Persistent Bad Breath: Exploring Gastrointestinal and ENT Issues

Foul-smelling breath?

Since October, I have been experiencing a foul odor in my breath that seems normal to me, although I can occasionally smell it (it's not pungent).
Every time I take the subway three times, people around me start to react to the smell (coughing, covering their mouths with masks).
In the elevator and on the subway, others can smell it as well.
I visited an ENT clinic three times, and they diagnosed me with pharyngitis, prescribing anti-inflammatory and antihistamine medications.
However, even after the inflammation resolved, the odor persisted.

I then went to another ENT clinic where they used an endoscope and noted mild rhinitis, prescribing medication, but the smell remained.
A week later, I visited a large hospital where they also performed an endoscopy.
The doctor stated there was no rhinitis, but there was slight gastric reflux, and they prescribed medication for that.

Later, I went to a hepatobiliary and gastroenterology clinic twice, where they prescribed medications for intestinal regulation and gastric health, but the odor still persisted.
In between visits to the ENT and gastroenterology specialists, I saw a dentist, had two wisdom teeth extracted, and underwent root canal treatment, yet the smell continued.

I maintain good oral hygiene, brushing my teeth, using dental floss, rinsing my mouth, and scraping my tongue.
I usually sleep between 10-11 PM, have healthy bowel movements daily, drink about 2500 ml of water, exercise for 40 minutes, and take vitamins C, D, B, CoQ10, and yogurt.
After meals, my intestines sometimes make noise, but recently I've been more mindful of my diet, and it only happens occasionally.
My stomach has been feeling bloated lately, and sometimes it also makes noise.
I occasionally experience mild pain in the lower right abdomen for about 10 seconds, and in the past month, I have had occasional tightness in my eyes and temples.
I generally eat quite healthily, focusing on whole foods, and have avoided coffee and spicy foods for a month and a half (only consuming mildly spicy foods).
I eat cookies once a week.
Should I test for Helicobacter pylori? Should I go to the gastroenterology department of a large hospital? Would a full-body checkup be helpful, or should I consider seeing a traditional Chinese medicine practitioner? Could you please advise me on the order of steps to take? Thank you.

peggy, 30~39 year old female. Ask Date: 2022/11/14

Dr. Chen Shidian reply Gastroenterology and Hepatology

Halitosis is primarily caused by dental issues.
Additionally, one can opt for self-paid testing for Helicobacter pylori and undergo eradication therapy.

Reply Date: 2022/11/14

More Info

Persistent bad breath, or halitosis, can be a distressing condition that often has underlying gastrointestinal or ENT (ear, nose, and throat) issues. Based on your description, it seems you have already consulted multiple specialists, including ENT doctors and gastroenterologists, but the problem persists. Let's explore potential causes and the steps you can take to address this issue.

Possible Causes of Persistent Bad Breath
1. Oral Hygiene Issues: Even with regular brushing, flossing, and tongue scraping, some individuals may still experience bad breath due to bacteria that thrive in the mouth, especially if there are areas that are difficult to clean. Dental issues such as gum disease or cavities can also contribute to halitosis.

2. Gastrointestinal Problems: Conditions like gastroesophageal reflux disease (GERD) can lead to the backflow of stomach contents into the esophagus, which may cause a sour or foul odor in the mouth. Additionally, issues such as gastritis or peptic ulcers can also produce unpleasant breath.

3. Sinus and Nasal Issues: Chronic sinusitis or nasal polyps can lead to post-nasal drip, which may cause bad breath. Even if your ENT specialists have ruled out significant nasal issues, mild inflammation or allergies could still contribute to the problem.

4. Dietary Factors: Certain foods, particularly those high in sulfur (like garlic and onions), can lead to temporary bad breath. However, if your diet is healthy and you are avoiding these foods, this may not be the primary cause.

5. Systemic Conditions: Conditions such as diabetes, liver disease, or kidney problems can also manifest as bad breath. If your liver or kidney function is compromised, it could lead to a buildup of toxins that may be exhaled.

Recommended Steps to Address the Issue
1. Consult a Gastroenterologist: Since you have already seen ENT specialists, it may be beneficial to revisit a gastroenterologist. Request tests for conditions like H. pylori infection, which can cause gastritis and contribute to bad breath. A comprehensive evaluation, including an endoscopy if necessary, may provide insights into any underlying gastrointestinal issues.

2. Full Body Check-Up: A general health check-up can help rule out systemic conditions that might be contributing to your symptoms. Blood tests to check liver and kidney function, as well as glucose levels, could be informative.

3. Consider a Dental Evaluation: Since you have had dental work done, ensure that there are no residual issues. A thorough examination by a dentist, including checking for gum disease or other oral health issues, is crucial.

4. Explore Dietary Adjustments: While you mentioned eating a healthy diet, consider keeping a food diary to identify any potential triggers. Sometimes, food intolerances or sensitivities can lead to gastrointestinal symptoms that manifest as bad breath.

5. Hydration and Saliva Production: Ensure you are adequately hydrated, as dry mouth can exacerbate bad breath. If you notice a decrease in saliva production, consider discussing this with your healthcare provider, as it can be a side effect of certain medications or conditions.

6. Alternative Medicine: If conventional treatments do not yield results, you might explore traditional Chinese medicine (TCM) or other holistic approaches. Acupuncture and herbal remedies may help balance your body’s systems.

7. Follow-Up: Keep a log of your symptoms, dietary habits, and any changes you notice after implementing these suggestions. This information can be invaluable for your healthcare providers in diagnosing and treating your condition.

Conclusion
Persistent bad breath can be multifactorial, involving oral hygiene, gastrointestinal health, and systemic conditions. Given your proactive approach in seeking medical advice, it is essential to continue this journey by consulting the right specialists and considering a comprehensive evaluation. By addressing potential gastrointestinal issues, ensuring optimal oral health, and exploring dietary factors, you can work towards alleviating this distressing symptom.

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