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by Kristy Menage Bernie, RDH, BS

Achieving Optimal Oral Health Through Oral-Malodor Management

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The American Dental Hygienists' Association defines optimal oral healthas a standard of health of the oral and related tissues that enable an individual to eat, speak, or socialize without active disease, discomfort, or embarrassment and which contribute to overall well-being and total health. Interestingly, the Canadian Dental Association recently adopted a similar definition. The origin of this definition is from the British Public Health authorities and is an all-encompassing one that includes consideration of comfort and social factors as well as disease status.

It is important to recognize that, by and large, the dental hygiene profession focuses on the disease status of the patient versus the social aspects. As a result, there has been a new interest in addressing social-related concerns, such as preventing/treating bad breath and smile enhancement. This article provides a step-by-step process of care for the dental hygiene experience that addresses oral malodor, including the prevention and verbal/clinical techniques hygienists can employ to broach the topic professionally.

The health history/patient update phase
Starting with the medical history review, clinicians should pay particular attention to complaints of malodor, especially if the odor has a fruity/acetone quality. This type of odor can be indicative of uncontrolled diabetes. Additionally, other systemic illnesses may have an odor component; however, most individuals suffer from oral/nasopharengeal-related odor. Some medications and foods also can lead to a transient type of odor that generally abates with time and can be masked temporarily by mouthrinses, chewing gum, or breath mints. Consequently, it is important to review medical histories in the event malodor is related to one of these causes.

The next area to evaluate includes determining the patient's usage of oral malodor-related products. For example, record the specific brand of toothpaste and mouthrinse and the times used per day. In addition, ask the patient about the use of breath mints, chewing gum, or breath sprays. It is critical to determine the specific brand used, since many breath-related products contain sugar. As with toothpaste and mouthrinse, it is important to record the frequency with which these products are used. This will give you a good idea of the patient's concern — voiced or not — about fresh-breath management.

The assessment phase
When performing a comprehensive periodontal examination, indicate that periodontal probing depths of 4 mm or more are areas from which bad breath emanates. These subgingival areas harbor gram-negative anaerobic bacteria, which not only produce endotoxins that destroy periodontal tissues, but also volatile sulfur compounds (VSCs), which are responsible for the odor component in bad breath. VSCs also increase mucosal permeability, thus increasing bacterial invasion. And they have been shown to interfere with collagen and protein synthesis, which may negatively impact wound healing. Involving patients in the charting process by allowing them to hear pocket depths gives them the opportunity to "count" how many areas are affected. This gives patients valuable information on the bad breath "potential."

Additional assessment can include oral cancer screening as well as an evaluation of the tonsil region for the presence of tonsilloliths. Tonsilloliths are calcified material and bacteria imbedded in the tonsillar tissue. These, as well as oral lesions, can contribute to oral malodor. An evaluation of the tongue — including the condition of the surface, areas of coating or debris, thickness, color, and texture — also should take place. The tongue coating can be four to six times greater in patients with periodontal infection, and the coating in periodontally healthy patients is the main source of bad breath. This assessment is important in that daily removal of the posterior tongue coating can effectively maintain fresh breath all on its own. An additional benefit realized through daily tongue deplaquing is a decrease of the oral flora and bacteria load, which may enhance overall oral health.

A final area that is routinely addressed, but perhaps missed in terms of its contribution to bad breath, is identifying restorations, crowns, and bridges that need replacing. These conditions represent ideal bacteria traps and need to be eliminated not only for their role in bad breath, but for optimal oral health as well. Motivating a patient via a "bad breath" elimination strategy can be very effective for treatment acceptance. Keeping the causes of oral malodor in mind during the medical history and assessment phases will set the stage for incorporating oral-malodor control strategies during the clinical phase.

The clinical phase
At the beginning of clinical care, many practitioners use preprocedural rinses to minimize exposure to aerosols containing oral flora. Antibacterial mouthrinses also will neutralize VSCs and begin the oral-malodor treatment, giving the patient an opportunity to taste recommended mouthrinses for the control of VSCs. Rinses should be used for 30 seconds prior to instrumentation.

Elimination of plaque and calculus certainly is the main goal in clinical intervention. Not only will this result in improved periodontal health, but it also will reduce the production of VSCs. Instrumentation alone can dramatically reduce malodor. Powered instruments in combination with an antimicrobial agent neutralize VSCs subgingivally while detoxifying the subgingival tissue of the periodontium. Regardless of your preferred instrumentation techniques, the benefit of meticulous accretion removal is fresher breath. This needs to be communicated to the patient.

The polishing phase of the preventive appointment is cosmetic in nature and should be performed selectively based upon the presence of stain. Once this has been completed, the next clinical intervention should be tongue cleaning. This new addition to the dental hygiene experience will be the most effective means of reducing oral malodor and communicating prevention strategies to your patients. The procedure should be performed with the patient observing in a mirror and with a tongue-scraping device.

Tongue scrapers have been proven to be more effective in removing greater quantities of bacteria as well as being a safer option for tongue cleansing. Two companies now offer clinical tongue deplaquing kits: ProActive Care Prophy Pak from Discus Dental, and Rembrandt Prophy Pro from Den-Mat. These products easily and economically facilitate the tongue-deplaquing process in addition to introducing patients to tooth whitening.

