HOW CAN YOU HELP YOUR CLIENTS WITH HALITOSIS? Kerry Lepicek RDH klepicek@gmail.com 416-889-8751 Dr. Jim Hyland DDS drjimhyland@gmail.com 416-930-0310 LEARNING OBJECTIVES: Recognise how whole mouth biofilm influences halitosis and periodontal treatment Understand how stress, meal frequency, and hydration can impact halitosis Learn assessment strategies to find the source and locations of your clients' halitosis Find out why microbial analysis is required for halitosis care Gain insight to different treatment options that help control oral malodour Understand how healthy looking mouths can have breath odour THINK ABOUT THE FOLLOWING: 1. What are the factors you feel cause bad breath? 2. What treatments do you offer? 3. How do you diagnosis it? 4. How do you assess success of your treatments? 5. Are you comfortable talking to your clients about halitosis? 1
Why don t our clients tell us about their halitosis? Why is there a big gap? I see this as an opportunity we need to explore. Most professionals and clients get their information from the media, and reps who come into our office. The problem is most people do not understand the cause of halitosis. If you can find the cause then the treatment will be more systematic THE AVERAGE BREATH CLIENT PROFILE? 1. How is their home care? 2. Do they normally have PDD? 3. Do they normally have decay? 4. Do they see the dentist/ hygienist regularly? DO YOU HAVE CLIENTS IN YOUR PRACTICE THAT HAVE BREATH ODOUR? What questions do you ask them to find out more about their breath odour? How do you tell your client that he/she has bad breath? What do you look for on their medical history? 2
BREATH SCREENING QUESTIONS 1) Do you worry about your breath all the time? 2) Do you frequently notice a bad taste in your mouth? 3) Is bad breath affecting your work or social life? 4) Do you use mints, gum and mouthwash every day? 5) Does your breath affect your confidence? 6) Would you like fresher breath? BREATH SCREENING QUESTIONS 7) Does anyone else in your family have gum disease or bad breath? 8) Do you have any health concerns? 9) Does your mouth feel dry? 10)Do you skip meals? 11)Do you work out? MEDICAL HISTROY RED FLAGS TO LOOK FOR: 1. Acid reflux 2. Post nasal drip 3. Sinusitis 4. Hiatis Hernia 5. Diabetic 6. Dietary concerns 7. Tonsil stones 8. Kidney disease 9. Sleep and air way 10.Cancer 11.Smoker/Alcoholic 12.Medications causing dry mouth 3
CLIENTS WHO SUFFER FROM HALITOSIS MAY: Neurotic behavior Holding breath in elevator, sitting near door to push bad breath out Social withdrawal - They won t apply for jobs or promotions Poor self image People think that they are dirty and don t brush Compulsive use of mints and gum Can lead to TMJ issues, wear or decay Significant stress They think about it all the time Halitosis Infectious biofilm - Bacterial - Inflammation 50% of the population have some halitosis, in 20% of the population it is chronic or severe Whole mouth biofilm disease Often minimal clinical signs Impact Oral Systemic Health Socially transmissible Chronic and Persistent Bad taste Odours - Bleeding Pockets DEFINITION OF BAD BREATH Bad breath, also known as halitosis, is a symptom in which a noticeably unpleasant odour is present on the breath. It can result in anxiety among those affected. It is also associated with depression and symptoms of obsessive compulsive disorder. https://en.wikipedia.org/wiki/bad_breath 4
Halitosis - Person who has bad breath Person thinks they have Halitophobia bad breath TMAU TMAU (Trimethylaminuria) Person smells like rotten eggs or fish all the time. Very rare. WHAT ARE VSC S Volatile Sulfur Compound (VSC), material produced by malodorous volatile gases resulting from bacteria metabolizing protein in the oral cavity. Most clients perceive oral malodor to be primarily a cosmetic problem, there is an increasing volume of evidence dental literature demonstrating that VSC s produced by bacteria, even at low concentrations, are toxic to tissues and play a role in the pathogenesis of periodontitis. https://medical-dictionary.thefreedictionary.com/volatile+sulfur+compound Milella L. J Vet Dent. 2015 Summer;32(2):99-102. The Negative Effects of Volatile Sulphur Compounds. https://www.ncbi.nlm.nih.gov/pubmed/26415386 Hydrogen Sulfide Highly toxic - may be fatal if inhaled, corrosive to tissues There is a loss of smell and taste on exposure to gas Increases mucus membrane permeability Methyl Mercaptan Irritating to the eyes and the respiratory tract May cause harmful effects on the central nervous May cause lung damage. Exposure at high levels may result in unconsciousness followed by death 5
