Author: Dr Zahid Siddique (BDS,Mpharm)
The holiest month in the Islamic calendar has arrived. Ramaḍān is the ninth month of the Islamic lunar calendar. Every day during this month, Muslims around the world spend the daylight hours in a complete fast.
The Holy Qur’ān says with regards to fasting in Sūrah Al-Baqarah: “You who believe, fasting is prescribed for you, as it was prescribed for those before you, so that you may be mindful of Allāh.”
Allāh (subḥānahu wa taʿālā) is addressing the believers and commanding them to observe the fast. Fasting means to submit to Allāh (subḥānahu wa taʿālā)’s command with a sincere intention and to abstain from food, drink and carnal and sensual temptations. The benefit of such an abstention is that it purifies the self from immoral acts and builds a character which distinguishes right from wrong and virtue from vice.
However, hunger and thirst are not the only obstacles during this month, a common complaint especially amongst fasting Muslims required to work with others is bad breath medically known as halitosis, a term used to describe an unpleasant odour exhaled through the mouth. Bad breath can lead to a decrease in self-confidence and insecurity in social and intimate relations, and is the third most common reason for patients to visit a dentist.
So what can we do to reduce or eliminate bad breath whilst fasting? To be able to understand how to reduce bad breath, it would be prudent to have some understanding of the origins of it.
How is bad breath produced?
Bad breath is most often a result of certain bacteria that live in the oral cavity and which break down food remnants into foul-smelling gases or volatile sulphur compounds (VCSs). In most cases (85-90%) the origins of bad breath are from the mouth. In 5-10% of cases bad breath originates from the nose and sinuses and in 3-5% of cases from the tonsils. Other rarer origins are systemic diseases such as GORD (gastro oesophageal reflux disease) or H-pylori infection.
Bad breath is thought to originate mainly from the dorsum of the tongue. Large quantities of naturally-occurring bacteria are often found on the posterior dorsum of the tongue, where they are rather undisturbed by normal activity. This part of the tongue is also quite dry and poorly cleansed, and bacterial populations can thrive on remnants of food deposits, dead epithelial cells and postnasal drip (PND). The convoluted microbial structure of the tongue dorsum provides an ideal habitat for anaerobic bacteria. Over 600 types of bacteria can be found in the average mouth, of which several dozen produce high levels of foul odours when incubated in the laboratory.
Other parts of the mouth may also contribute to the overall odour, but are not as common as the back of the tongue. These include inter-dental and sub-gingival niches, faulty dental work, food-impaction areas in-between the teeth, abscesses and unclean dentures.
Causes of Bad breath
Poor Oral Hygiene
The number one cause of bad breath is poor oral hygiene. If we do not maintain good oral health by brushing twice a day / flossing /using a mouth wash, we are less likely to wash away and reduce the number of these natural bacteria thus resulting in bad breath. Not removing and disturbing the bacteria in the mouth (plaque) will also lead to dental diseases such as periodontal disease (gum disease) which, along with bad breath, will cause other dental problems. Maintaining good oral health is discussed in further detail later in this article.
The intensity of bad breath however can differ depending on diet and dryness of the mouth etc. As a result of the mouth being drier whilst fasting (where drinking any form of liquid is impermissible), there is more of a potent smell.
During fasting bad breath seems to be worse. Why would this be? Saliva is the natural mouthwash we were born with. It contains antibacterial agents, and competes with bacteria for scarce resources such as iron. Saliva helps wash bacteria and food from the mouth, and the saliva layer helps the oral odours from escaping. Bad breath is worst when there is little or no saliva flow, for example during a long fast. This is because whilst we are fasting we abstain from all food and drink during day light hours thus lowering our salivary stimulary flow causing us to have a dry mouth. If the mouth is dry, dead cells and bacteria can build up on the tongue, gums and the insides of our cheeks. These cells then start to rot and give off an unpleasant smell thus intensifying our breath. As soon as one begins to eat and drink the Parotid salivary gland is stimulated and starts to salivate causing the dead cells and bacteria to be washed away reducing the unpleasant smell.
A dry mouth is also the reason why we have bad breath first thing in the morning compared to later in the day. Our salivary flow drastically decreases whilst we are sleeping causing dry mouth and thus leading to bad breath for the reasons explained above. This is worse in people who tend to sleep with their mouth open. It is therefore imperative to ensure we clean our mouths properly before going to bed to limit the number of bacteria in the mouth.
