The exam room door was wide open, which was a little unusual, since most patients prefer a little privacy when they come to the doctor's office. I walked in to see my young patient seated at attention in her chair while her mother kept her distance on the room's second seat. "She's got really bad breath," the mom explained apologetically, "so we kept the door open to get a little fresh air."
The 10-year-old, who had a long history of sinus infections, had been congested for more than two weeks, and now presented with thick nasal discharge and obvious mouth breathing. Despite a valiant attempt at good oral hygiene, mom reported that her child's breath was almost unbearable. After examining the girl, I diagnosed her with sinusitis and sent her home with a prescription for a course of antibiotics. I told the mother that, after completing therapy, her daughter's sweet-smelling breath was sure to return.
In their Contemporary Pediatrics article, Mel Rosenberg, Gary Robinson and Erica Amir report that while bad breath can be found in kids with systemic illnesses, the majority of pediatric oral malodor, or halitosis, is due to problems arising from the mouth, nose and throat.
Postnasal drip from sinusitis or allergies leads the list of bad-breath culprits. Tooth and gum issues such as dental plaque, severe dental decay, gingivitis and trapped food particles can also result in noticeable halitosis. In addition, mouth breathing, resulting from blocked nasal passages or enlarged adenoid tissue, can lead to pediatric bad breath.
Rosenberg and colleagues find that the nasal area follows the mouth as a common source of halitosis. Nasal causes of bad breath are easy to distinguish from oral causes, as the smell has a characteristic "cheesy" odor, and can actually be detected coming out of the nose, instead of the mouth. Foreign bodies in the nose (yes, little kids put things in there, too!), nasal polyps, and anatomic disorders such as cleft palate are all predisposing factors for malodor.
Bad breath can be blamed on a variety of other conditions including tonsillitis, inadequate fluid intake resulting in dry mouth, cigarette smoking - surprisingly, in secondhand exposure as well as in direct use of tobacco - and serious systemic diseases such as untreated diabetes. The three pediatric authors note that, despite coming under frequent suspicion, the gastrointestinal tract rarely is the source of halitosis.
The American Dental Association encourages careful attention to oral hygiene to eliminate the pesky intraoral bacteria that produce the "volatile odoriferous molecules" thought to cause the majority of halitosis. Bacterial deposits on the tongue act as the primary source of oral malodor. The ADA finds that while tooth brushing reduces bad breath measurements by 30 percent, tongue brushing drops the indicators by an impressive 70 percent.
Daily flossing and visits to the dental hygienist and dentist for professional cleanings and checkups every six months also help keep a child's mouth clean and fresh smelling. Keep in mind that you should continue to assist your younger children in their oral hygiene routine, as kids under 8 years of age generally need adult supervision for effective flossing and brushing.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.