Pediatric Bad Breath (Halitosis in Children)

Bad breath, or halitosis, has been around for centuries and is even mentioned in the Talmud as a grounds for divorce. Whereas malodors emanating from the mouth are more frequent in adults, they may occur in children. In either case, the odor-causing culprits are Gram negative anaerobic oral bacteria that decompose proteins to amino acids. Further bacterial decomposition of the sulfur-containing amino acids, cysteine and methionine, generate foul-smelling sulfides, such as hydrogen sulfide, dimethyl sulfide, and methyl mercaptan (the “rotten egg odor”).

Sources of Halitosis

The most common odor-producing sites in the oral cavity include the back of the tongue, the spaces between neighboring teeth, and under the gingiva (gum line). Food particles and cellular debris accumulate in those areas.

The back of the tongue, with its convoluted surface containing groves and crevices, is an ideal trap for the accumulation of food debris, dead desquamated epithelial cells from the surface of the tongue, postnasal drip, and anaerobic bacteria. This region of the tongue is seldom properly cleansed, allowing the bacteria an opportunity to proliferate and metabolize the protein-containing materials to yield volatile sulfur-containing gases. The suggested treatment for halitosis as related to tongue-related halitosis is gentle cleaning of the surface of the back surface of the tongue with a soft-bristled brush, or with a tool designed to clean the tongue: a tongue scraper.

Postnasal drip is another potential cause of halitosis. Every day glands in the nose produce about one quart of mucus, a thick protein-containing substance whose function is to moisten the nasal passages and to trap impurities. Under normal conditions, mucus mixes with saliva and moves harmlessly down the throat. Allergies, viruses (such as influenza virus and common cold virus), and microbial sinus infections trigger the production of excess mucus, which drips down the throat. Termed postnasal drip, mucus that falls on the back of the tongue is an excellent substrate for bacterial decomposition activities and is thought to play a major role in halitosis in those children with numerous cold and sinus infections.

Bacterial decomposition activities of food debris between adjacent teeth are another source of halitosis. Toothbrush bristles alone cannot clean effectively in these tight spaces. In 2009,

the American Dental Association (ADA) stated that flossing in combination with tooth brushing can help prevent halitosis and gum disease (gingivitis). Flossing removes both the trapped food debris between adjacent teeth and the biofilm of bacteria that forms between adjacent teeth. Although these are proven facts, recent studies diminish the importance of self-flossing, as opposed to professional flossing by a dentist.

Gingivitis, common in children, may manifest as recurrent bad breath, accompanied by reddened, puffy gums that easily bleed, and, that may eventually retract from the teeth. Gingivitis can be controlled by better oral hygiene, with the child brushing twice a day. Should the condition worsen, professional dental cleaning may be required to eliminate plaque and the build-up of tartar, a hardened plaque, that form below and above the gum line and require removal by a dentist.

Another cause of childhood bad breath is related to a child’s breathing pattern (“mouth breathing” versus “nose breathing”), which affects the flow of saliva, which in turn affects the amount of oral bacteria in the mouth. Breathing through the mouth, either due to habit or because of a stuffy nose, can dry out saliva from the oral cavity. Without saliva, the anaerobic bacteria proliferate causing bad breath. Conversely, breathing through the nose creates a moist environment, allowing saliva to saturate the oral cavity. Saliva, with its antibacterial properties, destroys bacteria and serves as a natural wash for the mouth. For children with halitosis due to a dry mouth, the treatments are relatively simple. The child should drink plenty of water and chew sugar-free gum to stimulate the secretion of saliva from the salivary glands. Starting a child’s day with a nourishing breakfast is a healthy way to stimulate saliva flow and to lower the number of bacteria within the oral cavity.

Lastly, tonsils, which are natural growths of lymphoid tissue, can also be the site of halitosis. When enlarged during infection, the tonsils trap food and bacteria. In extreme instances, stones called “tonsilloliths” (hardened, calcified accumulations of debris) may emit a strong odor. If diagnosed, an ear nose and throat (ENT) physician should be consulted.

In summary, the key to prevent halitosis is children is maintaining proper oral hygiene, including tongue cleaning, tooth brushing, flossing, developing into the habit of nose(rather than of mouth) breathing, drinking ample amounts of water, and maintaining an adequate flow of saliva.