WHAT DO VSC S SMELL LIKE? Hydrogen Sulphide: old eggs, garlic and onions produce hydrogen sulphide Methyl Mercaptan: composting, fecal or periodontal odour. These chemicals increase the permeability of the mucous membrane allowing toxins to penetrate tissue contributing to the progression of disease. Dimethyl Sulphide: sour, old cabbage this chemical can be related to stomach gases Pungent: strong odour that affects smell and taste, usually hydrogen sulphide and mercaptan based. Odours are long lasting and may intensify over time HALITOSIS, ORAL MALODOR OR BAD BREATH 90% of halitosis cases originate in the mouth. The most common locations of odour producing gm ve anaerobic biofilm is on the back of the tongue, below the gingiva and in the PD pockets The odors are produced by the breakdown of proteins into amino acids, which then produce detectable foul gases called VCS Herpes simplex and HPV can also contribute to malodour due to the viral infection https://en.wikipedia.org/wiki/bad_breath Inter-dental And Subgingival Niches Dentures, Night Guards, Invisalign, Retainer, Other Areas that Can Contribute To Odour: Faulty Dental Work Abscesses Foodimpaction https://en.wikipedia.org/wiki/bad_breath 6
TRADITIONAL TREATMENTS RECOMMENDATIONS FOR HALITOSIS Rinses Gums Mints Brush Floss Clean teeth 3-4X a year Waterpic WHY DON T THESE TREATMENTS WORK? Minimal visible biofilm Minimal or no BOP Pockets 3mm and less Excessively brush, rinses and floss BREATH ODOUR IS NOT YOUR FAULT Most clients I have helped have tried everything with little success. The have seen an ENT and have had their teeth cleaned every 3 to 6 months. If you can t find the problem it is usually coming from: Bactria in your mouth Missing meals and dehydration Stress The problem is many people think breath odour is because of the person doesn t brush, or not seeing the dentist. Most over the counter mouthwashes have not helped.. They will usually control odours for 15-30min 7
CLEVLAND CLINIC - DOES A BREATH SCREENING CHECK FOR: 1. Gum disease 2. Cancer Lung cancer 3. Allergies that produce mucus and nasal drip 4. Diabetes ketoacidosis that leads to ketones which are eliminated through the urine and lungs that produce an acid/fruit like breath 5. Liver disease fetor hepaticas mushy smell 10 Health Conditions that Cause Bad Breath Dr. Edward Group DC, NP, DACBN, DCBCN, DABFM https://www.globalhealingcenter.com/natural-health/10-health-conditions-cause-bad-breath/ CLEVLAND CLINIC - DOES A BREATH SCREENING CHECK FOR: 6. Kidney Failure metabolic changes lead to dry mouth, and altered taste 7. Yeast 8. Acid reflux - influx of acid and partially digested food into esophagus and mouth accumulate causing odours 9. H Pylori occurs frequently in clients with stomach ulcers and GI problems when cleared 10. Sjogren s Syndrome dry mouth from an auto immune disorder inhibits salivary production 10 Health Conditions that Cause Bad Breath Dr. Edward Group DC, NP, DACBN, DCBCN, DABFM https://www.globalhealingcenter.com/natural-health/10-health-conditions-cause-bad-breath/ STEPS WE USES TO TREAT HALITOSIS 3 HOURS Assessment/ Diagnosis Treatment Evaluation in 4 weeks Health history, breath history, organoleptic testing, Perio Chart, BOP, PBS, ph, 6site GS sampling, disclose, OHI & nutrition Routine care + OraVital antibiotic and chlorhexidine rinse with unique home care, improved diet and meal patterns Confirm absence of or identify local areas of breath odour, repeat microbiology, check diet, OHI, Perio Chart, BOP, PBS 8
