For October 30, 2001

Heart to Heart Talk

With Philip S. Chua, M.D.

Halitosis: Bad Breath !

BREATH RX TM
BREATH MANAGEMENT SYSTEM

HALITOSIS
• Halitosis is caused by volatile compounds (VSC) which are foul smelling
odors caused by anaerobic (gram negative) bacteria.. Anaerobic=no air
or oxygen
• An anaerobic bacterium hides in the dark moist places between teeth and
at the back of the tongue.
• Eliminate the anaerobic bacteria, and VSC does not form. IF you
neutralize the VSC, there is no odor.

4 TYPES OF VSC’s
• HYDROGEN SULFIDE
• METHYL MERCAPTAN
• DIMETHYL SULFIDE
• DIMETHYL DISULFIDE

CHARACTERISTICS OF HALITOSIS
ORAL HALITOSIS
• Varies with the time of the day.
• Morning is usually the worst.
• Varies with age, gender, and hunger state.
• Varies with intensity and quality.
PRIMARY SITES
• Tongue
• Gingival Crevices

- Gram negative bacteria metabolizes protein which results in

malodor

- Gram-positive bacteria metabolize protein but do not cause

malodor.

pH and HALITOSIS

• A pH level of 7.2 or more in the mouth increases the growth of gram-

negative bacteria.
• A pH level of 6.5 or less in the mouth increases the growth of gram-
positive bacteria.
• The normal pH of the mouth is slightly acidic (6.5-6.9)

SALIVA:
The function of Saliva in the mouth

• Cleanses
• Muscosal Integrity
• Antimicribial
• pH Buffer
• Digestive
• Lubrication
SALIVA FLOW
Factors Affecting Saliva Flow
• Aging
• Light
• Circadian Rhythm
• Body Position
• Olfactory Stimulation
• Smoking

Techniques to Increase Saliva Flow

• Consumption of foods requiring chewing: Carrots, Celery.
• Use of inert materials, such as gum, mints etc.
• Holding objects in your mouth, such as marbles, olive points.
• Consumption of Citric Acid Substances.

PERIODONTAL DISEASES
“There is a direct connection between Volatile Sulfur Compounds in the
mouth and patients with periodontal disease.”

(1992 Journal of Periodontal Research: Yaegaki & Sanada)

THE TONGUE
• The tongue is the major contributor in healthy mouths to oral malodor
• The tongue coating contains desquamated (dead) epithelial cells, & bacteria

THE TONGUE
• A similar bacterium whish is found in the tongue is also found in periodontal
pockets and services.
• For people with Perio disease, the increase in bacteria found in the tongue and
a periodontal pocket greatly increases halitosis.
• Scraping your tongue reduces oral malodor by approximately 75%.
MORNING BREATH

CAUSES OF MORNING BREATH

MORNING BREATH

• Saliva flow decreases during sleep.

• Proteinaceaus debris increases.
• PH shifts to alkaline (7+).
• Gram-negative bacteria increase.
• Production of other debris in the mouth increases.
• Putrefication of debris increases.
• Oral malodor increases.

MYTHS AND FACTS ABOUT HALITOSIS

• An estimated 40,000,000 Americans have halitosis.
• Americans spend over $ 500,000,000 on Halitosis products
• Most halitosis products mask, and do not eliminate bad breath.
• 1992 Consumer Reports tested 15 mouthwashes. All of them masked bad
breath after 10 minutes. Only a few lasted after several hours.
• There are two types of halitosis: Transitory and Chronic.
• Halitosis caused by medical problems account for only 10% of chronic
halitosis. (Diabetes, Liver Failure, Chest Infection).
• The bad odor from halitosis can reveal the source of halitosis:
• Oral Thrush will result in a fruity malodor
• Ulcers will result in a distinct metallic smell
• Diabetes will have a sweet acetone smell
• Chest Infection will be distinguished by a foul odor.
• Liver Failure will smell of decaying blood.
• A person cannot smell his or her own halitosis.
• Women have a better sense of smell than men.
• Saliva helps balance acid levels in the mouth.
• Morning breath is caused by decreased saliva flow during sleep, which allows
bacteria to grow.
• 92% of dentists polled at the 1995 JADA (Journal of the American Dental
Association) reported they had patients with bad breath.
• The JADA survey also reported that the average number of patients that
dentists see with bad breath on a weekly basis is 6.
• The normal pH of the mouth slightly acidic (6.5-6.9).
HISTORY OF HALITOSIS
• Writings on halitosis date back to 1847.
• 1847 Howe described several cases of fetid breath occurring during emotional
distress in people. We still don’t know why other than the increase in
hormonal activity.
• 1927 Stallard showed onions and garlic remain in the breath for up to 72
hours. These odors can also be secreted through the skin pores.
• 1931 Hartzell found that the tongue is the source of halitosis.
• 1942 Cronin & Dash found that mouth odor (transitory halitosis can also be
caused by the exhaling___________
• 1947 Fosdick found that saliva from people with perio disease putrefied more
rapidly than normal.
• 1949 Lapp found that Chlorophyll had a remarkable deodorizing effect
• 1977 Tonsetich wrote the Production & Origin of Malodor
• 1990 Persons wrote on the formations of hydrogen sulfides and methyl
mercaptans by oral bacteria.

