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Profile in Oral Health Trisha E. O’Hehir, RDH, MS Editorial Director, Hygienetown

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by Trisha E. O’Hehir, RDH, MS

Although many topics once considered taboo are openly discussed today, bad breath is still not easily discussed, even among friends and colleagues. Not discussing it doesn't mean people don't spend money on it. Fresh breath is big business! Many of the several billion dollars spent on oral health care products each year are spent on mints, candies and rinses that mask but do not eliminate the volatile sulfur gases of bad breath.

Agree or not, you are in the fresh breath business, so why not turn it to your advantage? Start offering a new service for your patients in the form of a fresh breath program. This is how you can take the time for oral hygiene instructions/patient education and actually charge for your time and expertise, instead of giving away such valuable information. Offering a fresh breath program is also a good way to attract new patients to your practice

What is Bad Breath?
According to the research, 90 percent of oral malodor comes from the oral cavity. This odor originates with periodontal disease, caries, overhangs, open margins and deposits on the very back of the tongue. Ten percent of oral malodor comes from extraoral factors. These would be infections in other parts of the body. The volatile sulfur compounds (VSCs) are released in the blood and taken to the lungs where they are expelled. This is recognized in the late stages of disease, not usually in the beginning stages. When all oral factors have been ruled out, referral to a physician might be necessary, but only in a few cases.

Fifty percent of people have bad breath sometimes – usually in the morning – with 25 percent of people suffering with chronic bad breath. Bad breath is the third most common dental complaint after caries and periodontal disease. People who believe they have bad breath, when no bad breath can be confirmed by organoleptic testing, suffer from halitophobia or imaginary bad breath. Patients need reassurance that they do not have bad breath and if they still don't accept your diagnosis, might need a psychological referral.

The actual smell of bad breath is due to gases in the mouth – volatile sulfur compounds. The smells associated with these VSCs are quite distinctive. Methyl mercaptan smells like feces, hydrogen sulphide smells like rotten eggs and dimethyl sulphide smells like cabbage, sulphur and gasoline. Periodontal disease is associated with methyl mercaptan and dimethyl sulfide, or the smells of feces, cabbage, sulphur and gasoline. Add to that a breath mint and you have perio breath with an overlay of sickly sweet mint. Add in cigarettes and you recognize the smell immediately. Linking the treatment of periodontal disease to fresh breath might increase your case acceptance for periodontal treatment.

Besides periodontal disease, bad breath is linked to stress, dry mouth, dehydration, certain foods, alcohol, tobacco, medications, hormonal changes, metabolic disorders, chronic nasal problems, tonsil stones or tonsilith and hunger.

History of Fresh Breath Clinics
The first official U.S. fresh breath clinic was opened in 1992 by Dr. Jon Richter, in Philadelphia, Pennsylvania. This was the first clinic devoted entirely to treating oral malodor. In addition to dental hygiene and periodontal therapy, Dr. Richter used a modified ultrasonic scaler tip with a throat shield to detoxify the tongue using a chlorine dioxide solution. ProFresh is the line of chlorine dioxide fresh breath products developed and sold by Dr. Richter.

The first West Coast fresh breath clinic was opened by Dr. Harold Katz in 1994 after being faced with helping his daughter overcome bad breath. He now has several California breath clinics and a product line called TheraBreath.

Our neighbors to the north had a halitosis assessment clinic at the University of Toronto. When it closed in 1993, Canadian hygienist Anne Bosy and pediatric dentist Dr. Julian Geller opened a new fresh breath clinic by renting space in a Toronto dental office one half-day each week. In 1995 the fresh breath clinic moved to its own facility and today the name of these clinics across Canada is OraFresh.

In 1995, Drs. Phil Stemmer and Mel Rosenberg opened the Fresh Breath Centre in London, UK. Hygienist Mhari Coxon provided tongue manicures as part of the fresh breath treatment there. In 1997, Dr. Geoffrey Speiser opened the Australian Breath Clinic (formerly called BreezeCare) in Sydney, Australia. Dr. Speiser uses Halicheck gas chromotography to evaluate breath odors and recommends the oral probiotic K-Force to introduce missing bacteria that combat bad breath.

All of these clinics around the world offer their own line of oral health care products. Undoubtedly there are more fresh breath clinics across this country and the world, as well as many dental practices offering a fresh breath program as part of their full array of dental and dental hygiene services.

Starting Your Fresh Breath Program
First, let's cover what your fresh breath program isn't. It is not simply a mouth rinse and toothpaste. It's much more than that. It includes data collection about the person's experience with bad breath, diagnosis of the actual bad breath problem, a treatment plan including any professional treatments needed, what the patient will do at home on a daily basis, what products are provided or recommended and the follow-up visits to measure success of the fresh breath program. And of course, there is a fee for this program.