Healthy gums are usually pink in color and do not bleed during tooth brushing or flossing. Gingivitis, or inflammation of the gums, is manifested by swollen, reddened gums that easily bleed during tooth brushing or flossing. The gums may be tender and painful to touch.


Inflammation is caused by bacteria that form a sticky biofilm (plaque) along the gumline, causing the gums to become reddened and swollen. Plaque is composed of bacteria, mucus, and food debris; if not removed, it turns into a hard deposit called tartar (or calculus), that is trapped at the base of the tooth, irritating the gums. Inflamed gum tissue may separate from the neck of the tooth, forming small gaps or pockets between the teeth and the gums. Bacte- ria settle in these pockets and produce digestive enzymes and endotoxins to promote inflam- mation.


If gingivitis proceeds unchecked, the pockets open up between the gums and the teeth, ex- posing the roots of the teeth. Bacteria may occupy those spaces and cause decay in the roots of the teeth. Periodontal disease develops when bacteria in the gum pockets adversely affect the periodontium, the specialized tissue that supports and maintains the teeth. Upon further inflammation and destruction of the periodontium, the teeth can gradually become loose and fall out or need to be removed. Persistent bad breath is an indicator of periodontitis.


Regular oral hygiene, including brushing and flossing, is the best defense against gingivitis. There is some evidence that flossing in conjunction with toothbrushing reduces gingivitis to a greater extent than toothbrushing alone. Other studies showed a greater reduction in plaque and gingivitis upon using powered/electric toothbrushes as compared to manual toothbrushes.

There is evidence that toothpaste containing fluoride is effective in preventing gingivitis. Mouthwashes with antimicrobial agents, such as hydrogen peroxide, triclosan, and chlorhexi- dine digluconate, are also effective therapies against gingivitis. Mouthwashes with essential oils, such as methyl salicyclate, eucalyptol, menthol, and thymol, were approved by the American Dental Association as plaque reducers and as anti-inflammatory agents. Mouthwash- ing with warm salt water may alleviate gum swelling.

Importance of Cleanings

Professional dental cleanings are required for removal of tartar, by scaling and root planning. Scaling is the procedure in which tartar and bacteria are removed from tooth surfaces and from beneath the gumline. Root planning is a more aggressive procedure that involves instru- mentation, a laser, or an ultrasonic device. These procedures remove bacterial metabolic products causing inflammation and smoothes root surfaces.

Young children may need supervision or assistance with their brushing technique. Older chil- dren and young adults may be more susceptible to gingivitis as they often have orthodontic appliances that make it more challenging to maintain proper oral hygiene.

Early Childhood Caries (Tooth Decay)

What is Caries (Tooth Decay)?

Dental caries, commonly termed “cavities” or tooth decay, is the breakdown of teeth as a re- sult of bacterial biochemical reactions that generate acids. Dental caries is caused by bacte- ria and considered to be the most common chronic infectious disease in childhood. Specifical- ly, it is caused by the metabolic activities of bacteria on sugary foods, thereby generating acids that adversely affect the tooth enamel. Although enamel is the hardest substance in the human body, the acidic end products of the bacterial decomposition of sugars cause de- mineralization of the enamel, leading to dental caries. Newly erupted teeth with immature enamel are highly susceptible to developing caries. A baby is not born with the oral bacteria that cause cavities, but may acquire the bacteria from its mother or caregiver through sali- vary contact (e.g., by sharing utensils) or from other children in daycare (e.g., by sharing things that have made oral contact with others).

Effects of Caries

Infants or toddlers with caries have a much greater probability of subsequent caries in both the primary teeth and the permanent teeth. The ramifications of untreated cavities are many and are varied. If the child’s condition remains untreated, dental health deteriorates and is more difficult and costly to treat. Severe cavities may lead to extreme pain, discomfort, acute and chronic infections, and altered eating and sleeping habits. Because of the associat- ed pain with cavities, and lack of desire to eat, young children may be underweight. A young child with rampant early childhood cavities may weigh less than 80% of their ideal weight and grow at a slower rate than dental caries-free infants. Cavities leading to tooth loss have psy- chological, social and physical effects, including impaired speech development, absence from school, and lowered self-esteem.

