Halitosis Diagnosis & Treatment

Diagnosis & Treatment of Halitosis

Diagnosis and Treatment of Halitosis

Jon L. Richter, D.M.D., Ph.D.

Excerpted and edited article of the same title published in Compendium, April 1996.

Introduction

Most adults and many children suffer from bad breath (halitosis) occasionally, chronically or regularly at specific times of the day. Public awareness and concern for this phenomenon is evidenced by the support of an $850 million mouthwash industry in the United States despite wide agreement that commercially available products have no significant effect on halitosis.¹

Physicians and dentists are generally poorly informed about the causes and treatments for halitosis. It is the purpose of this paper to review briefly our understanding of the etiologies of halitosis and developments in its diagnosis and treatment. The clinical techniques and strategies for diagnosis and treatment that are described below have been drawn from the research methods and results of Tonzetich², Preti³, Rosenberg⁴, Yaegaki⁵ and Bosy⁶ as well as my own experience in treating over 600 patients presenting with a chief complaint of bad breath.  This paper discusses a unique treatment that was developed through clinical studies and has been clinically proven to be 99% effective in removing the bacterial conditions that cause bad breath.

Origins of Halitosis

Research reports about the etiologies of breath malodor agree that the vast majority of halitosis originates with the anaerobic bacterial degradation of sulfur containing amino acids within the oral cavity resulting in the emission of hydrogen sulfide (H2S), methyl mercaptan (CH3SH) and dimethyl sulfide (CH3SCH3), collectively referred to as volatile sulfur compounds (VSC)^2-5,7.  Therefore, it is clearly the responsibility of dentists to diagnose and manage breath malodor. When systemic or other non-oral etiologies are suspected, dentists must be prepared to prescribe the appropriate medical referrals. While there are many common non-oral diseases cited in the literature⁹, for which halitosis can be a symptom, halitosis typically occurs late in the pathogeneses of these diseases when other more obvious or more urgent symptoms are present^7,10,11. Rapid onset and progressively intensifying breath malodor is suggestive of an infective process, possibly secondary to carcinomas or other localized pathologies in the airway^8,10. However, patients with a sole, chief complaint of long-standing, chronic halitosis have, almost without exception, an oral etiology for halitosis or are suffering from “imaginary halitosis”.

Imaginary Halitosis

In dealing with patients seeking professional care for halitosis, one must be prepared to differentiate between those patients who emit above average malodor, those who emit average or near average malodor but are more sensitive to it, and those who emit below average or no odor but believe that their breath is offensive despite objective evidence to the contrary.  In the former two cases treatment for malodor is warranted; in the latter it is not.  If breath malodor cannot be detected organoleptically from a patient complaining of bad breath, if above normal VSC cannot be demonstrated instrumentally and if the patient cannot provide reliable third-party verification of an odor problem, olfactory reference syndrome ("imaginary halitosis") must be considered.

Oral Causes of Breath Malodor

Tonzetich² demonstrated that incubated whole saliva produced a putrid odor and that hydrogen sulfide (H2S), methyl mercaptan (CH3SH) and dimethyl sulfide (CH3SCH3) were the principal malodorants. When the saliva is filtered, incubated supernate alone produces very little VSC.  Saliva filtrate contains dead epithelial cells, live and dead bacteria, white blood cells, other blood elements and food debris all of which are rich in proteins and amino acids. Through a series of painstaking experiments, Tonzetich and co-workers established that the malodorous volatiles produced by incubated whole saliva were due to the action of anaerobic bacteria on sulfur-containing amino acids derived from degraded proteins present in salivary filtrate. He also observed that the incubated saliva of patients suffering from periodontal disease produced a more rapidly developing and a more intense evolution of VSC. VSC that evolved from substrates high in the amino acid cystine were high in hydrogen sulfide, while VSC that evolved from high methionine substates evolved VSC high in methyl mercaptan.

Direct measurement of breath volatiles using gas chromatography-mass spectroscopy confirmed that an in vitro mechanism of VSC production in incubated saliva was similar to what occurs in human mouths that produce malodor. Kostelcl⁸ and others^{12, 13} have shown that patients suffering from periodontal disease produced more breath malodor and VSC than patients with healthy periodontiums. However, it has been reported that periodontal disease is not a prerequisite for the production of high levels of orally generated VSC and consequent oral malodor⁶. I have personally seen many young children, young adults with no clinical evidence of periodontal diseases, adults with inactive and/or well controlled periodontitis, and totally edentulous patients who have high levels of orally generated VSC and oral malodor.  Some of these patients have extremely intense malodor and extremely high VSC in their mouth air.  Yaegaki⁵ and others^14-16 have identified the tongue and other soft tissue surfaces of the mouth as principle locations of intra-oral bacterial growth and odor production.