STEPS WE USES TO TREAT HALITOSIS 3 HOURS Maintenance Monitor in 6-8 weeks Breath Recare in 6-12M Together with the client select maintenance rinses and home care routine Re-evaluate on a regular basis to see if maintenance is effective or if changes are needed Follow assessment appointment outline Maintain regular 3m hygiene appts TECHNIQUES TO ASSESS HALITOSIS AND FORMULATE A TREATMENT PLAN 1) Gas chromatography: This test measures three volatile sulfur compounds: hydrogen sulfide, methyl mercaptan, and dimethyl sulfide. 2) Clinical findings Periodontal charting, BOP (bleeding on Probing), PBS (Papillary Bleeding Score), Plaque Score 3) Organoleptic testing by the client 4) Microbiology 5) ph Levels 6) Diet 7) Life style/exercise Everything you need to know about bad breath Tim Newman Last updated Wed 10 January 2018 GAS CHROMATOGRAPHY UESED TO MEASURE VSC S Measurements of VSCs from the gingiva and tongue Measures hydrogen sulfide methyl mercaptan dimethyl sulfide Halimeter Oral Chroma 9
GAS CHROMATOGRAPHY Can be used with every client healthy or diseased Is an indirect way of measuring gram negative anaerobic biofilm activity It can be elevated in clients with halitosis, healthy individuals and clients with both periodontal disease and halitosis. Objective evaluation of your clients breath VSC s can affect the epithelial cells of the gingival crevice their job is to form a barrier to the penetration of microbial substances. High concentrations of methyl mercaptan such as 50ng/ml have an inhibitory effect on the growth and proliferation of epithelial cells The effects of methyl mercaptan on epithelial cell growth and proliferation - T. Setoguchi 23 September 2014 https://doi.org/10.1002/j.1875-595x.2002.tb00933.x ORAL CHROMA SCAN BEFORE TREATMENT GOALS FOR ALL OF MY CLIENTS: Every client should have: Less than 10 BOP 0 PBS No biofilm with disclosing Pockets 3mm or less Healthy balanced biofilm No breath odour No bad taste 10
6 SITE BOP SCORE WITH PERIODONTAL CHARTING # of BOP Sites Description and Treatment Suggestion Less than 10 Stable, if no other risk factors 10 to 20 Disclose and review oral hygiene Suggest an antibacterial/maintenance rinse 20 to 30 Disclose and review oral hygiene Maintenance rinse may be sufficient depending on risk factors Suggest DNA test May need to consider antibiotic & antimicrobial 30+ Disclose and review oral hygiene Suggest DNA test Antibiotic rinse and Antimicrobial rinse Maintenance rinse after PAPILLARY BLEEDING SCORE (PBS) PBS Score PBS Score Description and Treatment Suggestions 0 Stable, if no other risk factors 1 Light localized bleeding (25% of sites tested) Disclose/Suggest an antibacterial/maintenance rinse 2 Moderate bleeding (50% of sites) Disclose/Maintenance rinses may be sufficient depending on risk factors Suggest DNA test May need to consider antibiotic & antimicrobial rinses 3 Heavy bleeding (75% or more of sites) Disclose Suggest DNA test Antibiotic and antimicrobial rinses followed by maintenance rinse 11
ARE YOU DISCLOSING? = TONGUE CLEANING - May people will use tongue cleaners to remove the dead skin cells and reduce biofilm buildup on the tongue - Improves taste and breath - Should be reviewed with any clients who have - Inflammation - Bleeding -Decay - Halitosis - Tonsillitis BIOFILM WHERE DOES IT LIVE? Biofilm lives everywhere in the oral cavity. In dentistry our focus is on cleaning teeth, clients with breath odour are always cleaning the teeth but they sometimes miss the throat, tongue and cheeks, This is why we have to open our scope of practice and include tongue, throat, cheek areas into our assessment. 12
PHASE CONTRAST MICROSCOPE Used at chair side Powerful tool clients see their own active and living biofilm Allows sampling from site specific areas BiofilmGS (Gram Stain) Numbers of bacteria as counted by shapes Yeast, white blood cells and amoebae can be identified Density of potential pathogens established in locations that are sampled. Information provided by gram stain analysis Approximate numbers of potential disease producing bacteria Location of these bacteria Allows practitioner to direct treatment at the most infected locations 13
