By Glenda Klaas, RDH, BS
As dental professionals, we know that the mouth is the entrance to the body. If halitosis is present, it's more than just embarrassing-it can affect overall health. Halitosis, or bad breath, affects 50% to 65% of the world's population.1 In spite of the high prevalence of bad breath, only a few patients seek treatment for it from their dental offices. But halitosis is a health concern that should be diagnosed and treated. Dental professionals hold the solutions for eliminating bad breath, so it is important for us to know what to look for and what questions to ask.
Halitosis can be caused by diet, habits, intraoral or extraoral conditions, or medications.
Halitosis can be associated with foods such as garlic, onions, or spicy foods, or with habits such as caffeine, alcohol, and tobacco.2 Cigarette smoking causes bad breath and contributes to periodontal disease and the healing process. Alcohol gives off a certain smell, and its dehydrating properties contribute to bad breath. Coffee causes bad breath because it is also dehydrating.
From decay to dry mouth, treating intraoral conditions can help patients control their halitosis. Special attention should be paid to the presence of nasal obstruction, mouth breathing, reports of snoring and sleep apnea, postnasal drip, allergies, tonsillitis, and tonsilloliths.3,4 It's up to us to educate our patients and to let them know that because of these conditions, they may also be dealing with halitosis. Patients might not know that they have bad breath because it affects their sense of taste and smell and also because other people might not tell them; most people don't know how to tell someone that he or she has bad breath.5,6 With the presence of bad breath, patients need to know where it is coming from, so they can protect their health and address the problem.6
A patient who learns that his or her periodontal condition is causing halitosis is more likely to accept treatment. When addressing halitosis, however, we need to do so in a kind and gentle way. No one wants to hear they have bad breath.
For example, you might say, "Mr. John, when I was cleaning the upper right, I got a bad smell from that area, and that worries me because it could affect your breath. Let's see if we can make that better by using flossers, interproximal brushes, and tongue cleaners." (Or, you can recommend whatever you think will help your patient.)
Extraoral halitosis is handled by treating the cause, which usually involves referring the patient to his or her physician for further investigation.2 However, with extraoral conditions, it is especially important to diagnose halitosis because this indicates the presence of gram-negative bacteria, such as P. gingivalis, P. intermedia, or T. denticola. These anaerobes produce substantial amounts of the volatile sulfur compounds (VSCs) found in breath.4 These volatile sulfur compounds increase the permeability of membranes and increase the inflammatory response.7
The volatile sulfur compounds found in breath include:
- Hydrogen sulfide-associated with poor oral hygiene and gingivitis. This gas is toxic and can inhibit the sense of smell and taste.8
- Methyl mercaptan-associated with periodontal disease and is the strongest-smelling volatile sulfur compound. The gas alters immunological compounds, leading to decreased healing, degraded collagen, and increased tissue destruction in periodontal pockets.8
- Dimethyl sulfide-associated with systemic, metabolic, and respiratory conditions. These gases produce bacteria capable of breaking down the amino acids cysteine and methionine. The odors produced are often compared to rotten eggs, fecal odor, and rotting cabbage.
Along with a complete medical history to identify systemic health issues, a list of the patient's medications should be taken. Some medications have an effect on saliva, causing halitosis. Saliva is also very important to fight halitosis because it removes particles from the mouth. In fact, patients who have dry mouth might have good hygiene but struggle with bad breath.
Knowing the cause is the first most significant step to overcoming this common problem. Assessing the issue with periodontal charting, x-rays, and a dental exam can help you to determine the cause and come up with an effective treatment plan to treat halitosis. However, some patients may need to be referred to their physicians for follow-up or treatment if halitosis is still present.
Depending on the condition or type of halitosis, the patient will need guidance about how to control his or her bad breath. Patients with dry mouth should be advised to stay hydrated. Chlorhexidine mouth rinses and mouthwashes with zinc are found to be effective, as well as natural herbs and spices, such as thyme, peppermint, sage, and cinnamon, just to name a few.6
In conclusion, knowing the cause is informative for the patient and important to his or her overall health since halitosis could be a sign of a systemic condition. Having these gases present does not tell us which disease is the culprit, but it does warrant further investigation with a physician or specialist (as this is not in our realm of practice). Halitosis is no longer only a dental issue-it is a medical one. RDH
Testing for halitosis
There is a new device on the market that tests the gases found in breath and can assist clinicians in diagnosing the cause of halitosis.3 The OralChroma is a gas chromatography device for measuring halitosis. Is there halitosis and if so where is it coming from? Oral hygiene, periodontal disease, or something systemic?
Using a small syringe, the dental hygienist takes a sample of the gases found in the patient's mouth and then places it into the OralChroma. Results are available in four minutes. The OralChroma is attached to a computer with data management software that collects the data and can help with tracking improvement. This is a great tool to use and can help with treatment case acceptance and home-care compliance. Offering OralChroma breath analysis can also generate revenue and bring new patients to your practice. Most importantly, though, it can help with finding the source of this embarrassing problem.
Before you perform a breath analysis for a patient, there are protocols to follow to ensure an accurate reading. About two hours before, the patient should take nothing by mouth-no mouthwash, gum or mints, garlic, onions, spicy foods, coffee, alcohol, or tobacco. Also, the patient should not be taking any antibiotics, which can distort the results.
Glenda Klaas, RDH, BS, practices clinically in Palos Heights, Illinois. She is also a part-time educator and consultant for Nissha USA. Her videos can be seen at OralChroma.us. She can be contacted at [email protected].
1. Badanjak SM, S. C. (2013, May 5). Oralchroma.
2. Badanjak SM. Halitosis in the absence of oral causes: Recent research on the etiology of non oral origins of halitosis. Can J Dent Hyg. 2012;46(4):231-237.
3. Salako NO, Philip L. Comparison of the use of the Halimeter and the Oral Chroma in the assessment of the ability of common cultivable oral anaerobic bacteria to produce malodorous volatile sulfur compounds from cysteine and methionine. Med Princ Pract. 2011;20(1):75-79.
4. Seemann R, Conceicao MD, Filippi A, et al. Halitosis management by the general dental practitioner-results of an international consensus. J Breath Res. 2014;8(1):1-7.
5. Heiligenstein M. Holy halitosis. Saturday Evening Post. 2014;286(6):100.
6. Marawar PP, Sodhi NKA, Pawar BR, Mani AM. Halitosis: A silent affliction. Chronicles of Young Scientists. 2012;3(4):251-257.
7. Cohen PR, Tschen JA. Tonsillar actinomycosis mimicking a tonsillolith: Colonization of the palatine tonsil presenting as a foul-smelling, removable, unilateral, giant tonsillar concretion. Int J Dermatol. 2010;49(10):1165-1168.
8. Greenman J, Lenton P, Seemann R, Nachnani S. Organoleptic assessment of halitosis for dental professionals-general recommendations. J Breath Res. 2014;8(1):1-9.