Sir, your breath is regulated by United Nations Security Council mandates on germ warfare. Please

April 1, 1996
`Sir, your breath is regulated by United Nations Security Council mandates on germ warfare. Please don`t breathe until you`ve reached the desert.`

`Sir, your breath is regulated by United Nations Security Council mandates on germ warfare. Please don`t breathe until you`ve reached the desert.`

Actually, there`s a better way to say it...

Howard Strassler, DMD

It is called halitosis, fetorosis, and oral malodor. Most of us know it as plain and ordinary bad breath. At one time or another most of us have had bad breath, although no one will admit to it. Our patients are many times too embarrassed to ask what to do about it. In some cases, they are not even aware they have it.

Dental hygienists experience at least one patient a day where distance during treatment is desirable due to the foul odor emanating from that patient`s mouth. For these patients, both dentists and dental hygienists are usually hesitant to investigate and review the problem with them.

Is the mouth the culprit?

What is bad breath? What can our patients do about it? How can dental professionals give patients guidance in its causes and treatment? Bad breath, in many cases, has its origin from the mouth. In some circumstances, bad breath may be due to other causes. Bad breath is a sign or symptom and not an actual disease. It is important to identify not only the cause of the patients` bad breath but provide clinical recommendations for its control.

Although halitosis is caused mainly by oral conditions, not all cases of bad breath are from the mouth.

In some cases bad breath may be related to bacteria-causing infection in any of the respiratory passages - the sinuses, nose, or lungs. The most likely cause of bad breath from the respiratory tree is a bacterial sinusitis. Many of these patients have had this problem before and can acknowledge the presence of a post-nasal drip or other infected drainage.

The practitioner should also be aware that even an infection in the lungs can cause unacceptable odors. Lung infections are associated with coughing, and many times that patient smokes. In these cases, the patient should be referred. Successful diagnosis and treatment with antibiotics by a physician will cure the infections and the halitosis associated with it.

The tonsilar region adjacent to the oral cavity can also be associated with bacterial infection and can be responsible for the malodor. A clinical examination of the back of the throat can reveal either inflammation, enlargement, coating, and residual food debris, exuding pus or combinations of all these signs. With this information, the dental hygienist and dentist can refer the patient to a physician for a confirmation in the diagnosis.

Although very infrequent, tumors of the respiratory passages and upper gastrointestinal areas can cause bad breath. This odor will be more distinctive as the smell of decaying tissues. While it is not possible to see the lesions, a history of blood from the nose or throat will alert the practitioner.

Although very rare, systemic illnesses can be responsible for oral malodor. The odors from systemic conditions are usually a result of metabolic product breakdowns that are excreted through the bloodstream into the lungs. For these patients, the diagnosis of their problem in all likelihood has already been done through a physician.

Examples of oral malodor due to systemic medical problems include:

- Acetone breath from a patient that is an uncontrolled diabetic.

- A person with severe liver failure would be having bad breath that smells like rotten eggs and garlic.

- Someone with kidney failure would have a smell of ammonia.

Frequently, when one thinks of bad breath, the eating of foods, drinking of beverages, or smoking come to mind. In fact, the association of the degree of bad breath usually increases as one gets older. Children rarely have bad breath while older adults more frequently have offensive mouth odors. This may be in direct relationship with their dental conditions, to the oral habits, or smoking and drinking of alcohol-containing beverages.

Dining, wining, and smoking - it can add up

The foods we eat can contribute to bad breath. Foods high in garlic and onion content are the most serious offenders. Garlic, onions, and other spices are absorbed from the intestine, metabolized in the liver, released into the bloodstream, and excreted through the lungs and other routes - hence the odor of these foods coming from the mouth.

The wide diversity of ethnic backgrounds in the United States brings with it a wider diversity in diets and foods. Odors particular to a specific ethnic cuisine might be offensive to those not familiar with those foods. Individuals who have a similar diet might ignore or not even be aware of what was eaten recently.

Smoking and ingestion of alcohol-containing beverages may provide an odor offensive to some. In the last decade, a significant decrease has occurred in the use of some tobacco products and hard liquor in the adult population. Among teenagers, though, smoking and other tobacco usage is on the rise. Those who indulge will have offensive mouth odors that they will try to mask with mints and mouthwashes.

A patient`s dental condition also can lead to the presence of halitosis. Dr. Mark Kutcher, an associate professor with the University of North Carolina Dental School, recently wrote an article on halitosis. He stated that about 90 percent of the population had bad breath due to oral causes.

Research has shown that the primary cause of halitosis is the uncontrolled growth of gram-negative, anaerobic bacteria. These bacteria produce chemicals that evaporate quickly and are present in expired air. These chemicals - hydrogen sulfide, methyl mercaptan and other sulfur-containing compounds - are responsible for the distinctive odor of bad breath.

