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DESCRIPTION
Halitosis, also known as "bad breath or oral malodor", is a common disorder with more than 90 million Americans suffering from it. It can be embarrassing for those people who are experiencing it. Most adults probably suffer from bad breath occasionally, with perhaps about 25 percent suffering on a regular basis.
Bad breath could be a sign of a health problem and is typically caused by poor dental hygiene and the activity of bacteria in the mouth. However, other factors may be involved, including gum disease, tooth decay, heavy metal buildup, sinus infection, nose or throat infection, improper diet, gastric problems, constipation, smoking, diabetes, foreign bacteria in the mouth, indigestion, inadequate protein digestion, liver malfunction, postnasal drip, stress, and too much unfriendly bacteria in the colon.
In the past, bad breath was often considered to be an incurable affliction. However, in recent years it has become increasingly evident that bad breath is usually treatable once a proper diagnosis is made.
The main problem is knowing whether we have it or not, because we are poor judges of our own breath odor. Some people suffer from bad breath without knowing it, while others build up exaggerated fears about breath odor even though they do not have it. The best way to find out whether we have bad breath is to ask for someone else's opinion. If we don't ask, other people are unlikely to tell us. And since bad breath can sometimes - fortunately rarely - be a sign of a significant general health problem, we should not be reluctant to tell people dear to us that they have a bad breath problem.
FREQUENT SIGNS & SYMPTOMS
Some people who come to dental and medical clinics claim that they can smell their own breath. They do this in a variety of ways some ingenious. The most common thing to do is just to cover your mouth and nose with your hands and take a deep whiff. Some people are able to detect odor in this manner. An easier thing to do is to lick your wrist. Some people smell their odor on the telephone receiver after a conversation. Others rub their gums with their finger and smell it. One woman claimed to be able to smell her own bad breath by covering her head with a blanket.
The problem with all these techniques is getting an objective viewpoint of the odor coming out. In a recent study, 52 people were asked to smell their own bad breath and score it on a scale. In general, the results showed that people were unable to score their own bad breath in an objective fashion. This is probably because we all have a certain preconception of how bad our breath smells, and when we come to score what we smell, we are heavily influenced by our mindset, regardless of how bad the smell actually is.
Several years ago, a Japanese company came out with a little bad breath detector that looks like a small powder box, mirror and all. But when you open it, there are little buttons and lights that go on and off. You blow over a small grid, and within several seconds it gives you a score. However, there is a serious question as to whether these small instruments are at all accurate.
Most people have bad breath at one time or another. The best way to find out if your have it on a regular basis, is to ask someone close to you. Provided that they love you, and that they have a sense of smell, family members will find a way of telling you the truth. You can also ask a very close friend.
CAUSES
Though there may never be an easy way to tell someone they've got bad breath, there are better ways to diagnose and treat the condition today than ever before. Today, dentists are much more capable when it comes to treating bad breath since about 75% of bad breath stems from the mouth. It is caused when decay and debris produce sulfur compounds that cause foul odor and gum disease.
This is a summary of different odor-related problems and their possible causes:
Problem
Possible cause or source of malodor
Odor after fasting, dieting, sleeping, taking medications, prolonged speaking, exercise
dryness in the mouth, insufficient saliva flow
Gums bleed and/or smell
gum problems, poor cleaning between teeth
Odor upon talking
postnasal drip on back of tongue
Odor at onset of menstrual cycle
swelling of gums
Small whitish stones with foul odor appear on tongue
tonsilloliths from crypts in tonsils
Odor appears suddenly from mouth of young children
onset of throat infection
Odor appears suddenly from nose of young children
foreign body placed in nose
Odor appears suddenly from entire body of young children
foreign body placed in nose
Taste or smell of rotten fish
trimethylaminuria (rare)
Odor in denture wearers
dentures kept in mouth at night or not cleaned properly
Odor from nose
sinusitis, polyps, dryness, foreign body, hindered air or mucus flow
Bad taste all day long
poor oral hygiene, gum disease, excessive bacterial activity on tongue
Halitosis also known as oral malodor or bad breath can be caused by many localized and systemic disorders. Halitosis caused by normal physiological processes and behaviors is usually transitory.
Non-pathologic halitosis may due to hunger, low levels of salivation during sleep, food debris, prescription drugs, and smoking.
Chronic or pathological halitosis stems from oral or non-oral sources. In addition there appear to be several other metabolic conditions involving enzymatic and transport anomalies (such as Trimethylaminuria) which lead to systemic production of volatile malodors that manifest themselves as halitosis and/or altered chemoreception. Some of the oral causes are:
- Periodontal disease, gingivitis, and plaque coating on the dorsum of the tongue.
