Trisha E. O`Hehir, RDH
We all smell "perio breath," especially in perio patients who also smoke. I`m sure you can also think of several perio patients who didn`t have the typical "perio breath" or any noticeable oral malodor. Although it is generally assumed that bad breath and periodontal disease go together, this may not always be the case.
Researchers in Toronto have demonstrated that a large proportion of individuals with bad breath were periodontally healthy and that the source of odor was actually the tongue`s surface. With no attempt to remove bacteria from the tongue, accumulations can be significant. Since the tongue can play an important role in the development of bad breath, patients should be aware of several options to clean it.
Bacteria in the mouth, as well as oral epithelial cells, produce VSC when broken down. We`re not talking about Victoria`s Secret catalogs here, but rather volatile sulfur compounds. VSC are the primary culprits in the development of bad breath. Measurements of VSC in the mouth correlate strongly with bad breath.
In addition to producing bad breath, VSC have been shown to alter the permeability of sulcular epithelial cells, facilitating the access of toxic metabolites to underlying connective tissue. Based on that fact, bad breath may actually be a precursor to periodontal disease, as well as being associated with active disease.
The relationship between perio and bad breath
The Canadian malodor research was carried out at the Halitosis Assessment Clinic at the University of Toronto. In order to recruit people with bad breath, requests were placed in both the newspapers and on television, inviting people with bad breath to participate in the study. A total of 101 subjects participated over a seven-month test period. Extensive baseline data were collected, including:
- Periodontal and dental clinical indices.
- Bacterial samples from periodontal pockets and the tongue.
- Saliva samples from the palate and vestibular regions.
- Measurements of VSC in the mouth.
- Organoleptic (smell evaluations) of mouth air, nose air, and interdental plaque removed with dental floss.
The data showed a direct correlation between bad breath and the VSC content of mouth air. The surprising result was that only 23 subjects exhibited both periodontitis and moderate to severe levels of bad breath, compared to 52 subjects exhibiting bad breath with no clinical signs of periodontitis. Those with bad breath and no perio disease did have heavy accumulations of bacteria on their tongues. Bacterial growth, especially on the tongue, appears to be critical for the development of oral-related bad breath.
A subjective opinion that`s often incorrect
Dental hygienists also know that people are not objective about their own bad breath. Some people may incorrectly believe they have bad breath, while others with terrible breath do not seem to notice. What clinicians have learned from experience has now been confirmed through research. People are not objective about their own oral malodor.
Comparisons made between preconceived notions and objective measurements confirmed these discrepancies. Researchers in Tel-Aviv tested 52 subjects. First, they asked each person to rate their oral malodor. Then they had each person rate their own whole mouth, tongue, and saliva malodor levels.
For whole mouth scores, they were instructed to cup their hands over their mouth and nose, breathing out their mouth and in through their nose. For tongue measurements, they licked their wrist and then smelled it. In order to smell saliva, it was expectorated and held in a petrie dish for five minutes prior to smelling. As each individual progressed through these tests, an odor judge also made his evaluations. (How would you like the job of odor judge?) The judge and the subject did not share their scores. In addition to smelling for malodors, clinical indices, laboratory measurements, and psychopathological profiles were completed for each person.
Out of the 52 people tested, bad breath complaints were voiced by 43. However, objective as well as subjective evaluations did not correlate. The findings by the odor judges correlated strongly with measurements of VSC and clinical indices. But they did not correlate with the self-evaluated scores of the participants.
It seems that people are not objective about their own breath. Many people worry about bad breath, but don`t understand the importance of daily plaque removal.
Bacterial accumulations on the tongue are strongly associated with bad breath, and patients need to be aware of this link with oral hygiene. They also need to know what they can do about it. When thinking of bad breath, the general population first thinks of mouthrinses. Advertisers have been very good at promoting the fresh breath image for their products. In addition to masking bad breath, mouthrinses are capable of killing surface bacteria for a short time.
Routine mechanical removal of bacteria from the tongue, however, provides a longer lasting result. This is something people should do everyday. It is actually becoming a marketing tool for dental offices who advertise as, "Fresh Breath Clinics."
If someone is unaware of the necessity of tongue cleaning, they may very well have a heavy coating of bacteria on their tongue. Professional removal of this accumulation can provide immediate results. A "Fresh Breath Clinic," as they are advertised in the United States, uses a combination scraper-irrigator to deplaque the tongue. Rather than water to irrigate, chlorine dioxide is used, since it has been shown to neutralize VSC.
Daily deplaquing of the tongue can be done with gentle brushing, but some find this technique uncomfortable as well as ineffective. Tongue scrapers have been around for years, more as a novelty item than as a serious oral hygiene aid.
Most tongue scrapers are simple in design and easy to use. They are made of a flexible material, either metal or plastic. Similar in shape to a tongue blade, they are slightly longer and narrower. To use it, simply bend it into a "U" shape. Using both hands to hold the ends of the scraper, the curve of the "U" shape gently scrapes several times from the back of the tongue to the front. Other tongue scrapers have a spatula shape with a beveled edge for scraping.
There is no need for a specialty tool to deplaque the tongue. A teaspoon also works well. Another method involves a soft cotton washcloth wrapped around the index finger and gently wiped from the back to the tip of the tongue. The greatest accumulation is found on the back of the tongue, a difficult area to reach comfortably!
As this subject receives more attention in the research as well as in the general press, tools will be developed to aid both the clinician and the patients in deplaquing of the tongue. If you have an idea for a tool or machine for tongue deplaquing, this may be your opportunity as an inventor!
Trisha E. O`Hehir, RDH, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.