AIDS? Hepatitis B? Alcoholism? No, this latest peril is known as chronic bad breath, or halitosis, and in recent months a pioneering crew of dentists in the greater Miami area has launched a battle against this malady. They're armed with high-tech equipment, new research, an arsenal of mouth rinses A plus a determined promotional campaign to alert the public to the menace they face and the fresh (so to speak) hope for solving the problem. Since last fall, the Richter Center Program, developed by Philadelphia periodontist Dr. Jon Richter, has been offered by five different dental offices in Dade, Broward, and Palm Beach counties. Richter Centers' newspaper ads speak directly to sufferers: "She's got a good job and a great wardrobe. But the problem is her breath," states one, showing a worried-looking woman standing all alone next to a window, phone grasped in her hand. "Chronic bad breath can affect your success and self-confidence." Another ad shows a couple sitting close to each other on a couch: "Life is more fun when you don't have to worry about bad breath," the headline points out.
Richter offers an industrial-strength treatment. A key element of this supposed breakthrough approach is the use of a special rinse, ProFresh (made exclusively by a Richter company), which contains an antibacterial chemical called chlorine dioxide. This ingredient is so powerful that it also is used as a disinfectant in municipal water plants, according to Richter and several studies in dentistry journals.
The Richter approach isn't the only method designed to administer to victims of "breath malodor," as it's sometimes referred to in the growing number of research studies and dental seminars devoted to this topic. Tucked away on the first floor of a Brickell Avenue office building is the Fresh Breath of Florida Halitosis Center, also known as the dental office of Dr. Brian Tschirhart. "We saw an opportunity to help the problem A and to meet new patients," Tschirhart says of his decision to open a breath clinic last year targeted primarily at Latin American and Hispanic patients. Indeed, bad breath may be especially "noticeable" to them because "in the Latin community people stand closer together," the Anglo dentist asserts. The centerpiece of his method is the use of another mouthwash, Oxyfresh, which allegedly contains a form of chlorine dioxide, although the ProFresh faction disputes that claim A just one of several points of contention between the ProFresh and Oxyfresh forces. Both camps, not surprisingly, seek to dominate the bad-breath marketplace. Accusations and hints of fraud, profiteering, and questionable dental care are being hurled back and forth between the rival odor fighters.
What's not in dispute is the profit to be found in catering to those with bad-breath concerns. They make up a potentially lucrative market: Polling by mouthwash companies several years ago indicates that an estimated 25 million people have chronic halitosis. In a typical recent ad in the trade publication Dental Products, a major Oxyfresh distributor alerted dentists to the potential gold mine that awaited them if they joined the bad-breath-battling bandwagon:
"DIAGNOSE and TREAT HALITOSIS while increasing PATIENT FLOW and PRACTICE INCOME," the ad shouted. Underneath the headline was a cartoon of a long line of patients snaking through a door waiting for an appointment, while one dentists says to another, "Wow! Who would have believed that treating bad breath would have led to this?"
The Miami area patients who have turned to such treatment programs in increasing numbers don't see themselves as a new revenue source for dentists, but rather as people desperate for help. On a recent afternoon, one of them (we'll call him Alan) sits in a dental chair in the office of a Richter acolyte, North Miami Beach periodontist Isaac Garazi, an earnest, dark-haired man who says that bad-breath patients make up only a small portion of his business.
Before Garazi and his staff get down to the uncomfortable business of actually smelling and measuring Alan's breath, the dentist needs to probe the history and psychological impact of the problem. (In fact, he says, at least ten percent of the patients seeking treatment from him don't really have serious bad breath A they just think they do. As a result, he sometimes suggests psychological treatment.) Alan, still in his twenties, could have a genuine problem, though, Garazi believes, and only a painstaking examination by the bad-breath detectives can determine just how serious it might be.
Alan's parents first called it to his attention when he was in his late teens, he explains, but even after gum treatment the problem persisted. Garazi, sitting a short distance away from Alan in an adjoining chair, asks, "Anything make you think that it is still a problem?"
"There were no comments, but people backed off a little," Alan notes. Garazi asks about his use of mints and mouthwash to mask the smell, then presses on. "When we think about breath, we think about distance. Is this a comfortable distance for you?" The two men sit about three feet apart.
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.
Afterward, Alan stands near a wall, his hand rising occasionally to cover his mouth. Then he moves closer to the receptionist: to hand over a $495 check for three visits. (Since Alan's visit, the three-session fee has risen to $595, up to half of which may be paid by insurance.)
The dental professionals who treat people such as Alan bravely go where no one has dared to go before: into the heart of darkness itself, odors the rest of us would do anything to avoid. Garazi admits, "I don't want to smell people's breath A that's not what I trained for." But, he adds cheerily, "It's better than being a proctologist or a gynecologist." Facing unpleasant realities is just part of his job, he says with a kind of stoic heroism. "You have to get used to it," he notes. "It's not much different than treating a patient with severe gum disease." On the other hand, he concedes, "Maybe when they're not looking, you make a face."