DNA TESTING OPTIONS BiofilmDNA Test Report Patient Information Ordering Information Name of Patient: Jane Doe Ordered By: Age: 16 Gender: F Clinic Name: Habits: 6mths + Hygiene Frequency Address: Medical History: none State/Province/Country: Dental concerns: Severe Gingivitis Generalized Sample Collected: Periodontal disease: Mild Generalized PD Sample Received: Pocket Depth Range: 2 4mm Report Date: Halitosis: yes and bad taste Decay: Yes Result summary: High risk and moderate risk pathogens detected The black bars indicate normal levels of each pathogen. Oral Microbiology Report Tongue Base Tongue Dorsum Teeth OV1 OV1 OV1 OV1 OV1 OV1 Q1 Q2 Q3 Q4 Gram +ve Cocci M L VH VH H H Bacilli H VH M M Gram ve Cocci MH MH VH VH VH H Straight L H VH H MH Bacilli Fusiforms VL L M L Spirochetes What is the difference between these two microbiology reports? Curved Bacilli MH H M L Yeast L L Amoebae WBC Notes: OV1: The samples from the tongue are normal. There are substantial numbers of Gram negative straight bacilli, many fusiforms, moderated to high levels of curved bacilli in the teeth samples, indicating the presence of infection. Treatment should be based on the medical history, risk factors, periodontal charting and this report. 14
Oral Microbiology Report Tongue Tongue Teeth Base Dorsum OV1 OV1 OV1 OV1 OV1 OV1 Q1 Q2 Q3 Q4 Gram +ve Cocci H M VH VH VH VH Bacilli M H VH H H Gram ve Cocci H H VH VH VH VH Straight L L MH H H H Bacilli Fusiforms L VL L L M M Spirochetes L L Curved VL M M M MH Bacilli Yeast L M M MH MH Amoebae L L WBC Notes: OV1: Tongue biofilm is normal. There are moderately high to high levels of Gram negative straight bacilli, moderate numbers of fusiforms and curved bacilli in the teeth samples, indicating that oral infection is present. Treatment should be based on the medical history, risk factors, periodontal charting and this report BiofilmDNA Test Report Patient Information Ordering Information Name of Patient: Dog Ordered By: Age: 4 Gender: F Clinic Name: Habits: Not reported Address: Medical/Dental concerns: Not reported State/Province/Country: Periodontal disease: Not reported Sample Collected: Pocket Depth Range: Not reported Sample Received: Allergies: No Report Date: 10/03/2017 Antibiotic History: No Result summary: High risk and moderate risk pathogens detected The black bars indicate normal levels of each pathogen. Legend: Green Normal below threshold Orange: Monitor <1 below threshold Red: Infection above threshold High Risk Periopathogens Moderate Risk Periopathogens High Risk Cariogenic Pathogen 9 8 7 6 5 4 3 2 1 0 7.00 3.00 2.00 0.00 Pg Td Tf Aa 9 8 7 6 5 4 3 2 1 0 6.00 5.00 5.00 Fn Pm Ca 9 8 7 6 5 4 3 2 1 5.00 Sm Abbreviations of bacteria names and normal absolute counts of test species pathogen per biofilm sample 15
WHY USE PH PAPER? To determine the consistency of saliva, check each ph paper strip for viscosity and flow of saliva as you remove the strip. If the flow of saliva is normal, the ph paper will wet quickly. UNDERSTANDING ph - Ideally, mixed oral saliva has a ph of 6.75 or just below neutral. - The sublingual saliva most often measures at 6.5 to 7. - Vestibular saliva (from the Parotid gland) most often measures at a ph of 6. Tastes: - At 5.5 the client may perceive a sour taste - At 7.5 to 9 the taste may be bitter or simply unpleasant. Check tongue, throat, saliva & teeth Bacterial imbalance Help located areas of infection The only way to know if your client has odours is to check the mouth with your client Odour Assessment is important 16
