Operation of bad breath clinicsMirdza Neiders, DDS, MSVBrigette Ramos, DDS"

The diagnosis and management of bad breath can be easiiy incorporated in routine dental care by attend-ing dentists. This articie ouliines the information necessary tc establish a differential diagnosis of oral mal-odor This indudes evaluation of medical, dental, and haiitosis history it also includes the examination ofextraoral and intraoral tissues and a thorough periodontai examination. The presence of bad breath is es-tablished with organoieptic and hydrogen sulfide-monitor (Halimeter) measurements. The treatment ofmaiodor resuiting from orai overgrowth of anaerobic organisms in the oral cavity consists of mechanicaland chemical reduction of the microbial flora by methods that are supported by scientific evidence.¡Quintessence Inf 1999:30:295-301)

Key words: bad breath clinics, cfilorfiexidine, Halimeter, oral malodcr, fongue scraping

The dental profession's response to patients' com-plaints of bad breath has been very slow to de-

velop. A literature survey of 20 years ago revealed suf-ficient information to determine that the major causeof bad breath is oral organisms that produce volatilesulfur compounds (H.S and CH.SH)' and that thismaiodor can be controlled by cleaning the teelh andtongue.'"'' Recent reldndling of the concern about oralmaiodor^"' has revived this area of concern in the den-tal profession.

Several clinics that specialize in oral maiodor as aprimary complaint have been established. Such clinicsprovide diagnosis and treatment to those patients whocannot obtain this service from their attending dentist.These clinics also provide clinical research in diagno-sis and treatment of oral maiodor and can function astraining sites for dental students and practitioners.

'Professor, Department of Oral Diagnosis, Scfiool of Dental Medicine,Sfate University of New Vork al Buffalo, Buffalo, New York.

"Clinical Instructor, Departmenf of Oral Diagnosis, School ol DenfalMedicine, State University of New York at Buffalo, Buffalo. New York.

Raprinf requests: Dr Mirdza Neiders, Professor, Departmenl ol OralDiagnosis, School of Dental Medicine, State Uniuersity of New York atBuffalo, South Campus, Buffalo, New York 14214. E-mail: mirdza_neidersS sum. buffalo edu

Another approach is to incorporate the diagnosisand treatment of oral maiodor in the routine care ofeach patient. This approach is compatible with thegeneral practitioner who practices comprehensivedental care. It is more efficient because some of the di-agnostic procedures and treatment modalities requiredfor oral maiodor overlap diagnosis and treatment ofother oral diseases.

This article outlines an approach to diagnosis andtreatment that has been developed by the authors. It isapplicable to clinics that are developed solely fortreatment of bad breath as well as to practices thatprovide total patient eare.

PATIENT HISTORY

Chief complaint

It is important to determine initially whether the com-plaint of bad breath is a primary reason for seekinghelp or if it is one of several complaints that a patientbrings to the clinician. Complaints about disturbedtaste should also be noted. Some patients assume that,if they have bad taste in their mouth, it is the result ofa substance that is volatile and can be perceived byother people. However, taste disorders may be due toother causes.̂ In many cases, taste dysfunction may becaused not by problems with taste but by alterations inthe perception

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Medical fiistory

Medical history cart be obtained by itsing standardself-reported health questionnaires, but self-adminis-tered questionnaires are often significantly insufficient.It is imperative that a personal dialogue be combinedwith a detailed questionnaire.'"

Particular emphasis should be placed on a thor-ough history of nose, nasopharynx, and sinus diseases.In one study," in approximately 8% of patients withbad breath, the odor was found to be caused by tonsil-litis, sinusitis, or a foreign body in the nose. There areanecdotal reports of tumors in the respiratory tractthat produce malodor that emanates from the oraleavity.'- Facial injuries, cosmetic surgery, radiation,and chemotherapy may affeet the olfactory epitheliumlocated on the dorsal aspect of the nose, the nasal sep-tum, and superior turbinatc. This may result in alteredtaste and smell."'' A history of gastrointestinal dis-eases, such as gastritis, or duodenal and gastrie ulcers,has also been found in some patients with oral mal-odor,'̂ but a relationship has not been established.

The patient should be asked ahead to bring in allmedications. Each medication must be evaluated forpotential contribution to bad breath. Medications canresult in the produetion of hody odor and ean also dis-tort perception of taste and smell.'" These include an-timicrobial agents, antirhcumatic, antihypertcnsive,and psychopharmacologic drugs.