- Halitosis may be aggravated by a reduction in salivary flow.
- Radiation therapy, Sjorrgen's Syndrome, some lung conditions, including cancer, peritonsillar abscess, cancer of the pharynx and cryptic tonsils can also contribute to oral malodor.
- Nasal problems such as postnasal drip that falls at the posterior dorsum of the tongue may exacerbate the oral malodor condition. Odor generated in this manner can be easily distinguished from mouth odor by comparing the odor exiting the mouth or nose.
The non-oral causes of halitosis include diabetic ketosis, uremia, gastrointestinal conditions, and irregular bowel movement, hepatic and renal failure and certain types of carcinomas such as leukemia.
The accurate clinical labeling and interpretation of different oral malodors both contribute to the diagnosis and treatment of underlying disease.
Seven Common Sources of Halitosis
1. Mouth and tongue sources 2. Nasal, nasopharyngeal, sinus, and oropharyngeal sources 3. Xerostomia-induced oral malodor 4. Primary lower respiratory tract and lung sources 5. Systemic disease-induced malodor 6. Gastrointestinal diseases and disorders-induced malodor 7. Odiferous ingested foods, fluids, and medications
Taste and smell can be altered due to facial injuries, cosmetic surgery radiation and olfactory epithelium located on the dorsal aspect of the nose.
A relationship between gastrointestinal diseases such as gastritis and oral malodor has not been established. However, oral malodor has been reported in some patients with a history of gastritis, or duodenal and gastric ulcers.
Saliva plays a central role in the formation of oral malodor. Such formation has its basis due to bacterial putrefaction, the degradation of proteins, and the resulting amino acids produced by microorganisms.
Many patients with a chief complaint of oral malodor have some level of gingival and or periodontal pathology sufficient to be the etiology, but clearly periodontal pathology is not a prerequisite for production of oral malodor.
Medications such as antimicrobial agents, anti-rheumatic, anti-hypertensive, antidepressants and analgesics may cause altered taste and xerostomia.
Halitosis in healthy people arises from the oral cavity and generally originates on the tongue dorsum. The sulfur producing anaerobic bacteria appears to be the primary source of this odors. The large surface area of the tongue and its papillary structure allow it to retain food and debris. This is an excellent putrefactive habitat for gram negative anaerobes that metabolize proteins as an energy source. The bacteria hydrolyze the proteins to amino acids, three of which contain sulfur functional groups and are the precursors to volatile sulfur compounds (VSC's). These gaseous substances, responsible for malodor, consist primarily of hydrogen sulfide (H2S), dimethyl sulfide [(CH3)2 S], methyl mercaptan (CH3SH) and sulfur dioxide (SO2). Cadaverine levels have been reported to be associated with oral malodor and this association may be independent of VSC. Subjects challenged with cysteine rinses produced high oral concentrations of VSC, which thus seems to be a major substrate for VSC production. The other sulfur-containing substrates had much less effect. It was found that the tongue was the major site for VSC production.
- Tongue Plaque Coating: Research suggests that the tongue is the primary site in the production of oral malodors. The dorsoposterior surface of the tongue has been identified as the principal location for the intraoral generation of volatile sulfur compounds (VSC's). The tongue is a haven for the growth of microorganisms since the papillary nature of the tongue dorsum creates a unique ecological site that provides an extremely large surface area, favoring the accumulation of oral bacteria. The proteolytic, anaerobic bacteria that reside on the tongue play an essential part in the development of oral malodor. The presence of tongue coating has been shown to have a correlation with the density or total number of bacteria in the tongue plaque coating. The weight of the tongue coating in periodontal patients was elevated to 90 mg, while the VSC was increased by a factor of four. The CH3SH/H2S fraction was increased 30-fold when compared with individuals with healthy periodontium. This high ratio of amino acids can be due to free amino acids in the cervicular fluid when compared with those of L-cysteine. The BANA (Benzoyl-DL-arginine-2 napthylamide) test has been used to detect T.denticola and P.gingivalis. The two organisms that may contribute to oral malodor can be easily detected by their capacity to hydrolyze BANA a trypsin-like substrate. BANA scores are associated with a component of oral malodor, which is independent of volatile sulfide measurements, and suggest its use as an adjunct test to volatile sulfide measurement. Higher mouth odor organoleptic scores are associated with heavy tongue coating and correlate with the bacterial density on the tongue and it also correlates to BANA-hydrolyzing bacteria--T. denticola, P.gingivalis, and Bacteroides forsythus.
