Each year, millions of people complain about bad breath. Here`s what you need to know to treat it.
Louis Malcmacher, DDS, FAGD
Halitosis affects approximately 25 percent of the U.S. population. Interestingly, I asked the audience at a recent lecture I gave at the Yankee Dental Congress if anyone had bad-breath problems. Remember, this was a group that included dentists, hygienists, and other dental personnel. About 40 percent of the audience raised their hands! I was shocked, because these were people who worked in a dental office and were dental professionals.
Millions of people each year complain about bad breath at one time or another. For many people, it is a chronic problem, while others only have acute episodes occasionally. Patients have been complaining to the dental profession about halitosis, and they continue to complain every day we are in the office. It is easy to understand why consumer products to fight bad breath are a multi-billion dollar-a-year business. It certainly is time for us to begin integrating bad-breath treatment into our treatment plans.
Unfortunately, many of us do not have the tools or the knowledge necessary to properly diagnose and treat halitosis from a dental perspective. Hygienists can play a key role in identifying malodor and the treatment and prevention of it.
Scientific data has come out recently that help us understand this problem. Rarely, if ever, does bad breath come from the stomach, despite the marketing done by a number of products that promote that fallacy. I constantly am amazed at how many dentists think bad breath only comes from the stomach. It just goes to show you the power of marketing.
We have been trained to believe that bad breath only comes from some form of periodontal disease. In the past, when patients would come in with a complaint of halitosis, we would make sure they had a prophylaxis. When they continued to complain about bad breath, we then would perform a thorough scaling and root-planing under anesthesia. If they still complained, we might do another scaling and root-planing and/or suggest they buy an irrigator and one of the strong mouthwashes available on the market. In most cases, this treatment plan would help briefly. In some cases, it did not help at all. We perhaps did not want to believe there were any other causes for halitosis, because we had no other treatments to combat it. Truthfully, we lacked the knowledge and clinical expertise to treat these cases successfully.
Finding the cause
Obviously, periodontal disease can be a major contributor. When halitosis is related to periodontal disease, it should be treated appropriately. However, many patients come into our offices with excellent oral hygiene and still complain of bad breath. Some other pathology is going on, and we need to look outside of our traditional thinking to figure out where the problem lies. Research has taught us that anaerobic bacteria, which produce volatile sulfur compounds, are the primary source of most halitosis cases. These anaerobic bacteria, which cannot survive in the presence of oxygen, lie deep within the fissures of the tongue and in gingival pockets. The tongue is an especially wonderful hiding place for these bacteria, particularly the back and sides of the tongue where the tongue filaments are the longest and deepest. They then combine with proteinaceous debris to produce volatile sulfur compounds, which causes that "rotten egg" smell commonly identified as bad breath.
Volatile sulfur compounds include such gases as methyl mercapten and hydrogen sulfide. Patients frequently are able to identify the exact place in their mouth where they feel the smell is coming from, because of the strong odor of these gases. I`ve had many patients tell me that, "Oh, the smell is coming from between my central incisors" or "I feel a bad taste from between my upper molars on both sides." In a few cases, the origin of the halitosis may be from the nose, pharynx, or stomach. Unfortunately, it is beyond the purview of this article to go into all of the causes of halitosis. Suffice it to say that most of the problem is oral, and dental professionals can and should be the most proficient at treating breath disorders.
Patients who have struggled with this problem usually have put forth a great deal of time, effort, and money in trying to tackle their bad breath. Many times, patients will describe a slew of things they have tried to rid themselves of bad breath.
Let`s take a quick look at the most commonly thought of remedy for bad breath - over-the-counter mouthwashes. Are they effective? The problem with most over-the-counter mouthwashes is that they contain alcohol. We all know that alcohol is a drying agent. Many patients will tell you that their breath feels good for a little while after they use an over-the-counter mouthwash, but then the bad breath comes back even stronger than before. The reason is simply because of alcohol`s drying effect on the mouth that increases the anaerobic bacteria`s activity, thereby increasing the volatile sulfur compounds. In reality, most OTC mouthwashes make the bad breath problem worse and not better. This, then, causes people to use more of the same mouthwash with no long-term benefits at all.
