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ON PRACTICE MANAGEMENT by Janyce Hamilton :
Breath odor diagnosis and care in dental offices
Breath odor diagnosis and care in dental offices
May 22, 2009
Curiously, bad breath is not often diagnosed in the dental office. The reasons why vary and are discussed below in my interview with four oral malodor experts from academia, organizations and industry.
Interviewed were:
Sushma Nachnani, MS, PhD
- President-elect, International Society of Breath Odor Research (ISBOR), and member since 1994
- President, University Health Resources Group, Inc., contract research organization doing clinical trials for companies, Los Angeles
- Past Associate Director, UCLA School of Dentistry, Clinical Research Center, Los Angeles
Mel Rosenberg, PhD
- Co-editor-in-chief, Journal of Breath Research
- Professor of Microbiology, Sackler Faculty of Medicine and the Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University.
- Co-founder, ISBOR
- Inventor, Dentyl pH, a mouthrinse.
Michael Phillips, MD, FACP
- Founder and chief executive officer, Menssana Research, Inc, Fort Lee, NJ, developer of breath tests for detection of diseases
- Professor of Clinical Medicine, New York Medical College, Valhalla, NY
- Member, International Association for Breath Research
Sean S. Lee, DDS
- Associate Professor, Department of Restorative Dentistry; Faculty, Graduate Studies; Director of Clinical Research, Center for Dental Research, Loma Linda University, School of Dentistry, Loma Linda, Calif.
- Private Practice, San Bernardino, CA
- Author, Breath: Causes, Diagnosis and Treatment of Oral Malodor
The interview
Janyce Hamilton (JH): How did you get interested in breath research?
Michael Phillips, MD, FACP: I started getting interested in making things in early childhood, although I couldn’t tell you what my very first invention was. Besides breath, I’ve also tested the utility of human sweat as a test. For example, I wanted to know if sweat could be used for monitoring alcohol consumption. Subjects wore a patch on their skin for a week, and then I measured it against controls. The test worked and I published my findings. The reaction was a collective yawn. No one interested in using such a test. So just because you prove something works, doesn’t necessarily mean people will want to use your invention.
Sushma Nachnani, MS, PhD: Dr. Mel Rosenberg of Israel has been called the father and even the grandfather of the field of oral malodor research…
Mel Rosenberg, PhD: I don't call myself that. The Father of modern oral malodor research in my mind is the late Dr. Joseph Tonzetich from the University of British Columbia. Before Joe, there were others. So I am a link in the chain, at best.
JH: Go on, Dr. Nachnani.
Dr. Nachnani: So, in the early 1990s, the Dean of Research at UCLA just got back from Tel Aviv, Israel, where he had met Dr. Mel Rosenberg of Tel Aviv. I had already met him once in 1994 in Belgium. But my Dean insisted that I must call him and gave me Dr. Rosenberg’s book and told me to look into the clinical trials and the research as a microbiologist. So I did. Later that year, Dr. Rosenberg and I had a brief meeting and I began to organize courses. I didn’t want to do it at first, but it slowly began to grow in interest for me until I threw myself into it. I was running studies on whitening, gingivitis, plaque and breath odor. At UCLA, I was called the Queen of Oral Halitosis [laughing]. Today, you can see this area of research has had an impact. Fresh breath clinics are all over the world.
Dr. Rosenberg: I was a petroleum microbiology student studying how oil-eating bacteria stick to oil droplets. We found that bacteria from the mouth also stuck to oil droplets and invented a two-phase oil:water mouthwash that bound and desorbed oral bacteria and debris, and reduced oral malodor for 8-18 hours. The mouthwash was what got me hooked on this subject.