- Microbiota Associated With Oral Malodor: The actual bacterial species that cause oral malodor have yet to be identified from among the 300 plus bacterial species in the mouth. Putrefaction is thought to occur under anaerobic conditions, involving a range of gram-negative bacteria such as Fusobacterium, Veillonella, T.denticola, P. gingivalis, Bacteroides and Peptostreptococcus. Studies have shown that essentially all odor production is a result of gram-negative bacterial metabolism and that the gram-positive bacteria contribute very little odor. Fusobacterium nucleatum is one of the predominant organisms associated with gingivitis and periodontitis and this organism produces high levels of VSC's. The nutrients for the bacteria are provided by oral fluids, tissue and food debris. Methionine is reduced to methyl mercaptan and cysteine. Cysteine is reduced to cystine, which is further reduced to hydrogen sulfide in the presence of sulfhydrase-positive microbes. This activity is favored at a pH of 7.2 and inhibited at a pH of 6.5. Isolates of Klebsiella and Enterobacter emitted foul odors in vitro which resembled bad breath with concomitant production of volatile sulfides and Cadaverine both compounds related to bad breath in denture wearers. The amounts of volatile sulfur compounds (VSC) and methyl mercaptan/hydrogen sulfide ratio in mouth air from people with periodontal involvement were reported to be eight times greater than those of control subjects.
PREVENTION
FLOSSING
Researchers, for the most part, suggest flossing as a very important addition to tooth brushing. In research, subjects who said that they floss had much less bad breath (as well as gum disease) as compared with those that said they did not. It is important to use floss properly, following professional instruction. Remember to floss around the ends of the teeth at the ends of each row.
Children would probably have problems flossing, since it requires a delicate control of the fingers they don't have yet.
One of the great advantages of using floss, is that you can smell the floss directly following each passage between the teeth, and clean the smelly areas more diligently.
Consult your dentist or hygienist for instructions for proper flossing.
MOUTH RINSES/MOUTHWASHES
The best time to use any mouth rinse appears to be right before bedtime. Since in many instances, bad breath involves the back of the tongue, it is probably helpful to gargle the mouth rinse. Some clinicians recommend extending the tongue while gargling, in order to allow the mouth rinse to reach farther back.
Mouthwashes have been used as chemical approach to combat oral malodor. Mouth rinsing is a common oral hygiene dating back to ancient times. Antibacterial components such as cetylpyridinium chloride, Chlorhexidine, Triclosan, essential oils, quaternary ammonium compounds, benzalkonium chloride hydrogen peroxide, sodium bicarbonate41, zinc salts and combinations have been considered along with mechanical approaches to reduce oral malodor. Any successful mouth rinse formulation must balance the elimination of the responsible microbes while maintaining the normal flora and preventing an overgrowth of opportunistic pathogens.
Most commercial mouth rinses/mouthwashes only mask odors, providing little antiseptic function and should not be used. Most of these products contain nothing more than flavoring, dye, and alcohol. Even when these mouth rinses do contain antiseptic substances, the effects are usually not long-lasting. The microbes survive antiseptic attacks by being protected under thick layers of plaque and mucus. While they may kill bacteria that cause bad breath, the bacteria soon return in greater force. These type of mouth rinses/mouthwashes can also irritate the gums, tongue, and mucous membranes in the mouth.
Many commercially available rinses contain alcohol as an antiseptic and a flavor enhancer. The most prevalent problem with ethanol is that it can dry the oral tissues. This condition in itself can actually induce oral malodor. In addition, there is some controversy as to whether or not the use of alcohol rinses are associated with oral cancer. The FDA states that there is no evidence to support the removal of alcohol from over-the-counter products but alcohol-free mouth rinses are becoming increasingly popular.
People having present or past alcohol-dependency (alcoholism) problems should avoid mouth rinses that contain alcohol.
TYPES OF RINSES
Zinc Rinses: Clinical trials conclude that zinc mouth rinses are effective for reducing oral malodor in people with good oral health. Zinc rinses (in chloride, citrate or acetate form) have been found to reduce oral volatile sulfur compound (VSC) concentrations for greater than three hours. The zinc ion may counteract the toxicity of the VSC's and it functions as an odor inhibitor by preventing disulfide group reduction to thiols and by reaction with the thiols groups in VSC's. It has been reported a zinc-based rinse was more effective as compared to chlorinedioxide based rinse when both rinses were used twice a day for 60 seconds over a 6-week period. Zinc containing chewing gum has been shown to reduce oral malodor.
Chlorhexidine Rinses: Chlorhexidine digluconate is useful in decreasing gingivitis and plaque buildup. It is one of two active ingredients in mouth rinses that has been shown to reduce gingivitis in long-term clinical trials and appears to be the most effective anti-plaque and anti-gingivitis agent known today.