Diagnosis and Treatment of Orally Generated Breath Malodor

The patient is given a complete dental examination since crown and bridge washouts, uncontrolled periodontal diseases and other dental infections can contribute to orally generated breath malodor. Localized dental infections are often the source of patients' complaints of self-perceived bad tastes or odors which are not necessarily perceived by others. With the exception of anterior crown and bridge cement washouts, dental and periodontal diseases need not be treated definitively in order to gain control of breath malodor. However, the ease with which patients can maintain control of their malodor after treatment is enhanced by traditional treatments of infective dental and periodontal diseases.

Because orally generated breath malodor is caused by the emission of thiols and sulfides by anaerobic bacteria, treatment is directed toward permanently reducing oral anaerobes. For this purpose an intraoral liquid-air spray device and an ultrasonic intraoral dental cleaner unit have been designed¹⁷ to deliver an irrigant¹⁷ for antiseptic debridement of the hard and soft tissues of the mouth. Following this procedure patients are instructed in the use of home soft tissue cleaners¹⁷ and a high oxidation potential mouth rinse¹⁷. The regime performed two times daily, in the morning and evening, is sufficient to maintain control of breath odor in most individuals after undergoing the in-office antiseptic debridement. 

Common Approaches to Halitosis

Products related to oral hygiene have created a billion-dollar industry, however the most popular means of combating halitosis—tooth brushing and common mouthwash rinses—are not effective in treating chronic halitosis. While regular tooth brushing is effective in preventing plaque and removing food particles that can contribute in small part to halitosis, they cannot reach the back of the tongue where the prime odor-causing bacteria reside. Common mouthwashes mask the odors caused by bacteria for a brief time, but do not eliminate the odor-causing bacteria themselves. Many also contain alcohol, which dries the mouth, accentuating a condition that leads to halitosis.

Tongue scraping with a proper tool, in conjunction with proper oral hygiene is the most effective of the common procedures employed to address halitosis. Since the bacteria that causes the condition is primarily anaerobic and thrives in alkaline environments, results can be further enhanced by:

1)     Rinsing the mouth with a 3% solution of hydrogen peroxide to ensure higher levels of oxygen.  This solution has a strong taste and it should not be swallowed.

2)     Brushing with baking soda as toothpaste to buffer the ph levels in the oral cavity.

While these approaches will temporarily alleviate halitosis, the underlying problem remains - volatile sulfur compounds that build and rebuild on the back of the tongue. 

Effective Treatment of Orally Generated Breath Malodor

In 1992, I founded the first U.S. clinic to specifically address the issues of bad breath odor, the Center for the Treatment of Breath Disorders in Philadelphia. Working with patients in a clinical trial study, I discovered that a powerful and safe germicide called chlorine dioxide had excellent results when used as an active agent to remove the oral bacteria that cause malodor.  99% of 600 patients I treated during the first year found that the use of a chlorine dioxide rinse following tongue cleaning eliminated their halitosis.

The anaerobic bacteria that cause halitosis are readily oxidized and destroyed by the oxidant chlorine dioxide (Cl02), which has long been used to disinfect and deodorize municipal water supplies worldwide. There have been many attempts to make a mouth rinse that contains chlorine dioxide to combat halitosis. The most conspicuous of these have been rinses that contain sodium chlorite which is a salt used in the manufacture of chlorine dioxide. Because it is a chemical precursor of chlorine dioxide, sodium chlorite is also called "stabilized chlorine dioxide" despite the fact that it does not contain chlorine dioxide.  "Stabilized chlorine dioxide" rinses were introduced in the 1970's and claimed the benefits of chlorine dioxide without any substantiating research. Today we still have "stabilized chlorine dioxide" rinses such as TheraBreath®, Oxyfresh® and CloSYSII® which are marketed with claims as though they contain chlorine dioxide although they do not.

ProFresh^® Mouth Rinse, (links to About ProFresh) which I developed, is the only mouth rinse that can contain chlorine dioxide as an active ingredient.  It is a unique patented formula that cannot be replicated.  This chlorine dioxide mouth rinse maintains a constant concentration of 25-35 mg per liter of chlorine dioxide over a period of 8-10 weeks after activation. Each bottle is activated by the user upon opening. The ProFresh formula is U.S. Patented and registered with the FDA.

By following a simple daily regimen patients can eliminate the source of breath malodor. In tandem with regular brushing and oral hygiene, patients with halitosis adhere to a quick and easy two-minute breath maintenance program twice a day that includes tongue cleaning and rinsing with ProFresh Mouth Rinse.

To date, we have treated more than 6,000 patients at the Center for the Treatment of Breath Disorders with equal success.

Conclusion

Bad breath is a major concern for many people. Because it nearly always originates from the mouth, it can and should be diagnosed and treated professionally by dentists.  Recent developments in the understanding of the etiologies of breath malodor have spawned new techniques for its assessment and management. A clinical protocol for diagnosing and treating chronic halitosis has been outlined here that is highly effective, reliable and leads to long-term patient satisfaction.

References

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Profresh, Inc., Philadelphia, PA.