Abstract

Introduction

The production of bad breath (oral malodor, halitosis) is multi-factorial and may involve both oral and non-oral sources.^1,2  Non-oral sources of breath odor are generally related to systemic problems and/or medications.  Conditions such as diabetes, liver and kidney disorders, and pulmonary disease may contribute to offensive breath odor.  This is also true of some medications, especially those that reduce salivary flow such as antidepressants, antipsychotics, narcotics, decongestants, antihistamines, and antihypertensives.  These non-oral sources of breath odor have been well reviewed in the literature.^2,3,4  However, while systemic conditions and medications can contribute to breath problems, most authorities seem to agree the majority of bad breath originates in the oral cavity.

Bacterial putrefaction^5,6,7 by gram-negative anaerobic bacteria, particularly those residing on the posterior dorsum of the tongue, utilize sulfur containing amino acids, primarily cysteine and methionine,^8,9,10 to produce volatile sulfur compounds (VSCs).¹¹  Although other organic components (e.g., organic acids, indole/skatole, putrescine, cadaverine) may be involved in the production of halitosis,¹² hydrogen sulfide (H₂S), methyl mercaptan (CH₃SH), and dimethyl sulfide [(CH₃)₂S] have been identified as the predominate VSCs responsible for oral malodor.^9,13,14  While the tongue is considered the primary source of VSC production, other dental problems can generate these offensive gases.

Dental conditions such as gingivitis, periodontal disease, gross carious lesions, and poor oral hygiene have been shown to contribute to bad breath.^5,10,15-19  However, when dental disease is the source of oral malodor, treatment of the condition will often eliminate the problem.^5,10,17,19  Likewise, transient breath problems from eating spicy foods, smoking, and drinking certain beverages will most often disappear shortly after their use is discontinued.^1,20  However, while eliminating these sources can successfully treat the majority of patients who suffer from bad breath, some individuals continue to have chronic breath problems.

It has been estimated that up to 25% of the population suffer from bad breath on a regular basis in spite of having good physical and oral health and after the elimination of offensive foods and beverages.^21,22,23  It is these patients that most need our expertise.  While there are many new products and emerging information regarding the treatment of oral malodor, the dental professional also needs to feel comfortable sharing this information and these products with their patients.

Self-Consciousness:  A Barrier to Communication

Regardless of the source of oral malodor, chronic breath problems can be detrimental to one's self-image and confidence causing social, emotional, and psychological anxiety.  The problem of assessing and treating oral malodor is exacerbated by the personally sensitive nature of the topic.  Even in close relationships, people are often reluctant to inform others their breath is offensive.  Asking a trusted confidant or experienced health professional is considered the most reliable method of confirming a chronic breath odor problem.  This, however, can be awkward and embarrassing for both the patient and the dental professional, who historically has been hesitant to broach the subject.  Since the dental office is the most logical place to assess and treat oral malodor, it is important to develop the communication skills and knowledge base that will enable dental professionals to respond to our patients who seek information about and treatment for bad breath.

Since oral malodor can be related to certain medical conditions or medications, taking a comprehensive medical/dental history, including questions pertaining to breath concerns, can lay the groundwork for open dialogue about breath problems.  When patients initiate a dialogue about their breath concerns, dental professionals need to be comfortable with explaining the etiology of and treatments for oral malodor.  Think for a moment about how you would respond to the following situations:

Amy Wu is a 43-year old married woman who has been referred to your office by a co-worker.  During the appointment she tells you her husband frequently complains that she has bad breath.  She tells you she has tried to assess her own breath by cupping a hand over her mouth and nose and smelling the expired breath, however, she is unable to detect a problem.  She asks you for your professional opinion.  How will you proceed to address her concern?

Jeff Olsen, a 22-year old man, is being seen for his semiannual prophylaxis.  Jeff is reserved and timid.  When you ask if he has any other concerns or questions, he is too embarrassed to share that he has a bad breath problem and can often detect the offensiveness himself.  You sense there is an unspoken concern; what can you do to encourage Jeff to be forthcoming about his problem?

Michelle Thomas is a 51-year old woman who faithfully schedules her six-month recall appointments.  She is a model patient and her home care is meticulous.  While greeting Michelle, you notice her breath is very offensive, even from a distance of several feet.  Will you say anything about this to her?

Carlos Suarez, a 36-year old businessman, has scheduled an appointment specifically to discuss his bad breath.  He tells you he is so self-conscious about the problem that he turns his head when talking to others to avoid breathing directly on them.  He believes his breath is chronically bad and is certain he currently has bad breath.  You are unable to detect any offensiveness; in fact, you detect "a pleasantness" in his breath.  What will you say to him?

The P-LI-SS-IT System

This paper introduces a communication model that has been used successfully by people in a range of helping professions when providing sexuality-related information.  The model is J.S. Annon's P-LI-SS-IT system.²⁴  The acronym stands for the model's four progressive levels:

The P-LI-SS-IT system is flexible and adaptable to many settings and to whatever amount of time is available.  The model allows for a range of treatment choices geared to the level of competence of the individual clinician.  This information discusses how the P-LI-SS-IT model may be applied to the dental setting for discussing the personally sensitive topic of breath odor concerns with patients.

Before introducing the P-LI-SS-IT model, a brief review of interviewing skills and counseling techniques is in order.

Preparation for Interviewing and Counseling Patients

Before an effective clinician/patient dialogue can take place, it is important that the dental professional feel secure about their own knowledge level regarding the etiology and interventions available for treating breath problems.  A strong knowledge base enables the clinician to personalize the treatment plan to the particular problem of an individual patient and rely less on standardized techniques and "one size fits all" regimens.  Furthermore, it is important to be familiar with interviewing and counseling techniques that encourage open communication, reduce anxiety, and establish rapport.

