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2nd. Edition

Experiences of an Israeli Malodor Clinic

Oral malodor is an intimate human problem which crosses over many scientific disciplines and has many nuances.
Whereas laboratory research is of great importance in understanding various aspects of oral malodor, clinical experience is also a prime factor. For the past three years, we have provided an oral malodor consultation service in a medical center in Tel-Aviv. The present report summarizes some of our findings, with particular reference to 308 individuals who sought our advice between February and December, 1992.
Individuals who presented at the clinic between February and December, 1992 (N=308) became aware of the clinic primarily through (i) articles in the local press and in radio interviews; (ii) referrals from dentists and physicians; and (iii) spouses and other family members who sought our help. Sixty percent (N=185) were women.

Consultations were performed in the following manner. First, an interview regarding general health and medical history was conducted, with emphasis on oral hygiene practice, and any other conditions which might conceivably lead to malodor (primarily involving nose, throat, and allergies). The subjects were then asked to present a history of the complaint itself, including a brief description of the perceived effect on their lives. Subjects were asked to estimate their own malodor level, prior to measurement, on a 0-5 intensity scale (preconception). Subjects were then judged organoleptically on the same 0-5 intensity scale, in half-integer increments (Rosenberg et al., 1991a), in several manners. First, whole mouth malodor was assessed, as described in previous studies (Rosenberg et al., 1991a,b). Tongue dorsum (anterior) odor was assessed by asking the subject to extend his/her tongue and lick his/her wrist in a perpendicular fashion (Kozlovsky et al., 1994).
The odor level was assessed after five seconds. Tongue dorsum (posterior) was assessed by scraping this area with a small, disposable, plastic spoon, and assessing the odor on the spoon after five seconds. Nasal odor was distinguished from oral odor (Frankel, as cited by Prinz, 1930) by asking the subject to close his/her mouth and to exhale through the nose.

Mean values for self- and odor judge assessments are summarized in Table 1. Whereas women scored significantly higher than men in rating their own malodor (p<0.001), men were assigned higher mean judge scores in all odor judge tests (p<0.001). Self-estimates were significantly higher than odor judge scores for both men and women (p<0.001). Posterior tongue dorsum odor judge scores were consistently higher than anterior tongue dorsum levels (p<0.001).

As shown in Figure 1, whole mouth odor judge scores were distributed normally. Distributions of tongue dorsum scores (anterior and posterior) are compared in Figure 2. The frequency of very high scores was greater in the case of posterior scores as compared with anterior levels. Furthermore, low anterior scores were more frequent than low posterior scores. 
Distributions of self-estimates for men and women are shown in Figure 3 and Figure 4, respectively. In the case of women, 25 out of 88 scored themselves as a "5" (worst conceivable odor), whereas the odor judge assessments of these 25 individuals did not exceed 3.5 (Fig. 5). 
Among the many types of odors which may present from the mouth and nose, several kinds of odors were found to predominate. These included (i) odor of subgingival putrefaction, often encountered during dental flossing or scaling of deep pockets; (ii) odor of the tonguedorsum anterior, as sampled from licking the wrist; (iv) odor of the tongue posterior, as sampled by the spoon method; (iv) odor of nasal origin (although this odor has been termed "ozena" in previous reports [e.g. Spouge, 1964], this term should be reserved for description of frank nasal infections [see also Finkelstein, this volume]); (v) smokers' breath; and (vi) denture odor.

Table 2 describes the frequency of finding four such "typical" odors, as compared with atypical odors deriving from the respective sites. Tongue odors appeared typical in practically all instances. In the case of whole mouth and nasal malodors, in 85% and 78% of the cases, respectively, the odors seemed typical in nature. 
Although the large majority of cases summarized here were deemed to involve malodors of oral origin, nasal odors were not uncommon (Table 2). Two cases are worthy of mention. In the first, a 28-year-old woman from abroad was referred by a dentist, and claimed to have bad breath, despite an excellent dentition. Three types of odors were simultaneously detected: (i) low level of oral odor; (ii) cigarette odor, and (iii) atypical nasal odor. The woman was subsequently referred to an ear-nose-throat specialist who found a calicified object in the nasal passage which had been previously overlooked. The object was removed by surgery and proved to be a children's bead, presumably left up her nose for some 25 years.
In the second case, a 19 year old male, with Kleinfelter Syndrome (XXY), microcephalus and severe mental retardation, was brought to the malodor clinic. The patient was referred to us by a hospital dental clinic, where he had been treated for the past 11 years, and to which his parents had initially brought him two months earlier, with the complaint of oral malodor. During this period, he had been to see various specialists with no improvement in the presenting odor. The odor was typically nasal in its character, yet appeared to emanate from his entire body. However, closer examination revealed that the odor was strongest from the nasal region, but also appeared on the hair, hands and clothes. Regions of the body with which the patient's hands did not come into contact (e.g., the back, the ankles) were relatively free of odor. It was thus apparent that the odorous, purulent discharge had been spread from the nose by hand to other parts of the body, simulating a generalized body odor (Syfert, 1979). A subsequent otolaryngologic examination revealed putrefied tissue which was removed, with concomitant disappearance of the presenting malodor.