The efficacy of chlorhexidine as a mouthrinse to control oral malodor has not been studied extensively. The primary side effect of chlorhexidine is the discoloration of the teeth and tongue. In addition, an important consideration for long-term use is its potential to disrupt the oral microbial balance, causing some resistant strains to flourish, such as Streptococcus viridans.
The effect of 1-stage full mouth disinfection in periodontitis patients (Scaling and root planing of all pockets within 24 hrs together with the application of Chlorhexidine to all intra-oral niches followed by chlorhexidine rinsing for 2 months) resulted in a significant improvement in oral malodor when compared to a fractional periodontal therapy (consecutive root planings per quadrant, at a 1 to 2 week interval).
While Chlorhexidine appears to be clinically effective from these open-design clinical studies, it is not an agent that should be used routinely, or for long periods of time, in the control of oral malodor, because of its side effects. Mouth rinse containing Chlorhexidine, Cetylpyridium chloride and Zinc lactate was evaluated in a clinical study for two weeks. Eight subjects participated in this pilot study and this formulation showed improvement in organoleptic scores and a trend to reduce tongue and saliva microflora.
Antimalodor properties of chlorhexidine spray 0.2% chlorhexidine mouth rinse 0.2% and sanguarine-zinc mouth rinse were evaluated on morning breath. Oral malodor parameters were assessed before breakfast and four hours later after lunch. Results indicated that a sanguarine-zinc solution had a short effect as compared to chlorhexidine that lasted longer.
Chlorine Dioxide Rinses: Chlorine Dioxide (ClO2) is a strong oxidizing agent that has a high redox capacity with compounds containing sulfur. Chlorine dioxide is also used in water disinfection and in food processing equipment sanitation and functions best at a neutral pH. Commercially available mouth rinses are a solution of sodium chlorite since chlorine dioxide readily loses its activity. Further independent clinical investigations are needed to substantiate the effectiveness of sodium chlorite containing rinses for the control of oral malodor. In fact, chlorine dioxide, the agent most widely touted on the Internet, has no published clinical studies (as of December, 1999) to substantiate the claims to reduce oral malodor. Benzalkonium chloride in conjunction with sodium chlorate has been shown to be effective in reducing oral malodor. In this pilot study subjects with mild to severe periodontitis were instructed to use the mouthwash twice a day for a period of six weeks and periodontal and oral malodor parameters were assessed.
Triclosan Rinses: Triclosan (2,4,4'-trichloro-2'-hydroxydiphenylether) is a broad spectrum nonionic antimicrobial agent. This lipid soluble substance has been found to be effective against most types of oral cavity bacteria. A combined zinc and triclosan mouth rinse system has been shown to have a cumulative effect, with the reduction of malodor increasing with the duration of the product use.
Two-Phase Rinses: Two-phase oil-water mouth rinses have been tested for their ability to control halitosis. A clinical trial reported significant long-term reductions in oral malodor from the whole mouth and the tongue dorsum posterior. The rinse is thought to reduce odor-producing microbes on the tongue because there is a polar attraction between the oil droplets and the bacterial cells. The two-phase rinse has been shown to significantly decrease the level of volatile sulfur compounds eight to ten hours after use, although not as effectively as a 0.2% chlorhexidine rinse. Positive controls such as Chlorhexidine and Listerine® that had previously shown to reduce organoleptic scores were used in these clinical studies.
Hydrogen Peroxide: The potential of hydrogen peroxide to reduce levels of salivary thiol precursors of oral malodor has been investigated. Using analytical procedures, percent reduction in salivary thiols levels post treatment compared to baseline was found to be 59%.
Topical Antimicrobial Agents: Azulene ointment with a small dose of Clindamycin was used topically in eight patients with maxillary cancer to inhibit oral malodor that originates from a gauze tamponade applied to the postoperative maxillary bone defect. The malodor was markedly decreased or eliminated in all cases. Anaerobic bacteria such as Porphyromonas and Peptostreptococcus involved in generation of malodor also became undetectable.
Breathnol is a proprietary mixture of edible flavors, which was evaluated in a clinical study, and this formulation reduced oral malodor for at least 3 hours. Certain lozenges, chewing gums, and mints have been reported to reduce tongue dorsum malodor.
Alternative Remedies: Some of the natural controls for oral malodor include gum containing tea extract. Also recommended are natural deodorants such as copper chlorophyll and sodium chlorophyllin. Alternative dental health services suggest the use of chlorophyll oral rinses in addition to spirulina and algae products.