Many drugs produce xerostomia, and it is suspectedthat bad breath is inversely related to salivary flow.̂ '̂"*The drugs that produce xerostomia include analgesics,anticholinergics, antidepressants, antihypertensives,psychotherapeutics, and numerous others." Othercauses of xerostomia, such as Sjögren's syndrome andradiation therapy, also have to be evaluated.

Antibiotics suppress the oral flora that producesbad breath, so that patients who are undergoing an-tibiotic therapy cannot be evaluated for oral malodoruntil after their antibiotic regimen is completed.'

Dental history

A standard dental history can be used to evaluate thepatients' past dental treatment and oral eare. This his-tory can be used to identify those patients with badbreath who come to the dentist for routine care. Inour experience, a significant portion of patients re-spond positively to the direct question in a question-naire, "Do you feel you have bad breath?" The direetapproach sometimes can identify patients who feel tooembarrassed to bring up the subject.

A detailed history of oral hygiene habits is requiredto assess tbe patient's education, ability, and commit-ment to the maintenance of oral hygiene. The patient's

frequency of brushing and flossing, use of mouthwash,types of toothbrushes and toothpaste, is useful infor-mation for improving oral care.

Diet and tiabit history

Habits such as alcohol and tobacco use can contributeto bad breath, as can odoriferous foods, such as garlic,onion, and some ethnic foods.'" A careful record of thediet may be necessary if the patient or the examinerbelieves that the bad breath is related to food intake,'*

Oral malodor history

Direct interview is the most informative means of as-sessing the history of bad breath, it is important to de-termine how the patient concludes that he or she hasbad breath. It has been established that self-assessmentis a relatively poor way for a patient to assess his or herown oral malodor.''* Another major problem ariseswhen the patient imagines he or she has bad breath,and the examiner cannot detect malodor.̂ ''• '̂ In thiscase, it is a great help if there is a confidant of the pa-tient who can corroborate the patient's observations,'

The history of how long the bad breath has beenpresent, whether it is associated with certain periodsof the day, and whether certain activities reduce theoral malodor helps to further define the problem. Theeflect of bad breath on the patient's life also has to hedetermined. Other history items that may belp are fur-ther evaluation of the extent of the patient's concern,whether the patient has sought professional help, andwhether the suggestions and treatment have helped. Italso has to be determined what steps the pafient istaking every day to minimize the oral malodor.

EXAMINATION

Extraoral examination

A thorough extraoral examination may eliminate fromconsideration some extraoral causes oí bad breath.Infection or tumors in the oropharynx may produceenlarged lymph nodes. Salivary gland swelling can re-sult in xerostomia or drainage of purulent material.The patency of nasal passages can be established byhaving the patient pinch one nostril closed and blowthrough the other nostril.

Intraoral examination

Intraoral examination consists of an assessment of allabnormal findings of oral soft tissues as well as teeth.Radiographs may be necessary to evaluate carious ex-

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tension in the pulps of the teeth. Cases have been doc-umented in wbich soft tissue or endodontic lesionshave caused oral malodor.

Examination of tbe tongue may reveal a potentialsource of bad breatb. Tbe amount of tongue coatingmay be related to the degree of oral malodor. In addi-tion, anatomic variations may contribute to the indi-vidual's inability to keep the tongue clean. Tbe tongueappears to be the principal contributor to oral mal-odor in periodontally healthy individuals.^-^^^

Periodontal examination

Deposits of oral microorganisms in the plaque onteeth-'' or in periodontal pockets'"' may contribute tobad breath, although other studies question therelationship between periodontal disease and oralmalodor* Nevertheless, it is necessary to evaluate theextent of plaque, gingival inflammation, and periodon-tal disease present in each patient. We use PeriodontalScreening and Recording'*' as a method for evaluationof periodontal disease. The gingival index used is thatdescribed by Loe and Silness.-' The plaque index'" isusually performed after the measurements of oral mal-odor, because the use of disclosing solution may effectoral malodor levels.

Assessment of oral malodor

Many clinicians have noted that eating, drinking, andoral hygiene procedures decrease the amount of badbreath. Therefore, the patient should refrain from drinli-ing, eating, chewing, rinsing, gargling, and smoldng forat least 2 hours before appointments.' Patients sbouldalso avoid using scented cosmetic products before ex-amination. Our new patients are generally examined inthe morning prior to eating and performing oral hygieneprocedures. Patients who are taking antibiotics are seen2 weeks after discontinuation of tbe medication.

Bad breath is assessed organoleptically (sniff test) ona 5-point scale, as described by Rosenberg et a!.'̂ Bothmoutb air and nasal air are evaluated.'^ Tongue odor ismeasured by scraping tbe dorsal surface with a plasticspoon and smelling its odor.' The supragingival plaqueodor is estimated by passing floss through interproxi-mal contacts of molars in all 4 quadrants of teeth.Measurements of volatile sulfur compounds of mouthand nasal air are aiso made witb the Halimeter(InterScan).

