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Halitosis
Introduction
Historically, bad breath has had many names...halitosis, fetor oris, fetor
ex ore. The terms bad breath, halitosis, and breath malodor all mean an
unpleasant breath odor that is objectionable to others. The truth is that
bad breath under any name can be an indication of a serious disease
entity for many people and a life time of social problems for others.
Nearly everyone, in fact, experiences bouts of halitosis from time to
time. It is fortunate that most bad breath is caused by oral conditions.
The history of halitosis is well documented with references to the
condition dating back to ancient civilizations. Halitosis, from the Latin
for breath (hali) and condition (tosis), refers to a systemic-related
malodor. Fetor ex ore and fetor oris are terms that directly relate to oral
conditions producing malodor. Researchers and experts in the malodor
field have suggested that the condition should be referenced as oral
malodor or nonoral malodor. Oral malodor can be either transitory or
chronic. Transitory malodor is described as a food-related malodor that
may last up to 72 hours and is a condition all individuals suffer from at
one time or another. Chronic malodor is generally oral-related and in
some cases due to a medical/ systemic condition, such as diabetes.
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 breath. 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.
Public awareness and concern for this phenomenon is evidenced by the
support of an $850 million mouthwash industry in the United States
despite wide agreement that commercially available products have no
significant effect on breath malodor.
Understanding the Problem
Halitosis, and the treatment of this problem, is quickly becoming the
growth area of the 90's in dental practices throughout North America.
Oral malodor is a very pervasive problem, and can be simply an
embarrassment to some, or the sign of potentially serious systemic
problems for others. 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.
Professionals are being drawn to establish this treatment service within
their offices for several reasons. Perhaps the primary reason is the
power of this concept as a marketing tool. It is an excellent way of
attracting new patients, particularly those who are not regular users of
dental services. The treatment of halitosis is often viewed as a "nondental" procedure by the public, and so does not carry the
psychological impact of other dental treatment. This allows these people
to become comfortable with the dental environment in a non-threatening
fashion. Amongst existing patients it is a strong motivator for the
acceptance of dental treatment, particularly in the area of periodontal
disease, which is known to be a major source of halitosis. Finally, there
are now the means to quantify this problem, and some definitive means
to treat the problem, once properly diagnosed.
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, in the absence of this
information, 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 inquiries, suggesting that the problem is common, or that
people with the problem are not seeking treatment. But this is not the
same as well designed epidemiological studies to provide accurate
prevalence figures.
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 an
underlying psychological condition. Thus, one of the outstanding needs
is reliable data on the prevalence of malodor among various age groups
and communities.
Causes of Halitosis
Bad breath is a condition that has many different causes and even
though it is most often caused by oral problems, bad breath can also be
a symptom of a serious disease. One of the best examples of this is
diabetes. While an odor is not detectable in well- controlled patients, an
acetone sweet fruity odor can often be detected in the uncontrolled
patient. This odor can even be a sign of an impending coma.
It used to be thought that bad breath could originate directly from the
contents of the stomach. We now know that this is not true except when
belching or vomiting since odor and gas cannot escape when the
esophagus is in a normal closed condition.
Instead, most of the odors which are not intra-oral in origin enter our
breath through the lungs. The most common example of this is the odor
which comes from some of the food we eat. The bi-products from
ingested foods are absorbed, carried through the blood and excreted
through the lungs. This explains why patients complain of garlic or
onion breath long after they have eaten and even after they have
brushed, flossed and rinsed.
It is thought that disorders of the oral cavity cause up to 85% to 90% of
all the cases of halitosis. Some of the more common causes are: a dry
mouth due to lack of flow of saliva during sleep, denture wearing, food
retention, poor oral hygiene, dental decay, gingivitis, gum disease, an
unclean tongue, and smoking. Most of these factors have in common an
increase in bacteria in the oral cavity. These bacteria produce
compounds like hydrogen sulfide, methyl mercaptan, dimethyl sulfide
and dimethyl disulfide. Collectively they are known as volatile sulphurcontaining compounds or VSC. These are the compounds responsible
for bad breath.
