What is the cause of my bad breath?

I have bad breath.  I cannot smell it myself but my wife lets me know when it happens.  I might go 2-3 weeks with no problem and then it starts again: on one day, off the next, on next two days, ad nauseum.

It is very very rare in the morning.  Most likely to occur about 1 hour after eating.  The smell then lasts about 3-5 hours.  It seems more likely that I will have a problem if I have eaten protein (meat, dairy, eggs, etc).

Potential sources:

MOUTH: My dentist looked at me like I was crazy when I asked him about it.  I have healthy gums and no cavities.  I brush my teeth everyday, use a tongue scraper, and a chlorine dioxide rinse.  I have tried Peridex in the past to no avail.

NOSE/SINUSES: I have had bad allergies (cat, molds, dust) in the past (and suspected post nasal drip as the culprit) but through immunotherapy from my allergist and daily Singulair and Sudafed I am breathing A-OK. The drip is no longer visible on my throat.

STOMACH: My family doctor hears my story and says "GERD": That stomach contents are refluxing into my esophagus and causing the smell.  I go on Prilosec, Nexium, then Protonix with no apparent change. I have never had heartburn or other symptoms.  I do not feel spit up in my throat.  

Test for H. Pylori is negative.  Test for liver, kidney function is A-OK.  Barium Upper GI shows reflux and proper stomach emptying.  No ulcers. No hiatal hernia.

After receiving these results I have continued on Protonix and modified my diet: no soda, coffee, tea, chocolate, mint, peppermint, onions, tomato, or spicy foods (it hasn't been interesting eating).  After one week of this new diet the problem has not gone away.

MISCELLANEOUS:

- Overall, I think I belch and have more flatulence than the average individual.
- This problem is making me stressed, depressed, and reclusive.

THOUGHTS?

[Kevin Pho, MD]

You have certainly covered all the likely scenarios.  If the ENT and dental aspects have already been investigated, I would ensure that GERD is indeed not causing the symptoms.  A 24-hr pH study can be done to confirm whether GERD is present or not.  If the medications aren't controlling the symptoms and there is persistant acid reflux, you may want to investigate surgical approaches.  

Some physicians may suggest oral antibiotics if the symptoms are coming from the mouth, but this is normally effective for the short-term.  

There are several dentists that specialize in halitosis (bad breath), and you may want to inquire about a referral to them for further evaluation.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[yoshi]

flatulence is a sign food is not well digested.
animal protein is hard to digest.
how old are you??as we age ,our stomach produced less acid to digest food,taking Gerd medication also reduces the acid level .
Cranberry juice & pineapple juice raise the acid level.

[zaphod_b]

I should mention that I am 28 years old, male, 195lb. I am fairly active: walking about 1 mile a day + hiking 10 miles on weekends.  I do desk work about 40 hours a week.

[nd]

I had the same problem, not to mention with a very healty mouth. My physician and ear, nose throat specialists can't find anything wrong. Then I read about Thera Breath online and used their mouthwash. It worked! I was using Listherine and apparently that caused dry mouth which led to bad breath. And I started using listherine more often since the bad breath was persistant, and it was actually the cause for me. So my suggestion, if you haven't already tried, give a chance to Thera Breath. You can get it online or go to their website and find out where you can buy it in your state. It's around $8. Good luck.