Untitled Document

The individual usually seeks out dental treatment because of a toothache, bleeding gums, unhappiness with the appearance of his/her teeth, or because he/she has been told that he/she has bad breadth. The dental profession has dealt quite adequately with the first three of these complaints, but has tended to neglect the fourth or the malodor complaint. Most dental schools have no formal lectures on this subject and provide the student with no hands on experience with the treatment of oral malodor. Thus a very important and common problem from the patient’s perspective has been essentially ignored by the dental community.

Perhaps it was only a matter of time before this problem came to the attention of the dental community. Or perhaps it required a breakthrough study, or an articulate spokesperson, to bring this issue to the dental community and hope to the public. These events overlapped in the late 1980s when Mel Rosenberg showed that a portable monitor, used to detect volatile sulfur compounds in the workplace, could be easily adapted to measure volatile sulfur compounds (VSCs) in exhaled air. Rosenberg showed that the readings on the monitor were highly related to the organoleptic scores that could be given to patients based on how bad their breadth smelled to a calibrated examiner. But more importantly he showed that this condition could be improved by mechanical cleaning of the tongue, and by using antimicrobial mouthrinses. Somehow this information was rapidly communicated to the public, and certain members of the dental community has become very interested in treating oral malodor.

This awareness of malodor as a treatable oral condition has to be tempered by our relative lack of knowledge of the epidemiology and pathophysiology of this problem. And absent this information there is There is no body of epidemiological studies which describes the prevalence of this problem in any given population. Advertisements seeking subjects with malodor for clinical trials often elicit many inquires, suggesting that the problem is common, or that people with the problem are ever seeking treatment. But this is not the same as well designed epidemiological studies to provide accurate prevalence figures. The Japanese investigators have published the most on this subject and we should pay heed to their findings. They find that some individuals have no physical evidence of malodor, but rather their complaints of such odors seemed to be based on the presence of certain phobias. This has been confirmed by other studies, and indicates that the individual with a complaint of malodor but without evidence of such may have on underlying psychological condition. Thus one of the outstanding needs is reliable data on the prevalence of malodor among various age groups and communities.

The pathophysiology of malodor seems to be simple, bacteria on the tongue, most likely anaerobes, are producing volatile sulfur compounds, volatile fatty acids and other obnoxious compounds from proteinaceous products. But this is too broad a statement. Which bacteria are involved? Is it a limited number of bacterial species, or is it a broad based overgrowth of all, or most bacterial species? The answer to this might help in the management of the problem. Just what are the bacteria fermenting? What is the nature of the proteinaceous substrate? Is it host derived?, salivary derived? , dietary derived? or something else? Can we reduce the microbes access to this substrate(s)?

Another, more immediate problem relates to the treatment of malodor. There is enough anecdotal evidence that mechanical debridement of the tongue and the usage of antimicrobial mouth rinses offer some help for most people for some period of time. But it is unlikely that well controlled clinical studies which document this benefit will ever be performed. This is because the mechanical brushes, scrapers, etc. do not come under the regulatory jurisdiction of agencies such as the FDA, and chemical antimicrobial agents such as zinc salts, cepthypyridine chloride, and chlorine dioxide are generic agents that anyone can use. If a company were to spend hundreds of thousands dollars to perform a multi-center study using one of these agents in order to show efficacy, then its competitors could spend even less money showing that a comparable agent could have the same effect. The company who advertises would most likely capture the market. It remains to be seen whether novel agents or novel combinations, such as the CPC oil/water mouthrinse developed in Israel, will generate enough funding to perform the scientific studies which document efficacy and safety.

The most effective agent described in the literature is chlorhexidine. But this is a prescription drug and certainly not recommended for long term use. Will there be other formulations of chlorhexidine that might be just as efficacious, but with fewer drawbacks? This anticipates that question that long term usage is necessary to control malodor on a daily basis. We have no data that shows that an individual needs to use an antimicrobial agent on a continuing basis in order to control malodor. We also have no data that shows that an antimicrobial agent will work on a long term basis. Thus caution is advised when using these mouthrinses.

VISIT MEL ROSENBERG'S SITE ON ORAL MALODOR FOR ADDITIONAL INFORMATION!