Risk Factors Associated With Halitosis
Non-disease related
Disease related
Oral
• Inadequate oral hygiene
• Candidasis
• Long periods of mouth closing
(i.e., morning breath after sleep)
• Cancer
• Xerostomia (e.g., dry mouth due
to mouth breathing, medication)
• Gingivitis
• Tongue coatings
• Mouth infection, inflammation,
ulceration
• Periodontitis
Non-oral
• Aging (reduced salivary flow)
• Gastrointestinal
(gastroesophageal reflux, hiatal
hernia, cancer)
• Alcohol
• Nasal (rhinitis, sinusitis, tumors,
foreign bodies)
• Hunger
• Pulmonary (bronchitis,
pneumonia, tuberculosis, cancer)
• Pungent foods (i.e., onion, garlic)
• Systemic (cirrhosis, dehydration,
diabetes, fever, hepatic disease,
leukemias, uremia, rheumatologic
disease)
• Tobacco
• Psychogenic (delusions,
depression, hypochondriasis,
suicidal tendencies, schizophrenia;
also associated with temporal lobe
epilepsy)
• Therapeutics (amphetamines,
anticholinergics, antidepressants,
antihistamines, decongestants,
antihypertensive drugs,
antiparkinsonian agents,
antipsychotics, anxiolytics,
hemotherapeutic agents, diuretics,
narcotics, analgesics, radiation
therapy)
Adopted from Replogle and Beebe, 1996.
Source:
The Oral Care Report
Dr. Chester W. Douglass
Department of Oral Health Policy
Harvard School of Dental Medicine
188 Longwood Avenue
Boston, MA02115
Pathogenesis of Halitosis
It is generally known and agreed that VSC's (Volatile Sulfur Compounds)
are responsible for the odor, and that 80-90% of these come from oral
sources. VSC's are produced by bacterial and cellular degradation, and
include hydrogen sulphide, methyl mercaptan and dimethyl sulphide.
The nature of the odor may vary in intensity (strength of the smell) and
quality (the type of odor). These traits are key diagnostic indicators of
underlying disease; halitosis linked to disease is more intense and has a
distinct quality which is often related to the underlying source. The fact
that oral odors can originate from sources other than the oral cavity
demands that a proper diagnosis be done, requiring a thorough exam
and history. It is known that systemic disorders, medications, and ENT
problems can all contribute to halitosis.
Research identifies the production of volatile sulfur compounds (VSCs)
by gram-negative anaerobic bacteria in the oral cavity as the chief
culprit in oral malodor. The posterior dorsum of the tongue and the
sulcus have been identified as key areas for harboring these bacteria.
The coating on the tongue comprises dead epithelial cells, anaerobic
gram-negative bacteria, and food debris. In periodontally healthy
patients, this is the primary cause of oral malodor. In the patients with
periodontal disease, the gingival sulcus/periodontal pocket has proven
to be an additional reservoir for odor-producing bacteria. In addition, the
shift from gram-positive to gram-negative bacteria populations, as seen
in gingivitis and periodontitis, increases oral malodor.
Hydrogen sulfide (H2S) and methyl mercaptan (CH3SH) are the two main
odor-causing VSCs produced by gram-negative anaerobic bacteria.
Hydrogen sulfide has been associated with periodontally healthy
individuals, whereas methyl mercaptan has been associated with
periodontal patients. Additionally, research suggests that these
compounds may be especially important in periodontal infection, as
they may interfere with collagen and protein synthesis. Research also
suggests that the presence of these compounds may affect the
permeability of the gingival sulcus, may enhance the ability of bacteriaproduced toxins to pass into the bloodstream, and may accelerate the
infection process. This correlation between oral malodor and
periodontal infection warrants serious clinical consideration and
treatment for patients.
Psychogenic Halitosis
A complaint of bad breath, possibly based on psychologic factors, that
others do not perceive.
Psychogenic halitosis may occur as a symptom in various psychologic
disorders. It may also be associated with anxiety. It may be reported by
the hypochondriacal patient who commonly amplifies normal body
sensations. At times, the complaint may reflect a serious thought
disorder (e.g, somatic delusion). An obsessional patient may have a
pervading sense of uncleanliness, or a paranoid patient may have the
delusion that his organs are rotting.
In dealing with patients seeking professional care for halitosis, one must
be prepared to differentiate between those patients who emit above
average malodor, those who emit average or near average malodor but
are more sensitive to it, and those who emit below average or no odor
but believe that their breath is offensive despite objective evidence to
the contrary. In the former two cases treatment for malodor is
warranted; in the latter it is not.