TYPES OF HALITOSIS
TRANSITORY VS CHRONIC

TRANSITORY HALITOSIS
Transitory halitosis lasts between 24 and 72 hours and is usually caused by foods
such as garlic, pepper, and onion. Everyone has transitory halitosis.

CHRONIC HALITOSIS
The caused of chronic halitosis is usually oral in nature but 10% of cases are
reported to be caused by other factors such as a disease or ailment.

CAUSES OF HALITOSIS
• The mouth is home for numerous bacteria, which can cause halitosis.
• Odors of halitosis come from the production of compounds, which come from
the proteins we eat, debris in the mouth, and from the natural process of
shedding the lining in the mouth.
 • Bacteria that cause halitosis are from the family of bacteria labeled
“anaerobic” under the gums, crevices in the tongue, and in between the teeth.
• Bacteria also thrive when the environment of the mouth gets out of balance
such as morning breath.

PHYSIOLOGICAL VS. PATHOLOGICAL

• Age
• Morning Breath
• Hunger Breath
• Menstrual Breath
• Food & Drugs
• Tobacco
• Less Intense
• Transient
• Non-Descript
• Generally Responds
Improve Oral Hygiene
• Chronic
• Mouth, Nose, Smus
• Tonsils, Pharynx
• Digestive Organs
• Systematic Organs
• More Intense
• Distinct in Quality
• Persistent
to • Requires Treatment of the
Underlying Cause

PRIMARY FACTORS AFFECTING HALITOSIS

• Saliva Flow
• Gram Negative Bacteria
• PH
• Presence of protein Cellular and Food Debris

MICROBIATA IN HALITOSIS

• T. Denticola • P. Endodontalis
• P. Intermedia • P. Metaninogenica
• B. Forsythus • R. Denticariosca
• Fusobacterium

ROLE OF SALIVA
• Bacterial Putrefaction
• Provides Substrates
• Facilitates Oxygen Depletion
• Affects the pH of Oral Cavity
MEDICAL CAUSES OF HALITOSIS

• Respiratory • Systemic
• Liver • Gastrointestinal
• Kidney • Psychiatric

RESPIRATORY
• Sinusitis • Pharyngitis
• Tonsillitis • Tumors
• Bronchitis • Tuberculosis
• Pneumonia • Emphysema

LIVER AND KIDNEY

• Liver Cirrhosis
• Liver Failure
• Gall Bladder Disease
• Uremia

GASTROINTESTINAL
• Esophageal Reflux
• Hiatal Hernia
• Pyloric Stenosis
• Stomach Cancer
• Malabsorption

DIABETES
• Diabetes • Chemotherapy
• Stress • Radiation Therapy
• Leukemia • Sjorgens Syndrome
• Cancer • Chandidiasis (Oral)

MEDICAL CAUSES OF HALITOSIS

• Sinusitis • Pneumonia
• Emphysema • Liver Failure
• Tumors • Gall Bladder Disease
 • Esophageal Reflux • Bronchitis
• Stomach Cancer • Liver Cirrhosis
• Diabetes • Uremia
• Tuberculosis • Hiatus Hernia
• Tonsillitis • Malabsorption
• Pharyngitis