LOCATING BREATH ODOUR 1. Ask client not to have anything to eat or drink 2 hours before your appointment. 2. Tell your client's not to use aftershave, body wash or perfume on the day of their appointment. 3. Ask client to floss and tell you where the odours and bad tastes are located record locations 4. Ask client to smell mirror on the back of the tongue and top of the tongue - record location of odours 5. Record ph results can show where gram ve biofilm location 6. Look at VSC numbers using gas chromatography 7. Review microbiology results when available TONSILLOLITHS/TONSIL STONES Tonsilloliths were similar to dental biofilms, containing corncob structures, filaments, and cocci. There is an acid production within the tonsilloliths, dropping the ph from 7.3 to 5.8 in the center. The depletion of oxygen and acid production following addition of sucrose allows the proliferation of anaerobic/acidophilic bacteria growth They can occur in palatine tonsils and also in lingual tonsils. Otolaryngol Head Neck Surg. 2009 Sep;141(3):316-21. doi: 10.1016/j.otohns.2009.05.019. Tonsillolith: not just a stone but a living biofilm. Stoodley P1, Debeer D, Longwell M, Nistico L, Hall-Stoodley L, Wenig B, Krespi YP. TONSILLOLITHS/TONSIL STONES Visit many ENT for help with little success Chronic sore throat Bad taste Bad breath Emotional stress Hormone level Changes 17
TONSILLOLITHS/TONSIL STONES Affects confidence/social interaction/ quality of life/ sense of smell and taste. Impacts systemic health Utilize DNA testing Disclose and coach effective homecare Use daily mouthwash May require treatment again every 3 to 6 months TONSILLOLITHS/TONSIL STONES 1. Ask Patient to make a note of the personal history of their stones How often, how many etc. before and AFTER treatment 2. Ask client to remove stones with a Q-tip if possible 3. Gargle/swishing the mouthwash is required to reach the tonsils 4. Some clients place the medication directly to the area with a Q-tip DOES THEIR DIET REALLY MATTER? Your clients diet can feed inflammation and disease Dental professionals should look at the water intake, carbohydrate consumption, sugar sources, protein intake and overall diet We should reach out to nutritionist, naturopaths, nurses/nurse practitioners for additional support 18
NUTRITIONAL ASSESSMENT Purpose of nutrition: to provide energy and nutrients necessary for health. Look for the: 1. Quantity - are they eating enough 2. Source home made vs. store/drive through 3. Meal frequency should eat every 4hrs 4. Sugar consumption food and drinks 5. Amount Processed food chicken vs. chicken sandwich meat 6. Whole natural foods apples vs apple juice 7. AND Make simple recommendations HOW CAN YOU HELP CHAIR SIDE? What food groups are they missing? How often are they eating? 19
Print, Email Or Order For Your Patients DO YOU ROUTINELY TALK TO YOUR CLIENTS ABOUT TAKING SUPPLEMENTS? What else do you suggest to your clients? Swim Fly. Grow 20
FUN WATER FACTS Forgotten ingredient Water is the main food the body needs. Aids the process of digestion Accounts for 50-65% of body weight Without water, you can only survive a few days 2% reduction of water levels in the body can lead to a 20% decrease in mental & physical performance Exercise is an easy to way to reduce stress. What are your clients doing to reduce stress? Keep the goal simple. Take a walk at lunch, use the stairs Everyone can fit some exercise into their routine. They just have to see the need and value 21
TREATMENT OPTIONS FOR HALITOSIS CLIENTS 1. OTC Rinses different options 2. ANTIBOITC/ANTIFUNGAL RINSES Vs SYSTEMIC MEDICAION 3. Oral Probiotics -Lozenge Or Gum 4. Neti Pot If client has Sinusitis or Post Nasal Drip 1. CHOOSE THE RIGHT OTC RINSE VS SODIUM CHLORITE (CHLORINE DIOXIDE) RINSES: Bacteriostatic rinse: intercepts enzymes that break down amino acids in gm-ve anaerobes. The come in flavored, unflavoured, colour-free options Neutralizes odours formed by bacteria Recommended for periodontal and halitosis clients Purchased only through dental offices or off the web ph-balanced to reduce germ growth Can have fluoride, xylitol or zinc depending on the brand 22
CPC RINSES: Contains Cetylpyridinium Chloride - CPC Disrupts the bacterial cell membrane, leading to cell death Active against wide variety of aerobic and anaerobic bacteria Works similar to chlorhexidine 2. PILLS VS ANTIBIOTIC RINSES Rinses Colloidal antibiotic and antifungal rinse suspension Less then ½ systemic dose of antibiotic Directly applied to tongue, throat, saliva and gingiva Have to be made a certified pharmacy's but free delivery to the dental office Can use when clients is taking Coumadin Pills Traditional way of taking medication Clients are not able to consume alcohol Can pick them up at the local pharmacy Many women end up with yeast infections Clients on Birth Control, effects blood thinning if client is on Coumadin 23