There are many patients who complain of chronic bad breath for whom
no objective evidence of breath malodor can be identified. Olfactory
reference syndrome is a recognized psychiatric condition in which there
occurs a somatization of some distress resulting in a belief on the part
of the patient that an offensive odor emanates from some body part,
usually the mouth. This condition interferes with normal social
interactions for fear of offending others with breath malodor and has
been described in the psychiatric literature for over 100 years.
Affective disorders and schizophrenia were reported to develop in
patients whose initial complaints were limited to breath malodor, and
some success has been reported in treating olfactory reference
syndrome with tricyclic antidepressants and the neuroleptic primozide.
If breath malodor cannot be detected organoleptically from a patient
complaining of bad breath, if above normal VSC cannot be
demonstrated instrumentally and if the patient cannot provide reliable
third-party verification of an odor problem, olfactory reference
syndrome ("Imaginary halitosis") must be considered.
[Richter, Jon L., DMD PhD, Diagnosis of Treatment of Halitosis. Compedium of
Continuing Education in Dentistry, April 1996]
The Relationship Between Oral Malodor, Gingivitis, and
Periodontitis
by Perry A. Ratcliff and Paul W. Johnson
Volatile sulfur compounds (VSC) are a family of gases which are
primarily responsible for halitosis, a condition in which objectionable
odors are present in mouth air. Although most patients perceive this
condition as primarily a cosmetic problem, an increasing volume of
evidence is demonstrating that extremely low concentrations of many of
these compounds are highly toxic to tissues. VSC may, therefore, play a
role in the pathogenesis of inflammatory conditions such as
periodontitis. Since these compounds result from bacterial putrefaction
of protein, investigations have been conducted to determine whether
specific bacteria are associated with odor production.
Two members of this family, hydrogen sulfide (H2S) and methyl
mercaptan (CH3SH), are primarily responsible for mouth odor. Although
many bacteria produce H2S, the production of CH3SH, especially at high
levels, is primarily restricted to periodontal pathogens. Direct exposure
to either of these metabolites adversely affects protein synthesis by
human gingival fibroblasts in culture. However, methyl mercaptan has
the greatest effect. Other in vitro experiments have demonstrated that
cells exposed to methyl mercaptan synthesize less collagen, degrade
more collagen, and accumulate collagen precursors which are poorly
cross-linked and susceptible to proteolysis. CH3SH also increases
permeability of intact mucosa and stimulates production of cytokines
which have been associated with periodontal disease. VSC, and in
particular methyl mercaptan, are therefore capable of inducing
deleterious changes in both the extracellular matrix and the local
immune response of periodontal tissues to plaque antigens. J
Periodontol 1999;70:485-489.
Diagnosis
Identification and diagnosis of the patient who suffers from oral malodor
is not a specific science. This can make the diagnostic process difficult
and uncomfortable for the dental professional. In addition, oral malodor
may or may not be an issue to the patient when addressed during the
preventive appointment (see the table below). From the most complex of
equipment to the use of organoleptic judges, researchers have yet to
establish a method that will consistently and easily quantify oral
malodor.
Oral Malodor Patient Types
Type I—Those who have it and know it.
Type II—Those who have it but deny or do not know they have it.
Type III—Those that do not have it, but think they do.
The most effective means of oral malodor identification is counterpart
assessment. Family members, close friends, and spouses can assist
patients in identifying objectionable malodor and provide key
information about its duration, frequency, time of the day, and intensity.
Additional diagnostic means include the use of a volatile sulfur monitor,
bacterial culturing tests, and use of organoleptic judges. The first two
options have limitations, while the use of specially trained researchers
(organoleptic judges) has been the most reliable method and is the
standard against which diagnostic tools are measured.
Regardless of the method utilized, patients are interested in the
prevention of oral malodor. A simple preventive approach will provide
the desired results. Therefore, daily management of oral malodor,
versus a one-time treatment, should be implemented to achieve effective
oral malodor control.
Some specific pieces of equipment have been developed to help the
dentist diagnose halitosis. These are known as the halimeter and the
periotemp. Many dentists do not have these devices and you may need
to ask your dentist for a referral to a dentist who has them if your
problem is severe.
The halimeter is a gas analysis machine designed to measure the
amount of sulfur bonds in a volume of gas. With the halimeter it is
possible to directly measure the quantitative amounts of offending VSCs
present.
