Gastroesophageal Reflux Disease and Bad Breath

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Q: I have gastroesophageal reflux disease and have been taking over-the-counter omeprazole once a day for several years. My concern is that I have bad breath. Can this odor be caused by the medication or by the acid reflux itself? I would also like to know the symptoms of acid reflux and the other potential causes of bad breath.

A: There are many potential causes of halitosis, or bad breath. While most commonly caused by poor dental hygiene and/or gum disease, bad breath can also result from gastroesophageal reflux disease. Additionally, some medications used to treat reflux can "dry" the tissues inside the mouth and indirectly lead to mouth odor. In fact, one small but limited study released in 2006 on omeprazole rasied the possibility that the category of drugs known as proton pump inhibitors could lead to an overgrowth of bacteria, and subsequently, bad breath.

Common causes of bad breath

Finding the source of your bad breath and taking measures to minimize or eliminate the odor is important for many reasons, including personal well-being and your social life. That said, the most common causes of bad breath include the following:

Insufficient brushing and flossing of the teeth
Peridontal disease caused by bacteria on the teeth that leads to the buildup of plaque
Infection of the throat or mouth
Xerostomia (dry mouth) caused by mouth breathing, certain medications, or a lack of or decreased production of saliva
Illness such as diabetes, chronic sinusitis, post-nasal drip, kidney disease, autoimmune disorders leading to dry mouth, gastroesophageal reflux disease, and others
High protein or severe calorie-restricting diets that can trigger the body into a state of "ketosis"
Smoking tobacco
Eating foods containing volatile compounds (garlic, onions) that are absorbed into the bloodstream
Poorly fitting dentures that can lead to trapped food particles and bacterial-related decay

A visit with your family dentist for a full dental and oral health examination would provide the expertise needed to diagnose and potentially eliminate the source of your problem. In the meantime, try these ideas to help minimize bad breath:

Brush your teeth at least twice per day in combination with daily flossing at the end of the day when you have finished eating and snacking.
Chew sugar-free gum containing xylitol to help increase the production of saliva and potentially decrease the growth of cavity-producing bacteria.
Avoid excess use of sugary products like soft drinks, fruit-juice drinks, and chewy candy; raisins and bananas are also culprits.
Avoid mouthwash containing alcohol as this may further dry the tissues in the mouth.
Eat foods like raw apples, celery, or carrots, which increase the production of saliva and naturally clean the teeth.

Reflux symptoms

While the cause of your mouth odor may very well be linked to gastroesophageal reflux disease, symptoms vary and are often dependent upon body type (whether you're thin or obese), social history (if you're a drinker or smoker) and personal medical concerns (such as diabetes or an autoimmune disorder). Additionally, if you eat just prior to going to bed or eat large meals instead of small ones, you might be contributing to your reflux symptoms. Food choices like chocolate, peppermint, fatty foods and caffeinated drinks can also play a role.

The following symptoms can occur with other medical conditions, including heart disease, and should be discussed with your doctor. But in general, gastroesophageal reflux disease symptoms include the following:

Heartburn or "indigestion" two or more times per week. This is often described as a burning sensation in the lower to mid-chest, and is more common after meals or when lying down.
Periods of belching, especially after eating
Difficulty in swallowing
Sour, "foul" or acid-like taste and odor in the mouth, especially after small amounts of liquid is regurgitated from the stomach, into the esophagus and sometimes, into the throat. While uncommon, this may lead to a wearing down of the tooth enamel due to the acidic nature of the reflux.
Sore throat and hoarseness
Dry cough and/or asthma like symptoms
Unexplained nausea

Putting it all together

If you have been taking gastroesophageal reflux medication for several years, it's important that you undergo a full medical evaluation. This disease may cause ulcerations and a narrowing of the esophagus, as well as a pre-cancerous condition known as Barrett's esophagus. There's also the potential that it can lead to an infection of the lungs known as aspiration pneumonia. A visit with your physician may indicate the need for specific tests such as an upper endoscopy or barium swallow radiograph.

For further information, please visit the American Dental Association and the American Academy of Family Physicians, as well as the American College of Gastroenterology.

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Robert Danoff, D.O., M.S., is a family physician and program director of The Family Practice Residency, as well as the combined Family Practice/Emergency Medicine Residency programs at Frankford Hospitals, Jefferson Health System, Philadelphia, Pa. He is the medical correspondent for CN8, The Comcast Network, a regular contributor to Discovery Health Online and a contributing writer to The New York Times Special Features. (Read his full bio.)