With the patient observing, apply an antibacterial tongue gel or spray to the surface of the tongue and have the patient extend his tongue. Position the scraper as far posterior as possible on the surface. Then engage the scraper, pulling forward and eliminating the debris via suction or on a 2"x2" gauze. This procedure not only represents a new addition to clinical protocol, but also segues nicely into oral hygiene recommendations and instruction. In addition, it allows for open dialog regarding bad-breath prevention.

The following statements can make it more comfortable to broach the topic in a professional environment: "Did you realize that simply cleaning your tongue daily will prevent bad breath?" or "We've added this important procedure to every dental hygiene visit, because we've learned that bacteria that cause periodontal infection and bad breath resides here on the tongue." This type of discussion may lead to more questions from the patient about bad breath and personal experiences with the condition.

Oral hygiene recommendations
It is well-known that the motivation behind any hygiene routine is social in nature. With this in mind, oral-malodor discussion provides a effective, emotional motivation for daily oral hygiene practices. With regard to bad-breath prevention, adequate daily plaque control — including daily tongue scraping — combined with chemotherapeutic agents to neutralize VSCs will result in prevention and treatment of oral malodor. No longer will flossing be about maintaining periodontal health, but about preventing bad breath. The inclusion of tongue cleaning in the daily routine will produce tangible results realized by the patient and clinician alike.

Bad breath is a major concern to consumers as proven by the billion-dollar breath-care industry. Currently, consumers are self-diagnosing and self-treating bad breath with products that actually could cause more infection and disease.

The role of the dental professional is clear: Recommend products that provide results and do not cause further harm. Basic guidelines for breath products include those containing zinc and those that do not contain sugar. Some clinicians also prefer those without alcohol. Most of the oral-malodor product options are only available through professional dispensing. This gives clinicians control over the products that are used by consumers, while affording them the opportunity to educate patients on the proper use of products.

Additionally, professional product dispensing provides a key patient convenience and establishes a consistency within daily and clinical care; you are making the same "clinical-strength" products available to your patients. This instills a sense of individualized care that differs from the mass-marketed products that may or may not be effective.

Finally, professional dispensing provides another avenue for production within the dental hygiene entity of the practice. Maximizing product availability is easily accomplished with professional product displays, use of promotional materials — such as manufacturer-supplied recall cards, posters, and statement stuffers — and clinical use of the products. These approaches avoid the "sales-pitch" impression, as well as provide the opportunity to communicate key information regarding product efficacy, use, and benefits.

Integrating oral-malodor management into every dental hygiene experience not only will provide clients with a well-valued service, but also potentially leads to an improvement in overall oral health. In light of concerns relating oral health to systemic health, it has become even more important to motivate patients to achieve and maintain oral health.

References available upon request.

Kristy Menage Bernie, RDH, BS, is the co-founder and owner of Educational Designs, a national meeting planning and corporate consultation company. As an active member of the ADHA since graduation, she is currently serving as president-elect of the California Dental Hygienists' Association and delegate to the ADHA. In addition, she lectures extensively on the topics of full-mouth disinfection and innovations in periodontal therapy, oral-malodor management, and esthetic dental hygiene. She can be reached at kmenageb@aol.com, or call (925) 735-3238.


Oral hygiene recommendations for fresh breath

  • Automated toothbrushes
  • Automated interdental devices
  • Active-agent impregnated floss
  • Tongue scrapers/deplaquing devices combined with antibacterial tongue gels or sprays
  • Neutralizng agent containing toothpastes, mouthrinses, mints, chewing gum, or other vehicle options
  • Avoid sugar-containing chewing gum, mints, or lozenges


Oral malodor facts

  • You get to wear a mask at work ... your patients, don't!
  • The billion-dollar bad-breath industry is an indicator that patients are self-diagnosing, self-treating, and willing to spend money for fresh breath.
  • Tongue deplaquing at every dental hygiene visit is the most effective means to "show" patients their bad breath and involve them in their oral care.
  • Probing depths greater than 4 mm produce VSCs and subsequent bad breath.
  • Over 80 percent of malodor is oral in nature.
  • Patients expect oral-malodor assessment by the dental profession.
  • Social factors are the primary motivation behind all successful hygiene routines.
  • Many breath-control products contain sugar and may increase the chance for other oral diseases.
  • Tongue deplaquing is one of the most effective means to maintain fresh breath.
  • Full-mouth disinfection protocol reduces bad breath more than standard scaling and root-planing protocols.


Active agents for neutralizing VSCs and/or impacting gram-negative oral flora

  • Zinc — the most recognized and effective VSC-neutralizing agent
  • Essential oils — known antigingivitis properties
  • Chlorhexidine gluconate — broad-spectrum antimicrobial agent that also neutralizes VSCs
  • Chlorine dioxide — known VSC-neutralizing agent as well as mild antimicrobial activity
  • Cetlyperadium chloride — known mild antimicrobial agent
  • Triclosan — known mild antimicrobial agent
  • Combination of above agents


VSC detection devices

PerioProbe 2000 by PerioDigm
Standard-configured periodontal probing device that is FDA-approved for detecting the presence of VSCs subgingivally and on the surface of the tongue. The device also includes a tongue paddle to measure VSCs on the posterior dorsum of the tongue.

BANA Test by OraTec
Chairside diagnostic tool for determining the presence of an enzyme produced by certain anaerobic bacteria. A positive BANA test has been correlated with the presence of VSCs.

Halimeter by Interscan Corporation
Volatile sulfur detection device used chairside to detect VSC content in the oral and nasal cavities.

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