The periotemp measures elevated temperatures in the periodontal
pocket surrounding the teeth. If an elevated temperature reading is
detected , this equates with the degree of inflammation that is occurring
at a specific gingival site. This inflammation directly relates to the
presence of periodontal (gum) disease. The specific bacteria that causes
malodor also is responsible for causing periodontal disease.
Medical History
Due to many possible causes of bad breath, diagnosis of the origin of
halitosis is essential for its treatment. The first step to making a proper
diagnosis is the taking of a complete medical history. Some of the
questions you may ask are:
When is the last time you visited the dentist?
Someone who does not go to the dentist regularly has a higher risk of
halitosis from decay and gum disease.
What are your oral hygiene habits? a) Brush daily b) Brush & floss
daily c)Brush, floss, and rinse daily
This is an important question because even patients who are very
meticulous about brushing and flossing may still suffer from bad breath
that is oral in its origin. This is because the tongue is believed to be one
of the main sources of oral odor. Most people have never been taught to
brush their tongue.
Do you use an over-the-counter mouth rinse regularly? a)Yes? What
brand? b) No?
Although millions of dollars are spent every year on over-the-counter
mouthrinses and deodorizing sprays, it is clear that most of them will
only mask bad breath temporarily. Furthermore, most of these
mouthrinses contain a high percentage of alcohol which when used too
frequently will tend to dry out the mouth's tissue.
When you sleep do you breathe through your mouth?
Dryness of the mouth is almost always associated with halitosis.
Are you taking any medication?
Many medications can cause dryness. Some also have a distinct odor of
their own which enters the breath via the lungs.
Have you been experimenting with ethnic foods that use different
spices ?
Many spices like garlic and onions affect the breath. In the digestive
system the by-products of these spices are able to enter into the
bloodstream. From there they enter the breath by being excreted from
the lungs.
Are you on a special diet?
Dieting can make you prone to halitosis, When a person doesn't eat he
or she experiences what has been called "hunger odor". This may
actually be caused by the juices in the stomach. Dieters also burn
stored fat which gives off acetone. These odors enter the breath via the
lungs.
Do you drink alcohol ?
Remember alcohol tends to dry out the oral tissues. Alcohol is also
excreted into the breath via the lungs.
Do you smoke?
Smoking encourages periodontal disease, decreases salivary flow and
causes a tongue condition which can trap food debris and tobacco odor.
If you are a denture wearer, how often and by what method do you
clean your dentures? a)Brush? b) Soak? How often?
Dentures tend to collect food more than natural teeth. It is also true that
since most denture wearers are older their salivary flow seems to be
less. Both these factors contribute to an increase in halitosis for the
denture patient.
How long have you noticed the problem?
The duration of the problem can be significant in making a diagnosis.
For example, a long duration of symptoms is more consistent with
persistently poor hygiene while a short duration of symptoms may
suggest an infectious source like an abscess.
Has your bad breath been confirmed by others?
It is very difficult to determine for yourself if you have bad breath. Trying
to smell your own breath usually doesn't work and having a bad taste in
your mouth doesn't necessarily mean that you have bad breath. Since
most patients do not have access to sophisticated measuring
instruments, the only way they can really tell if they have bad breath is
to ask somebody to check it for them.
Today, the technology exists to measure the level of volatile sulfur
compounds right in the dental office with the use of an instrument called
a halimeter. This along with other new techniques will usually allow you
to pinpoint the cause of patient's bad breath.
Management of Oral Malodor
Odors must be eliminated on the molecular level before halitosis can be
controlled. Masking of odor is only transient. It is not only ineffective,
but it generally creates an additional odor problem that is also
disagreeable and more complex than the original smell.
As opposed to anti-plaque and anti-gingivitis claims, breath freshening
remains a cosmetic claim in many countries. Since water also reduces
bad breath for a given period (albeit a very brief one), practically all oral
products can fit neatly into this category. Consumers and dentists
themselves have a conspicuous difficulty in determining which products
actually "take your breath away," and for how long. Few papers have
been published on malodor reduction for periods of above 2 or 3 hours.