Fresh Breath Data Collection
The periodontal examination including bleeding points will provide a basis for discussing bad breath. Bleeding and periodontal pockets are primary sources of VSCs between the teeth. Your patient questionnaire should cover several topic areas including oral hygiene habits, eating habits, medical issues and a description of the problem in their own words. Questions about oral hygiene habits will cover products they currently use including both interdental and tongue cleaning, and their use of mints, sprays and rinses for fresh breath. Diet questions will determine if the diet is high in proteins, dairy products, spices, alcohol or coffee that all impact oral malodor. Diet questions should also cover frequency of eating during the day, special diets and hydration.

The impact of medications that cause xerostomia should be considered with medical history questions. Mouth breathing questions should include questions about snoring, talking a lot for work, running or working out and the stress level they experience.

Diagnosis of Bad Breath
The three primary ways to diagnose bad breath, ways that are used in research as well as clinical practice, are organoleptic testing, sulfide monitoring and gas chromatography. The gold standard is organoleptictesting, or one person sniffing another's breath. People who are organoleptic breath testers are trained to distinguish between different levels of odor and types of odors. This can be done simply by placing your nose close to the mouth and smelling the breath. It can also be done by extracting mouth air with a disposable syringe and then in the same room with the patient or in another room, smell the air as it is expelled from the syringe. Organoleptic reports from the patient's friends and loved ones can also be used, by asking for that feedback from the patient. Has someone complained to them about their bad breath?

The Halimeter is a portable sulphide monitor that calculates the level of volatile gasses produced by oral bacteria. The patient is instructed to close the mouth, breathe through the nose for one minute, allowing VSCs to accumulate in the mouth. After one minute, the patient is instructed to take a deep breath through the nose and hold their breath while a straw is inserted one to two inches into the mouth, careful not to touch teeth or tissues and resting on the back of the tongue. The lips are gently not yet completely closed around the straw, leaving a slight gap. The straw is attached to a hose going to the machine. While the patient holds their breath, the Halimeter reads the mouth air to determine the total level of VSCs. The peak VSC value for the air sample is visible on the digital display.

The OralChroma, also called Halicheck, is a digital gas chromatograph that measures VSCs in the mouth and provides a computer readout of the findings. A syringe is placed in the mouth for 30 seconds and 5cc of mouth air is extracted by pulling back the plunger. This air sample is injected into the OralChroma unit and within eight minutes the breath analysis is visible on a monitor. The same three VSCs that are measured with the Halimeter are measured with the OralChroma, but this machine will distinguish between the three, providing a score for each individual VSC. This provides more information about what might be the cause of the malodor.

Treatment Plan
Periodontal treatment, as well as any necessary restorative work, is essential to eliminating sources of bad breath. Oral hygiene will include tongue cleaning, especially the back of the tongue and cleaning between the teeth with floss, interdental tools or water. Dry brushing the inside first and brushing until the teeth feel clean and taste clean before brushing with toothpaste will assure more effective plaque biofilm removal.

Several products should be considered for your fresh breath program including xylitol, chlorine dioxide, zinc and oral probiotics. One hundred percent xylitol-sweetened products used five times daily will reduce bacterial biofilm levels by 50 percent, a significant reduction leading to lower levels of VSCs. Chlorine dioxide will neutralize VSCs and kill bacteria. It is used extensively to purify the public water supply. Zinc will also kill the bacteria associated with oral malodor. Oral probiotics provide an additional tool to change the balance of bacteria in the mouth, leading to fresher breath. Research in this area has identified missing bacteria in the mouths of those with bad breath and periodontal disease. By providing a daily oral probiotic, a natural balance of oral bacteria can be achieved, thus eliminating an overgrowth of malodor-producing bacteria.

Diet modifications are made based on the information collected in the written questionnaire completed by the patient. Reducing intake of dairy products, garlic, onions and spices will reduce oral malodor if these foods have been identified as culprits in bad breath.

A fee for this service should be decided, based on your current fee structure. Scheduling 30 minutes of the hygienist's time for the analysis and discussion should be a fee comparable with your current prophylaxis fee. This fee will also cover the cost of products you provide the patient. Having the products you want them to use available at the appointment will insure better compliance than sending them out to buy the products. The necessary restorative and periodontal treatment will also need to be scheduled.

To introduce your new fresh breath program, consider placing a table-top display in your reception area with a photo, two lines of text and the fee if you want. The line above the photo: "Worried About Bad Breath?" and the line below the photo: "Ask about our Fresh Breath Program." This lets the patients know you offer this service and provides an opportunity for them to ask about it.

Measuring Success
Follow-up visits are needed to see if the treatment is working. Re-evaluation is done with the same diagnostic tool you used at baseline. Discussion with patients will reveal how the treatment has impacted their social interactions with friends and loved ones. In only a few cases, bad breath remains despite treating all oral aspects. In these cases, referral to a physician is indicated to rule out a systemic cause.

You now have a fresh breath program in your practice! Join the message board on Hygienetown to see the wide range of products available for fresh breath and to compare notes with others implementing a program in their practices

Dentaltown Magazine
September 2025
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