Take My (Bad) Breath Away...

Aug. 1, 1999
Because of new links with periodontal conditions, the patient`s `need` for routine treatment of oral malodor is validated.

... please?

Because of new links with periodontal conditions, the patient`s `need` for routine treatment of oral malodor is validated.

Kristine A. Hodsdon, RDH, BS

A woman was beginning to cook a roast for dinner. Her spouse, helping prepare the meal, noticed that his wife cut off the two ends of the roast before placing it into the pan. He asked, "Honey, why did you cut off the ends of the roast before you placed it into the pan?" His wife responded, "That`s the way my father always did it when he prepared dinner. I will ask him why he cut off the ends when he arrives for dinner."

Later that evening, when her father arrived for dinner, the wife asked him to explain why he had always prepared the roast with the ends cut off. Her father stated that he learned that by watching his mother. The wife then turned to her grandmother and repeated the question. Her grandmother said, "The reason I used to cut off the ends of the roast before I would cook it was because it did not fit into my pan."

In the dental and dental hygiene professions, many appointments are structured around the disease-centered model or old-practice paradigms, rather than the social- or client-based approach.

Oral health care professionals have a solid academic background, and a majority of education has been founded in research and proven results. We focus on what textbooks define as healthy. Throughout my career, I have been skeptical of many of the changing or newer (now acceptable in the mainstream) hygiene practices when they were first introduced. I held on to my past beliefs and academic standards with a vengeance. For example, when a multilevel toothbrush was first introduced, how many of us would acknowledge its effectiveness? In retrospect, many of my clients came into my treatment room with questions about the newer designs, with a reinforced passion for brushing, and with healthy results. Perhaps these successes were subjective and nonqualifiable, but the client`s oral health fell "within normal limits." Similar areas of controversy have been the efficiency of automated toothbrushes vs. manual toothbrushes, selective polishing vs. full-mouth polishing, and the integration of personal protective equipment and infection control standards. With the growing volume of knowledge that links many systemic conditions to the health of the oral cavity and vice versa, it is more important than ever to establish a successful oral health program. This program must have a foundation based on what motivates clients, rather than controlling clients and determining for them what they should want to achieve for their own oral health.

As clinicians, can we validate the needs of our clients by listening to their concerns and asking ourselves how we meet their needs, both spoken and unspoken? What motivates the proverbial Mrs. Jones? Answer: A great smile and fresh breath. She may not be as interested in her "pocket depths" as you are. However, when you deplaque her tongue and allow her to see the food and bacteria that sits on her tongue, that will excite her more than beginning a discussion about "the migration of her epithelial attachment." Progressive clinicians need to rethink the traditional disease-model paradigms as a means to motivate the client. Instead, present treatment and management options that interest and actively involve the client.

Over 80 percent of malodor cases stem from oral-related sources. Oral malodor is a direct result of gram negative anaerobic bacteria and accumulated food debris. These bacteria are responsible for the production of volatile sulfur compounds (VSC), byproducts of the putrefaction process of gram negative anaerobic bacteria. VSC have distinctive related odors. There have been four types of VSC identified as the primary odor-causing compounds: hydrogen sulfide, which is associated with clients who are periodontally healthy; methymercaptan, which is associated with periodontal patients; dimethyl sulfide; and dimethyl disulfide. By dramatically reducing pathogens in the oral cavity, the major source of oral malodor is eliminated. Instead of masking, we actually remove the cause of the odor.

Research is moving in the direction of assessing the link between VSC and their role in periodontal infection. The presence of VSC has been shown to increase the breakdown of oral mucosa, increase bacteria invasion, increase the permeability of the gingival sulcus, interfere with the collagen and protein synthesis, and may have an important role in periodontal disease progression and management. Practitioners have often coined the phrase "perio breath," as it relates to patients who have active periodontal disease. Now we can begin to support such conclusions by acknowledging that oral malodor is a side effect of periodontal disease.

To further define the correlation, pocket depths of 4 mm or more provide the ideal environment for growth of odor-producing bacteria. In addition, the precursor of methylmercaptan, methionine, is found in excess in infected pockets. Cervical fluid that shows an increase in methionine may lead to an increase in VSC which, in turn, directly influences the causative nature of malodor. As more research becomes available, oral malodor treatment and management will find its way to the diehard periodontal-based clinician, who will continue to present the healthy vs. unhealthy model to patients. It will evolve into a science with more significance than just the social concern of clients. Informing clients of the periodontal disease and oral malodor connection will go far in encouraging them to become actively involved in their daily oral hygiene routine.

Oral malodor can be broken down into two subgroups: transitory and chronic. Transitory may last between 24 and 72 hours and is usually caused by foods such as garlic, pepper, and onions. Everyone has had an episode with transitory malodor at one time or the other. Chronic oral malodor is usually oral in nature. Seven common malodor sources that have been identified include:

- mouth and tongue

- nasal, nasopharyngeal, sinus, and oropharyngeal

- xerostomia-induced

- primary lower respiratory tract and lung

- systemic disease

- gastrointestinal disease and disorders

- odiferous ingested foods, fluids, and medications

Treatment of transitory malodor can be managed through the use of breath mints, chewing gum, and breath sprays. Avoidance of causative food sources (onion, garlic, and alcohol) will also eliminate this malodor source. Gastrointestinal, systemic, and lower respiratory tract and lung diseases make up a small percentage of malodor conditions. A careful review of the client?s medical history will be helpful in identifying these types of malodor cases. These sources will not respond well to oral hygiene methods and a medical evaluation may be indicated for these clients. For clients with nasal or sinus malodor sources, it may be important to involve an ear, nose, and throat specialist or an allergist. Xerostomia as an inducer of malodor may be u decreased with the use of artificial saliva or saliva substitutes.