Sean S. Lee, DDS: Academics and research were both interesting, since I enjoy being with dental students and being a researcher. But, compassion for my fellow humans led me to see a great deal of suffering from the embarrassment of feeling unattractive. Years ago, a few of my acquaintances had bad breath. Whenever they passed, others subconsciously kept their distance. Social courtesy does not allow telling others of their bad breath. One would opt to keep silent. One day, I told one of those people that he was experiencing bad breath. He got immediately upset and told me that it was not my business to tell him. Since that day, I started to collect literature published on oral malodor. In fact, as of today I have collected and examined all medical and dental journal articles I could find published during the last 100 years. Also, as a result of frustration over the lack of educational resources or references about the disease of halitosis, I started to conduct my own research. More than that, I wanted a comprehensive source of information to help all of us in the field, so I wrote a book, “Breath: Causes, Diagnosis and Treatment of Oral Malodor,” which was published in February, 2009.
JH: Dr. Phillips, I know as a physician, all my questions may not apply to you, but thank you for giving me your thoughts on those that do. I am told that you may be the most admired breath diagnostics researcher in the U.S. if not the world.
Dr. Phillips: I don’t know that I can comment on that. I only know I am the most admired man in the world by my children. Other teams are doing breath research internationally, but we are doing it rather intensely at my lab. It’s our only focus full-time.
JH: What is your current research or clinical focus?
Dr. Phillips: My focus is to develop diagnostic tests useful to the clinician and the patient for detecting diseases and conditions including halitosis, that are severe inconveniences.
Dr. Nachnani: We are trying to see if we can build a device to mimic the nose to diagnosis bad breath. Other teams are working on this too. Oral malodor is the politically correct term. Certain odors are associated with certain diseases. I’ve been working on it off and on with different companies, but I am not there yet. There are lots of technical issues with scent stabilizations. It will happen but we have to work it out. It’s not one smell that is produced by the breakdown on organic volatile compounds, it differs from person to person chemically. Even in the same person each 10 minutes, the smell changes! This makes it tricky to assess.
Dr. Rosenberg: We are trying to develop a simple enzymatic kit to predict bad breath risk, based on the presence of a bacterial enzyme (beta-galactosidase) in saliva. We are also working on an anti-malodor flavor ("breathanol"). Finally, we are studying how alcohol turns on pathogenic mechanisms in microorganisms, including those found in the mouth.
Dr. Lee: Oral malodor and tooth whitening are the two major areas for which I design studies, run trials and pursue discoveries toward furthering the research on making the teeth white and the breath pleasant, safely and effectively.
JH: Researchers and clinicians seem to bring up halitophobia regularly. Is this as common as real breath odor problem? How so and are there incidence numbers of halitophobics versus chronic oral malodor sufferers?
Dr. Lee: Halitophobia is reported in the literature often, but researchers have not studied it widely. Exact prevalence is not known, however, this is not an uncommon affliction. A halitophobic individual given testimonial of no breath malodor by others and no objective findings by clinicians may not accept a clinician’s pronouncement of no breath problem. This individual feels “vaguely certain” that he has bad breath regardless of what others think. Even given repetitive organoleptic and equipment measurements showing no offensive gases were found in the “before” and the “after” breath sample, he or she may still claim to be a social outcast as a result of an ongoing malodor scourge. Suspicion, skepticism, mistrust are common traits among this group of patients who, often, display hostility to the clinician.
Dr. Nachnani: We have to separate out people who have bad breath from those who just think they do. Some people, even kids, worry about it but don’t have it. I had a patient at the UCLA clinic who came to me all the time. His wife told me, “He doesn’t have bad breath.” He couldn’t believe it. The people closest to you know if you have it or don’t, and they tend to be correct. People sometimes have bad breath, but it does not last—that’s transitional. Chronic oral malodor stays even after oral hygiene measures at home. We ask the patient’s household members to verify it. I once had a professor who came to me and said he was going to lose his promotion because he had bad breath, even though his dentist told him he didn’t think he had a problem. My professor’s dean said she wouldn’t promote him due to his oral malodor problem. Sometimes dentists cannot judge bad breath if they haven’t been trained and don’t have the tools.