Conclusions About Mouth rinses/Mouthwashes:
Many of the mouth rinses available today are being used for the prevention and or treatment of oral malodor. Much more research is required to develop an efficacious mouth rinse for the alleviation of oral malodor. The treatment of oral malodor is relatively a new field in dentistry and many of the treatments thus far have involved a trial and error approach, but the knowledge and experience gained so far will hopefully facilitate clinical investigations in this field and eventually lead to improved diagnostic techniques and treatment products.
SMOKING & TOBACCO USE
For at least a century, people have smoked in order to cover up other oral odors. In my mind, this is not advisable. First, smoking itself is a health hazard, not only to you, but to those around you. Smoking can exacerbate gum (periodontal) disease and post-nasal drip, two important bad breath risks. Furthermore, in many people, the smoke odor lingers in the mouth itself and mixes with the other smells, resulting in a particularly noxious aroma.
Smoke odor comes out of two places: the mouth and the lungs. Interestingly, in some people the smell from the lungs is much weaker than that coming out of the mouth. This observation indicates that smoke components are retained in the mouth itself. On one hand, it is true that this may have an effect in reducing the activity of bacteria in the mouth. However, the toxic components in smoke have a similar effect in injuring our own cells. All in all, smoking is not a good idea as far as breath freshening is concerned.
Tobacco smoke may occasionally be detected on the breath of people who don't smoke at all. These individuals have been continually exposed to the smoke of others, and end up having telltale odor as a result.
BAD BREATH (HALITOSIS) IS USUALLY WORSE...
- Upon awakening.
- When your mouth is dry (lots of things cause dry mouth - not drinking enough fluids, having just given a long speech, being under stress, hundreds of medications...)
- After indulging in products with high levels of proteins, such as milk products and meat. If a little piece of meat remains between you teeth for a time, it is rapidly putrefied. Coffee may increase malodor, although no scientific evidence is available. Foods containing onions, garlic, (cabbage?) and various spices may cause bad breath. Some of this odor may be due to the odorants being released into the lungs from the blood stream, sometimes for days following ingestion.
- Directly prior to or during the menstrual period, perhaps because the gums tend to get swollen and trap bacteria and/or debris.
TIPS FOR TONGUE BRUSHING
Brush your tongue whenever you brush your teeth. Choose a brush (make sure that the bristles are not hard) that minimizes gagging reflex. Stroke from near the throat (as far in as you can get) in an outwards motion. Take care not to press to hard, as you don't want to do damage your tongue. For even better results, try wetting the brush with an effective mouthwash.
Another way of cleaning your tongue is to use a tongue scraper. Several kinds are currently available. You can also try using a piece of gauze, washcloth or other material, which you can wet with mouthwash or water.
People with hairy tongues (you can ask your dentist whether yours is hairy) may have more likelihood of having bad breath from their tongue. So do people with periodontal disease. Smokers may similarly suffer from foul tongue odor. In such instances, back-of-the-tongue cleaning becomes even more important.
TREATMENT
Oral malodor has been recognized in the literature since ancient times, but in the last five to six years it has increasingly come to the forefront of public and dental professional awareness. Approximately 40-50% of dentists see 6-7 self-proclaimed oral malodor patients per week. Standard diagnosis and treatment for oral malodor in the routine care of each patient has not been established in the dental or the medical field. However the transfer of knowledge is increasing because of pioneering researchers and clinicians that have developed reputable clinics dealing with this condition. Dental and medical schools must incorporate diagnosis and treatment of oral malodor into their curriculum, so that the future generations of clinicians can effectively treat this condition.
To date, there have been four international conferences where the experts in the field have gathered and published their observations and research findings. The fourth international conference was held at the School of Dentistry, University of California (UCLA) and it was a big success and demonstrated a continued enthusiasm towards further meetings and scientific research in the area of oral malodor. Although this area of research has been ridiculed, at least 50% of the population suffers from a chronic oral malodor condition by which individuals experience personal discomfort and social embarrassment leading to emotional distress. The consequences of oral malodor may be more than social; it may reflect serious local or systemic conditions. Oral Malodor research has gained momentum with increasing suspicions being directed at the sulfur-producing bacteria as the primary source of this condition.
DIAGNOSIS
HALITOSIS ASSESSMENT:
Organoleptic Measurements: One major research problem that must be tackled is the lack of an established gold standard for rapidly measuring oral malodor condition. The objective assessment of oral malodor is still best performed by the human sense of smell (direct sniffing-organoleptic method) but more quantifiable measures are being developed. At present, confidant feedback and expert odor (organoleptic) judges are the most commonly used approaches. Both assessments use a 0-5 scale in order to consistently quantify the odor (0= No odor present, 1= Barely noticeable odor, 2= Slight but clearly noticeable odor, 3= Moderate odor, 4= Strong offensive odor, 5= Extremely foul odor). Individuals are instructed to refrain from using any dental products, eating or using deodorants of fragrances four hours prior to the visit to the clinic Individuals are also advised to bring their confidante or friends to assess their oral malodor.