Before treatment can be initiated, a comprehensive dental examination (oral cancer exam, periodontal exam, and hard tissue exam) can help determine the dental causes of bad breath. Patients who have both poor oral hygiene habits and the presence of the odor-producing bacteria are susceptible to having bad breath.

Examples of oral conditions that are implicated with bad breath include:

- Large numbers of bacteria that combine with foods retained in nooks and crannies of teeth, restorations, and on the tongue.

- Periodontal disease, moderate to severe levels of caries, and endodontic and periodontal abscesses.

- Extensive dental restorations - including large amalgams, composite resins, crowns, bridges, and partial and complete dentures - which combine with poor oral hygiene.

Although the above are the most common oral conditions associated with bad breath, other contributing factors must be recognized and discussed with patients. The inherent dryness of the oral tissues, for example, can contribute to increased oral odors. Mouth dryness may be caused by breathing through the mouth, drug-induced xerostomia (decreased salivary flow), and xerostomia induced by radiation therapy.

Medical treatments causing decreased salivary flow may be unable to be altered. If the dry mouth is caused by medication, a discussion with the physician concerning alternate drugs may be helpful. In some cases, the dryness cannot be changed physiologically, but it will need to be considered when treatment recommendations are made.

Patients sometimes specifically complain that they have "morning breath." This condition has been popularized by manufacturers of mouthwashes. "Morning breath" can be due to several different causes. In most cases, though, patients do not brush adequately before going to bed, and this combines with a physiologic decrease in salivary flow while sleeping.

The presence of periodontal disease may exacerbate the "morning breath" problem. Another noteworthy point is that patients may be chewing antacid tablets before going to sleep. They do this to decrease stomach acidity and discomfort due to esophageal reflux, but one side effect is a highly alkaline environment in the mouth which can contribute to oral malodor.

How do you break the news?

Bad breath is an embarrassing condition. The halitosis patient may be unaware of its presence. A patient`s self- assessment of having halitosis is sometimes based upon an odd taste that they have in their mouth. Rosenberg and co-workers reported that individuals who are convinced that they have foul oral malodor many times do not. Self-estimation of bad breath can lead to obsessive behaviors, an avoidance of social interactions, and even reports of individuals contemplating suicide.

For this reason, discussions with a patient about the presence of the condition are very delicate. Halitosis is, in many ways, considered to be a "social disease." So the consultation between dental hygienist or dentist and patient concerning bad breath should be done seriously and professionally.

The assessment of the halitosis odor should be done in a professional way. In the most common clinical evaluation, the patient pinches their nose and either breathes into a mylar balloon or exhales at a distance of 10 centimeters from the evaluator. From the odor smelled, the evaluator scores the degree of foul odor. Either technique can be used for the practitioner to smell the odor or lack of odor from the expired air.

Patients can perform a self-assessment of foul odors by cupping their hands over their nose and mouth. They then breathe from their mouth in and out three to four times, inhaling through their nose to smell their breath. This technique has been described in dental literature so patients can evaluate their own bad breath.

Recently portable sulfide monitors have become available and are being used in some dental offices to compare before and after treatment results.

To rule out non-oral causes of bad breath, the dental professional can have the patient breathe in and out from the nose only for several cycles. From a distance of 10 cm, the practitioner can smell the odor, if any. Foul odors from the nose only are most probably of a non-oral source.

When foul odors of a non-oral source are determined, the patient should be referred to a physician for further investigation.

Diagnosis of oral condition pinpoints problems

Once the assessment has determined the presence of halitosis, the practitioner needs to develop a careful and thorough diagnosis based upon collected data, including the following:

- Review the patient`s history to determine the chief complaint of halitosis; past history with condition; current history of oral habits, oral hygiene regimen, diet, tobacco use, alcohol use, and medications; and medical history.

- Perform a thorough oral examination and charting - oral cancer exam, periodontal exam, and hard tissue exam. Examine the tongue to assess for coatings or a highly fissured or papillaed tongue.

- Collect other data such as radiographs and bacterial or fungal cultures when indicated.

With the information, a definitive diagnosis about the oral causes of the problem can be developed. A treatment plan can be developed that will correct the oral condition that controls the halitosis.

The treatment of oral malodor should be based upon the diagnosis and discovery of the causes. In most cases, the solution is based on good, sound dental treatment and care. The patient needs to understand the goals of treatment so that they can participate in the resolution of the problem. Since the cause of most oral forms of bad breath are bacterial, the patient must accept their role in the final treatment of the disorder.

A team approach to treatment

The dental hygienist and dentist must work as a team in the initial phase of treatment. All defective restorations must be replaced. If periodontal disease is present, it must be treated.