Childhood Caries

As compared to permanent teeth, newly erupted baby teeth are particularly susceptible to cavities. The enamel and underlying dentin of baby teeth are thinner than permanent teeth and the progression of a cavity to the inner pulp occurs more rapidly in baby teeth. Cavities, missing teeth, and tooth restorations on toddlers and preschool age children are a particularly challenging situation.

Early childhood caries (“ECC”) is defined as one or more cavities or missing teeth, due to cav- ities in a child under age six. ECC is a multifactorial disease with a multitude of causes. Diet is an important factor, principally, the consumption of fermentable carbohydrates and the length of time of exposure of teeth to sugar. Bottle feeding and sleeping with a bottle of sweetened drink has been correlated with ECC. Although breast milk is considered the per- fect nutrient for an infant, prolonged and nocturnal breastfeeding has also been associated with ECC.

What Can Parents Do?

Parents may need to refine their feeding behaviors, such as shunning ad libitum (on demand) breastfeeding after the eruption of the first primary tooth, avoid putting a child to sleep with a bottle containing fermentable carbohydrates, (i.e., milk or juice), weaning the child from the bottle at 12 to 14 months of age, encouraging the child to drink from a training (sippy) cup, and avoiding between meal snacks. Plain water before bedtime or naps is the most ideal drink.

Fluoride, either in a tooth paste or in water, has a positive effect on reversing the process of ECC, as it promotes re-mineralization of the tooth surface, as opposed to bacterial acids which promote de-mineralization of the tooth surface.

About Canker Sores

Canker sores (aphthous stomatititis) are small, shallow ulcers characterized as non-malignant, non-contagious, and non-sexually transmitted sores within the oral cavity. Their appearance is of a round or elongated ulcer with a yellow, white, or grey floor surrounded by a reddened halo. Canker sores occur as superficial lesions within the mouth, specifically on the oral mucosa of the floor of the mouth, cheeks, and vestibule and are sometimes concentrated towards the anterior portion of the mouth.

The most common form of canker sores have a diameter of less than 10 mm, occur in multiples of 1 to 5 ulcers, and lasts for 7 to 14 days with a 3-month recurrence rate. They initially appear in childhood and adolescence, affect up to 25% of the general population, and are more common in females. These ulcers cure spontaneously and the time between ulcer recurrences is variable.

Differences From Cold Sores

Canker sores are distinct from cold sores. Cold sores, termed fever blisters and herpes virus type 1 blisters, are lesions caused by viral infection, occur as fluid-filled vesicles which are painful, highly contagious, and are often found outside the mouth. Canker sores are found inside the mouth.


The cause of canker sores is unknown, but apparently involves an immunological aspect activated by the type of white blood cell termed a cytotoxic T-cell lymphocyte (“T-cells”). An ulcer results from the destruction of the mucosa (i.e., the surface, moist lining of the inner mouth and tongue) mediated through a T-cell mediated immune response. The trigger for this response is not known yet and is considered a multifactorial. Although there is some aspect of genetic predisposition, other factors that may trigger ulcer formation include nutritional deficiencies (e.g., of vitamin B12 and folic acid), allergic reactions to certain foods (e.g., tomatoes), sensitivity to commercial chemicals (e.g., sodium lauryl sulfate present in some brands of toothpaste), emotional stress, any trauma, and abrasion by dental appliances (e.g., braces).


As these ulcers are self-limiting (i.e., the lesions will go away by themselves), treatment focuses on reducing pain, healing time, and lowering frequency of recurrence. Pain is most intense on the days immediately following the emergence of the ulcer and subsequently subsides as the healing process progresses; no scarring is evident. For most, the pain is tolerable and dietary modification may be suggested, such as the avoidance of spicy foods, citric and acidic foods and beverages. Some cases of canker sores may require the need for topical anesthetics to reduce pain and therapeutic mouthwashes to decrease the number of ulcer days. Vitamin B12 may also be helpful in treating canker sores. Some cases of canker sores may require seeing the dentist for appropriate medications and topical medicaments. Use of a dental soft tissue laser can quickly lessen the discomfort by sealing off nerve endings and can promote faster healing.