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Bad Breath in Patients: Discussing and Treating Back to Course Index



This course is designed to provide dental professionals with practical strategies to facilitate the discussion and treatment of oral malodor in the dental office.

This course describes a useful communication model specifically aimed at discussing potentially sensitive issues. 


Upon successful completion of this course the learner will be able to:

  • Understand the importance of developing communication skills for discussing bad breath concerns with patients.
  • Identify the primary source of oral malodor.
  • List the sulfur compounds most commonly associated with bad breath.
  • Identify systemic disorders and medications known to contribute to oral malodor.
  • Explain a useful communication model: Permission, Limited Information, Specific Suggestions, and Intensive Therapy.
  • Describe interview strategies used by clinicians to facilitate patient counseling.
  • Treatment options for oral malodor.
  • Observe the American Dental Association’s (ADA) Code of Professional Conduct for the Dental Profession recommending bad breath treatments.


Bad breath is a common problem that can cause significant psychological distress.
There are a number of potential causes and treatments available.




Only a dental or medical professional can determine whether halitosis is the result of bad oral habits or something more serious.  The production of bad breath, known as oral malodor and/or halitosis is caused by several factors that may involve both oral and non-oral sources.   

Bacterial putrefaction of proteins by gram-negative and some gram-positive anaerobic bacteria particularly those residing on the posterior dorsum of the tongue, utilize sulfur-containing amino acids, primarily cysteine and methionine, to produce volatile sulfur compounds (VSCs). Although other organic components (e.g., organic acids, indole/skatole, putrescine, cadaverine) may be involved in the production of halitosis, hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and dimethyl sulfide [(CH3)2S] have been identified as the predominate VSCs responsible for oral malodor.   While the tongue is considered the primary source of VSC production, other dental problems can generate these offensive gases.

Dental sources of breath odor include gingivitis, periodontal disease, gross carious lesions, and poor oral hygiene. However, when dental disease is the source of oral malodor, treatment of the condition will often eliminate the problem.  The tonsils have also been reported as a possible source of halitosis.   Likewise, transient breath problems from eating spicy foods, smoking, and drinking certain beverages will most often disappear shortly after their use is discontinued.  However, while eliminating these sources can successfully treat the majority of patients who suffer from bad breath, some individuals continue to have chronic breathing problems.  

Non-oral sources of breath odor would include pathologic conditions outside the mouth such as nasal, paranasal, laryngeal regions, the pulmonary or upper digestive tract (non-blood-borne extra-oral halitosis). An example of an extra-oral, blood-borne odor is cirrhosis of the liver. In this example, the odor is emitted via the lungs but its origin is from the liver. Conditions such as type 2 diabetes, kidney disorders, and pulmonary disease may also contribute to offensive breath odor.  Serious diseases such as some cancers, and conditions such as metabolic disorders can cause bad breath as a result of the chemicals they produce in the body. These conditions should not go undiagnosed, and a dentist will be able to rule out other potential causes of halitosis and determine if an individual should visit a doctor to get screened for cancer or other diseases.  

Medications, especially those that reduce salivary flow such as antidepressants, antipsychotics, narcotics, decongestants, antihistamines, and antihypertensives can exacerbate breath odor. These non-oral sources of breath odor have been well reviewed in the literature. However, while systemic conditions and medications can contribute to breathing problems, most authorities seem to agree the majority of bad breath originates in the oral cavity.  As mentioned, the primary source for oral malodor is the tongue, home to bacteria stored inside all of its grooves and cracks. When particles of food aren’t completely removed from the mouth, they collect bacteria on the tongue and around the gums.  These bacteria feed on the food and protein material in the mouth, as well as their byproducts.  A possible result–bad breath.

The foods individuals eat affect how the breath smells because what is eaten affects the air that is exhaled.  After being absorbed into the bloodstream, some of the components of foods are transferred into the lungs, where they’re expelled when someone breathes. Ingredients such as garlic, for example, contribute to bad breath odor.  The objectionable odors may linger until the body naturally eliminates those foods’ components.

There are other reasons why oral malodor can occur. Chronic dry mouth can cause oral malodor because saliva is necessary to clean the mouth and remove particles that may cause bad breath.  Bad breath may also be caused by a medical condition, such as respiratory infections, diabetes, or gastrointestinal disturbance.


