Nepal, Dec. 26 — Whenever I open my mouth, people either lean away, cover their nose or have an unpleasant expression on their face because of my bad breath. It’s so distressing,” I remember one of my patients telling me. another complained that her husband had the problem and that it was becoming really difficult to deal with. in fact, two out of ten patients coming into the dental clinic express similar issues with bad breath. Breath malodor is a rather embarrassing social problem; it has been documented that almost US $1 billion a year is spent in the US on mouth rinses and mints to counter bad breath. Wouldn’t it be better to spend this money on a proper diagnostic treatment instead of short-term and ultimately inefficient masking attempts?

Halitosis, in medical terms, can be defined as chronic, long-term bad breath, caused by anaerobic sulfur-producing bacteria breeding beneath the surface of the tongue and often in the throat and tonsils. the causes can be intra oral or extra oral. Intra oral causes mostly deal with poor dental habits leading to food impaction and infection, associated with gingivitis and periodontitis. Besides that, xerostomia (dry mouth) or the accumulation of food remnants intermingled with exfoliated cells and bacteria causing a coating on the surface of the tongue can also lead to halitosis. Extra oral causes could be owing to Eye-Nose-Throat (ENT) infections, pulmonary problems such as chronic bronchitis, bronchiectasis and bronchial carcinoma, liver diseases, renal diseases, systemic metabolic disorders such as Type-1 diabetes, hereditary metabolic conditions such as trimethylaminuria and hormonal disorders.

The process of halitosis begins when there is proteolytic degradation of peptides present

in saliva, food debris, inter dental plaque,

postnatal drip and blood by gram-negative anaerobic bacteria. Thus wherever the cause is located, a common pathophysiology effect is tissue destruction and putrefaction of amino acids.

Due to the varied etiological factors that cause halitosis, a proper diagnostic approach is necessary. Clinicians must consider relevant medical history and note the frequency of occurrence-daily, weekly or monthly;

time of appearance within the day to exclude other associated diseases; any medications the patient might be on; and dryness of the mouth or any other symptoms, so that a complete picture can be drawn and appropriate treatment given. Lastly, the clinician must be able to differentiate between intra oral and extra oral origins.

While there are different instruments available in the market through which the level of halitosis can be analysed such as the portable volatile sulfide monitor, gas chromatography, phase contrast microscope etc, these are too cumbersome for a small clinical setup. this is why most clinics employ the ‘Organoleptic Rating’ method. in organoleptic rating, a trained judge smells the expired air and rates its intensity ranging from 0 to 5 (where 0=no odor and 5=extremely foul odor). Although it is entirely based on the olfactory faculties of the clinician, it is considered the standard. another method is through self-examination. A patient is asked to smell a plastic spoon after scraping the back of his/her tongue. Similarly, licking one’s wrist and allowing it to dry and then smelling it, or inserting a toothpick between one’s teeth and testing the smell can very well reflect one’s level of malodor. Of course, these aren’t foolproof methods or completely accurate, but they generally work in detecting whether there is cause for concern.

Dental clinicians should not take halitosis lightly and must strive to diagnose and treat malodor, because more than 85 percent of cases of bad breath have intra oral origins. Treatment should be centered on reducing the bacterial load by effective mechanical oral hygiene procedures, which could comprise simply of teaching patients the proper way of brushing, including tongue scraping. Periodontal diseases should be treated and controlled, and as auxiliary aid, oral rinses containing chlorhexidine, triclosan, hydrogen peroxide or stannous fluoride may be prescribed to further reduce symptoms. If breath malodor persists after these approaches, it could be owing to extra oral origins and medical consultation should be sought immediately.

Dr Roy is a Dental Surgeon working in Dharan Published by HT Syndication with permission from EKantipur.com. For any query with respect to this article or any other content requirement, please contact Editor at