Oral and Non-Oral Detection Methods
1. Self-monitoring oral malodor tests 2. Spousal and friend/ confidante feedback 3. Spoon Test 4. Home microbial testing 5. Wrist-lick test 6. In-office oral malodor testing 7. Odor Judges 8. Microbial and fungal testing 9. Salivary incubation test 10. Artificial noses including the Halimeter®
In order to create a reproducible assessment, subjects are instructed to close their mouth for two minutes and not to swallow during that period. After two minutes the subject breathes out gently, at a distance of 10 cm from the nose of the their counterpart and the organoleptic odors are assessed. In order to reduce inter-examiner variations, a panel consisting of several experienced judges is often employed. A study on the inter-examiner reproducibility indicates that there is some co-relation, albeit poor. Gender and age influence the performance of an organoleptic judge. Females have a better olfactory sense and it decreases with age. Dentists and periodontists may not be ideal judges if they do not use masks on a daily basis.
Oral malodor can be analyzed using gas chromatography (GC) coupled with flame photometric detection. This allows separation and quantitative measurements of the individual gasses. However the equipment necessary is expensive and requires skilled personnel to operate it. This equipment is also cumbersome and the analysis is time consuming. As a result, GC cannot be used in the dental office and is not always used in oral malodor clinical trials. Recently a closed-loop trapping system followed by off-line high resolution gas chromatography ion trap detection was used for detection of compounds from saliva and tongue coating samples. Numerous volatile components were detected ranging from ketones to many unknowns. Adding casein (to provide cysteine and methionine) during incubation led to the appearance of nine new sulfur-containing compounds.
Better treatment begins with improved detection. And that starts with new devices, such as the Halimeter, that can detect the amount of sulfur-producing bacteria in the mouth.
Portable Sulfide Meter: The portable sulfide meter (Halimeter®--Interscan Corporation, Chatsworth, CA.) has been widely used over the last few years in oral malodor testing. The portable sulfide meter uses an electrochemical, voltametric sensor which generates a signal when it is exposed to sulfide and mercaptan gases and measures the concentration of hydrogen sulfide gas in parts per billion. The halimeter is portable and does not require skilled personnel for operation. The main disadvantages of using this instrument are the necessity of periodic re-calibration and the measurements cannot be made in the presence of ethanol or essential oils. In other words, the measurements may be affected if the subject is wearing perfume, hair spray, deodorant, etc. In addition, this limitation does not allow the assessment of mouthwash efficacy until after these components have been thoroughly rinsed out or dissipated.
The Electronic Nose: The "Electronic Nose" is a hand held device, being developed to rapidly classify the chemicals in unidentified vapor. Its application by scientists and personnel in the medical and dental field as well as it is hoped that this technology will be inexpensive, miniaturizable and adaptable to practically any odor detecting task. If the Electronic Nose can learn to "smell" in a quantifiable and reproducible manner, this tool will be a revolutionary assessment technique in the field of oral malodor. This device is based on sensor technology that can smell and produce unique fingerprints for distinct odors. Preliminary data indicates that this device has a potential to be used as a diagnostic tool to detect odors.
CONVENTIONAL MEDICAL TREATMENT
MEDICAL MANAGEMENT OF ORAL MALODOR
A large number of so called "Fresh Breath Clinics" are offering diagnostic and treatment services for patient complaints of oral malodor. There are no accepted standards of care for these services, and the clinical protocols vary widely.
A thorough medical, dental and halitosis history is necessary to determine whether the patient's complaint of bad breath is due to oral causes or not. It is important to determine the source of oral malodor; complaints about bad taste should be noted. In most cases patients that complain of bad taste may not have bad breath. The taste disorders may be due to other causes. It has been reported that in approximately 8% of the individuals the odor was caused by tonsillitis, sinusitis, or a foreign body in the nose. This percentage of individuals may be higher, additional research is needed in this area. Approximately 80-90% of the oral malodor originates from the dorsum of the tongue. Therefore the treatments targeted towards reduction of the oral malodor will require antimicrobial components directed against the tongue microbiota.
Treatment of oral malodor is important not only because it helps patients to achieve self-confidence but also because the evidence indicates that volatile sulfur compounds can be toxic to periodontal tissues even when present at extremely low concentrations. The best way to treat oral malodor is to ensure that patients practice good oral hygiene and that their dentition is properly maintained.