Arbuz, his assistant, recalls how difficult it was for her to evaluate breath initially. "The first time I was very nervous. It was traumatic A he had really bad breath," she notes. "Now I'm very comfortable doing it. You just take a deep breath and put your face four inches away from theirs." The key for her is maintaining her professionalism: "You have to put yourself in their situation. If you were a patient, you wouldn't want anyone going, 'Oh my God!'"
Dr. Brian Tschirhart is a bit more blunt about the downside of his chosen line of work. "It can be very noxious," he says. But he has his own mental technique for dealing with the hazards of slaying the dragon of bad breath: "I focus on the results."
For many patients, those results can be quite positive. According to Esther Hoffman-Gonzalez, a Miami gallery owner, she began noticing a problem over a year ago, when her husband started telling her, "'Honey, you've got bad breath.' Our married life was down to a dull roar," she continues. "It was interfering with my work: You could see people take three steps back. You're embarrassed." Before conquering her problem, she went to an ear-nose-and-throat doctor, visited a gastroenterologist (a doctor who treats stomach disorders), got X-rays of her sinuses, and switched mouthwashes. Nothing helped. She learned about Tschirhart's clinic about five months ago, then went in for treatment that included the scraping away of gum bacteria and the regular use of Oxyfresh toothpaste and mouth rinse. "Everything's back to normal," she says, "and my sense of self-esteem got a push."
Similar testimonials are mustered by the ProFresh side. One convert is a dentist himself, Dr. Carlos Sierra, of Miami Beach, who turned to Richter's ProFresh after using Oxyfresh for about five months. His patients didn't complain about his breath A although, he jokes, "Dentists overall have bad breath; that's one reason we're constantly using a mask." His wife, though, was more forthright about his problem. After learning about Dr. Richter's program, he decided to give it a try. "The treatment was a little hairy," recalls Sierra, particularly the daily use of a plastic, ridged tongue scraper, which made him gag. But, he adds, it's been worth it: "I don't think about whether I have bad breath."
Alan is hoping for similar results when he returns for his second visit a week later. A hygienist cleans his teeth, then uses a special, curved metal device that thoroughly scrapes his tongue while spraying a concentrated version of ProFresh into his mouth. "It's a spray cleaner," hygienist Jennifer Jacobs explains, "like doing a carpet." Alan gags a bit during the process, but about fifteen minutes later, it's all over. Then she gives him instructions about the home-treatment procedure, which includes the tongue scrapings and careful rinsing. He says he's willing to do that, but he balks at her request to have someone he's close to make a "daily assessment" of his breath odor, which he's told to record on an evaluation log for two weeks. The assessment form reads, in part, "The 'assessor' should position his/her nose 4-8 inches from your opened mouth. Exhale slowly through your mouth.... This exercise is designed to provide you with the objective feedback you need to have confidence that your breath odor is no longer offensive."
"I've got roommates," Alan protests. "I don't feel like asking them." As a result, they make arrangements for him to stop by the office for periodic checks. He's sent off into the world with two sixteen-ounce bottles of ProFresh A they're reordered by mail at nine dollars a bottle (plus shipping) A and uplifting words from Jacobs: "I'm going to guarantee that the breath odor will go way down. We haven't had one failure in our office." Alan schedules a return visit in several weeks for a complete retesting.
A few days after the treatment, he stops by for a quick smell check, and the results are encouraging. He says later, "The hygienist told me it was fine. I think I've made progress, and the regimen is getting easier." Still, he admits he hasn't had the nerve to ask his roommates to smell his breath.
With such encouraging results, why is there, well, a bit of a bad odor about the treatment of halitosis? One reason, of course, is that the field itself is so new. Richter opened his first center to the public only two years ago and is only now seeking to publish data about his method's efficacy; the Oxyfresh people have been marketing their mouth rinse since 1984, but have no scientific studies showing that their product works. "There's no standard practice for treating bad breath," says American Dental Association consumer advisor Richard Price, a clinical instructor at Boston University's dental school. "It's all in its infancy."
Thus far Oxyfresh has generated the most controversy because of its aggressive marketing tactics, and questions A raised mostly by rival ProFresh A about its products' claims. The Spokane-based Oxyfresh has a network of thousands of distributors, including dentists, for its extensive line of skin, hair, and dental products; it even sells a breath rinse for dogs. Oxyfresh, in essence, is structured like an Amway program for dentists and other marketers, with each distributor getting a slice of a new recruit's revenues. Consequently, the dentists who sell the mouth rinse and other Oxyfresh dental products are becoming increasingly visible at dental conventions and in trade journal advertisements. This faddishness worries consumer advisor Price, who cautions, "Let's not turn this into tanning salons."
