in the throat" sensation, heartburn, sour
taste in the mouth, and (sure, let's include it) bad breath.
But there are certainly a few other things which can lead
to bad breath. Tooth decay (dental caries) is one
possibility. Chronic sinusitis can certainly do it, but this
should have shown up on your CT scan (however, don't accept
the verdict that the scan is "negative" until your ENT has had a chance to examine your nose endoscopically, and
has had a chance to review the films herself. It is not all
that uncommon for a negative sinus CT to demonstrate a mild
degree of sinusitis which the radiologist missed. Like
the rest of us docs, not all radiologists are created equal).
Chronic rhinitis is another possibility, and is another
reason why your ENT should examine your nose with an
endoscope. The fact that you "always seem to be
swallowing something" is suggestive of rhinitis and/or
sinusitis, but I can think of a few uncommon possibilities
which might also generate such a sensation: something called
a Thornwaldt's cyst/abscess; or perhaps, foul drainage from
your Eustachian tubes (in which case I would have expected
you to report a history of chronic ear disease).
One unlikely, although potentially very serious,
possibility is that there may be a tumor somewhere in your
upper aerodigestive tract. Some tumors tend to die as they grow (they
outstrip their own blood supply) and the dead tissue is very foul-smelling.
In your case, I think this possibility is unlikely, since you have had this problem
for "many years." Such tumors tend to declare
themselves in a matter of months or weeks. (Also, you had
that negative CT...) But I include it in this discussion in
case other folks reading this page have had bad breath for
only a short period of time, so that they will realize how
important it is to get their butts down to an ENT. (This is
an uncommon explanation for bad breath; usually, the patient
has a great deal of other problems due to their tumor, so
that bad breath is usually the least of their worries.)
I'm afraid I don't know anything about the efficacy of
chlorophyll in the treatment of bad breath. Probably won't
hurt to try it. I do think that you are doing the right thing
in visiting an ENT. If you think tooth decay is a
possibility, you should make a trip to your dentist as well.
How can you help your ENT? Before your appointment, think
carefully about the history of your problem; think carefully
about any other symptoms you are having -- anything at all --
as these symptoms could prove to be valuable clues. Be sure
you provide your ENT with your complete medical and surgical
history.
Q: I started the medication last Thursday, and see no
difference in any reflux-type symptom or breath odor. The
medication is Prilosec (20 mg) 1 per day. How long do you
believe it will take for me to see if it is working? What
can I do in the meantime? I have tried Scope and all
that, but it only lasts about 10 minutes before the
odor/taste comes back. Also, I still cannot believe that
my breath odor is coming from that. My dentist has given
me a clean bill of health with the teeth and gums. I also
seem to have a bitter/different taste in my mouth and the
odor is worse when I talk for long periods. Well, I have
rambled enough. I am very eager to learn your response.
A: To answer your first question, it can take two or
three months, or more, for some reflux-related symptoms (such
as hoarseness) to resolve. But I have some doubts as to
whether Prilosec is the right intervention here. Prilosec
blocks acid production in the stomach. Thus, the material
which refluxes from your stomach will be less acidic, and
therefore less irritating. Prilosec does not prevent reflux,
though. If your bad breath is coming from the refluxed
stomach contents, you will probably continue to have bad
breath.
What else might cause breath odor, particularly one which
is worse when you talk for long periods? In addition to the
possibilities mentioned above, I would also consider the
diagnosis of chronic sialoadenitis: infection/inflammation of
the salivary glands. Chronic sinusitis is still a possibility.Two other possibilities are chronic
tonsillitis and ingested substances (i.e., you eat lots of
onion or garlic). Finally, I should also ask you the obvious
question-- does your breath smell bad to anyone but you? Some
people are obsessed with their breath, but on questioning, it
soon becomes apparent that the bad breath is a very
subjective observation. Hope this helps!