Management of Oral and Non-Oral Malodor
1. Local chemical/antibacterial methods 2. Systemic antibacterial methods 3. Mechanical debridement of the tongue 4. Salivary stimulation and/or substitutes 5. Nasal mucous control methods 6. Avoidance of foods, fluids and medications 7. Correction of anatomic abnormalities 8. Medical management of systemic diseases
Traditional procedures of scaling and root planing can be effective for patients with OM caused by periodontitis. All patients should be instructed in proper tooth brushing and flossing and tongue cleaning. Mouth rinses should be recommended based on scientific evidence. Caution should be exercised and professional advice should be sought as to administration and type of mouth rinse to be used. Tongue scraping should be demonstrated and patients should be asked to demonstrate to the dental hygienist the appropriate use of tongue scrapers. The tongue has a tendency to curl up while tongue scraping therefore a combination of flexible tongue scrapers and tongue scrapers with handles should be recommended to the patients.
The saliva functions as an antibacterial, antiviral, antifungal, buffering and cleaning agent and so any treatment that increases saliva flow and tongue action, including the chewing of fibrous vegetables and sugarless gum, will help decrease oral malodor. Finally, oral rinses can be used as supplement good oral hygiene practices.
For most people, a healthy diet, good oral hygiene on a daily basis and visiting the dentist twice per year for cleanings and exams are adequate to prevent bad breath. If you follow this advice, your days should be filled with hugs and kisses. For more information on fighting halitosis and to obtain a dental referral call 1-800-DENTIST to find dentists in your area.
HOME TREATMENT
One method often used, but is not totally reliable is "Licking the back of your hand, letting it dry, and smelling it". It is considered to still be a powerful tool for self diagnosis to see if you have bad breath.
Along with good oral hygiene, some of the most promising treatments are mouthwashes, toothpastes, and other oral products that contain both chlorine dioxide and zinc. Zinc stops an enzyme from breaking down an amino acid that makes the sulfur and by doing this stops the process for a longer period of time. The chlorine dioxide kills the already formed bacteria. As a rule, do not use commercial mouthwashes. Most contain nothing more than flavoring, dye, and alcohol. While these may kill the bacteria that cause bad breath, the bacteria soon return in greater force. Mouthwashes can also irritate the gums, tongue, and mucous membranes. Look for a product containing zinc and chorine dioxide. Often such products can eliminate bad breath for up to eight hours. Use liquid chlorophyll, 1 tablespoon per 1/2 glass water for a gargle/mouthwash or a chlorophyll based mouth rinse. Use helpful mouth rinse daily as needed.
Another breeding ground for odiferous bacteria is a dry mouth. When mouths are dried out, there's a sixfold increase in such sulfur compounds. The dryer the mouth, the less saliva, and the worse the breath. Alcohol as well as some medications, including antidepressants, asthma drugs, antihistamines, and some blood pressure medications, may dry the mouth out. Be sure to drink plenty of quality water and other healthy liquids daily to help alleviate "dry mouth" issues.
Brush your teeth and tongue after every meal. You have to get to the bacterial source and remove it. Try tongue rakes or tongue scrapers that gently scrape bacteria off the tongue and clean between the teeth with dental floss. Use Stim-U-Dent wooden toothpicks, available in most drug stores, after every meal to massage between the teeth. This is important for the prevention of gum disease.
Replace your toothbrush every month, as well as after any infectious illness, to prevent bacteria buildup. Keep your toothbrush clean. Between uses, store it in hydrogen peroxide or grapefruit seed extract to kill germs. If using hydrogen peroxide, rinse it well before brushing. There are bacteria-destroying toothbrush sanitizers available that turn on automatically at intervals throughout the day.
Bad breath may be a sign of an underlying health problem. Treatment is dependent on what's found and what the reasons are for your halitosis. The first step toward treating bad breath is to isolate the cause. For instance, if the cause is gum disease then your health care provider or dentist will treat the gum disease. If it is caused by calcium deposits on the tonsils that are bad smelling, your health care provider can remove them from the folds of the tonsils. Consult your health care provider for a thorough checkup if the suggestions given in this web page do not improve the condition.
CONSIDERATIONS
See Peridontal Disease, Sinusitis, and/or Sore Throat for more information.
HERBAL & HOLISTIC RECOMMENDATIONS
Unless otherwise specified, the dosages recommended here are for adults. For a child between the ages of 12 and 17, reduce the dose to 3/4 the recommended amount. For a child between 6 and 12, use 1/2 the recommended dose, and for a child under the age of 6, use 1/4 the recommended amount.