Mouthwashes shown to reduce bad breath for 8 hours or more include
0.2% chlor-hexidine formulations (Rosenberg et al., 1981; 1982),
Listerine™ (Kozlovsky et al., 1994) and a recently developed twophase oil:water mouthwash (Rosenberg et al., 1982; Kozlovsky et al.,
1994). Studies such as in Consumer Reports have shown that
mouthrinses and other commercial products have effects that are very
short lived (as in a few minutes) and no significant effect on halitosis.
[Source: Rosenberg, Mel; Bad Breath: Research Perspectives. 2nd Edition (1997).]
The goal of oral malodor management is achieved by eliminating the
associated odor producing bacteria from the oral cavity. A combined
approach that includes mechanical debridement with chemotherapeutic
adjuncts will provide patients with good results. Mechanical
debridement includes daily deplaquing of the dorsum of the tongue.
This procedure alone will significantly decrease oral malodor. Tongue
deplaquing is best achieved through the use of implements designed
exclusively for use on the tongue rather than brushes designed for
teeth. The higher profile of toothbrushes make them less effective on
the tongue. In addition, tongue scraping has proven to be more effective
in reducing odor-causing bacteria because it facilitates an even
pressure that will force bacteria, food debris, and dead cells from the
crevices of the tongue surface. Daily tongue hygiene, combined with
chemotherapeutic support, will control oral malodor as well as enhance
overall oral health.
Chemotherapeutic products such as mouthrinses, toothpaste, and
tongue gels are popular with patients; therefore, the progressive
clinician needs to have a good understanding of the options available.
By and large, product criteria should include products that are alcoholfree and sugar-free, and contain an antibacterial agent known for its
effectiveness in controlling oral malodor. Agents such as zinc chloride,
essential oils, and chlorine dioxide have proven effective in reducing
oral malodor. Chlorine dioxide acts by neutralizing the VSCs. Essential
oils, such as thymol and eucalyptol, kill anaerobic bacteria, while zinc
chloride will effect bacteria cell walls and neutralize volatile sulfur
compounds. Other antibacterial agents also may prove effective in oral
malodor control. More research in the arena will assist clinicians in
making appropriate product recommendations.
Mouthrinses, toothpastes, tongue gels, and chewing gum are popular
vehicles for delivering antibacterial agents. It is important to recognize
that patients want and use chemotherapeutic options. The combined
approach of mechanical deplaquing and chemotherapeutics will provide
effective oral malodor control and should be introduced and utilized
during the dental hygiene appointment.
Clinical Protocol for Oral Malodor Management
1. Pre- and post-procedural use of an antibacterial mouth rinse to
neutralize VSCs.
2. Eliminate/reduce plaque and calculus:
A. Instrumentation as indicated—Take the opportunity to
correlate periodontal conditions with oral malodor.
B. Subgingival irrigation to neutralize VSCs that have been linked
with an increase in mucosa permeability, interference with
collagen and protein synthesis.
C. Remove remaining plaque from interproximal regions.
D. Perform selective polishing as indicated.
E. Perform tongue deplaquing procedure using tongue scraper
and antibacterial tongue gel.
Involve the patient in this process and open dialog regarding the
tongue coating and its relationship to oral malodor and bacteria
accumulation.
3. Evaluate for additional preventive care:
Sealants
Topical fluoride treatment
Daily fluoride use.
Professional and daily fluoride therapy is indicated based upon caries
activity. A patient, regardless of age, who has had an incipient or active
lesion within the past year is a candidate for fluoride therapy.
4. Introduce smile-enhancement options:
Toothwhitening, laminate veneers, crown/ bridge, composites, periocosmetic options, and dental implants are all examples of aesthetic
options. Be aware and informed about these options and discuss them
with each patient.
5. Patient education for daily care:
Consideration of appropriate tools should include automated devices,
inter proximal cleansing, use of appropriate chemotherapeutics and
tongue scrapers. Make the correlation between plaque removal and
fresh breath.
6. Appointment for recare and restorative/ aesthetic procedures
Source: Kristy Menage Bernie, RDH, BS. Discus Dental.
Patient Teaching
Since most bad breath is caused by oral factors, the elimination of these
factors should be the first step in the treatment approach. The following
steps are recommended:
Improve oral hygiene techniques.
Since improper oral hygiene is probably the most common underlying
factor in halitosis, the institution of an effective home care program is
essential. In addition to conventional tooth brushing and flossing, daily
irrigation of the oral tissues and regular scraping or brushing of the
tongue is recommended.