Dr. Rosenberg: About a quarter of those who seek help for the complaint of bad breath [are halitophobic]!!! Since we have trouble smelling and evaluating our own breath odor (especially if we worry about it), there is no way of knowing by yourself.
About 20 percent of the population worry a lot about having bad breath. About 20 percent have it. These are not necessarily the same populations!
Severe concern (debilitating) occurs among 0.5-1percent of the population according to research done by Professor Murray Stein, MD, MPH [Psychiatry and Family & Preventive Medicine at the University of California San Diego].
JH: Why are the etiology, diagnostics and treatments for halitosis not taught in U.S. dental schools?
Dr. Rosenberg: That's an excellent question. It should be.
Dr. Nachnani: I know bad breath diagnosis is not taught in dental school. In fact, only a few universities are including mention of it and telling the dental students about research associations. So often, dentists just get used to the smell of patients’ breath. The U.S. is the most advanced in breath malodor field, next is a tie between Japan and Korea. I put a grant application in to the NIDCR, NIH for breath research study. The grant reviewers said the science was good, but that they could not justify funding it because bad breath isn’t a serious issue.
Dr. Lee: I try to teach some principles of halitosis to my students at Loma Linda, but I cannot speak for whether instructors at other dental schools are doing this or not. I think oral malodor diagnosis and treatment is so fundamental to dentistry that it can be expanded to a whole course or unit of study. In time, I believe it will be, especially when important diagnostic breakthroughs such as using breath to diagnose cancer, lung and kidney diseases and other life-threatening diseases becomes widespread.
JH: Around the world, dentists do not say anything to their patients about the quality of their breath, why?
Dr. Phillips: I can’t comment on that. They might not think there’s an available treatment.
Dr. Nachnani: I was in Germany at the latest ISBOR meeting this month talking with one of the reps from a company that offers a breath assessment product, and he said most German dentists are not aware that oral malodor has to be addressed in the dental office. This is a very sensitive issue. People are afraid to be told they have bad breath and people are afraid to tell. There are even companies you can use to have them contact a person about their bad breath and keep you anonymous.
Dr. Rosenberg: It's a delicate issue around the world, and dentists have generally not been taught to deal with it. I teach the subject at our dental school at Tel Aviv University.
Dr. Lee: Not many dentists are taught in any depth or even hear a mention that this might be a service to improve the lives of patients in school or in continuing education. This is curious because I read in the dental journals about talking to the patient on eating disorders, methamphetamine use, abuse and even tongue piercing. We can say all that but not, “I detect an unusual odor on your breath. Have you had any unusual taste in your mouth or certain diet change? Do you mind if I do a quick check to rule out problems?”
Dental schools and organized dentistry groups are encouraged to teach and debate how dentists can openly discuss malodor problems with their patients. Social stigma perpetuates the problem. A recent IRB-approved survey was conducted at the Loma Linda University School of Dentistry. The study results revealed that, in fact, many participants wanted to be notified in some way of their bad breath. This could mean that the general public’s perception on being told they have a breath issue is changing.
JH: Do you have an tactic or approach that works best for bringing up oral odor topic with patients?
Dr. Rosenberg: Definitely. We ask the patients whether they floss their teeth (most don't). We then pass the floss between two molars and let the patients smell it. This helps make the connection and increases compliance greatly. If the patients ask whether their breath smells as bad as the floss, we say no (unless it does), and tell the patients that they can schedule a separate breath consultation.
Dr. Lee: I feel comfortable explaining that: “oral malodor is my area of interest and I do studies all the time. Would you ever be interested in getting a breath checkup free of cost?” It’s usually a “yes” unless they are in a rush. Then we fill out a quick habit survey, and we might do a nose screening and explain the findings. We are very low key about it, never using extreme or concrete language so that if they choose to not pursue any extraordinary treatment, there is “wiggle room” to still feel OK about being my patient and not feeling bad or being judged. It’s an art that takes a little practice. And I continue working to develop and refine my approach.