DRUG CAUSES OF HALITOSIS

• DMSO
• Chloral Hydrate
• Metronidazole
• Anti-Parkinsonians
• Narcotics
• Antihistimines
• Anticholinergics
• Amyl Nitrate
• Paraldehyde
• Anti-Depressants
• Anti-Psychotics
• Decongestants
• Anti-Hypertensives

ORAL CONDITION CAUSING ORAL MALODOR

Periodontitis Gingivitis
Apthous Ulcers Traumatic Ulcers
Dental Abscesses Herpetic Infections
Chandidiasis Oral Cancer
Xerosytomia Poor Oral Hygiene

NON-ORAL SOURCES CAUSING ORAL MALODOR

Nose/ Sinuses Pulmonary

Tonsils/ Pharynx Systematic Illness
Digestive Organs

SYSTEMIC ILLNESS PSYCHIATRIC

• Diabetic Ketoacidosis
• Liver Failure
• Renal Failer
• Schizophrenia
• Olfactory Reference
Syndrome
 DIAGNOSIS

• Self-Assessment- Lick your wrist, wait 5 min, then smell

• Counterpart Assessment- Wife, Husband, Partner
• Halimeter-Measures VSC, parts per Million, by Abiodent
• Periotemp-Detects changes in the gingival temperature
• Diamenes Test-Only used in Research
• Smell Chromatography
• Tin Dioxide-Only used in Research
• Perio Check
• Fresh Breath Detective- Uses Cotton Swabs
• Oral Judges

TREATMENT OF HALITOSIS
CLINICAL TREATMENT OF HALITOSIS
• Eliminate VSC-Zinc Chloride and Improve Oral Hygiene
• Eliminate Debris-Tongue Cleaning, Increase Saliva Flow, Improve Oral
Hygiene
• Reduce Bacteria-Improved Oral Hygiene
• Create Optimal Gingival Health- Improved Oral Hygiene

CLINICAL TREATMENT OF HALITOSIS

Improved oral hygiene is a key factor in the successful clinical treatment of

halitosis.

SUMMARY OF HALITOSIS PRODUCTION

• Gingivitis
• Periodontal Disease
• Saliva
• pH
• Oxygen
• Plaque Thickness
• Gram Negative Bacteria
• Gram Negative Bacteria
• Gram Negative Bacteria
• Gram Negative Bacteria
• Gram Negative Bacteria
• Gram Negative Bacteria
 CHLORINE DIOXIDE
CLO2
• A strong Oxidant currently used in water disinfections & sanitation of food
equipment.
• Oxidizes and destroys VSC in oral malodor
• The same properties, which make Chlorine Dioxide, also allow for instability
in solutions of near normal pH.

IMPORTANT: Chlorine Dioxide should NOT be confused with “stabilized

Chlorine Dioxide which is a solution for sodium chlorite.

There is uncertainty with regard to the safety of Chlorine Dioxide use

and its stability.

Retardent-Rowpar & Oxyfresh both use Chlorine Dioxide.

Others use alcohol to eliminate the bacteria that cause VSC

OVER THE COUNTER MOUTHWASHES

Alcohol Content of OTC Mouthwashes
• Listerine 26.9%
• Cepacol 14%
• Scope 8.9%
• Plax 8.5%

INTRODUCING
ZYTEX TM
The Breath Rx System is designed to make the most of the powerful dual
action of Zytex, a state oral hygiene complex that works in 2 ways to fight
bad breath.
ZYTEX is a blend of:
• Thymol
• Eucalyptus oil
• Zinc Chloride

CAUSE AND EFFECT

The Thymol and Eucalyptus Oil work as antibacterial agents that kill the anaerobic
bacteria while the zinc Chloride inhibits the formation of the VSC’s.

ADMINISTERED ONLY THROUGH DENTIST

BREATH RX 9 Different Products
• Starter Kit
• Cleansing Mouth Rinse
• Tooth Brushing Gel
• Gentle Oral Brush
• Gentle Tongue Scrapper
• Breath Cleansing Mints
• Halispheres Chewing Gum
• Breath Cleansing Daily Gel Caps
• Daily Breath Spray

BREATH RX * STARTER KIT

• Contains Basic 3 products, Cleansing Mouthrinse, Tongue Spray, Tooth
Brushing Gel, and Gentle Tongue Scrapper.
• Offers trial sizes of convenient take-along products
• Patient booklet explains each product and encourages patient compliance
through the use of the Daily Progress Report.
• Ample sizes give enough products for trial.