Oxyfresh's sales strategy also has drawn fire, not surprisingly, from Richter and his representatives. Says Richter, "I'd be concerned about the advice you receive if your dentist's source of income hinges on whether you buy a product." And Garazi charges, "The problem is that most of them use it as a come-on to get patients into their office and sell them dental work."
These sorts of charges raise the ire of Oxyfresh dentists, including Dr. Ronald Scheele, director of health profession relations for Oxyfresh. "That's absolutely ludicrous!" he fumes. "We have 7000 highly ethical dentists [offering our product], and they're not out hustling for business." (The company won't disclose how many dentists offer the product in South Florida, but Garazi estimates about twenty.) Scheele portrays the Amway-style marketing technique as merely "colleague referral to the program by those who have been finding success with it. They get a finder's fee for referring others."
Pointedly addressing Richter's accusations, Scheele adds, "This is a competitor's response to the competition. There's a profit motive on both sides. Why don't you ask him how much he makes on his seminars? It's substantial." (Richter counters by noting that he doesn't make a profit on his introductory or training seminars, although he estimates he grosses about $500,000 annually from the sale of ProFresh products through ten dental offices around the country, including his own. By the end of the year, he expects to have authorized and trained personnel in 200 more offices in the use of his product.)
Despite Scheele's protestations, there's little doubt that dentists offering Oxyfresh A and to a lesser degree, ProFresh A hope that the rinse will increase the number of new patients needing actual dental work. There's the evidence of those crude trade journal ads, of course. And Tschirhart, who specializes in crown and bridge work, says, "We like to take patients to as healthy state as possible, so we need new patients." Currently, people seeking treatment for bad breath make up about forty percent of his patients, compared to about five percent for Garazi's practice. In addition, as an article by a pair of dentists in the trade publication the Profitable Dentist points out, thanks to the Oxyfresh program, "we have found ourselves diagnosing and performing a four-fold increase in periodontal therapy...."
Oxyfresh's partisans, including Tschirhart, emphasize the importance of a thorough periodontal exam and treatment for any gum disease as an essential element of fighting bad breath. But Garazi and Richter, among others, disagree with that perspective. Garazi says, "We have patients with severe gum problems who we treat for bad breath without clearing up their gum problems." (Garazi says he usually refers halitosis patients with gum disease back to their own periodontist or dentist unless they ask otherwise.) Richter, citing various recent research articles, is more adamant: "The current wisdom that infectious gum disease causes most bad-breath problems does not hold water. Less than twenty percent of bad breath is caused by gum disease." The most definitive recent article on this earthshaking subject appeared in the January 1994 issue of the Journal of Periodontology; it concluded, "A large proportion of individuals with oral malodor are periodontally healthy."
The dispute between the bad breath behemoths gets even more heated over another burning issue: What the hell is in Oxyfresh anyway? Oxyfresh's advocates use the patina of scientific research to support A indirectly A their claims that their product contains an effective form of chlorine dioxide, a proven antibacterial agent that also neutralizes the sulfur-containing compounds that cause bad breath. In a more concentrated form, this volatile gas, after being dissolved in a liquid, is used to disinfect some city water supplies. (The Dade County Water and Sewer Department does not use it.) Oxyfresh's promotional material includes several studies showing the value of chlorine dioxide as a deodorizer and antibacterial agent. The only problem, Richter notes, citing laboratory studies paid for by him and independent research results he faxed New Times, is that Oxyfresh doesn't actually contain any chlorine dioxide. "It's fraudulent," he says.
The "stabilized chlorine dioxide" that the company touts as the product's main ingredient is actually a salt, sodium chloride, Richter points out. Oxyfresh's Scheele, concedes that point, but asserts that when that chemical reacts with the acidic chemicals in the mouth, it actually becomes activated chlorine dioxide A and goes to work fighting bad breath. (The reason Oxyfresh contends it has developed a "stabilized" form of chlorine dioxide is that the claim permits the company to offer dental products with long shelf lives; Richter's ProFresh, a yellowish solution composed of chlorine dioxide gas dissolved in water, loses its effectiveness within about two months of its being manufactured. Oxyfresh doesn't have any scientific studies to support its claims about the magic transformation of its "stabilized" chemical into chlorine dioxide in the mouth.
While the two companies duke it out over effectiveness, neither is willing to market its product formally as an antibacterial solution, because that would require spending tens of millions of dollars and years of research to prove their case to the FDA. "Who would want to go through that?" Scheele says.
So both ProFresh and Oxyfresh market their respective products as mere "deodorizers," while informally hyping the mouth rinses with scientific studies that make broader claims.
As the squabbling continues between the bad breath warriors trolling for the good-breath-challenged here in Miami and across the country, the ADA's consumer advisor has a caveat. "Before you invest hundreds of dollars in any of these centers or regimens, try cleaning your mouth yourself," says Dr. Richard Price. "Go to Walgreen's and buy a tongue scraper, and try any of the mouthwash products on the shelf.
