The doctor with halitosis

Jan. 1, 2002

This is the kind of breath that easily peels paint off walls! Sometimes I can smell it at a distance of four feet and through a facemask.

Dear Dianne,
Recently, I took a position with a wonderful doctor. He is a good clinician and has a kind, caring chairside manner. Additionally, he is well-respected in the community and very active in his church.

The problem is his breath! This is the kind of breath that easily peels paint off walls! Sometimes I can smell it at a distance of four feet and through a facemask. Some days it is worse than others.

Of course, the other staff members have noticed it as well. One assistant has been working here nine years, and she says his breath has always been bad. When I asked her if she had ever brought this problem to his attention, her answer was, "Are you kidding? I don't have that kind of nerve!"

Another thing I should mention is that the doctor is very physically fit and takes several dietary supplements, including garlic tablets. I know these tablets are "supposed" to be odorless, but I have a strong suspicion that this is the source of his malodor.

My question is this: Should I say anything to the doctor about this obvious problem, or should I just keep quiet?

Stinky Situation in Syracuse

Dear Stinky,
Oral malodor is a common problem. It affects people from every walk of life, including doctors and hygienists. Billions of dollars are spent yearly by people trying to combat or prevent halitosis. The problem seems worse when it involves dental professionals, since our focus is the oral cavity.

Most common forms of bad breath emanate from the mouth itself. People who experience postnasal drip frequently are bothered by halitosis. This discharge may not smell when it reaches the tongue, but after it sits there for a while, it takes on a very unpleasant odor. One solution to odor originating at the back of the tongue is to gargle with an effective mouthrinse and then clean the tongue with a tongue scraper. Initially, it is difficult to clean this area, because it initiates a gagging reflex. However, with time and practice, this usually can be overcome.

Additionally, the teeth and gingiva are common sources of malodor. Marginal overhangs, leaky crowns, and periodontal pockets are prime sites for anaerobic bacterial activity leading to putrefaction. Patients suffering from periodontal disease often have a particularly offensive smell that we refer to as "perio breath." Large numbers of bacteria associated with the disease can be found on the dorsum of the tongue, the tonsils, and in periodontal pockets. The pathogens Treponema denticola, Porphyromonas gingivalis, and Bacteroides forsythus have been found to be associated with high levels of whole-mouth odor. Further studies have found that both gram-negative and gram-positive organisms can be associated with halitosis. However, when the disease is eliminated, patients will notice that their breath-odor problem improves.

Dentures are another source of malodor, particularly if they are worn overnight. This odor can be identified if the dentures are placed in a plastic bag for a few minutes and then smelled.

It also has been suggested by several studies that oral malodor increases when the mouth dries out. For example, when we sleep, salivary flow decreases, microbial activity increases, and bad breath rises. Certain mouthwashes contain alcohol, which is known to increase dryness. Therefore, it is feasible that some mouthwashes only mask odor for a short time and actually contribute to increased malodor from the drying effect of the alcohol.

Volatile sulfur compounds (VSCs), particularly hydrogen sulfide and methyl mercaptan, have been studied as contributors to halitosis. The level of intraoral VSCs can be estimated chairside by using portable sulfide monitors. There are also nonsulfur-containing gases that can be released over time when the skin dries out.

For example, if you lick your arm, the odor can linger up to two hours after the skin has dried out. The implication is that when saliva dries out on oral surfaces, a range of VSCs and other volatiles are released.

Occasionally, some oral malodor originates outside the mouth. Of all the nonoral etiologies of halitosis, the nasal passages predominate. This odor can be distinguished by closing the mouth and having someone smell the air that comes from the nose. Nasal odor can arise from sinusitis or problems that affect airflow or mucus secretions, like polyps.

Although the tonsils also can be a source for oral malodor, their role is not clear. Children often exhibit bad breath when their tonsils are infected. The tonsillar crypts can emit a foul-smelling exudate when pressed. This exudate originates from sinus drainage that becomes lodged behind the tonsils and works its way out through the crypts. Tonsillar concretions, called tonsilloliths, are usually several millimeters in diameter, rough-edged, and white or yellow. These stones typically have a foul odor, but, according to several studies, do not appear to be a significant source of bad breath.

Other nonoral diseases, such as bronchial and lung infections, kidney failure, various carcinomas, metabolic dysfunctions, and biochemical disorders can result in bad breath. But all of these taken together account for a very small percentage of halitosis problems.

Additionally, bad breath emanating from the gastrointestinal tract is considered extremely rare. Under normal circumstances, the esophagus is closed off at the entrance, except for an occasional air bubble rising from the stomach (belch).

However, it is common knowledge that some foods, like garlic and onions, emit an odor for several hours after being ingested. It is believed that some malodors actually get into the bloodstream and are carried all over the body. For example, if you cut an onion and rub it on your skin, in one to two hours the odor will be detectable on your breath — even though you did not eat the onion. This helps to explain why ingesting garlic tablets may contribute to halitosis.

The reason that people frequently are unaware of their own bad breath can be attributed to adaptation, which is a dulling of sensation due to continual exposure.

This insensitivity can have grave consequences. Practices could experience patient-retention problems if the doctor has offensive breath. Patients could be turned off by a doctor with halitosis when considering elective or cosmetic dentistry. Many dentists suffer from bad breath to the chagrin of their patients, staff members, and friends.

What should you do? Certainly, it is difficult to tell people that they suffer from halitosis. However, we should be prepared to tell those we care for if they suffer from bad breath. Further, we should hope that the person we inform would reciprocate in kind, should it be necessary. I queried several of my dentist-friends as to whether they would want a staff member to tell them if they had bad breath. Every single one answered affirmatively to the question, and even said they would appreciate being told.


Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Lexington, N.C. To contact Glasscoe for speaking or consulting, call (336) 472-3515, fax (336) 472-5567, or email dglasscoe@ Visit her Web site at

The bad breath speech
When informing someone of his or her own bad breath, use extreme discretion and tact. You should speak to the doctor privately and use verbiage along these lines:

"Doctor, I want you to know how much I enjoy working here. I think you are a great doctor, and you have the best chairside manner I have ever seen. There is one thing, however, that is causing me some concern. Please understand that it is not easy for me to say this, but I really feel like you should know.

"It's your breath. I can sometimes smell it when you are speaking to patients. I feel sure that if I can detect an odor, patients can too. Knowing how good you are with people, I am certain that the last thing you would want would be to offend someone. And, if I ever have offensive breath, I would appreciate it if you would tell me."

Then stop and let the doctor share his thoughts. More than likely, he will thank you. Maybe this revelation will spur the doctor to discover the reason for his halitosis. Remember, if you don't tell him, he may never find out.

I know this will be an unpleasant task for you. If you find it impossible to summon up enough courage to confront the problem directly, why not clip out this article and pass it along anonymously?