I am treating a patient for persistent bad breath. GI workup, including Helicobacter pylori testing and esophagogastroduodenoscopy, is negative. A dental evaluation was normal. His father also has bad breath. Is this condition hereditary? Where do I go from here?
—Helen Song, RNP, Woodland Hills, Calif.

As noted, even a methodical exploration of sinuses, teeth, gums, tonsils, and GI system may not reveal the cause of bad breath. There is no evidence that bad breath is hereditary. Current science suggests that most halitosis is a result of anaerobic bacteria deeply embedded in the surface of the tongue. Volatile sulfur-compound gas produced by bacterial metabolism produces the offensive odors. Many home dental devices now emphasize tongue hygiene. Scraping and brushing are the most common methods. Another recommendation is to make the anaerobic environment more aerobic by increasing the oxygen. A gargle of 1.5% hydrogen peroxide is useful for this. OTC hydrogen peroxide, which is usually 3% concentration, can be diluted with an equal volume of water.
—Sherril Sego, MSN, FNP (99-1)

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