Since the tongue is a main reservoir for bacteria which produce VSC
one method to control odor is to eliminate the bacteria that live there.
This can be accomplished by brushing the tongue and using a solution
which contains chlorine dioxide. Studies have shown that sulfur
molecules are oxidized by chlorine dioxide. The reaction creates a
powerful deodorizing effect in which the volatile sulfur gas is eliminated.
This deodorizing agent along with brushing or scraping will abrade the
tongue and remove the bacteria. This product is produced by a few
companies and is called RetarDex, RetarDent and Oxyfresh. The patient
is provided a supply of this product to use at home. RetarDent, RetarDex
and Oxyfresh come in a toothpaste, gel and rinse.
Another hygiene technique which has been found useful in controlling
halitosis is the use of a new type of oral irrigator. These special units
can ionize whatever solution you care to use to irrigate the soft tissues.
It has been shown that by irrigating the soft tissues and the teeth with
ionized solutions you can inhibit the formation of plaque and tartar. This
technique is especially useful for patients who have a hard time flossing
properly.
Control gum disease (periodontal disease).
By eradicating periodontal disease you will destroy one of the main
sources of bacteria that produce volatile VSC.
Perform all necessary dental care.
Restoring all existing areas of decay, closing open contacts between
teeth, extracting all unrestorable teeth and correcting any other defects
like overcontoured fillings and crowns that are impossible to clean will
help to minimize the accumulation of the bacteria and food debris that
cause bad breath.
Increase salivary flow.
Eating smaller meals more frequently, drinking water with a little lemon
in it, chewing sugarless gum, and sucking a sugarless citrus or mint
candy, will all increase salivary flow. This will enhance the mouth's
natural ability to clean, thus reducing the number of oral bacteria as well
as their substrates and end-products that could stagnate and putrefy in
saliva. Patients who suffer from severe dry mouth can use an artificial
saliva to moisten the oral cavity without any untoward adverse
reactions.
Patients who wear dentures, or partials need special home care
instructions.
Since food debris easily gets caught around clasps and on denture
teeth, it is important to tell your patient to rinse out their appliances after
every meal. A good cleaning should be done at least once in the
afternoon and then prior to soaking them in a disinfecting solution for
the evening. Wearing dentures during sleep when salivary flow is
diminished will enhance the process that causes bad breath.
Patients wearing removable appliances also need to be given special
oral hygiene instructions.
Since these appliances are usually worn 24 hours a day, it is imperative
to take them out after every meal and clean them. They should also be
soaked once a day in a good disinfectant like CLEAN N' FRESH.
For people who eat spicy food like garlic and onions, excellent oral
hygiene is not enough to stop bad breath since the metabolites these
foods produce are absorbed, and excreted through the lungs.
One product which works well to control this type of bad breath is
Breathasure. This simple product which is made of parsley and
sunflower seed oil in a gel cap seems to prevent the odor-causing
byproducts of these foods from entering the blood stream.
When all the previously described oral measures have been taken and
they fail to improve the halitosis condition in a relatively short period of
time, systemic disease or some other cause should be suspected.
Referral to a physician for a complete medical examination should then
be made. Remember while halitosis is usually due to benign oral
disorders it may be the first manifestation of a serious or even fatal
disease.
Source: W.B. Williams, DMD
Suwance, Dental Care
Suwanee, GA
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Additional Reading, Continuing Education Seminars & Resources
Hodsdon KA: Supportive aesthetic therapies: What every dental hygienist should
know. Access 1998;12(9):47-51.
Linder AA: This hygiene check will build your practice. Dental Practice & Finance
1998;6(6):57-60.
Guide to Success—Enhancing Oral Health through Prevention and Aesthetics.
Includes information on presenting oral malodor management, tooth whitening and
fluoride therapy to patients. Available from Discus Dental, Inc. Call 1-800-826-9711 for a
copy.
Haywood VB (ed.): Current opinions on nightguard vital bleaching. Compendium
1998;19(8, special issue).
Principles of Aesthetic Dental Hygiene: A Patient Centered Approach. Continuing
education seminar (four hours) hosted by associations throughout the country.
Contact Educational Designs at 1-925-735-3238 for the seminar schedule or to
schedule a presentation for your group.
In-Office Training & Education on oral malodor, tooth whitening and preventives
through Building Blocks at Discus Dental. Call 1-800-600-9748 for more information.