DIFFERENTIAL DIAGNOSIS

The history, physical examination, and bad breath as-sessment determine whether bad breatb is present or

not and whether it is of oral or nonoral origin. If nomouth odor is present, another appointment is madefor reexamination for the presence of bad breath. Iftbe odor is nonoral in origin, an appropriate referral ismade. In some cases, additional data, such as dietaryhistory, determination of xerostomia, or a more exten-sive examination of the teeth, have to be collected. Inmost cases, the clinical impression will support theoral origin of tbe bad breath. To confirm diagnosis, apatient is assigned to a brief (7- to 14-day) intensivetreatment schedule and reexamined after this period,A definite diagnosis of bad breath resulting from oralcauses is confirmed if, following tbis treatment, thereis substantial reduction or absence of oral malodor.

TREATMENT

There is wide agreement tbat bad breath originating inthe mouth is due to overgrowth of oral microorgan-isms, particularly anaerobic bacteria that producevolatile sulfur compounds and other volatile com-pounds.'''^^" Therefore, the treatment is focused onmechanical and chemical reduction of the total loadof oral microorganisms in the oral cavity.

Mechanical reduction of microorganisms by im-proving oral hygiene procedures has been associatedwith a reduction of malodor^ Particular empbasis hasbeen placed on tongue-cleaning methods."--^ Tbere isample evidence in the literature tbat mechanical meth-ods used to reduce the number of microorganisms intbe oral cavity reduce oral malodor-'*-"'" Both pro-fessional and oral hygiene procedures play a key rolein controlling oral malodor.

Chemical reduction of microorganisms may be ac-complished by mouthwashes. The main use of mouth-washes hy the patient is to control bad breath." Thereis no scientific evidence of the ability of many motitb-wasbes to reduce tbe number of microorganisms orbad breath. Mouthwashes are considered cosmeticproducts, and studies of the efficacy and safety neednot be provided by the manufacturer. Some productsmay act by masking the oral malodor, but such mask-ing acts only for a brief period."'̂ ^ This approacb doesnot deal with the etiology of bad breatb.

Evidence of antibacterial activity of a mouthwashor agent used in the mouthwash can be obtained fromstudies on plaque reduction in vivo. If a product is an-tibacterial, it is assumed that the product will also de-crease the number of microorganisms that producemalodor in the oral cavity. One of the most effectiveagents for plaque reduction has been chlorhexidinegiuconate, used as a rinse,̂ ^"'* The major problem withthis agent is that it results in extrinsic staining of teeth.Addy et aP^ have proposed that such staining is

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caused by a local precipitation reaction tbat occursbetween tooth-bound chlorhexidine and chromogensin food and beverages. Limiting the drinking of teaand coffee immediately after the use of chtorhexidinemay control chlorhexidine-associated tooth staining.'"

Other agents that have been effective in reducingplaque bave been essential oils that arc used inListerine (Warner-Lambert)."*"-" Triclosan-containingmoutbrinses are popular in Europe and have beenfound to be effective in plaque reduction in severalstudies."**^

Another metbod to evaluate mouthwashes as an-tibacterial agents is to determine the effect of themouthwash on tbe ability to reduce salivary bacterialcounts,•'̂ ••'̂ In sucb studies, cblorhexidine bas beenmost effective, but triclosan and zinc cbloride (insome formulations) also sbow some reduction in sali-vary bacterial counts over saline controls.''''

Tbere are relatively few studies on reduction of oralmalodor by moutbwasb products, and most of thesearc for periods of less than 3 hours.'= It has beendemonstrated that chlorbexidine gluconatc'" rinsesand Listcrinc'"' reduce oral malodor for 3 to 6 boursafter use. New mouthwashes are currently being devel-oped for reduction of oral malodor.-'̂

For a large number of moutbwashes that are beingsold over the counter to reduce oral malodor, tbereare no scientific data as yet available to demonstratetheir efficacy in reduction of plaque, salivary bacterialcounts, and/or reduction of malodor. It is quite possi-ble that tbese mouthwashes possess mechanisms tbatreduce oral malodor, but witbout scientific evidence oftheir effectiveness in vivo, recommendation of tbeseproducts by the dentist or hygienist is problematic.

Other orai care products, such as toothpaste,'* arealso being investigated for the control of oral malodor.In several years, tbere may be data on a number ofsafe and effective options tbat can be used to supple-ment oral hygiene procedures in tbe control of oralmalodor.