  • Poor oral hygiene
  • Periodontal disease
  • Tongue coating
  • Food impaction
  • Unclean dentures
  • Faulty crowns, bridges, and fillings
  • Tobacco
  • Medications (several drugs produce dry mouth as a side effect)
  • Diet
  • Systemic illness, including gastrointestinal disorders

It has been estimated that up to 25% of the population suffers from bad breath on a regular basis in spite of having good physical and oral health and after the elimination of offensive foods and beverages.   It is these patients that most need our expertise. While there are many new products and emerging information regarding the treatment of oral malodor, the dental professional also needs to feel comfortable sharing this information and these products with their patients.



Here are some key points about bad breath. 

  • Bad breath is estimated to affect 1 in 4 people globally
  • The most common cause of halitosis is bad oral hygiene
  • If particles of food are left in the mouth, their breakdown by bacteria produces sulfur compounds
  • There are a number of common causes of bad breath, including smoking, tooth decay, and alcohol consumption
  • Keeping the mouth hydrated can reduce mouth odor
  • Bad breath in children is often due to a trapped item in the nasal cavity
  • Rarer causes of bad breath include bowel obstruction, ketoacidosis and aspiration pneumonia 
  • The best treatment for bad breath is regular brushing, flossing, and hydration
  • Crash diets can cause bad breath because of the build-up of ketones.





Not everyone is this honest!  Telling someone they have bad breath is awkward.  Regardless of the source of oral malodor, chronic breathing problems can be detrimental to one’s self-image and confidence causing social, emotional, and psychological anxiety. The problem of assessing and treating oral malodor is exacerbated by the personally sensitive nature of the topic. Even in close relationships, people are often reluctant to inform others their breath is offensive. Asking a trusted confidant or experienced health professional is considered the most reliable method of confirming a chronic breath odor problem. This, however, can be awkward and embarrassing for both the patient and the dental professional, who historically has been hesitant to broach the subject. Since the dental office is the most logical place to assess and treat oral malodor, it is important to develop the communication skills and knowledge base that will enable dental professionals to respond to our patients who seek information about and treatment for bad breath.

Since oral malodor can be related to certain medical conditions or medications, taking a comprehensive medical/dental history, including questions pertaining to breath concerns, can lay the groundwork for open dialogue about breathing problems. When patients initiate a dialogue about their breath concerns, dental professionals need to be comfortable with explaining the etiology of and treatments for oral malodor. 



The P-LI-SS-IT System

As a professional in this situation, it is critical that you approach the issue with knowledge and sensitivity.  This course introduces a communication model that has been used successfully by people in a range of helping professions when providing sexuality-related information, also sensitive in nature. The model is J.S. Annon’s P-LI-SS-IT system.   The acronym stands for the model’s four progressive levels:

  • Permission
  • Limited Information
  • Specific Suggestions
  • Intensive Therapy

This course discusses how the P-LI-SS-IT model may be applied to the dental setting for discussing the personally sensitive topic of breath odor concerns with patients. The P-LI-SS-IT system is flexible and adaptable to many settings and to whatever amount of time is available. The model allows for a range of treatment choices geared to the level of competence of the individual clinician.

Before introducing the P-LI-SS-IT model, let’s go over general interviewing skills and counseling techniques.

Before an effective clinician/patient dialogue can take place, it is important that the dental professional feel secure about their own knowledge level regarding the etiology and interventions available for treating breathing problems. A strong knowledge base enables the clinician to personalize the treatment plan to the particular problem of an individual patient and rely less on standardized techniques and “one size fits all” regimens. Furthermore, it is important to be familiar with interviewing and counseling techniques that encourage open communication, reduce anxiety, and establish rapport.

The more knowledge of the etiology and treatment of oral malodor a clinician has, the more confidence they will experience when interviewing and counseling patients about breath odor. Beyond this course, several sources of information are available to expand one’s knowledge base regarding oral malodor.

Armed with the basics and more it is also very important to know basic interviewing skills to gather information and explore your patient’s possible causes.  Most of us have heard the adage “It’s not what is said but how it’s said that makes a difference.” This is particularly true when discussing subjects that are inherently sensitive. What follows are specific suggestions for interviewing and counseling patients:

The Setting

It is very important the clinician and patient have some degree of privacy when discussing personally sensitive issues. Patients are typically reluctant to share sensitive information that might be overheard by others. For this reason, if you can offer patient privacy, it’s best to do so. When privacy is limited, it is best to postpone discussions until the clinician is alone with the patient and to speak in a low volume.

