Halitosis: Problem Solved!
Personal space is defined as the region surrounding a person which they regard as psychologically theirs. Nothing can expand this space quicker than someone with bad breath. We have all experienced it. The smell can hit you like a load of bricks. Your body involuntarily responds by backing up, and you pretend nothing is wrong. I don’t care how good looking he or she may be, all you want to do is end the conversation and get out of there!
As a dentist, sometimes it is even difficult for me to let my patients know they have bad breath. I detect it usually through organoleptics or the art of using ones nose to smell the smells. This technique can be quite accurate. It can distinguish between cigarettes, coffee, periodontal disease, stomach content, sinus infection, kidney disease, liver disease, diabetes mellitus, garlic, kimchi and gram negative anaerobes.
The human body is a most fascinating specimen of creation. It is basically a hollow tube with bacteria, fungi and viruses living all over it. It is of course sterile inside the tissue, but inside in the gut and on the skin it is teaming with trillions of microbes. There are many different types of bacteria. Some eat proteins, some eat fats, some eat carbohydrates, and some eat a combination of all nutrients in the human diet. Some use oxygen in their respiration like we do, and others use sulfur in their respiration. Sulfur is the oxidative element right under the periodic table from oxygen. Bacteria that use sulfur instead of oxygen for respiration are called anaerobes (or without oxygen). Different parts of the body support populations of microbes of different kinds. They are called the normal flora. The mouth has some 500+ different normal flora. Each individual bacteria are normally found infecting a certain percentage of the total amount of normal flora, and when they grow to a larger percentage usually found in the normal flora, they are considered a super-infection.
Gram negative anaerobes of the mouth are part of this normal flora. They live out of sight in the dark crevasses of the mouth where oxygen has a hard time penetrating. There they live on sulfur containing amino acids like cysteine, and methionine. On their outer cellular membrane are special receptor sites that detect, attach to, and then pull in sulfur containing amino acids to be digested. As the bacteria uses the sulfur to digest the amino acids, hydrogen sulfide gas is formed, and releases as a by-product of respiration just as we release carbon dioxide from our lungs with our oxygen respirations. Hydrogen sulfide gas is a very volatile and potent smelling gas. It is the compound that gas companies put into propane and natural gas so we can detect even the tiniest leak in their pipe lines. Other volatile sulfur gases are cadaverine, and putrazine that are formed from anaerobic bacteria in decomposing animal carcasses.
When for whatever reason gram negative anaerobes erupt into a super-infection in our mouths, others can detect the volatile sulfur compounds in our breath through organoleptics well outside of their personal space. This can be a devastating effect. Humans are basically social animals (Facebook) and crave others attention. When they have halitosis this personal social network breaks down and in some case even is turned-off. Lets face it, bad breath is bad!
Killing Bacteria by the Millions!
How many of us have heard that claim from a mouthwash? This, believe it or not, is true! There are millions upon millions of bacteria inside the normal mouth at any one time. Remember, they are called the normal flora. They are setup in a hierarchy of good to bad. The good ones are the most populated one in the mouth, and the bad ones are the least. Unless you are counting the over fed Streptococcus mutans in some people’s mouths, which is fodder for another blog on bacterial plaque. So when you use a bactericidal mouthwash you indeed wipe out a very large portion (millions) of the good bacteria and not necessarily the bad one which are hiding in the oxygen poor regions of the mouth. The heavy flavoring oils inside the mouthwashes then effectively mask the smell after that. You also do not kill yeasts, that have a plant-like cell wall to protect themselves from the mouthwashes toxic effects. One of the functions of a large population of good bacteria is to subdue, and inhibit the overgrowth of bad bacteria such as gram negative anaerobes. Continually “knocking-off” the good bacteria often leaves room for those lower percentage “bad” bacteria, and yeasts to overgrow into a super-infection, thus creating an imbalance in the normal flora of the mouth. Chronic bacterial and yeast imbalances in the mouth’s normal flora can cause halitosis.
As a side note: Most of the manufacturers of mouthwash say on their websites that it is gingivitis and periodontal disease that causes bad breath. Some want you to scrape your tongue as well (which is good to do, but generally not as effective as you would like against halitosis). This unfortunately is what most dentists think, too. The patient asks, “Geez doctor, I think I have bad breath. What should I do for that?”. The doctors answer, “Schedule yourself for a prophy cleaning and check-up regularly, and you will not have that problem”. If this is true, then how come we have patients with no gingivitis or periodontal disease with very bad halitosis?
Alcohol Containing Mouthwashes:
There are many products on the market today that claim to prevent bad breath, but do they? Most of the mouthwashes on the market today that have become a household name through millions of dollars in advertising, contain some kind of alcohol. Alcohols are a dehydrating, oxidative, soluble chemical that when placed in the mouth, essentially dries out the mucous membranes of the cheeks, gums, throat and tongue causing them to eventually slough off their outer layer of epithelium. Similar to when our skin peels from a sunburn. This in effect cause more sulfur containing amino acids that are found in the epithelial tissues to be available for the anaerobic bacteria to eat, and digest, thus causing a rebound halitosis, or a return customer for the mouthwash industry. It can become a mad cycle where the customer (you) can consume literally gallons of mouthwash per year.