Our approach to treatment consists of reevaluating,in detail, tbe oral hygiene procedures and reemphasiz-ing tbe proper use of tootbbrushing techniques (2times a day for 2 minutes) and flossing (once a day).Tbis is done witb the help of the disclosing solution.Particular emphasis is placed on cleaning the tonguewith tongue serapers. Cblorhexidine gluconate(0.12%) rinses are prescribed for use twice a day afterthe completion of the mechanical procedures. To ex-pose the tongue to chemical treatment, gargling isrecommended.'"

If professional prophylaxis is required, it can beperformed before, at the same time as, or shortly afterthe chlorhexidine mouthrinse is prescribed to thepatient.

To confirm the clinical diagnosis of bad breath re-sulting from oral causes, a patient is reexamined 7 to14 days after the orai bygiene regimen is initiated. Thisexamination should include tbe patient's report on theeffectiveness of the procedures on minimizing badbreath, a confidant's response (if available), evaluationof gingival and plaque indexes, and the assessment ofbad breatb. Tbe patient again is instrueted not tobrusb or floss on tbe morning of tbe appointment andnot to eat or drink before tbe appointment.

If tbe bad breatb is due to oral causes, and tbe patienthas complied with the oral hygiene procedures, a signifi-cant or total reduction of the positive measurements ofbad breatb can be expected. At this time, adjustments inthe oral hygiene regimen can be made to establish long-term control. Other dentai diseases tbat may contributeto the generation of bad breath, sucb as periodontal dis-ease, carious lesions, and involvement of pulp, must betreated to establish health in the oral cavity.

PROBLEMS

In several years of operation of the elinic, we haveencountered situations that have given us concerns.Some of the problems and our management of theseproblems follow.

Attitude of dental profession

In general, tbe dental profession is not yet very sympa-thetic toward the patient who eomplains of badbreath.•"~ It may be tbat dentists do not perceive oralmalodor as being as common or as intense as it is.Patients usually perform the most meticulous oral by-giene before going to a dentist, and thus tbe dentistmay underestimate the problem of tbe patient's oralmalodor.

The dentist also may extend this lack of concernabout oral malodor to other dentists who are commit-ted to helping patients wbo bave bad breath. Any pro-fessional becoming involved in managing breatb disor-ders may have to be prepared to receive some negativecomment from some dentists. Increased education ofdentists and dental students about patients' concernwith oral malodor may result in the conclusion tbatthe dental profession should diagnose and treat oralmalodor. Some patients we have seen in tbe clinicshave undergone extensive testing, including gas-troscopy, in their quest for identifying the cause of badbreath. Some are using products that have not yetbeen evaluated for safety and efficacy. Because, in tbegreat majority of patients, bad breatb is tbe result oforal causes, oral malodor should be tbe concern of thedental profession.

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Patients requesting a specific treatment

There has been an enormous increase in advertisingfor remedies for bad breath on the Internet, ontelevision, and in lay journals. There also have heennumerous informational articles on halitosis in laymagazines. This has raised the level of information,as well as misinformation, about bad breath amongthe patient population. It is not unusual for a patientto request a specific type of equipment forexamination or a specific treatment for oral mal-odor. These requests may include products that haveonly the manufacturer's claims to support theeffectiveness.

It is the dentist's obligation to inquire into the truthand accuracy of such claims. Caution has to be exer-cised before glowing reports of manufacturers about aproduct are accepted without verification by indepen-dent researchers. The major concerns are to protectthe patient's safety and to determine whether theproduct is effective for the proposed use. The dentistshould refer to articles published in peer-revieweddental journals to determine whether informationabout a particular product is available. The patient hasto be informed that the treatment given by the dentistis based on scientific evidence. Patients who dictatethe methods of diagnosis and/or treatment may notreceive the best management of oral malodor that canbe given by the profession.

Patients without bad breath

Most patients who complain of bad breath who areexamined in the morning prior to eating and oral hy-giene procedures have malodor that can be identifiedby organoleptic testing and/or by the hydrogen sul-fide monitor (Halimeter). However, in some patientswho believe that they have bad breath, a maiodorcannot be detected by established testing pro-cedures,"'' Before the diagnosis of imaginary halito-sis or delusional halitosis is made, the patient is wellserved by receiving a repeat examination. Also, if thepatient brings along a friend or relative who canmonitor the appearance of bad breath, it may help inassessing the patient's prohlem. Altered taste may re-quire further work up, as will be discussed in the nextsection.

