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Profile in Oral Health Trisha E. O’Hehir, RDH, BS & Sushma Nachnani, PhD

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Kissability

by Trisha E. O’Hehir, RDH, BS
& Sushma Nachnani, PhD

It’s hard to miss all the research and press coverage lately promoting the perio-systemic link. Headlines like “Floss or Die” make a strong case for cleaning between the teeth to prevent heart disease and add years to your life. If people truly desired to prevent heart disease, sales of cheeseburgers and ice cream and the ever-burgeoning weight of the American public would be in decline. It’s not happening. When it comes to motivating people to comply with effective oral hygiene procedures, “kissability” trumps heart disease. Just look at the dental products aisles of stores in your neighborhood. The number of products promising fresh breath far outnumber the choices for dental floss!

Everyone experiences oral malodor or bad breath sometime during the day. It’s often transient, due to overnight bacterial accumulation, eating odor producing foods or xerostomia. However, reports suggest that 40 percent of the population suffers from chronic bad breath and half of this group experiences severe problems and embarrassment due to bad breath.

Kissability, or fresh breath, is desirable at all ages (except perhaps among 10- to-12-year-old boys). It’s important as we go through life, on professional and social levels, where people find themselves close enough to smell each other’s breath. Even our elders living in nursing homes want fresh breath as much as teenagers. Talking comfortably with others requires fresh breath. Those with bad breath, either young or old, are shunned by others and left out of social gatherings. Dental professionals are the experts perfectly positioned to help those with bad breath. Adding a fresh breath program to your practice will provide a needed service. Helping people become kissable provides a double effect. First is fresh breath and second is reducing, controlling and preventing caries and periodontal disease. Patients are not all motivated by avoiding dental disease or heart disease, but most people do want to be kissable!

Bad Breath Facts
Breath contains more than nitrogen, oxygen, carbon dioxide and water vapor. In 1971 Linus Pauling reported measuring 250 substances in exhaled air. Some of these substances the human nose can smell, others it can’t. Modern technology has now measured 1,000 unique substances in expelled air using mass spectrometry (MS) and gas chromatography.

Bad breath falls into three broad categories: intraoral, extraoral and imaginary. Most bad breath (90 percent) is intraoral, stemming from oral bacteria breaking down proteins in food debris, blood or epithelial cells and releasing hydrogen sulfide gases in the mouth. Scrupulous oral hygiene including cleaning between the teeth, and tongue cleaning will eliminate most intraoral cases of bad breath. There is a link between periodontal disease and bad breath, but some people have no signs of periodontal disease and still suffer from bad breath. In these cases, the cause might still be intraoral bacteria, especially accumulations found on the dorsum of the tongue. Another contributing factor is dehydration and xerostomia which reduce salivary flow and therefore the protective washing and neutralizing benefits that naturally control oral odors. Talking for long periods will dry the mouth and increase oral malodor.

Approximately 10 percent of bad breath is extraoral. This type of bad breath is due to infections or conditions in other parts of the body other than the mouth. Some examples are gastroesophageal reflux, chronic nasal, sinus and throat infections, medications, liver and kidney diseases, various carcinomas, chemotherapy, hormonal changes, eating disorders, dieting, exercise, and even stress. Infections in areas other than the mouth can release sulphur compounds into the blood stream and these compounds are then released in expelled air through the lungs.

Imaginary bad breath is a psychological condition called halitophobia. These people, halitophobics, are convinced they have bad breath, despite all evidence to the contrary from clinicians and friends. They continue to seek treatment for bad breath, never believing clinicians who assure them they have fresh breath. These patients need reassurance from clinicians in order to build trust and eventually overcome their phobia. When all clinical treatment is complete, and the patient insists he or she still has bad breath, referral to a counselor might be indicated.

Precursor and Result of Periodontal Disease
Foul smelling gases are released when the amino acids of proteins are broken down, either through putrefaction of foods or blood. The bad breath associated with periodontal disease is due to the death and decomposition of epithelial cells within periodontal pockets. In health, the turnover rate of junctional epithelial cells is every two to four days. The rate increases eight-fold with periodontitis, which means cells die and give off volatile sulphur compounds every six hours. This is the smell that can be detected in the bad breath of those with periodontitis. You’ve probably diagnosed periodontal disease while standing in a crowd or waiting in line at the bank or grocery store.

Volatile sulphur compounds in the mouth have been shown to enhance the permeability of the junctional epithelial cells, thus allowing lipopolysaccharide toxins from the bacteria to penetrate through the attachment and into the underlying connective tissue, triggering the inflammatory response causing periodontal destruction. With these two examples of oral malodor, it is apparent that bad breath is both the result of periodontal disease and a precursor to the onset of periodontitis.

