Diagnosis and Treatment of
Halitosis
Jon L. Richter, DMD, Ph.d
Excerpted and edited by the author from his article of the same title
published in Compendium, April 1996.
Imaginary Halitosis (Continued)
. . . 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.
There are many patients who complain of chronic bad breath for whom no
objective evidence of breath malodor can be identified8,13-17,
Olfactory reference syndrome is a recognized psychiatric condition in
which there occurs a somatization of some distress resulting in a
belief on the part of the patient that an offensive odor emanates from
some body part usually the mouth. This condition interferes with
normal social interactions for fear of offending others with breath
malodor and has been described in the psychiatric literature for over
100 years13,14. Affective disorders and schizophrenia were reported
to develop in patients whose initial complaints were limited to breath
malodor, and some success has been reported in treating olfactory
reference syndrome with tricyclic antidepressants and the neuroleptic
primozide15-17. 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 was 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 in vitro mechanisms of VSC production in
incubated saliva was similar to what occurs in human mouths that
produce malodor. Kostelcl8 and othersl9,20 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 others2l-23
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
Before their first visit to the office, patients are instructed to
abstain from food. breath fresheners, and oral hygiene for 6 hours;
smoking for 12 hours; scented cosmetics for 24 hours; onions, garlic,
and spicy foods for 48 hours; and antibiotics for 3 weeks. The first
step in diagnosing the cause of a patient's complaint of bad breath is
to determine if the complaint is objectively verifiable. A history of
recent and repeated verbal confirmations of breath malodor from
friends or family members is usually a reliable indicator. Separate
organoleptic assessments of oral, nasal and pulmonary air are
performed and recorded independently by two operators in manners
similar to those described by Rosenberg24 and
Preti3.
Comparative VSC concentrations in oral, nasal and pulmonary air are
determined with a sulfide monitor modified since first described by
Rosenberg. The instrument is equally sensitive to H2S and CH3 SH in
the range of 0- I 000 ppb with a 0- 100 mv full-scale analog output
which drives a small penwriter. If nasal air VSC concentration and
malodor are above normal and significantly higher than those of oral
pulmonaryary air, the patient should be examined carefully for
oral-antral or oro-nasal fistulas and referred for a nasal endoscopy.
Should lung air VSC concentration and malodor be above normal and
significantly higher than those of oral or nasal air, the patient
should be referred for laryngoscopic and pulmonary examinations, and
liver function studies should be considered. In the vast majority of
cases the organoleptic and VSC assessments indicate that the oral
cavity is the source of malodor (Fig 1, a).
Figure 1. Typical VSC records of a patient before (a) and after (b)
treatment. In both records the first peak is nasal air, the second
oral air and the third pulmonary air. Record (a) was obtained 15
minutes prior to in office treatment. Record (b) was obtained 29 days
later. During the interval the patient followed the prescribed
maintenance regimen. Both records were taken under the same pre-visit
conditions and at the same time of day.
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 designed26 to deliver an irrigant26 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 cleaners26 and a high oxidation potential mouth rinse26. 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.
After treatment and maintenance instructions, patients are instructed
in a method for assessing breath odor at home for 2-4 weeks after
treatment. Patients then return for a post treatment evaluation at
which all organoleptic and VSC assessments are repeated under the same
pre-visit conditions and at the same time of day as the pre-treatment
evaluation (Fl, l,b). Adjustments in the timing and frequency of
the regimen are sometimes necessary if the home assessment indicates
malodor breakthroughs at specific times of day.
Utilizing these diagnostic and treatment techniques, breath malodor
was totally eliminated in 97% of all patients presenting with some
degree of verifiable breath malodor as judged by the above described
organoleptic and VSC assessments. The remaining 3% (11 patients) had
either significant improvement with which they were satisfied or
admitted to not following the maintenance regimen. As judged by a
post-treatment follow-up questionnaire mailed to patients between 4
and 20 weeks after in-office treatment, 73% of respondents indicated
that they had experienced "significant improvement" in their breath
odor as a result of treatment and maintenance. Another 24%
indicated a "somewhat significant improvement" and 5% indicated "no
improvement." There were 347 respondents.
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. There is no "stand-alone" product
solution for halitosis nor do traditional standards of dental or
periodontal care necessarily eliminate the problem. 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.
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