BREATH RX *CLEANSING MOUTHRINSE

Alcohol free mouthrinse, which combats micro organisms that cause bad breath, it also
works to eliminates VSC’s
• Contains Zytex
• No Alcohol
• No Chlorine Dioxide
• Clean Mint Peppermint Flavor
• Contains Xylitol, a sweetening agent that reduces tooth decay
 • Available in large 16 oz or 4oz bottle

BREATH RX * TOOTH BRUSHING GEL

It also contains halitosis fighting ingredients.
• Contains Zytex
• Clean Mint peppermint flavor
• Contains fluoride to fight cavities
• Contains Xylitol
• Contains Cabo-Sil, a mild abrasive

BREATH RX * GENTLE CARE ORAL BRUSH

Short, soft bristle brush, alternative to tongue scraper. This gently removes debris and
bacteria from the tongue and oral cavity.
• Unique ergonomic design
• Soft, short bristles for gentleness
• Special angel allows greater reach in the mouth
• Can also be used to brush the inside of the cheeks or the roof of the mouth.

BREATH RX * GENTLE TONGUE SCRAPPER

These secrets of Asia brought to us this device, used to safely clean the tongue. It
effectively removes debris and bacteria from the tongue.
• Light weight flexible plastic design
• Unique design to fit the shape of the tongue
• Special ridges to gently clean the tongue
• Most effective tool to help control halitosis

BREATH RX * HALISPHERES CHEWING GUM

Breath cleansing gumballs, peppermint flavored. IT works well to combat halitosis when
it is inconvenient to brush or rinse.
• Contains Zytex
• Clean mint peppermint taste
• Convenient pre-package 5 piece paks
• Easy to use, easy to carry

BREATH RX * BREATH CLEANSING GEL CAPS

• Contains special ingredient, green tea. Known for its deodorizing effects.
 • Contains parsely seed oilwhich has chlorophyll, known for its deodorizing
effects.
• Easy to use, easy to carry.
• Available in 50 count or 200 count containers.

BREATH RX * DAILY BREATH SPRAY

• Contains Zytex
• No alcohol
• Refillable container, easy to fill
• Convenient, discreet, easy to fit in pocket
• Contains Xylitol, a sweetener which reduces tooth decay
• Cool mint peppermint taste

What is halitosis?

Halitosis is the medical term for bad breath. Dental reports in the United
States say there are about 40 million Americans who have bad breath. In the
Philippines, as in other regions in Asia, the incidence, conservatively speaking, may
be as high as 50%-60%. This is a rough guesstimate, and the figure, of course,
varies in different subgroups in the community. Halitosis, as a general rule, is less
among those who live in the city, compared to rural areas, those who are more
affluent, higher in socio-economic status, those who are more educated or
professional, and those in the younger generation. Obviously, the financially
handicapped could ill afford the luxury of toothpaste, dental floss, mouthwash,
regular dental check-up and proper dental care. They may also be not as well-
nourished, and as healthy, as those who can afford.

What causes halitosis?

There are a variety of causes of bad breath. Eating food that causes foul
breath (like garlic, onion, etc), poor dental hygiene, decayed tooth or infection of the
gums or oral cavity, diseases like diabetes, esophageal diverticulum, esophageal
reflux, sinusitis, emphysema, etc. But the commonest underlying cause is poor
dental hygiene where care of the teeth and mouth is neglected. There are people who
do not brush their teeth at all and go to bed at night with food particles stuck in
between their teeth. They may gargle and rinse their mouth with water (or water
and salt) after each meal, or even use mouthwash, but the food caught in between
their teeth (especially meat and fish) rot and stink like dead animals on the street.
This is putrefaction and the foul smelling odor is from the sulfur compounds
produced by the decaying meat, which usually results in bacterial infection (and
more bad odor), and this makes the cycle a vicious one.

What are the types of bad breath?