Antibiotic/Antifungal Rinses Preparations Metronidazole and Nystatin Amoxicillin, Metronidazole and Nystatin Tetracycline and Nystatin Systemic Antibiotic Selection Metronidazole Amoxicillin Tetracycline Clindamycin and Nystatin Minocycline Antibiotic/Antifungal Rinse Effectiveness Pocket Depth Before After Difference 4mm 4.86 1.24 79% 5mm 1.22 0.15 84% 6mm 0.38 0.09 76% 7mm 0.17 0.04 76% Bleeding on Probing BOP 19.98 2.68 87% Number of Subjects N= 649 p. value: 0.0001* AGD 7/14 Effectiveness of an antibiotic rinse in treating breath odor and periodontal disease. Southward, Bosy CHLORXIDINE RINSES Can vary from 0.12% to 0.2% strength Sold though the dental office or the pharmacy Works well with gram positive Chlorhexidine is antimicrobial agent - that is the process of killing or inhibiting the disease causing microbes. 0.2% worked better for halitosis clients 24
3. WHY USE ORAL PROBIOTICS? 1. Supports digestive health (that begins in the mouth) 2. Oral probiotics support the immune health of the throat, ears and upper respiratory tract. As well as contribute to overall health and well-being. 3. Some offices air polish prebiotics and sell probiotic toothpaste paste for at home use. 4. They should be recommended after all systemic antibiotics, why don t we use them routinely in dentistry? ORAL PROBIOTIC WITH BLIS K12 Can reduce the incidence tonsils stones and sore throats by supporting the throats natural defence against undesirable bacteria Naturally supports fresh breath/ reduces the pathogens that produce VSC s, promoting fresh breath S. salivarius K12 may inhibit the process of invasion of C. albicans into mucous surfaces or its adhesion to denture acrylic resins Appl Environ Microbiol. 2012 Apr;78(7):2190-9. doi: 10.1128/AEM.07055-11. Epub 2012 Jan 20. 4. Neti Pot Saline solution used to remove the allergens and other irritants that cause sinus and post nasal drip problems. May people use them weekly even daily Helpful way to clean and remove loose biofilm and irritants in the nasal cavity 25
IS MORNING BREATH THE SAME AS HALITOISIS? The intensity of halitosis can change during the day depending on the foods consumed and if they contain garlic, onion, meat, fish, and cheese. Smoking, alcohol and hydration also play a huge role. The mouth is inactive during the night and is usually smells worse when people wake up. WHAT DO TO DO FOR CHILDREN SUFFERING FROM HALITOSIS 1. OTC rinses like CDLx or Closys 2. Disclose 3. Brush/scrape their tongue 4. Review diet and meal frequency 5. Interproximal cleaning 6.Suggest probiotics 7.Increase hygiene frequency WHAT DO TO DO FOR CHILDREN SUFFERING FROM HALITOSIS If that doesn t work then try: Microbiology Antibiotic rinses and chlorhexidine rinse (if required) Have the whole family tested for halitosis and PD Set up follow up breath check up appointments ***Have them document the tonsillitis or post nasal drip frequency if it applies*** 26
THINK ABOUT THE FOLLOWING QUESTIONS AGAIN: 1. What are the factors that cause bad breath? 2. What treatments can you offer? 3. Do you know how to assess and diagnosis it? 4. Do you understand how to evaluate the success of the treatments? 5. Are you comfortable now talking to your clients about halitosis? Fall 2018 Oral Probiotics - An Emerging Trend In Oral Health By Lorraine Gambacourt RDH Spring 2018 Probiotics and their Application to Oral Health Dr. Michael Glogauer, DDS, PhD 2017 Halitosis is Natures way of telling you your mouth is sick Kerry Lepicek RDH http://www.dentalhygienequarterly.ca/ OraVital.com Treatment of Oral Malodor and Periodontal Disease Using an Antibiotic Rinse Ken Southward, DDS, FAGD and Anne Bosy, RDH, MEd, MSc freshbreath.ca gumguardians.com 27
HELPING PEOPLE WHO SUFFER FROM HALITOIS CAN CHANGE THEIR LIFE FOREVER.. 28