I am happy to say that manufacturing companies are seeing the writing on the wall, and listening to dentists who are telling our patients to only use non-alcoholic fluoride containing mouthwashes. Even Listerine has followed suit by marketing a non-alcoholic mouthwash. It still doesn’t contain fluoride though, so I wouldn’t recommend it to my paitents.
Fluoride Containing Mouthwashes:
It simply makes no sense to me why a mouthwash would be manufactured today without fluoride. I find there are just not enough anti-fluoride people in the market to cater to. Even these non-alcoholic mouthwashes also indiscriminately kill off the normal flora of the mouth as well. Interfering with the normal flora can cause significant rebound halitosis.
Zinc Containing Dental Health Products:
There are many new and old products that have proprietary zinc compounds in their formula that have been proven to prevent halitosis caused by anaerobic bacterial respiration of sulfur containing amino acids in the mouth. They are designed to usually NOT kill bacteria by the millions or disrupt the normal flora of the mouth. Instead, the zinc containing compounds block the receptor sites on the outside of the bacterial membranes, thus blocking the uptake of sulfur containing amino acids in the first place. If the bacteria cannot get the sulfur into their cells, then they cannot produce hydrogen sulfide gas. No gas, no halitosis. It’s really that simple! Over time, using these zinc containing products, the normal flora percentages are re-established and the patient may possibly be weaned off of mouthwashes altogether.
- Smart Mouth (this is the one I recommend) has a patented zinc-ion technology that was settled in a lawsuit by their competitor Oxyfresh. It is sold as a pair of pump bottles. One pump bottle contains a minty fresh bluish-green liquid that contains all the zinc-ion technology (proprietary zinc chloride compound), and flavorings, and the other contains a nearly tasteless activator. You simply pump a small amount of each bottle into a medicine cup, swish for about 30 seconds and expectorate. I find this product to be very inexpensive and last a very long time because only a small amount is needed for the effect. The results are immediate and long lasting fresh breath. You can literally use it in the morning and prevent anaerobic bacterial halitosis for up to 12 hours. If you use it before bedtime, you can prevent the dreaded morning breath. And the mouthwash is sodium lauryl sulfate free! Too bad the Smart Mouth toothpaste isn’t.
- TheraBreath PLUS Mouthwash zinc gluconate
- Tom’s Wicked Fresh mouthwash with zinc chloride
- Oxyfresh zinc acetate
Who should use these products? Of course, this answer in simple: Anyone who thinks they may have halitosis. Why even ask this question? There are really only three types of patients when it comes to halitosis.
- Those who have halitosis, and know it
- Those that don’t have halitosis, but think they do
- Those that have halitosis, and don’t think they do
The first category are the easiest to treat. Just tell them about Smart Mouth and direct them to the nearest Walmart, Target or Walgreens. Teachers, sales people, lawyers, doctors, speakers, politicians, actors, you name it, routinely use this product every morning before they encounter the public.
The second group are the ones who cannot be convinced their breath is okay. For those people we can put them on a halimeter to measure the concentration of sulfur dioxide in their breath, and they still don’t believe it. A halimeter is portable gas chromatograph calibrated to measure volatile sulfur compounds. Again, the treatment for these patients is simple. You put them on Smart Mouth mouthwash, and it will not hurt.
The third group is the one that is tricky to work with. They are the ones who come in for a dental appointment, and you smell their bad breath. This bad breath is even there after their very thorough cleaning. What do you do as a dentist/hygienist? Unfortunately, most dentists and hygienists don’t want to inform a paying patient that they have a bad breath problem. After all, how do you tell someone they have bad breath without offending them? It is a really big problem as you can imagine. Think about how you would feel if someone told you you had halitosis right after you spent money to get your teeth cleaned. Not fun!
Halitosis. If you think about it, who would be better to tell someone about their super-infection than a dental professional? This is how I do it, and if you have a better way, then I’m all ears. There are really two ways I can start off the conversation. Sometimes I’ll say out loud to my hygienist, “Did you detect volatile sulfur compounds?”. For which the hygienist is trained to say, “Yes”. Then I go on with the exam. If the patient doesn’t catch the bait by asking what are volatile sulfur compounds, then I’ll ask if they use a mouthwash. If they say “Yes”, then I ask them why. This can then launch into switching to a better more effective mouthwash. If they say “No”, then you have to tell them you have detected volatile sulfur compound in their breath caused by a super-infection of gram negative anaerobes. This usually gets a bovine stare back from the patient before I dive into normal flora, bad bacteria, sulfur containing amino acids and proprietary zinc compounds. Then I tell them about Smart Mouth, and hope for the best. This does take a lot of time to counsel the patient, and I understand there is a dental assistant tapping their foot wanting you somewhere else. This is one of the main reasons why I, and other dentists/hygienists don’t spend the time needed to inform the patient of the treatment for halitosis. There could even be a down side to this scenario where you may not have presented the message very well, and the patient gets upset, and decides to take their business elsewhere. Bummer! Fortunately, I don’t think I have insulted anyone to that extent, but I could have, especially in the beginning, which was at least 15 years ago when Smart Mouth use to be called TriOral, and was only sold to the patients by dental offices. I am so glad we don’t have to do that anymore. I am perfectly happy to refer them to the nearest big chain pharmacy, to not have to keep an inventory of this product myself, and be the products only salesman.
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