The examples of dry mouth above are all temporary e.g. whilst fasting or sleeping, however if you suffer from dry mouth persistently it is important you consult your GP or Dentist as there is usually an underlying problem. The medical term for persistent dry mouth is known as Xerostomia and has a number of causes ranging from side effects from medication, diabetes and post cancer treatments.
Other causes of Bad breath
Smoking – can cause bad breath directly and indirectly. The most immediate and direct way that cigarettes cause bad breath is by leaving smoke particles in the throat and lungs. This effect is typical of nearly any tobacco product that involves inhaling smoke or rolling it around in the mouth. The smell of a freshly smoked cigarette can linger in the lungs for hours, hence the stale scent associated with smoker’s breath.
However, this is just the beginning. The chemicals in tobacco smoke can remain in the mouth, leading to a host of secondary indirect causes of bad breath such as causing dry mouth. Smokers are more likely to suffer from gum disease and other dental problems which cause bad breath. Smokers tend to have a reduced salivary flow rate causing dry mouth and are more prone to gum disease as a result of a reduced immune response causing bad breath as a secondary symptom.
During Ramaḍān, Muslims who are smokers abstain from smoking cigarettes during fasting hours (daylight) which otherwise in other months they would find difficult to do. However most tend to smoke after the fast is broken which will contribute to worsening their breath. This is why Muslims should use the month of Ramaḍān to help them quit smoking and thus vastly improve their health and lower their risks of all the harmful diseases associated with smoking. Smokers should consult their GPs, Dentists or pharmacists who can provide information on smoking cessation – helping you to quit the habit of smoking once and for all!
Food and drink – certain foods, such as onions, garlic and some spices may cause the breath to smell after consuming them. Bad breath from garlic is not caused mainly from the bacteria, but from the garlic itself – many people would argue that garlic breath is not unpleasant, and therefore not an example of halitosis. The bacteria in our mouths tend to give off higher volumes of smelly gases when they decompose proteins, such as meat or fish. If bits of meat get stuck between your teeth and you do nott clean them properly, your risk of having bad breath is significantly increased.
Medications – any medication that causes a dry mouth or nose is more likely to cause bad breath, examples include antihistamines and drugs for treating systemic diseases such as Hypertension (high blood pressure) and Diabetes. Patients who are on a cocktail of medication treating systemic diseases should speak to their GP before commencing Ramaḍān to ensure their fast will not affect the efficacy and use of their medication.
Poor denture hygiene – people who use dentures and don’t clean them regularly have a higher risk of bad breath. If the dentures do not fit properly food is more likely to get stuck. Patients should ensure they clean their dentures on a daily basis using a brush and water or denture cleaning tablets.
Illnesses, conditions and situations – experts say that about one tenth of all cases of halitosis are caused by an illness or medical condition. Examples include: Diabetes, GORD (gastro oesophageal reflux disease) and renal disease. Patients who are fasting and suffer from such diseases should consult their GP first.
How do we beat it?
Maintaining good oral hygiene
The things that we can do to reduce bad breath both during Ramaḍān and throughout the year should now be obvious and the reasoning should be easier to understand. We have established that the main cause of bad breath is poor oral hygiene. Therefore the main treatment for bad breath is to ensure we maintain good oral hygiene cleansing the mouth of bacteria and food remnants. Below are the current recommended evidence based guidelines in maintaining good oral hygiene as set out by the department of health toolkit “Delivering better oral health 2014”
Alongside brushing your teeth, studies have also shown using floss, interdental TePe brushes, tongue cleaners and anti-bacterial mouthwashes can disturb the plaque in your mouth and remove food remnants thus reducing bad breath.
During fasting, Muslims can brush their teeth with toothpaste as long as they do not intentionally ingest the toothpaste. It is also possible to use mouthwash as long as the mouthwash is not ingested. Brushing twice a day with the correct use of a mouthwash during Ramaḍān and throughout the year should significantly reduce bad breath from occurring.
Recommended mouth wash specifically for bad breath?
Studies have shown a mouthwash called CB12 has significantly reduced bad breath in patients.
The active ingredients in CB12 are zinc acetate and chlorhexidine (anti-bacterial). Zinc acetate is used to neutralise and prevent production of the VCSs (foul odour gases) from exhaled air. Small amounts of chlorhexidine are used to break down the sulphur gas molecules by interacting on their bond strength.
Gently cleaning the tongue twice daily is another effective way to keep bad breath in control; that can be achieved using a tongue scraper or a separate tongue toothbrush to wipe off the bacterial biofilm, debris, and mucus. Ask your dentist to recommend a scraper for your tongue. Brushing a small amount of saltwater onto the tongue surface will further inhibit bacterial action. Eating a healthy breakfast with rough foods helps clean the very back of the tongue too.