There are a number of patients who do not havebad breath but who exhibit excessive fear of havingbad breath. These patients may have a variety of psy-chopathologic symptoms,''̂ and the most severe casesmay fit body dysmorphic disorder,'" The managementand referral of these patients can be quite difficult.Treatment should never be instituted if the diagnosisof oral malodor cannot be made.

Patients compiaining of bad taste

Complaints of bad taste may be the result of impairedor altered gustatory and/or olfactory function," Bad oraltered taste may be due to oral causes, such as oralinfections, periodontal disease, candidiasis, dental ap-pliances, or poor orai hygiene,' These conditions maybe accompanied by oral malodor, and the bad tastewill disappear when the disease has been eliminated.

The problem patient is the patient who eompiainsof bad taste without any evidence of oral malodor ordental disease. The reasons for altered taste (dysgeu-sia) or altered smell (dysomia) are many. These includesinusitis, lesions in the nasal eavity, head trauma,surgery to nose or adjacent structures, chemotherapy,radiation therapy, salivary dysfunction, mouthwashes(including chlorhexidine), gels, dentifrices, and numer-ous medications,*''•' Also, bad taste is an importantciinical finding in patients who have trimethyiamin-uria,'- This disease is a rare entity in which a volatiletertiary amine with a fishlike odor is excreted in urine,saliva, and sweat. Referral of patients with trimethyl-aminuria to appropriate centers that deal withchemosensory problems may be appropriate.

Failure to reduce oral malodor after initial treatment

The patient with a diagnosis of oral maiodor resultingfrom oral causes should respond to some degree afterinitial treatment with improved oral hygiene of teethand tongue and use of chiorhexidine rinses. If thisdoes not occur, further evaluations have to be made. Ifboth patient and examiner feel that, regardless of rig-orous oral hygiene procedures, there has been no im-provement, it is likely that the malodor is not of dentalorigins. The most likely reason for persistence of mal-odor is associated with the nose and sinuses," If this issuspected, referral to an ear, nose, and throat special-ist is indicated, Malodor may also persist in patientswith trimethylaminuria,'^ Réévaluation of potentialsystemic causes and appropriate referral is the pre-ferred management strategy for these patients.

The patient who does not comply with the initialtreatment recommendations also represents a failure.The patient may conclude very early that orai hygieneprocedures do not work and may abandon treatment.The patient may have low motivation, or the proee-dures may be too difficult for the patient. An additionaiappointment for reexamination can be schcduied, ifthe patient can be motivated to foliow the therapeuticstrategy. Modification of orai hygiene procedures canmake them more acceptable to the patient,

A difficult group to manage is that of otherwisenormai patients who are without orai malodor on re-examination but who helieve that oral malodor is still

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present This should not be surprising, because it is ex-tremely difficult for an individual to assess his or herown oral maiodor.'' Some people have been con-cerned about bad breath for years, and it is hard forthem to conceive that the apparently simple oral hy-giene methods can control bad breath. These individu-als are greatly helped by a friend or family memberwho periodically evaluates the oral maiodor. Also, anadditional réévaluation may be of help to these indi-viduals. We have found that review of Halimeter find-ings prior to treatment and after treatment gives thosepatients additional reassurance.

SUMMARY

A thorough tnedical, dental, and halitosis history isnecessary to determine whether the patient's com-plaint of bad breath is due to oral causes or not.Particular emphasis must be placed on medicationhistory and previous history of upper face and sinusdiseases or injury. Complaints of bad taste also mustreceive a thorough evaluation. Intraoral examinationis necessary to reveal any disease that may contributeto bad breath, as well as the status of periodontal tis-sues and tongue. A patient's ability to perform oralhygiene procedures can also be evaluated during in-traoral examination. Organoieptic and Halimeter ex-aminations of motith and nasal air reveal the contri-bution of each to the breath odor. Organoiepticassessment of tongue scraping and plaque samplesmay identify the site that contributes most to the oralmaiodor.

Treatment of oral maiodor should be instituted onlyif the examination supports the presenee of bad breaththat appears to be the result of oral causes. Treatmentshould always be based on strong evidence. Such evi-dence is available for oral mechanical hygiene proce-dures that reduce plaque on teeth and tongue.^^^Mouthrinse recommendations should also be based onscientific evidence. While data on odor reduction maynot yet be available for the majority of mouthwashes,reduction of plaque and salivary counts of micro-organisms are available for some of the currently used

The major problems encountered in dealing withpatients with oral maiodor are patients who do nothave bad breath at the time of examination, patientswho have bad breath arising from other causes, pa-tients who do not comply with treatment, and patientswho do not accept that a positive treatment outcomehas been achieved.

We strongly support the incorporation of diagnosisand management of oral maiodor in comprehensivedental care.

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