Diagnosing these cases is similar to the job of a private investigator. Most of the time, these cases are fairly straight forward, but there are some cases when it is quite difficult to locate the source of the bad breath. For instance, I had a patient who had excellent oral hygiene, but definitely had the distinctive rotten egg smell emanating from her oral cavity. I treated her and eliminated 95 percent of her problem, but she still had a faint smell that bothered her and me. Imagine my surprise when she sent in her husband for dental treatment. He had Class IV periodontitis and the worst bad breath I had ever smelled in my life! As soon as he walked into the office, I knew back in my office that he was on the premises. When we finally got his breath disorder under control, we were able to completely eliminate his wife`s halitosis as well.
What to do first
The first thing hygienists can do is ask patients at the maintenance visits if they have a problem with bad breath. It is easier to ask and have them admit to a problem than to inform them of their bad breath (which may insult some people). The simple question - "Do you ever have a problem with bad breath?" - either on a patient form or asked directly, will elicit a wide array of responses. You will be amazed at the number of patients that will say yes to this question. Some patients respond by saying, "Yes, I have a problem, and I always wondered why you never asked me before. Can`t you smell it?" This question is perfectly legitimate for a dental professional to ask, because it may uncover other pathology that needs to be treated. I have never had a patient who reacted negatively to this question.
Another important question to ask is, "Do you ever buy over-the-counter products to fight bad breath?" This, again, can stimulate some interesting discussion.This will uncover some key information clarifying how often they experience the problem.
One of the primary roles the hygienist can play in helping to curb or eliminate a halitosis problem is to educate the patient about proper oral hygiene. Every hygienist is well-versed on hygiene of the teeth and gums. How many of us, though, educate and demonstrate to the patient proper tongue-cleaning? This is an area that has been ignored by many dental professionals.
There are numerous ways to perform tongue-cleanings. A toothbrush usually is too large to get to the back of the tongue without gagging the patient. Tongue-scrapers, while a step in the right direction, are used too aggressively by many patients, and they tend to damage the tongue. When this happens, patients eliminate them from their hygiene protocol.
A new tongue brush has just come out on the dental market, along with a special chlorine dioxide-based, tongue-cleansing gel. It has been shown to eliminate volatile sulfur compounds that are the primary cause of halitosis. In our own practice, this has been very well received by patients. The low profile of the tongue brush allows patients to easily get to the back and sides of the tongue without gagging. A gentle edge at the tip of the brush allows patients to clean the front part of their tongue more easily by dragging the brush forward. The tongue brush and tongue-cleansing gel are effective tools to use to begin eliminating a halitosis problem. They are a key and integral part to treating breath disorders.
Treatment of halitosis depends primarily on the information obtained at the diagnosis appointment. Diagnosing the source of bad breath requires some investigative work. The hygienist can be the key person in this fact-finding process. However, the hygienist has enough to do at a typical maintenance appointment, so a separate diagnostic appointment should be made to diagnose these cases correctly.
The hygienist also should be involved in the treatment process itself. Making and seating trays, dispensing the proper solutions, continuous monitoring of sulfide levels, and patient hygiene all fall under the purview of the hygienist. You are the key to helping people eliminate their bad-breath problem. You will find there is no happier patient than a patient who has been treated successfully for a halitosis problem.
Halitosis treatment is a very rewarding part of dental practice. The dental staff already has the tools in place to integrate this kind of treatment into the daily routine. Most of the halitosis treatment ? which includes fabrication of trays, alginate impressions, education, and the recommending and dispensing of products ? can be performed by dental hygienists. Offer this service to your patients and you will see a dramatic difference in your practice!
Dr. Louis Malcmacher practices in Cleveland Heights, Ohio. He can be reached by phone at (216) 321-5355, by fax at (216) 321-5399, or by e-mail at [email protected].