HERBS
Alfalfa is a good source of minerals and other nutrients for the body. It supplies chlorophyll, which cleanses the blood stream and colon, where bad breath often begins. Take 500 to 1,000 mg in tablet form or 1 teaspoon of liquid form in juice or water three times daily.
Gum disease is a major factor in bad breath. If infection is present, place alcohol-free goldenseal extract on a small piece of cotton and place the cotton over infected gums or mouth sores. Do this for two hours per day for three days. It should quickly heal the infected parts.
Use myrrh (to brush your teeth and rinse your mouth), peppermint, rosemary, and sage. Caution: Do not use sage if you suffer from epilepsy or other seizure disorders.
Chewing a sprig of parsley after a meal is an excellent treatment for bad breath. Parsley is rich in chlorophyll, the active ingredient in many popular breath mints.
NUTRITIONAL RECOMMENDATIONS
Go on a five-day raw foods diet. Eat at least 50 percent of your food raw every day.
Avoid spicy foods, whose odors can linger for hours. Foods like anchovies, blue cheese, Camembert, garlic, onions, pastrami, pepperoni, Roquefort cheese, salami, and tuna leave oils in the mouth that can release odor for up to 24 hours, no matter how much you brush or gargle. Beer, coffee, whiskey, and wine leave residues that stick to the soft, sticky plaque on teeth and get into the digestive system. Each exhalation releases their odor back into the air.
Avoid foods that get stuck between the teeth easily or that cause tooth decay, such as meat, stringy vegetables, and sweets, especially sticky sweets.
Go on a cleansing fast with fresh lemon juice and water to detoxify the system. See Fasting for more information.
Nutrients Supplement Suggested Dosage Comments Very Important Aerobic Bulk Cleanse (ABC) from Aerobic Life Industries
Or
Oat bran
Or
Psyllium husks
Or
Rice Bran1 tablespoon in juice or water twice daily, or on an empty stomach. Take separately from other supplements and medications. Needed for fiber. Fiber removes toxins from the colon that can result in bad breath. Chlorophyll (alfalfa liquid, wheatgrass, and barley juice are good sources) 1 tablespoon twice daily. Chlorophyll can also be used as a mouth rinse - add 1 tablespoon to 1/2 glass of water. "Green Drinks" are one of the best ways to combat bad breath. See Juicing or Nutrition Therapy Index for more information. Vitamin C 2,000-6,000 mg daily. Important in healing mouth and gum disease and in preventing bleeding gums. Also rids the of excess mucus and toxins that can cause bad breath. Important Acidophilus As directed on label. Take on an empty stomach. Needed to replenish "friendly" bacteria in the colon. Insufficient "friendly" bacteria and an overabundance of harmful bacterial can cause bad breath. Alfalfa 500-1,000 mg daily in tablet or 1 tablespoon in liquid form 3 times daily. Supplies chlorophyll, which cleanses the colon and blood stream, where bad breath often begins. Garlic (Kyolic) 2 capsules 4 times daily, with meals and at bedtime. Acts as a natural antibiotic destroying foreign bacteria in both the mouth and colon. Use an odorless form. Zinc 30 mg 3 times daily. Do not exceed a total of 100 mg daily from all supplements. Has an antibacterial effect and neutralizes sulfur compounds, a common cause of mouth odor. Helpful Bee Propolis As directed on label. Aids in healing the gums, aids control of infection in the body, and has an antibacterial effect. Vitamin A 15,000 IU daily. If you are pregnant, do not exceed 10,000 IU daily. Needed for control of infection and in healing of the mouth. Plus
Natural Beta-Carotene
Or
Carotenoid complex (Betatene)10,000 IU daily.
As directed on label.Needed for control of infection and in healing of the mouth. Vitamin B complex
Plus extra
Vitamin B3 (niacin)100 mg daily.
50 mg 3 times daily. Do not exceed this amount.Needed for proper digestion
Dilates tiny capillaries to help blood flow to infection sites. Caution: Do not take niacin if you have a liver disorder, gout, or high blood pressure.And
Vitamin B6 (Pyridoxine)50 mg daily. Needed for all enzyme systems in the body.
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You have symptoms halitosis, oral malodor, or bad breath. You need to be assessed as to the cause of the condition since treatment will be dependent upon the cause.
You have unusual symptoms or symptoms of infection. Infections need to be treated by your health care provider.
Prescription for Nutritional Healing: The A-To-Z Guide To Supplements
-- by Phyllis A. Balch, James F. Balch
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HELPFUL ORGANIZATIONS
American Dental Association (ADA)
ADHA - American Dental Hygienists' Association
HELPFUL LINKS
Halimeter.com: Oral Malodor - A Scientific Perspective