Background in Oral Malodor

The more knowledge of the etiology and treatment of oral malodor a clinician has, the more confidence they will experience when interviewing and counseling patients.  Several sources of information are available to expand one's knowledge base regarding oral malodor.

Readings

A self-study program of selected readings from the resource list at the end of this article may be helpful in acquiring relevant knowledge concerning oral malodor.  To better retain and apply the knowledge gleaned from these resources, it is helpful to discuss the information with colleagues and other interested persons.  In addition, there is an expanding body of oral malodor literature being reported in numerous books, professional journals, and online at websites such as this or the International Society for Breath Odor Research (http://www.tau.ac.il/~melros/Society.html).

Continuing Education Courses

Attending or participating in continuing education lectures and workshops that deal with oral malodor can also greatly increase the clinician's knowledge and skills.  Many product manufacturers now offer free online courses that are easily accessible.  Inviting appropriate speakers and specialists to conduct in-office seminars may also be an effective alternative.

While having a strong knowledge base about a topic is important, it is just as important to have a basic understanding of fundamental interviewing and counseling techniques to communicate this information effectively.

Basic Interviewing Skills

Most of us have heard the adage "It's not what is said but how it's said that makes a difference." This is particularly true when discussing subjects that are inherently sensitive.  What follows are specific suggestions for interviewing and counseling patients:

The Setting

It is very important the clinician and patient have some degree of privacy when discussing personally sensitive issues.  Patients are typically reluctant to share sensitive information that might be overheard by others.  For this reason, if you can offer a patient privacy, it's best to do so.  When privacy is limited, it is best to postpone discussions until the clinician is alone with the patient and to speak in a low volume.

The Initial Approach

Time is typically a consideration.  If the clinician does not have time available to talk in-depth about the patient's concern, she/he can give limited information (following the P-LI-SS-IT model discussed in this article) and make another appointment for the patient as soon as practical.  This way the patient does not leave feeling as though their needs were not addressed.

When initiating conversations regarding oral malodor, it is important to use statements the clinician feels comfortable with.  For example, after reviewing a patient's medical history or oral examination, one might begin by using one of the following questions:

"Do you have any other dental concerns or problems regarding yourself or a family member's oral health?"

"What dental products are you currently using on a regular basis?"

"Do you have questions regarding dental products you've seen advertised or heard about?"

If the patient says they do not have any concerns, it is recommended to accept this answer and do not press further.  Let it be known that if in the future he or she does have concerns that they feel free to contact you at the office.  Suppose the patient does have a concern, what does the clinician do?

Listening

The most common and serious mistake made by most clinicians is failing to really listen to what the patient has to say without interrupting.  It is important we don't jump in with suggestions before hearing the patient out.  For example, a dental hygienist at a general practice clinic who was thoroughly "prepared" has the following conversation with a patient.

Hygienist:  "Do you have any other dental concerns or problems regarding your oral health?"

Patient: "Well, yes...lately I've been having problems with bad breath..."

Immediately the eager dental hygienist launches in with:

Hygienist:  "Oh, don't worry about that.  Bad breath is a common problem and we can schedule you for a breath assessment appointment.  We have equipment that measures the amount of sulfur in your breath."

The dental hygienist finally pauses as she realizes the young woman wants to say something further.

Hygienist: "Is there something else that you wanted to say?"

Patient:  "Well, yes," replied the woman.  "I only have this problem when I get a sinus infection.  Once the infection clears up, my breath problem does too.  I just wanted to know if there was something I could use during those times?"

It is also important to determine whether the patient actually considers their concern a problem.  They may simply be sharing information to find out what your opinion is.  An example of a good follow-up question after the patient makes an initial statement is: "Does that bother you?" or "How do you feel about that?" The following conversation illustrates how the presented statement actually wasn't a real problem.

Hygienist:  "Do you have any other dental concerns or problems regarding your oral health?"

Patient: "Well, my co-worker always complains my breath smells like garlic."

Hygienist:  "I see.  How do you feel about that?"

Patient:  "To be honest with you, I don't really care.  I love garlic and eat it every day.  I haven't had a cold in three years and my cholesterol is great."

Hygienist: "If I hear you correctly, you're not concerned about your breath smelling like garlic and it isn't really a problem after all that I can help you solve."

Patient:  "That's right.  My partner eats garlic too.  It doesn't bother us at all that we smell like garlic, in fact, we actually like the smell of garlic."

This example illustrates the fact we need to listen and let the patient define the problem, rather than we, as clinicians, always defining the problem for the patient.

Assume the clinician is familiar with the etiology and treatment of oral malodor, has learned and practiced various counseling and interviewing skills, has a setting that ensures privacy, and has an easy initial approach.  He or she has learned how to listen and avoids interrupting.  The patient has carefully described his or her bad breath concern and waits expectantly.  At this point, how the clinician might respond will be the subject of the remainder of this paper.  Keep in mind that when providing professional services to patients it is important to preserve the patients' trust

The Dental Professional's Responsibility

With the advent of so many "bad breath" remedies and standardized regimens available for sale to patients, it is important for dental professionals to keep in mind the treatment procedures and/or products we recommend should be based on an individualized assessment.  Otherwise, there is no point in performing a comprehensive assessment if all patients go through the same treatment program.  Furthermore, it is important to keep in mind we have a professional responsibility to follow The Code of Professional Conduct for the Dental Profession.