The Initial Approach

Time is typically a consideration. If the clinician does not have time available to talk in-depth about the patient’s concern, she/he can give limited information (following the P-LI-SS-IT model discussed in this article) and make another appointment for the patient as soon as practical. This way the patient does not leave feeling as though their needs were not addressed.

When initiating conversations regarding oral malodor, it is important to use statements the clinician feels comfortable with. For example, after reviewing a patient’s medical history or oral examination, one might begin by using one of the following questions:

“Do you have any other dental concerns or problems regarding yourself or a family member’s oral health?”

“What dental products are you currently using on a regular basis?”

“Do you have questions regarding dental products you’ve seen advertised or heard about?“

If the patient says they do not have any concerns, it is recommended to accept this answer and do not press further. Let it be known that if in the future he or she does have concerns that they feel free to contact you at the office. Suppose the patient does have a concern, what does the clinician do?


The most common and serious mistake made by most clinicians is failing to really listen to what the patient has to say without interrupting. It is important we don’t jump in with suggestions before hearing the patient out.



With the advent of so many “bad breath” remedies and standardized regimens available for sale to patients, it is important for dental professionals to keep in mind the treatment procedures and/or products we recommend should be based on an individualized assessment. Otherwise, there is no point in performing a comprehensive assessment if all patients go through the same treatment program. Furthermore, it is important to keep in mind we have a professional responsibility to follow The Code of Professional Conduct for the Dental Profession.

The code of ethics reminds dental professionals to preserve the inherent trust in the dentist-patient relationship.  It also stresses the importance of verifying the accuracy of claims made by manufacturers and distributors about product safety and efficacy before inducing patients to purchase products or undergo procedures.  “The dentist has an independent obligation to inquire into the truth and accuracy of such claims and verify that they are founded on accepted scientific knowledge or research.”  

In the Ethics portion of the American Dental Hygiene Association’s Policy Manual states that “The American Dental Hygienists Association (ADHA) opposes misleading advertising and unsubstantiated claims connected with oral care products and services.

We have an ethical responsibility to base our clinical recommendations on sound scientific evidence. This practice of integrating the most current knowledge into clinical decision-making is referred to as Evidence-Based Decision Making (EBD). One way that we can be assured of using EBD in our product recommendations to patients is to endorse products that have undergone the rigorous evaluation by the ADA Council on Scientific Affairs and have received the ADA Seal of Approval.


The P-LI-SS-IT System

As mentioned earlier, the P-Li-SS-IT model that has been used successfully by school counselors, social workers, nurses, clergymen, and health aides when counseling persons with sexuality concerns and problems. The P-LI-SS-IT system is flexible and adaptable to many settings and to whatever amount of time is available.

The model allows for a range of treatment choices geared to the level of competence of the individual clinician. The first three levels involve “brief therapy,” and most patients ‘ bad breath problems can be successfully resolved at these levels. The fourth and final level involves “intensive therapy” and is reserved for those patients whose problems require more complex therapy. At this level, it is important the clinician has the appropriate training and experience to provide a highly individualized therapeutic program. This may include a referral for either medical assessment or psychological counseling.

This information discusses how the P-LI-SS-IT model may be applied to the dental setting for discussing the personally sensitive topic of breath odor concerns with patients. Let’s return to the scenarios presented earlier and outline some helpful responses using the P-LI-SS-IT model.


The dental professional should enter the conversation by gaining the patient’s permission to discuss the topic.  “Do you have any other concerns you would like to discuss?”  “Many of my clients like to ask questions about how flossing and dental hygiene can affect breath issues.  Some like to ask what products are preferred for cavity prevention?  Would you like to discuss those or any other concerns?”

The goal is to open up communication and ensure the client feels comfortable.



In this phase of the conversation it is important to let the patient know what are the possible causes, discussed above, and show that as a professional you have information to offer them, but not to overwhelm them.  “So it sounds like you experience bad breath only in the mornings.  This is usually caused by a lack of saliva through the night and bacteria.”

The application of this second level is a continuation of the first level of approach, permission. At the permission level, the patient is made to feel comfortable and encouraged to share their concerns. The clinician is primarily concerned with reassuring the patient that she/he is normal. At the limited information level, the patient is given specific factual information directly relevant to their specific problem. Typically, the information provided at this level can be incorporated into existing schedules and does not require additional appointment time.

