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2nd. Edition

Discussion

Bad breath is a condition which affects a large proportion of people around the world. In the clinic, we have encountered people from practically all walks of life, including teachers, bankers, lawyers, judges, dentists, politicians and airline pilots. Because of the importance of the mouth in self-esteem and self-image (Fisher, 1986), one's perception of suffering from oral malodor may have serious repercussions. Some of the statements made by the subjects reflect the severity of the perceived problem: "It ruins my life"; "I feel defiled", "I sleep separately from my husband"; "It's like having cancer".
Indeed, suicide cases linked to perceived bad breath have been previously reported (Crohn and Drosd, 1942; Yaegaki, this volume).

The data presented here provide further support for the premise that a significant number of individuals tend to grossly overestimate their own oral malodor levels (Iwakura et al., 1994; Cherniak et al., 1993; Spouge 1964). Subjects often remark of being able to measure their own bad breath by various techniques, including cupping hands over mouth and nose, licking hands, smelling saliva, smelling the telephone mouthpiece, rubbing fingers across the gums, and breathing beneath a blanket. These accounts formed the basis for a recent study on self estimation of oral malodor levels (Cherniak et al., 1993). Subjects were asked to score their own malodor by cupping hands over mouth ("whole mouth malodor"), licking their wrist ("tongue malodor) and expectorating into a petri dish ("saliva malodor"). Only in the case of saliva self-measurement was some objectivity observed. However, subjects tended to subsequently disregard the objective component in favor of their preconceived notions. Clinical studies have shown that objective improvements in malodor levels, following oral hygiene instruction and efficacious mouthrinsing, are not reflected in patients' self reports (A. Fleming, unpublished, 1990; Iwakura et al., 1994).

In order to overcome the problems inherent in self-assessment and self- reporting (Cherniak et al., 1993), we have adopted the procedure of encouraging individuals to bring family members (or friends) to the consultations themselves.
Accompanying persons are taught how to distinguish between oral and nasal malodor (Prinz, 1930). They are also asked to verify during the consultation whether the individual's odor reflects, in terms of quality and quantity, the presenting odor at other times.

Another benefit of the accompanying person is verification that the condition actually exists. When a person presents at the clinic without appreciable odor, accompanying persons can provide crucial information on whether the problem actually exists at other times, or is imagined. Unfortunately, most of the individuals who grossly exaggerate the magnitude of their oral malodor are those who insist on arriving by themselves, and also tend to be most convinced that a problem does exist.
The few cases in which we have succeeded in persuading such individuals to seek psychological counsel have shown marked improvements (A. Goldstein, personal communication).

The underlying reasons leading people to believe, mistakenly, that they suffer from bad breath are not yet clear. Advertisements on the subject of bad breath may elicit unwarranted concerns in suggestible individuals. Others may notice a bad taste in their mouth and rightly or wrongly assume that it must be related to bad breath (see also Preti et al., this volume). Foul-smelling calcified stones (tonsilloliths), coughed up from the tonsils, might also lead to incorrect assumptions of suffering from oral malodor (Pruet and Duplan, 1987). Some subjects recall having been told only once in their distant past that they had bad breath, yet continue to worry about it (see also Crohn and Drosd, 1942). In other cases, individuals cite a family member as having bad breath. Whether consciously or not, they may infer that they must suffer from the problem as well. One woman in her early twenties came for consultation, accompanied by her father. The woman was convinced that she suffered from terrible malodor, and was, in the words of her father, "suicidal at times". Whereas the woman's breath was pristine, her father's was particularly offensive and could be smelled at a distance of well over a meter.

In some cases, imaginary bad breath is accompanied by clear psychological pathologies (Davidson and Mukherjee, 1982; Hawkins, 1987; Iwu and Akpata, 1989). In some cases, the delusion of bad breath is so severe as to preclude classical psychotherapy. In one recent instance, a mother badgered her daughter repeatedly until the daughter was compelled to report falsely that her mother suffered from malodor. In another case, a local physician complained of suffering from oral malodor for over two decades and was extremely uncomfortable being near his patients. No objective basis for the oral
malodor was found, and the physician was initially able to accept this diagnosis on a professional level. Furthermore, after some brief coaxing, his spouse, with whom he had never spoken regarding this problem, arrived with him for consultation.
She maintained that she had never noticed that her husband suffered from oral malodor (indeed, he professed to maintaining impeccable oral hygiene), and promised to tell him should he ever have bad breath in the future. However, despite the good initial prognosis, a telephone inquiry several months later revealed that the physician's concerns had not abated.

The above notwithstanding, it should be emphasized that the inability of odor judges, or even family members, to verify malodor in the reporting individual does not guarantee that subject's perceived bad breath is purely psychological in nature and devoid of any physiological basis, such as persistent bad taste (Ayesh et al., 1993; Preti et al., this volume), or the presence of tonsilloliths (Pruet and Duplan, 1987).
Although the major role of the posterior part of tongue dorsum as a source of oral malodor has been acknowledged for many years (Grapp, as cited by Massler et al., 1951), the underlying etiology has not yet been established. In earlier studies, we sampled this area using a gauze pad (Rosenberg et al., 1991a). We subsequently found, however, that probing the area by scraping with a plastic spoon, was superior in obtaining a representative sample yielding this characteristic odor. Furthermore, we observed that strong odors from this area are often accompanied by the presence of a yellowish discharge on the spoon, physically similar to post-nasal drip. In the majority of cases, i.e., the absence of a frank nasal infection, this secretion may be initially odorless, but following putrefaction on the tongue itself, a unique type of smell arises. For tongue brushing to be of value in oral malodor reduction, it must include removal of this coating from the tongue dorsum posterior, a difficult task due to gagging reflex.

Among some thousand subjects whom we have tested over the past years, there has not been a single instance in which the gastrointestinal tract appeared to be directly involved in oral malodor. This is in agreement with previous investigators who suggested that since the esophagus is collapsed, odors cannot escape except during belching (Prinz, 1930).
Nevertheless, we continually encounter physicians and dentists who still believe bad breath to be primarily a gastrointestinal condition. Regrettably, many of our subjects had undergone gastroscopies before coming to see us.
Although the ear-nose-throat literature cites the tonsils as a not uncommon source of oral malodor (Costellani, 1936; Bogdasarian, 1986), this remains an open issue. Tonsils may harbor a variety of odorigenic microorganisms, including periodontal pathogens (van Winkelhoff et al., 1986). Although we were able, in some cases, to detect foul odors on the tonsils themselves, as well as emanating from tonsilloliths (Pruet and Duplan, 1987), they did not necessarily lead to bad breath. Modern treatments, such as laser cryptolysis (Finkelstein, this volume), may help clarify the direct contribution of the tonsils to the oral halitus.