When Bad Breath Happens to Good People

Is something rotten in the state of your mouth? Kill halitosis with costly new technologies!

Alan answers, "Yes, but a little closer would not be." The main problem, he continues, "is that it makes you self-conscious. You're constantly reminding yourself to stay back a little." But he adds with a slight smile, "I know people with worse diseases."

"I agree with you," Garazi replies, "but we get people in here who have considered suicide because their breath is so bad." He then begins checking Alan's teeth and gums for obvious signs of disease --- he doesn't seem to find any A and then invites his assistant, Rose Arbuz, to begin the gritty work of detecting the odor.

Before coming here this afternoon, the patient, on instructions from Garazi, avoided food, drink, breath fresheners, and toothpaste for eight hours. This ensures that his breath will be in its purest A and rankest A state. In most cases, according to studies in the Journal of Periodontology and other dental publications, chronic bad breath is caused by certain types of bacteria reacting with sulfur-based proteins in the mouth, creating foul-smelling gases known as "volatile sulfur compounds." One of these, hydrogen sulfide, smells like rotten eggs. (It's not known why certain people have significantly higher concentrations of these anaerobic, or oxygen-deprived, bacteria coating their tongue and other areas of their mouth, although the phenomenon appears to be linked to lower amounts of oxygen-rich saliva.) At very concentrated levels, these sulfur gases can be poisonous; accordingly, a machine known as an industrial sulfide monitor was developed to measure such gases in workplaces. Bad-breath experts have adapted and renamed the instrument the "halimeter" to measure the parts-per-billion concentration of sulfur gases in the mouth, almost as if Occupational Safety and Health Administration rules now applied to breath, too.

Here, however, the machine will be used to measure Alan's breath. First, Garazi tells him to keep his mouth closed for a moment. Then Arbuz wheels in a portable cabinet, opens a drawer, and unveils a forbidding one-foot-high beige and blue piece of monitoring equipment. With a needle attached to graph paper, the device resembles a mini-polygraph, designed to ferret out the truth about the gases inside the chemical factory known as Alan's mouth. Arbuz inserts a straw into the machine and tells Alan to wrap his lips around it. The needle jumps a bit.

Then, to rule out the possibility of a medical or sinus condition causing the odor, Arbuz makes even more onerous requests. "Pinch your nose and breathe through your mouth," she instructs Alan. Next, she tells him to close one nostril and breathe into a straw she places up his other nostril. As he breathes out, she seals this straw in a plastic baggie. Then using all the care usually associated with the handling of nuclear wastes, she places the straw into the machine for measurement. She takes similar steps to measure his lung air, derived from the little bit of breath remaining when Alan finishes exhaling again; this last procedure assesses any odors emanating from the stomach or other organs. All of that is followed by the swabbing of his tongue for bacteria with a cotton-covered Q-tip that will be placed in a test-tube culture.

The most daunting part now occurs A for Rose Arbuz anyway. She asks Alan to repeat the breathing tests he's just taken, but now she has to detect his odor herself. When he breathes out of his mouth, for instance, she quickly leans forward to smell it, then just as quickly leans back. In a remarkable display of restraint, she manages not to wince or exclaim, "Oh, gross!" She then has him repeat the nasal and lung exhalations, leaning in to smell them, too. She applies cotton gauze to the back of his tongue and flosses him quickly with dental floss, and then smells those items. After performing this "organoleptic assessment," she fills out part of an evaluation form that asks her to measure the odor on scale of zero to five, with two signifying mild odor, three equaling "moderately offensive," and five representing "extremely offensive." Alan rates a three.

Garazi returns to give Alan the grim news. Pointing to the graph results, he notes that the low level A one part per billion A at the bottom of the sheet measures the sulfur gases in the room's air. "But when you gave us mouth air, you see how it spiked up," he says. "It went up to 840 per million [actually it was per billion, but who's counting?]. The machine picked up the volatile sulfur compounds. Our physical exam showed that yours were in the midrange with some odor, but this [graph result] is a pretty high reading. And the tongue sample had a moderate odor."

Malevolent organisms, it turns out, have rendered Alan a bad-breath victim. "For the vast majority of our patients, breath odor comes from the buildup of bacteria on the back of the tongue," Garazi tells his patient. "The better we clean the tongue and remove the bacteria, the less odor will be generated." There is hope, after all.

Garazi sketches the pathway to Alan's new odor-free self: another office visit to scrape away the bacteria and rinse his mouth thoroughly with a concentrated version of ProFresh, followed by a home-treatment regimen of twice-daily tongue scrapings and rinsings. "As long as you do it, you won't have breath odor," Garazi announces. Alan nods quietly.

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