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Q: My 44-year-old son suffers from a bad case of halitosis. He also has a sinus drip.

He is extremely diligent about brushing, flossing his teeth, and scraping his tongue, but nothing helps much. He's in a supervisory position at work and states people in contact with him turn their heads away.

What type of medical doctor would be best for him to see about resolving this condition? Any information you could give me would be appreciated. Thank you.

-- C.M., Boston, N.Y.
A: Bad breath (halitosis) or the perception of bad breath is one of the most common problems people experience. There are many causes of halitosis, but they can be classified into three groups: oral, physiologic and psychosomatic.

The most common source of halitosis is oral (from the mouth and throat). This is primarily due to decaying food particles lodged in crevasses. Crevasses occur between teeth, in the tongue, in orthodontic devices and underneath dentures. Dental infections and cavities are other sources.

Food is commonly trapped in crevasses in the tongue, especially toward the back. There bacteria break down food and release sulfur compounds that smell like rotten eggs. Brushing and scraping the tongue is an important part of oral hygiene, but the effect on halitosis may only last a few hours.

Tobacco use and breathing through one's mouth can also result in bad breath. GERD (gastroesophageal reflux disease) does cause the regurgitation of some contents of the stomach into the mouth. This is usually stomach acid, which does not smell very bad itself. But the acid can cause a distinct bad taste in the mouth, which may give the perception of bad breath.

In a similar fashion, sinus or postnasal drip can be a source of bad breath if one or more sinuses are infected. This may be the source of your son's problem, so I suggest that he get medical advice about how to treat his sinus drip.

About 10 percent of the time halitosis is coming from somewhere outside the oral cavity: liver failure (a mousy odor), kidney failure (smell of stale urine), diabetes (acetone), and some lung infections (rotten smell).

Halitosis can also be caused by eating foods such as onions and garlic. And cleaning the mouth may not help because the "smelly" chemicals are often expelled from the lungs. B vitamins and fish oils may contribute to bad breath.

Some people think they have bad breath even when others can't detect an odor. This can also be caused by GERD, neurological problems and emotional disorders.

Your son needs to identify the cause so that it can be removed. If he wants to see a physician, I suggest that he see an ENT specialist. He may want to consult with his dentist as well.

In the meantime, he should try to remove one or more of the possible causes. Using chlorophyll, activated charcoal, and chewing gum can mask the problem. Chlorine dioxide can neutralize sulfur compounds, and some mouth washes can kill bacteria that may be causing the problem.

Update on drug costs: An article in the Journal of the American Medical Association points out the growing mismatch between the information patients need and the information they get from doctors regarding drug costs.

The article cites a study that found that two-thirds of physicians never discuss out-of-pocket costs of drugs. This is perhaps explained by another study that showed that physicians only correctly identified the cost of commonly prescribed drugs one-fourth of the time.

Hopefully, given how widely this publication is read, the article will encourage physicians to become more aware of the need to know and to communicate cost information. Since the journal is published by the American Medical Association, perhaps that organization will encourage its members along these lines as well.

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