Transitory halitosis is caused by food like onions and garlic and generally
lasts from one day to day and a half. Some people develop halitosis after drinking
pop or eating sweets, like dessert. The individual “oral metabolism” may have
something to do with this observation. The other form of bad breath is the Chronic
halitosis, which does not diminish or improve with time. It is permanently present
until the cause is abolished. The bad odor comes from the bacteria in the mouth
(between the teeth and on the tongue) which produce the foul smelling volatile
sulfur compounds (VSC) in the form of hydrogen sulfides.

Can tooth infection cause infection in the heart?

Yes, tooth infection can cause the bacteria in the mouth to circulate in the
blood stream to infect the heart valve, causing bacterial endocarditis, most
especially in people who may have had rheumatic heart disease when they were
young. This condition affects and weakens the heart valves, making them
susceptible to infection.
And those with artificial heart valves are even more prone to infection originating
from tooth decay or infection in the mouth.

Does infected tonsils cause bad breath?

Yes, any infection in the oral cavity (in the teeth, gum, tongue, tonsils, any
part of the mouth and throat) will cause halitosis.

Does eating bagoong, patis, century egg or durian cause bad

breath?

Yes, but only if one does not do proper oral hygiene after eating any of these,
or any other food items. If one brushes the teeth, does dental floss, gurgles with
mouthwash, and maybe chews minted gum, after eating these food items, there
should not be halitosis at all post-ingestion.

If, inspite of proper oral hygiene, bad breath is still present,

what can it be due to?
 If there is no tooth decay or any infection in the mouth or throat, the bad
breath may be coming from sinusitis, emphysema or from the stomach (as in
esophageal reflex, where the controlling valve between the stomach and the food
pipe is not closing ---airtight---properly). A dental, or even medical, evaluation may
be needed to ascertain the specific cause of this persistent halitosis.

Can mouthwash eliminate bad breath?

No, mouthwash alone cannot do the trick. First, the food particles that can
rot must be removed from in-between the teeth immediately after each meal (by
dental flossing, since tooth pick alone will not do the job). Then, brushing the teeth
using toothpaste (that contains fluoride and other ingredients like Poly
(methylvinylether) maleic acid coplymer and triclosan) for added tooth protection,
is essential at least 3 times a day, after each meal. Mouthwash can be used as a last
step in this routine as an added regimen. A study made on 15 mouthwashes showed
that most masked the bad breath for a few minutes, only a few were still effective
after a few hours. Most of the products sold over-the-counter do not eliminate
halitosis.

What are the dental problems caused by bacteria?

Besides bad breath, the other problems caused by germs in our mouth
include cavities, gum problems, plaques and tartar formation. Therefore, the
routine regimen of dental flossing (to eliminate food particles that will rot and
harbor bacteria), tongue-scraping, toothbrushing (to scrub food elements, juices and
stains from the teeth, and protecting the teeth and gums with those ingredients in
the toothpaste), and gurgling (with mouthwash that contain bacteria killing, and
plaque-and-tartar preventing ingredients), and visiting your dentist at least every 6
months will not only eliminate bad breath but lead to a healthier dental and oral
state.

Can mouth containing alcohol cause cancer?

Yes, according to a 1991 study in the Journal of the American Dental
Association, which stated that mouthwashes “containing more than 25% alcohol
could increase the risk of oral and pharyngeal (throat) cancer by 50%”.
Fortunately, most, if not all, mouthwashes in the market contain less than 15%
alcohol.

How effective are breath-freshener capsules?

If taken as directed, and as a part of the comprehensive regimen we have
discussed above, these breath-freshener capsules could be of help, especially for
those with gastrointestinal reflux.

How about chewing gum?

Not by itself, but if added to the daily oral hygiene regimen we

recommended, chewing (sugar-free) gum can be of help achieving a fresher and
kissable breath.

Do people know they have bad breath?

It is odd but most people with chronic halitosis do not know they have it.
Their own sense of smell is so conditioned to the bad breath in their mouth to the
point that they do not even perceive or know they have halitosis. And their friends
and relatives (including most spouse) will not even tell them, “to spare” them from
the embarrassment (which actually leads to more embarrassment because of the
persistence of this very offensive problem.) So, the next time you see your lover or
friend, or relative, beg him or her to be candid with you. This honesty might change
your reputation and love life forever.