Oral malodor assessment is a discipline at the conceptual level. However, we can provide real value measures at the practical level to assist our clients in maintaining periodontal health and address their social concerns. The best practices in the prevention of oral malodor are through a process of daily management. This daily routine combines mechanical plaque removal (tongue deplaquing) with the use of chemotherapeutic agents. Oral health professionals understand the importance of mechanical removal of bacteria and food in the maintenance of periodontal health, so the shift to the management of malodor should be easily acceptable. Often we feel comfortable only presenting the disease model in an attempt to inspire our clients rather than the social model. However, social concerns (smell good, look good) are the primary motivation behind a successful daily oral hygiene routine. A combined approach of our clinical expertise and social Ohot buttonsO will be most effective in the management and control of oral malodor.

Research and development have opened doors to advances necessary to expand treatment modalities for the preventive appointment. The explosion surrounding the billion-dollar cosmetic/antiaging industry, coupled with clinicians focusing on clients? social and esthetic motivators, will aid in the understanding and diagnosis of clients. Oral malodor assessment, management and prevention include the total system of toothpaste, mouthrinse, subgingival irrigant, breath spray, mints, gum, and tongue deplaquing as combinations of remedies for our clients. Chemotherapeutic, herbal, and essential oil therapies are wonderful additions to our periodontal therapeutic armamentarium and have a positive periodontal effect in addition to powerful breath control. By applying a client-centered approach or focusing on the needs and desires of clients, we are changing the rules and possibilities of our profession.


* Position Paper of the American Academy of Periodontology: Periodontal disease as a potential risk factor for systemic disease. Journal of Periodontology 1998;69 (7): 841-850.

* Tonzetich, J, Production and origin of oral malodor; A review of mechanisms and methods of analysis. Journal of Periodontology 1997;48(1); 13-20.

* Messadi D, Oral and nonoral sources of halitosis. California Dental Association Journal 1997; 25 (2);127-131.

* Bernie K, Principles of Aesthetic Dental Hygiene; A Patient-Centered Approach. Access Supplement 1999; 2-8.

* Christensen G, Why clean your tongue? Journal of the American Dental Association 1998;129(11);1605-1607.

* Nachnani S, The effects of oral rinses on halitosis. California Dental Association Journal 1997;24(2);145-150.

Kristine A. Hodsdon, RDH, BS, lectures nationally on Supportive Esthetic Dental Hygiene, Knowledge-Sharing Management and Fresh Breath Assurance. She is a published author and holds an adjunct dental hygiene faculty position at the New Hampshire Technical Institute. She currently serves on the New Hampshire Board of Dental Examiners and has managerial and clinical responsibilities in an esthetically oriented restorative practice. She also consults with dental manufacturers on new product developments. Her e-mail address is [email protected].

How to talk about breath in the office

Integrating oral malodor assessment in the dental hygiene experience can easily be accomplished. A careful dialogue with the client is necessary for a definitive diagnosis. This should include a comprehensive health, oral, behavioral, and social history; extraoral and intraoral examination; full-mouth periodontal examination; caries evaluation; charting of oral health status; and an assessment of the client`s use of oral malodor products such as chewing gum, mints, mouthrinse and breath sprays. This will give the oral care provider insight into related oral health conditions, especially if the client is using products that contain sugar or alcohol frequently throughout the day.

The clinical management of oral malodor should include the reduction of bacteria and VSC. A combined protocol that includes mechanical debridement with chemotherapeutic agents will provide clients with healthy results. The familiar standards of treatment, such as pre-post procedural rinsing, scaling and root planing, and subgingival irrigation/full-mouth disinfection should be employed. However, in addition to traditional methods of plaque control (for example, manual toothbrushing), clinicians need to address areas of the oral cavity, such as the tongue, that retain bacteria and instruct clients on daily cleaning procedures. Daily tongue hygiene removes food debris and bacteria. It decreases the periodontal pathogens as well as the odor-producing bacteria. Reduction of bacteria from the oral cavity will go far in helping to control disease. By deplaquing the client`s tongue during oral hygiene instruction, the clinician provides an excellent visual stimulation in the education process.

Chemotherapeutic products such as mouthrinses, toothpastes, tongue gels, and breath mints/gum are popular with clients. As practitioners, we need to accept and be familiar with the options available. Professionals should encourage clients to choose products that are alcohol-free and sugar-free and that contain an antibacterial agent known for its effectiveness in controlling oral malodor. Ideally, instead of just reducing bacteria, we would like to be able to stimulate regeneration of damaged, diseased tissues as well. Agents such as chlorine dioxide act by neutralizing VSC. Essential oils, such as thymol (which is a derivative of Red-Thyme; its action includes a powerful bactericide, antiseptic, and immunostimulator) and eucalyptol (a derivative of the essential oil of Eucalyptus), aid in tissue congestion. Zinc chloride will affect bacteria cell walls and neutralize VSC. Other antimicrobial players in this area may also prove to be effective in oral malodor control.