Treating halitosis has always been somewhat of an enigma in dentistry. Where does bad breath come from? Any reasonable dentist will tell you it comes from periodontal disease. We tell patients their buildup of plaque and calculus causes the breakdown of their periodontium. The bacteria then exponentially reproduce in the periodontal pockets, which makes the problem worse until it finally causes an obnoxious smell that we call halitosis. We put the patient through the regimen of prophylaxis, scaling and root planing, and even some periodontal surgery if necessary. Many times this does take care of the problem. However, after going through the periodontal protocol, if the problem of bad breath persists, we would once again put them through another scaling and root planing procedure, and insist they are not practicing good oral hygiene. We think, “if you, the patient, were practicing good oral hygiene, then bad breath would not be a problem.”
The Science of Bad Breath
This scenario is one that I struggled with for a long time. We have all seen patients who have gone through the standard periodontal protocol and still exhibit breath disorder symptoms. In fact, there are many patients with perfectly clean mouths who have bad breath. Over time I began to realize that there were numerous patients who had come into the practice with the complaint of bad breath who had very good oral hygiene and no periodontal disease. After putting them through the regimen that I described above for periodontal patients, they still complained of bad breath, and indeed, they were right. Based on these observations, many researchers around the world have theorized that while periodontal disease certainly is a cause of bad breath, there are many other causes as well. The challenge is to find the cause of bad breath in someone with a healthy, clean mouth.
Most cases of bad breath come from the patient’s own oral cavity. The current thinking about the origination of halitosis in patients with good oral hygiene is gram negative anaerobic bacteria, which produce volatile sulfur compounds (the VSCs that you have sometimes read about in the literature). Now, I must admit to you that when I initially investigated this topic, I thought this theory was rather hokey. However, over the years, there has been more and more research to support this view. These anaerobic bacteria lie in the deepest filaments of the tongue and in the deepest gingival pockets. They combine with proteinaceous debris to produce volatile sulfur compounds—that "rotten egg” smell. These volatile sulfur compounds generally take on the forms of hydrogen sulfide and methyl mercapten. Interestingly, methyl mercapten is what is added to natural gas to give it a distinctive smell so you know when you left your gas stovetop on.
Tongue Cleaning
The challenge in treating halitosis is to reduce the number of gram negative anaerobic bacteria in the mouth and either reduce or neutralize the volatile sulfur compounds. Needless to say, impeccable oral hygiene is a must to begin to eliminate halitosis. The most important part of this hygiene is proper tongue cleaning. Tongue cleaning is something patients rarely do, and we as dental professionals rarely teach. This by itself can substantially reduce the patient's bad breath.
As a dental profession, we need to be more consistent in educating and demonstrating proper tongue cleaning to our patients. According to some studies, the benefits not only include fresher breath, but also may include reduced dental caries and certainly less periodontal disease. Empirically, this makes a lot of sense. Tongue hygiene is an area that is surely left lacking by many dental staff, both personally and professionally.
There are numerous ways to perform tongue cleansing. Toothbrushes, while helpful, cannot do the job adequately enough. Any adult- or child-size tooth brush has a high profile that limits its ability to get far enough to the back of the tongue without gagging the patient. Tongue scrapers, while a step in the right direction, are only effective in removing the top layer of tongue deposits, and many times are made out of metal or hard plastics. These can easily damage the tongue when used aggressively by the patient. A motivated patient who is told about tongue cleaning will naturally want to do the best job possible and invariably will have a bad experience with tongue scrapers. As a result, the patient totally disregards their use altogether.
Some new products have come to market recently that are very effective in neutralizing and eliminating volatile sulfur compounds; these products help control bad breath significantly. Sunstar Butler has a very good tongue cleaner that has been very well-received by patients. The very thin head and low profile of the tongue cleaner easily allows patients to clean the back and sides of the tongue without gagging. There is also a gentle edge at the tip of the brush that helps patients clean the front part of their tongue more readily by dragging the brush forward. This tongue cleaner also is a one handed instrument, which makes it much easier for the patient to use because of its similarity to a toothbrush. This tongue cleaner provides a mechanical cleansing action and is an easy and effective way to begin to eliminate a halitosis problem. This is a key and integral part of treating breath disorders.
Mouth Rinses
What about over-the-counter mouthwashes? Are they effective? Believe it or not, mouthwashes can be helpful if the patient uses the right one that is appropriate for them. The problem with many over the counter mouthwashes is they contain alcohol. We all know alcohol is a drying agent. Many patients will tell you their breath feels good for a little while after they use an over-the-counter mouthwash, but then their bad breath comes back even stronger than before. The reason is simply because of alcohol's drying effect on the mouth, which increases the gram negative anaerobic bacteria's activity and thereby increases the volatile sulfur compounds. In reality, most over-the-counter mouthwashes make the bad breath problem worse. This then causes people to use more of the same mouthwash, which can then make their problem even worse. A high-in-alcohol mouthwash is not the best choice for these patients. The other significant challenge with using high alcohol containing mouthwashes is the intense burning feeling in the patient’s mouth.
There is a new over-the-counter mouthwash by Procter and Gamble that has become my choice for patients, Crest Pro Health Rinse. Crest Pro Health Rinse has no alcohol and has highly bio-active .07% cetylpyridinium chloride (CPC). The positively charged CPC interacts with the gram negative bacteria and solubilizes the bacterial membrane, thereby killing the bacteria. It has been found to be very effective in reducing gingivitis and bad breath in patients. Because there is no alcohol, there is no burning at all, which makes it much easier for patients to keep in their mouth for 30-60 seconds. Because patient compliance is improved, so will their results be in treating their bad breath. This is an exciting new addition to our armementarium for helping every patient improve their oral hygiene and reduce their bad breath and gingivitis.
Diagnosing Bad Breath
Diagnosing breath disorders is a challenging experience. Most of the necessary information-gathering can be done by a staff person. A detailed questionnaire follows, which includes the patient's medical history, medications, eating habits, tobacco and alcohol consumption, oral hygiene habits (including the use of any over-the-counter mouthwashes), toothpastes, bleaching products, and any other habits the patient may have. Combined with a very thorough oral examination, radiographs, and diagnostic casts, your team is now ready to diagnose the case. By far, especially in these cases, the diagnostic segment is the most important phase. Patients quickly realize this and are very impressed at the time taken to arrive at a diagnosis.
Once a proper diagnosis is made, a treatment plan can be established. Treatment may include periodontal services with oral hygiene instructions that include proper tongue cleansing as described above, a restorative phase, and the use of a specially designed tray system developed by this author for treatment of breath disorders. The patient is also advised to immediately stop the use of their present mouthwash and switch to a chlorine dioxide-based mouthrinse that has been shown to effectively reduce volatile sulfur compounds.
Diagnosing and treating breath disorder cases is a challenging, exciting, and an incredible practice-builder. Patients perceive your practice to be special, state-of-the-art, and different from the "regular" dentist who doesn't know how to treat these cases. Most of the time, patients seeking solutions for their breath problem want cosmetic and restorative dentistry. As one patient told me, "Now that I smell good, I want to look good!" Another advantage in treating these cases is the fact that these services are delegatable to your assistants and hygienists—the entire dental team gets involved. Expand your service base by learning more about this exciting new growth area in dentistry.