concepts
M Rosenberg
J Am Dent Assoc 1996;127;475-482
© 2008 American Dental Association. The sponsor and its products are not endorsed by the ADA.
ARTICLE 1
..l ... Ot is likely that the majority of adults suffer from bad breath at
least occasionally.' Since bad breath usually comes from the mouth
Bad breath typically originates in itself, the dentist should be the first professional whom individuals
the mouth, often from the back turn to for help.2 In recent years, there has been a growing aware-
of the tongue. Nasal problems
ness that bad breath is a problem that the dental profession should
recognize and address. Hundreds-perhaps thousands-of U.S.
also can cause bad breath; odor dentists currently advertise breath freshening as part of their clini-
generated in this manner can be cal services. Dentists and their staff members also may suffer from
easily distinguished from mouth
this problem, to the dismay of their patients.2
Together with the growing interest of dental practitioners in bad
odor by comparing the odor exit- breath diagnosis and treatment, there has been an increase in re-
ing the mouth and nose. In most search activity in this field, reflected in two recent international
cases, good professional oral
workshops dedicated solely to this subject (First International
Workshop on Oral Malodor, Herzliya, Israel, April 1993; Second
care combined with a daily regi- World Workshop on Oral Malodor, Leuven, Belgium, October 1995).
men of oral hygiene-including This article summarizes general concepts related to bad breath.
interdental cleaning, deep
Since the main clinical challenges for the practitioner are deciding
whether a given complaint of bad breath is justified and whether
tongue cleaning and optional the odor originates in the mouth or elsewhere, this article empha-
use of an efficacious mouth- sizes diagnostic modalities.
rinse-will lead to improvement. HISTORY AND FOLKLORE
This article discusses common Bad breath has been recorded in the literature for thousands of
causes of oral malodor as well years. The problem is discussed at length in the Jewish Talmud,3 as
as methods to assess the extent
well as by Greek and Roman writers.4 Islam also stresses fresh
breath in the context of good oral hygiene. The prophet Mohammed
of the problem. is said to have thrown a congregant from the mosque for having the
smell of garlic on his breath.3
Ancient folk remedies abound which are still in use. In the Bible,
the book of Genesis mentions ladanum (mastic), a resin derived
from the Pistacia lentiscus tree (Figure 1) which has been used in
Mediterranean countries for breath freshening for thousands of
years. Other folk cures include parsley (Italy), cloves (Iraq), guava
TAOfAL SOURCES OF
suffered from bad breath. Thus, women who complained of bad improve the association be-
the patient upon reaching breath, 25 rated their own tween sulfide monitor levels
adulthood may develop a con- breath as a 5 ("the most foul and odor judge scores. For ex-
cern of having inherited this odor imaginable") on a scale of 0 ample, in two studies, the asso-
trait. Advertisements on bad to 5, although corresponding ciation between volatile sulfur
breath may elicit unwarranted judge scores ranged from 0 to levels (as determined by the
concerns in suggestible individ- 3.5.9 For this reason, it is impor- sulfide monitor) and odor judge
uals. Others may notice a bad tant to ask the patient to bring scores was improved when
taste in their mouth and as- along a confidant, usually a car- BANA test results were fac-
sume (correctly or incorrectly) ing spouse or other family mem- tored into the regression analy-
that it must be related to bad ber. The confidant can provide a sis.12,3 In a third investigation,
breath. Some patients recall more objective picture of BANA scores were associated
having been told once in their whether the patient actually with floss odor (scored by an in-
distant past that they had bad suffers from bad breath and to vestigator after proximal dental
breath and have continued to what extent. Also, since bad floss passage) (P = .001) and
worry about it ever since. Fi- breath can vary with the time of were reduced after chlorhexi-
nally, as mentioned above, indi- day (as an inverse function of dine rinsing.20 Although such
1. Tonzetich J. Production and origin of oral 18. Tonzetich J. Oral malodour: an indicator
More than malodor: a review of mechanisms and methods
of analysis. J Periodontol 1977;48(1):13-20.
of health status and oral cleanliness. Int Dent
J 1977;98:309-19.
2. Rosenberg M. Bad breath: Diagnosis and 19. Rosenberg M, McCulloch CA. Meas-
treatment. Univ Tor Dent J 1990;3(2):7-11. urement of oral malodor: current methods and
just safe 3. Rosenberg M. Bad breath: Research per-
spectives. Tel Aviv, Israel: Ramot Publishing-
future prospects. J Periodontol 1992;63:776-
82.
Tel Aviv University;1995:1-12. 20. Rosenberg M, Kulkarni GV, Bosy A,
and 4. Geist H. Halitosis in ancient literature.
Dent Abstr 1957;2:417-8.
McCulloch CA. Reproducibility and sensitivity
of oral malodor measurements with a portable
5. Rosenberg M. Diagnosis and treatment of sulphide monitor. J Dent Res 1991;70:1436-
effective! bad breath. Cosmotolgy & Toiletries (in press).
6. Howe JW. The breath and the diseases
40.
21. Bosy A, Kulkarni GV, Rosenberg M,
which give it a fetid odor. 4th ed. New York: McCulloch CA. Relationship of oral malodor
D. Appleton and Co.;1898. to periodontitis: evidence of independence in
The American 7. Grapp GL. Fetor oris (halitosis): a medi- discrete subpopulations. J Periodontol
Dental
cal and dental responsibility. Northwest Med 1994;65:37-46.
1933;32:375-80. 22. Rosenberg M, Gelernter I, Barki M, Bar-
___D)A\____
ACCEPTED
Association Seal 8. Prinz H. Offensive breath, its causes and Ness R. Day-long reduction of oral malodor by
is awarded to its prevention. Dental Cosmos 1930;72:700-7. a two-phase oil:water mouthrinse as com-
American products that 9. Rosenberg M, Leib E. Experiences of an pared to chlorhexidine and placebo rinses. J
Dental Israeli malodor clinic. In: Rosenberg M, ed. Periodontol 1992;63:39-43.
Association e have been shown Bad breath: research perspectives. Tel Aviv, 23. Finkelstein Y. The otolaryngologist and
to be safe and ef- Israel: Ramot Publishing-Tel Aviv University; the patient with halitosis. In: Rosenberg M,
1995:137-48. ed. Bad breath: research perspectives. Tel
fective through rigorous scientific 10. Yaegaki K Oral malodor and periodon- Aviv, Israel: Ramot Publishing-Tel Aviv Uni-