Measuring Bad Breath
It’s very difficult to smell your own breath. The common practice of breathing into a cupped hand and then smelling is not accurate. Instead, ask a spouse or close friend to tell you if you have bad breath. To test your own breath, you can lick the inside of your wrist with the back of your tongue. Let it dry for 10 seconds and then smell it. That might give you an idea how your breath smells, but there are several more scientific ways to measure breath odor. The Halimeter is a portable sulphide monitor which calculates the level of volatile gasses produced by oral bacteria. OraChroma is a portable, digital gas chromotograph. The gold standard is still organolyptic testing, 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. New machines designed to measure substances in expelled air are compared to organoleptic measurements to establish their validity.

Due to hit the market by year’s end is a pocket-size salivary test called “Okay to Kiss.” Research by Professor Mel Rosenberg at Tel Aviv University has identified a symbiotic relationship between gram-positive and gram-negative bacteria that links to bad breath. It seems the way gram-positive bacteria process glycoproteins leaves a sugar molecule that’s easy for gram-negative bacteria to digest. Until now, most of the focus has been on the gram-negative bugs, when in fact, early detection of gram-positive bacteria might be the best indicator of bad breath. Spitting into a little spoon holding the reagent is not exactly romantic, so the research team is working on a less conspicuous way to conduct the test. This test might even have a place in the dental office to check oral hygiene. If the bugs are there and active, the oral hygiene is lacking. Professor Rosenberg’s saliva research is showing promise for the diagnosis of lung cancer, asthma and ulcers.

Also, be sure to keep an eye out for new consumer “quickchecks” for detection of bad breath causing compounds from QuantRx Biomedical and ALT BioScience later this year or early 2010.

Treatment
The primary treatment for 90 percent of those with bad breath is effective oral hygiene, including tongue cleaning. Bad breath is eliminated by reducing the bacterial load in the mouth, killing bacteria, neutralizing the volatile sulphur compounds, eating less fats, eating more frequently and drinking more water. The bacterial load can easily be reduced with good oral hygiene, both brushing and cleaning between the teeth. Tongue cleaning is particularly valuable when the back of the tongue is cleaned with either a tongue cleaner or toothbrush. Bacterial load can also be reduced considerably by ingesting xylitol five times daily. Xylitol can be taken in the form of chewing gum and candies as well as toothpaste, mouthrinse, dry mouth spray or tooth gel and can potentially reduce the bacterial load by 50 percent. Xylitol nasal spray or xylitol in a Neti pot will flush the mucus from the nasal passages, eliminating another protein source for bacteria.

Many fresh breath products simply mask the odor for a short time and do not deal with the primary cause of the odor: oral bacteria breaking down proteins and in the process releasing foul smelling compounds. Mouthrinses have been around for many centuries and have been concocted of a variety of ingredients. The Greeks were the first to use mouthrinse made of urine. Yes, urine was promoted as a mouthrinse in a 70 AD medical book of Dioscorides of Anazarbus. The Romans preferred more exotic urine than that of fellow Romans, thus importing Portuguese urine. Those who lived in what is now India found the urine of a child or a young cow to be the mouthwash of choice. Makes you wonder how bad the breath was back then that the smell of urine was an improvement.

Some dental products contain substances that do have a positive effect on the source of bad breath. Chemicals used to kill bacteria or neutralize volatile sulphur compounds include chlorine dioxide, zinc, sodium chlorite, peroxide, polyphenols, CPC, triclosan and chlorhexidine. Mouthrinses containing these chemicals or natural xylitol will reduce the level of free-floating bacteria in the mouth and provide oral malodor protection for three to 10 hours. The flavor is important when asking patients to comply with recommendations for daily use. People prefer different tastes, so it’s helpful to offer a variety of choices when recommending fresh breath products.

Chewing gum stimulates salivary flow, which helps control oral malodor. Despite the increased salivary flow, sorbitol-sweetened chewing gums feed the bacteria and bacteria can produce acids from sorbitol. Chewing gums sweetened only with xylitol provide no nutrition for the bacteria and will reduce the accumulation of bacterial biofilm in the mouth.

Another way to control oral malodor when infected tonsils are the source of bad breath is a tonsillectomy or laser cryptolysis to prevent the accumulation of bacteria or tonsillitis within the crypts of the tonsils.

Future
Breath researchers are designing an artificial nose to measure breath, thus taking the place of people sniffing breath. New treatment approaches include probiotics, salivary stimulators, and xylitol containing products. There are two international breath related organization: International Society of Breath Odor Research (ISBOR) targeting the dental community, and the International Association of Breath Research (IABR) a group focused on the diagnosis of medical conditions through exhaled breath analysis. These two organizations shared a joint symposium in 2009 and also share a research journal, the Journal of Breath Research. As these two organizations work closely in the future, we will see exciting advances in breath diagnostics and new therapies for eliminating bad breath.
Dentaltown Magazine
September 2025
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