Robert’s breath had become his worst nightmare and as a consequence he knew was starting to isolate himself socially. For three years, he’d tried every over-the-counter remedy. When he walked, Tic Tacs rattled in several pockets.
Robert had seen specialists, had his teeth cleaned every three months, and followed a twice-daily oral regimen that included flossing, brushing, and jet-streaming his gums. The finale was a vicious tongue-scraping that left his taste buds raw and aching. He’d then blast whatever was left with undiluted mouthwash.
Robert had tried everything.
“The tongue-scraping is especially horrible,” he told me. “I can actually smell that sewer odor coming from that guck I scrape off.”
One doctor said it was all in his mind, that he should see a good psychiatrist because his breath might be a symbol of some deeper issue and that he might be sinking into the terrain of obsessive-compulsive disorder. Robert was intelligent enough to consider this for a moment, but because his wife had recently remarked that his breath was interfering with their lovemaking he skipped checking the mental health benefits on his insurance.
An otorhinolaryngologist (ear, nose, throat specialist) scoped his sinuses and pronounced them clean. A gastroenterologist (GI) scoped his esophagus and stomach and found nothing out of the ordinary. The GI doc was less than hopeful. “My brother has had bad breath since he was 20. He’s 50 now and spent a fortune trying to figure it out. Nothing. Nada. He lives on Certs.”
Robert offered the doctor a Tic Tac and left the office.
My meeting with Robert
When I first saw Robert I was not hopeful. First of all, I couldn’t smell a thing, which isn’t saying much because I have a dreadful sense of smell. He’d already read one of my previous Health Tips citing poor digestion as a possible cause of bad breath, but a month of digestive enzymes and betaine didn’t make a dent.
I reviewed Robert’s entire health history and there wasn’t much. He did have some heartburn (gastroesophageal reflux disease, or GERD) that he’d self-treated on an as-needed basis with Nexium, one of the proton-pump inhibitors that reduce stomach acid. Robert told me he had frequent bloating, but generally his bowels were regular and there were no particular foods that gave him trouble. Except for seeing a dermatologist for some stubborn rosacea, there was nothing really wrong with him that decapitation couldn’t cure (I knew he’d laugh when I told him this).
Since he already had a primary physician (who had pronounced him healthy) and had been pretty thoroughly tested by other doctors, I ordered two tests of his gastrointestinal function.
- For the first, a Comprehensive Stool Digestive Analysis, he would send stool specimens to Genova Labs to determine if he was digesting and absorbing his food normally. This test would also look for intestinal parasites and determine if there were any imbalances in his intestinal bacteria. Robert’s results were normal. He was digesting and absorbing his food well.
- The second test would measure the contents of his breath for two gasses, hydrogen and methane. This test would determine if there were an overgrowth of bacteria in his small intestine, called SIBO for small intestine bacterial overgrowth. Some bacteria in the small intestine is allowable. But an overgrowth can produce all sorts of mischief, including bloating and impairing your digestion and absorption of food.
For the SIBO test (done at home), Robert would drink a small amount of lactulose, a harmless sugar that’s like cotton candy to the target bacteria, which promptly respond to this treat by producing more gas than ever. For the next two hours, Robert would collect samples of his breath by blowing into a specially designed balloon and then attaching a vacuum tube to extract an air sample. He’d send off six tubes of air, which looked empty, but definitely were not.
When the test results came back from the lab, I knew we had an answer. This link shows a typical mild-to-moderate case of SIBO. Note how the hydrogen-methane content rises as time passes. Robert’s started rising at the 20-minute point and remained at the very top of the graph for the rest of the two-hour collection period. His was among the highest gas levels I’d ever encountered.
Treating Robert’s SIBO
Robert’s response to Xifaxan, the antibiotic most widely prescribed for SIBO, was dramatic. On the fourth day of his ten-day Xifaxan prescription, the nauseating odor from his tongue scraping had vanished. By the tenth day, neither he nor his wife could detect any breath odor whatsoever and I hoped they were now able to resume their passions.
Just why Robert had developed SIBO is hard to say. Some people get it if they have a chronic intestinal inflammation, like Crohn’s disease. Some get SIBO as a consequence of using the Nexium family of meds, which reduce the stomach acid necessary to keep the small intestine’s bacterial population in check. SIBO has also been linked to anything that slows intestinal motility (movement), like underactive thyroid or constipation-dominant irritable bowel syndrome. But for most people with SIBO, the “why me?” is left unanswered.
Fortunately, as in Robert’s case, treatment can be dramatically successful. The only caveat is that the bacteria are stubborn and a return of symptoms can occur. We reduce this possibility using an antibiotic blend of herbs and a quality probiotic, since nobody needs to be carpet-bombing what helpful bacteria they do have by taking an antibiotic regularly.
Three intriguing points worth mentioning
First, the question of the garbage-y odor itself since the two gasses measured with SIBO testing, hydrogen and methane, are both odorless. The likely reason for the odor is that the bacteria are producing other gasses, especially hydrogen sulfide, the villain behind your odiferous farts. You’re better off not thinking about this too much.
Second, a few weeks after treatment, Robert’s rosacea had disappeared. The link between SIBO and rosacea is relatively new, first described by a group of Italian physicians in 2008. Unfortunately, testing for SIBO has been slow among US dermatologists seeking a rosacea cure, but the connection might explain how Flagyl (metronidazole) works. Flagyl, the top-prescribed drug for rosacea can also be used to treat SIBO if Xifaxan is unavailable. Perhaps dermatologists prescribing Flagyl are inadvertently curing SIBO, which in turn cures the rosacea.
Third, I have to wonder if something as thoroughly annoying as having horrible breath ever affects celebrities and other beautiful people. There’s a real imbalance in the universe. I mean, if Brad Pitt or Taylor Swift or Princess Kate had socially isolating breath problems, they’d be able to compensate by saying, “Thank god I’m Brad Pitt” or “Wow, at least I’m Taylor Swift” or “I’d be even more miserable if I weren’t a princess.”
Instead, this stuff strikes plebes like you and me. No justice.
David Edelberg, MD