Dr. Nachnani: A dental hygienist can say to a patient, “Do you need products to freshen your breath?”
She can add, “Did you know that a lot of bad breath comes from back of the tongue, probably 80-90 percent? The volatile organic compounds are there on your tongue so clean/scrape your tongue.” In 1994, there was no tongue scraper on the market! We didn’t advise it and were worried people would damage their tongue. Today, we know that the tongue has a heavy coating, and you can gently clean it. If you clean it everyday, it can change your life. About 10-15 percent of bad breath can reflect serious underlying causes such as kidney, liver or lung infection. A patient had leukemia whose breath had a “dried blood odor.” We sent her to a physician because she also complained of being tired. We know what a diabetic’s breath smells like. We had a little girl in the UCLA malodor clinic with a bead in her nostril. Her life changed after we removed it and her breath didn’t smell. One lady had a needle-type twig from her Christmas tree lodged in her lung. We found it on an x-ray! Here she was called “Dragon Lady” because she had such bad breath. Once it was removed, she was cured! People who have bad breath are isolated. So dentists should take this area of treatment very seriously.
JH: In 10-20 years where do you envision the dental and medical clinician to be doing in terms of oral malodor or breath analysis?
Dr. Rosenberg: Dental and medical schools [must] start introducing the subject. I have started lecturing our medical students on the subject.
Dr. Nachnani: We’ll have very sophisticated equipment to detect most diseases through the breath. We’ll have an electronic nose in the dental office with cheap sensor chips and we’ll be seeing a lot of patients with breath concerns. (Today this equipment is $5,000-6,000 on average).
Dr. Lee: Eventually, patients in many dental school clinics will get a breath odor analysis by a robotic nose, let’s say, by 2020, and the progressive dental practices will do the same. It will be in the waiting room and they will get a private readout so that they do not have to talk to their dentist about it if they do not wish. But before then, I anticipate breath quality strips, like pregnancy kits, at the pharmacy over-the-counter so you can see your saliva’s odor score before your public gathering.
JH: Are there profiteers out there who are hawking products that are the same things on the market for the last 20 years, and how can a dentist tell if a product is more effective than Scope or Listerine?
Dr. Rosenberg: This a very complicated question. The dentist should always consult the published peer-reviewed research. There is also the question of how to use the products properly.
JH: Or perhaps it is a convenience to offer a breath management system for sale in the dental practice?
Dr. Rosenberg: That would be an excellent project. Up until now, most such systems offered to dentists have been about business, not about science.
Dr. Lee: My philosophy is honesty makes for the softest pillow. Luckily, all a dentist has to do is get the ingredients and concentrations from the manufacturers and suppliers and do a little research before buying a line of breath freshening products to offer their patients. The problem is that very few products are new or different from what the patient can buy at the pharmacy. Since research is at the patient’s fingertips via the Internet, they’ll check up on what you just sold them and will lose faith in you as an ethical dentist if they discover it is really just overpriced, overhyped mouthwash, drops and lozenges. Researchers and R&D need to develop a product to diminish or cure the disease, so others can improve their quality of life. It is my sincere hope that a device which will enable the diagnosis of diseases from breath analysis even from remote access will soon be discovered. Early disease detection may save a human life.
JH: Which breath analysis tests do you use most?
Dr. Rosenberg: Smelling the breath from the mouth and the nose. It is still the gold standard.
Dr. Lee: My nose as an odor judge and the OralChroma and the Halimeter are the three most often used tools, plus I created a breath questionnaire that the patient can take to be screened.
I am testing variations on a new tongue coating index for the accurate assessment of potential odor-producing tongue coatings. It's the Lee Tongue Coating Index, or LTCI. There are other tongue coating indexes, but I have theories to improve utility and accuracy. For example, LTCI utilizes a double-layer concept for thick tongue coatings, using a binary scoring system. There are various versions of LTCI being tested that are shown at http://culminare.org. I am interested hearing from those who try them on patients as to which version they would likely use most often, and if any difficulties were encountered.
