The holiest month in the Islamic calendar is in full swing. Ramadan is the ninth month of the Islamic lunar calendar, where every day during the month, Muslims around the world spend the daylight hours in a complete fast.
Allah says with regards to fasting in Sūrat al-Baqarah,
“O you who believe, fasting is prescribed for you, as it was prescribed for those before you, so that you may be mindful of Allah.” 
In this verse, Allah (subḥānahu wa taʿālā) is addressing the believers and commanding them to observe the fast. Fasting means to submit to Allah’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 who are required to work with others – is bad breath. This is known medically as halitosis, a term used to describe an unpleasant odour exhaled through the mouth.
Bad breath or halitosis 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 per cent), the origins of bad breath are from the mouth.  In 5-10 per cent of cases, bad breath originates from the nose and sinuses, and in 3-5 per cent of cases, from the tonsils. Other rarer origins are systemic diseases such as GORD (gastro-oesophageal reflux disease) or H-pylori (Helicobacter pylori) infections.
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, 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 post-nasal drip (PND). The convoluted microbial structure of the tongue dorsum provides an ideal habitat for anaerobic bacteria. Indeed, 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 mouthwash, 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 daylight 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, thereby causing the dead cells and bacteria to be washed away, hence 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, in order to limit the number of bacteria in the mouth.
The above examples of dry mouth are all temporary, e.g. whilst fasting or sleeping. However, if you suffer from dry mouth persistently, it is important that 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
This can cause bad breath, both 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 also tend to have a reduced salivary flow rate, thereby causing dry mouth. They are more prone to gum disease as a result of a reduced immune response, causing bad breath as a secondary symptom.
During Ramadan, 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 Ramadan to help them quit smoking and thus vastly improve their health and lower their risks of all the harmful diseases associated with the habit. Smokers should consult their GPs, dentists, or pharmacists, who can all 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 not clean them properly, your risk of having bad breath is significantly increased.
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 Ramadan. This will confirm that their fast will or 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 that they clean their dentures on a daily basis, by using a brush and water or denture-cleaning tablets.
Illnesses, conditions, and situations
Did you know that experts say about one tenth of all cases of halitosis are caused by an illness or medical condition?
- GORD (gastro-oesophageal reflux disease);
- 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 Ramadan 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 by cleansing the mouth of bacteria and food remnants.
Below are the recommended evidence-based guidelines in maintaining good oral hygiene, as set out by the Department of Health toolkit, Delivering better oral health 2014. 
- Brushing using a fluoride (1,350ppm) toothpaste should occur twice daily as a minimum – clean teeth last thing at night before bed and at least one other time each day
- Brushing should last for two minutes, ensuring you brush all tooth surfaces including gum margins
- Patients who are not correctly brushing their teeth with a manual toothbrush should try to switch to an electric toothbrush, where studies have shown electric toothbrushes can significantly improve their cleaning (discuss your brushing technique with your dentist before moving to an electric toothbrush).
Alongside brushing your teeth, studies have also shown that using floss, inter-dental 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 Ramadan and throughout the year should significantly reduce bad breath from occurring.
Recommended mouthwash specifically for bad breath?
Studies have shown that 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.
This 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 fasting person must ensure they:
- Drink plenty of water out of the hours of fasting, drinking small sips but in regular frequency;
- They can rinse out their mouth with water (as long as no water is swallowed intentionally), most Muslims will perform this act thrice each time they perform Wudū (ablution) before offering obligatory prayers;
- Use miswāk to stimulate salivary flow;
- Speak to their GP/ pharmacist to check if any of their medication is causing dry mouth.
What about miswāk?
What would also be recommended to the fasting person is the specific use of 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 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 per cent of the bacteria, whereas the ordinary mints managed only 3.6 per cent.
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 (the US National Library for Medicine Service). The study concluded that miswāk was more effective than using a toothbrush in reducing plaque and gingivitis, provided that 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. This causes effective cleaning between the teeth.
Interestingly enough, the World Health Organisation (WHO) recommended the use of the miswāk in 1986. So we would have to agree that using miswāk is both rewardable and effective.
It goes without saying that there are many aḥadīth on the benefits and rewards of using miswāk and was a beloved Sunnah of the Prophet (ﷺ)!
In conclusion, if you want to beat bad breath during Ramadan, here are three key tips:
- 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 but keeping your mouth wet and stimulating saliva).
I would like to end on some aḥadīth from the Sunnah of our beloved Prophet Muḥammad (ﷺ).
Through various aḥadīth, it is a well-known fact the Prophet (ﷺ) would frequently, throughout the day, brush his teeth using miswāk.
He (ﷺ) would brush his teeth before reciting the Qur’ān or teaching the virtues of Islam, before entering a gathering, or embarking on any journey. He (ﷺ) would also brush his teeth before sleeping or when experiencing the pangs of hunger and thirst. 
The Prophet (ﷺ) placed a big emphasis on maintaining 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 salāh.” 
“Tooth brushing is purification for the mouth and pleasing for the Lord, Allah.” 
Finally it is important to remember that we fast in order to seek the pleasure and mercy of Allah (subḥānahu wa taʿālā).
Whilst we may think our breath smells bad during fasting, it is always important to remember this ḥadīth:
The Prophet (ﷺ) said,
“By Allah, in whose Hand is the soul of Muḥammad, the breath of a fasting person is sweeter to Allah than the fragrance of musk.” 
 al-Qur’ān, 2:183
 Social relations and breath odour, International Journal of Dental Hygiene, November 2003
 Review of attendance behaviour in Dental Update, April 2007
 The science of bad breath. Sci Am. 2002 April
 Rosenberg M. Clinical assessment of bad breath: current concepts. J Am Dent Association. 1996 April
 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
Please note, this is a revised version of a previously published Islam21c article