Overcoming dry mouth during fasting – To minimise the effects of having a dry mouth during fasting which, as discussed earlier, can intensify bad breath, a person fasting must ensure they ;
What about miswāk?
What would also be recommended to the fasting person is the specific use miswāk throughout the day. The miswāk (also known as siwāk or sewāk) is a teeth cleaning twig cut from a branch of the Salvadora persica tree, also known as the arak tree (or peelu tree). It is well-known amongst most Muslims—but is using a miswāk effective at cleaning one’s mouth?
The Wrigley Company carried out a study on miswāk which was published in the Journal of Agricultural and Food Chemistry. The study found that mints laced with miswāk extract were 20 times more effective in killing bacteria than ordinary mints. After half an hour, the mints laced with miswāk extract killed about 60% of the bacteria whereas the ordinary mints managed only 3.6%.
In the August issue of Journal of Periodontology (2008) appeared a study conducted by Swedish researchers on miswāk. The study apparently found that suspended miswāk pieces in a Petri dish (containing medium for growing bacteria) were able to kill bacteria that cause periodontal disease without being in physical contact with the bacteria. The researchers suggested that miswāk might be providing antibiotics as gases, trying to explain this phenomenon.
Another study which compared tooth-brushing and using miswāk can be found on Pubmed (U.S National Library for Medicine Service). The study concluded that miswāk was more effective than using a toothbrush in reducing plaque and gingivitis provided it was used correctly. Similarly a study conducted by a group of dentists at King Saud University concluded that using miswāk was at least as good as using a toothbrush, if not better.
The effectiveness of miswāk has been attributed to its strong antibacterial properties. Another feature of miswāk thought to contribute to its effectiveness, mentioned by the King Saud University study, is that its bristles are parallel to the handle rather than perpendicular which means effective cleaning between the teeth. The World Health Organisation (WHO) interestingly enough recommended the use of the miswāk in 1986. So we would have to agree that using miswāk is both rewardable and effective. There are many ḥadīths on the benefits and rewards of using miswāk and is a beloved Sunnah of the Prophet Muḥammad (sall Allāhu ʿalayhi wa sallam).
In conclusion, if you want to beat bad breath during Ramaḍān, then brush a minimum of twice a day for 2 minutes especially after those big iftārs and before you go to bed, clean your tongue and drink plenty of fluids whenever you can. Rinse the mouth frequently during the fast without swallowing any water keeping your mouth wet and stimulating saliva.
I would like to end on some ḥadīths and sunnah of our beloved Prophet Muḥammad (sall Allāhu ʿalayhi wa sallam).
Through various ḥadīths it is a well-known fact the Prophet Muḥammad (sall Allāhu ʿalayhi wa sallam) would frequently, throughout the day, brush his teeth using miswāk. He would brush his teeth before reciting the Qur’ān or teaching the virtues of Islām, before entering a gathering or embarking on any journey and he would brush his teeth before sleeping or when experiencing the pangs of hunger and thirst. The Prophet Muḥammad (sall Allāhu ʿalayhi wa sallam) placed a big emphasis on maintain good oral hygiene and therefore it should be as important to us.
“Had I not thought it difficult for my nation I would have commanded them to brush their teeth before every salāt”
“Tooth brushing is purification for the mouth and pleasing for the Lord Allāh.”
Finally it is important to remember we fast to seek the pleasure and mercy of Allāh (subḥānahu wa taʿālā). Whilst we may think our breath smells bad during fasting it is always important to remember this ḥadīth:
The Prophet Muḥammad (sall Allāhu ʿalayhi wa sallam) said,
“By Allāh in whose Hand is the soul of Muḥammad, the breath of a fasting person is sweeter to Allāh than the fragrance of musk.”
This is an updated version of a previous islam21c article
 Al-Qur’ān, 2:183
 Social relations and breath odour, published in International Journal of Dental Hygiene Nov. 2003
 Review of attendance behaviour in Dental Update April 2007
 The science of bad breath. Sci Am. 2002 Apr
 Rosenberg M. Clinical assessment of bad breath: current concepts. J Am Dent Assoc. 1996 Apr
 Delivering better oral health 2014
 Scully C, Rosenberg M. Halitosis. Dent Update. 2003 May
 Production and origin of oral malodour J Periodontol. 1977 Jan)
 http://deandentists.com/?page_id=158 “Miswak vs Toothbrushing”
 Bukhārī and Muslim
 Ibn Hibban and Ibn Khuzaymah
 Saḥīḥ Muslim 1151