JH: Are breath analysis tests still in the research phase or are they FDA approved?
Dr. Rosenberg: The halimeter approach was developed in my laboratory. It measures the sulfide gases associated with bad breath, not the odor itself. It cannot be used stand alone. There are many studies showing that it correlates with odor judge scores. Bad breath is not a disease, so the FDA does not ordinarily get involved.
JH: If they work, I am curious that they are not used as a common screening tool in dental school clinics or practices.
Dr. Rosenberg: Again, they are adjunct tests, alongside the actual odor judge measurements.
Dr. Lee: OralChroma and the Halimeter have its own advantages and disadvantages. Currently, none of the tools is considered ideal or perfect. Dr. Phillips is the expert, so I will let him comment on this question.
Dr. Phillips: Dentists need to know that my research group has done an NIH/NIDCR-funded study to detect oral biomarkers of malodor in the breath, and we found them, which shouldn’t be a surprise to anybody. We will come up with a quick and cost-effective test to detect and quantify oral malodor so its intensity can be measured, but we don’t know yet if it will be in the dental office or over-the-counter. For now, we’ve shown it’s possible to test for it. It’s not enough to show it works, however. The real problem is getting a test like this to the market. Everybody wants to be reimbursed for a test, so no one will use it if insurance won’t pay for it. So it needs FDA approval, then we need to convince insurers and Medicare to reimburse for using it.
JH: By the way, Dr. Phillips has developed a 2-minute portable breath collection apparatus. The person breathes into a small sorbent trap (which looks like a stainless steel cigarette) that is sent for laboratory analysis by gas chromatography and mass spectroscopy. The breath test uses markers of oxidative stress known as the breath methylated alkane contour (BMAC). Changes in the BMAC have revealed distinctive changes in a number of different diseases (for example, lung cancer, breast cancer, heart transplant rejection, kidney disease, ischemic heart disease, diabetes mellitus) each identified with its own unique "breath fingerprint." This work obviously goes well beyond “oral malodor” testing.
Dr. Phillips: Things are moving forward in my laboratory. We’ve published three separate studies on lung cancer. Now were doing an NIH funded large study just to get the FDA approval. We cannot market a diagnostic test until we get FDA approval, so this will take another year.
We already have the FDA approval for the heart transplant rejection test. Even though it’s approved, Medicare has not yet approved it for reimbursement. Even if you have a terrific test, if insurance won’t pay for it, it’s not marketable. We are working on that.
We just recently completed an Australian test for using a breath test for breast cancer and got good results. So next is a multicenter study.
Again, you have to leap through three flaming hoops to get a test on the market: prove it’s scientifically valid, get FDA approval, and Medicare/insurance to pay for it. Unless you have passed the three hoops, you have a lot more work. Having said that, we are looking at all the pathways, such as marketing outside the U.S., where it’s easier to get approval. Many tests people are willing to pay for themselves without insurance, so that’s an option.
JH: At least 15 academic institutions--including New York University, Cornell Medical Center, and MD Anderson Cancer Center--are trial sites for multicenter clinical studies on Dr. Phillips’ breath tests, and the findings have been published in major medical journals, such as Lancet, Scientific American and The Journal of Clinical Pathology.
Conclusion
Breath assays for oral malodor and for systemic diseases continue being researched and refined. Translating the laboratory and engineering successes to an affordable test--one that will become widely used by clinicians or American consumers who may find it one day in the oral care aisle, is a separate challenge. For the time being, dentists who want to offer breath odor testing to their patients will need to do some independent study, and have a nose for good scents.
Janyce Hamilton is an award-winning Chicagoland freelance dental
writer and editor. Send suggestions for topics to be covered, or any
comments on this column, to review@cds.org.
© 2009, Chicago Dental Society