The patient must be shown and then be able to demonstrate their ability to maintain their oral health. For many of these patients a rotating mechanical brush and even a water jet device are effective tools in removing plaque and food debris. If the patient wears removable prostheses, then they have to be shown how to maintain these appliances.

Often, the cleaning of the tongue is neglected. The tongue harbors large amounts of bacteria and can contribute to oral malodor. The patient can be shown how to effectively clean their tongue either with a brush or gauze. A coated tongue or a highly fissured tongue can contribute to bad breath.

In cases where the patient has the diagnosis of a Candidiasis infection, it must be treated aggressively with systemic antifungal agents (Nizoral or Diflucan). The treatment regimen for Nizoral (ketoconazole) is 200-mg tablets, one time daily for two weeks. Diflucan (fluconazole) is one 100-mg tablet each day for 14 days.

If the patient uses tobacco products, eats spicy foods (garlic, onion, or other odorous spices), and/or consumes alcoholic beverages, counseling the patient to refrain from these products and foods can reduce the presence of oral malodor.

Xerostomic patients should be given instructions to use over-the-counter oral lubricants, sip water continuously during the day (most effectively done by the patient placing ice cubes in an insulated sip bottle and sipping the melted ice to reduce total water ingestion), and chewing sugarless gum to stimulate salivary flow. Sucking sugarless citrus candies also stimulate salivary flow.

Over-the-counter mouthwashes are a valuable adjunct to the in-office dental treatment of halitosis, as well as home care. Mouthwashes should not be used as the only solution to mask bad breath. Early in treatment, mouthwashes are important to the patient in camouflaging their bad breath.

Patients need guidance in selection of mouthwashes. Over-the-counter mouthwashes can be classified according to their uses. They either control caries, gingivitis, and bad breath. Mouthwashes can be further subdivided on whether they contain alcohol or not. The primary reason why people buy mouthwashes is to control bad breath.

Whether pleasant and minty or medicinal in flavor, research confirms these mouthwashes are effective in killing the oral bacteria responsible for bad breath. Cuiffreda and co-workers demonstrated significant reductions in oral bacteria after a 30-second rinse with both alcohol-containing mouthwashes (Listerine, Warner-Lambert; and Scope, Proctor and Gamble) and alcohol-free mouthwashes (Clear Choice, Bausch and Lomb; and Rembrandt Mouth Refreshing Rinse, Den-Mat). Statistically, Listerine and Rembrandt were equally effective in killing oral bacteria. These reductions of bacteria were for up to two hours after a single 30-second rinse.

When the practitioner recommends a mouthwash for bad breath they are no longer limited to alcohol-containing products. My own recommendation for patients with halitosis is that, for both odor control and for antimicrobial effects, a mouthwash should be used three times a day with an evening rinse before bedtime. I usually recommend an alcohol-free mouthwash. Alcohol has been shown in research testing not to be necessary for a mouthwash to have antimicrobial properties.

As of May 1, 1995, the American Dental Association required that all manufacturers of mouthwashes who want to display the ADA Seal of Acceptance place child resistant caps on products containing more than 3 grams of alcohol. These products also display a warning label about keeping the product within "the reach of children." "This product contains alcohol. Do not swallow. Use only as directed."

Listerine, a mouthwash with approximately 26% alcohol, has the ADA seal for acceptance in the treatment of gingivitis. Their containers are available in both child-resistant caps and standard caps for adult-only households. These bottles are clearly labeled.

With a thorough understanding of the problem, patients will accept the treatment plan. Periodontal therapy, restorative treatment, and good oral care will help the patient control their problem. When the patient sees the positive results of treatment in combating their problem, they will be more accepting of the follow-up phase of treatment.

The follow-up phase of treatment is just as important. The patient needs continuous evaluation to prevent the return of their problem. Additional periodontal and restorative treatment may be necessary to keep halitosis under control.

The dental hygienist plays an important role in the monitoring of any recurrence of the problem, as well as evaluating and reinforcing the oral hygiene techniques the patient needs to do to continue to be successful.

Halitosis is a common oral condition. Even though bad breath may be due to non-oral conditions, malodor is dentally related in most cases. With a comprehensive evaluation and diagnosis that is combined with a well-laid out treatment plan, patients can obtain successful treatment for bad breath.

To guarantee long-term success, the dental team must be understanding and professional when addressing the problem of oral malodor. The patient must also be motivated so they can play their role in the achievement of oral health with no bad breath.

Howard E. Strassler, DMD, FADM, is a professor and director of operative dentistry at University of Maryland Dental School in Baltimore. Dr. Strassler has been involved in clinical studies with oral care products and the microbiologic assessment of the effectiveness of commercial mouthwashes.