If giving limited information is not sufficient to resolve the patient’s concern, there are two options available to the clinician at this point. The patient may be referred for appropriate treatment elsewhere or, providing the clinician

has the appropriate setting, knowledge, skills, and experience, he or she can proceed to the third level of treatment: specific suggestions.


Once you have gathered all of the information from the patient, listening carefully and completely, you can present specific suggestions based on a full evaluation of the presenting problem.

When providing specific suggestions, clinicians may wish to supplement verbal instruction with appropriate readings; resources include published articles, patient education brochures, and Internet websites. Reading materials provide both non-intimidating information sources as well as being time-saving, for both the clinician and the patient.

While it may be possible to incorporate the information provided at this level into existing appointments, it may also be necessary to schedule additional appointment time(s). The fees charged for these procedures will be determined by individual offices and will be based on the time involved, the expertise of the clinician, and the products provided to the patient.

There may be times when the specific suggestions that have worked for others do not work for a particular patient’s problem. When a clinician believes they have done as much as they can from within the “brief therapy” framework, then it is time for highly individualized intensive therapy.


Intensive therapy involves an in-depth assessment of the patient’s specific situation in order to develop a highly individualized comprehensive therapeutic program unique to them. Clinicians with appropriate training in the etiology of and treatment modalities for oral malodor could initiate such treatment. Otherwise, this is the point at which you would refer patients for appropriate treatment elsewhere. The important point to keep in mind is we have an ethical responsibility to first try to resolve patients’ problems from within the brief therapy approach.

It is important to keep in mind that while the brief therapy part of the model may be sufficient to resolve many of our patients’ oral malodor problems, it is not intended to resolve all bad breath problems. If we don’t have the expertise in our office, we have an ethical responsibility to identify and refer patients to those who do.



As mentioned breath odor can have an oral origin, medical issue, or be related to other factors such as the food someone eats.  When other factors are ruled out diagnostic tests can utilize X-rays and computed tomography (CT) scanning for cross-sectional views.   Rhinoscopy can be performed to examine the nasal passage.  In addition, clinicians can utilize clinical symptoms such as pain and palpation or pain while leaning their heads forward to diagnose a sinus pathology.  The ADA considers tools, equipment, and all instruments for measuring breath odor as secondary tests; organoleptic judging is the primary test.  There are generally only a few different instruments regularly used in the US for the general clinic.  One is called the Halimeter equipped with an electrochemical sensor and the Breathtron described as a portable monitor with a zinc-oxide think film semiconductor sensor specific to VSC’s.  Gas chromatography (GC) equipment can also detect and discern gasses in the breath.  some dental offices now have equipment that can detect VSC levels in the breath.

The intraoral, paranasal, ear, nose, and throat examination involves the observation of all types of surface abnormalities, including color, texture, and palpation in areas of interest.  A hand-held penlight is suitable for a quick analysis, but lamps or headlights should be used for thorough investigations.  

Oral examinations begin with a visual examination, then proceed to palpation.  All hard and soft tissues are observed.  Lumps, bumps, lesions, and discolorations need to be noted.  All teeth, including third molars and implants, need to be examined for pericoronitis and periimplantitis.  

Oftentimes, oral malodor is multifactorial.  Places harboring bacteria and detained food damaged hard and soft tissues are all sites or oral malodor production that may not show on an x-ray.  An odor that is emanating from the marginal opening of a crown, inside of which could have unchecked decay and debris leaking out.  It is not only crowned beneath which pathogenic bacteria, decay, and odor can seep but also beneath all types of faulty restorations where plaques can accumulate and not be cleaned.  

Ulcerations, surgical wounds, gingival and periodontal disease, TC, and even pericoronitis can be culprits that should be investigated during the examination. 

Observing the tongue and making assessments about the depth and breadth of a tongue’s coating is one method of making a gross judgment about potential malodor.

Scientists have developed indexes to record various conditions including tongue coating.  Judging the tongue’s coating is considered one useful method of detecting oral malodor.  There is a strong correlation between a thick tongue coating and halitosis.                                                                                    

Since chronic bad breath causes severe repercussions, suffers are anxious to find a cure. 
Halitosis treatment products have spurred a billion-dollar industry.   The most popular means of combating chronic halitosis, after eliminating other medical causes for bad breath, include toothbrushes, mouthwash, and tongue scrapers.  Brushing and flossing play an important role in oral hygiene. 

Tongue scraping, together with proper oral hygiene is the most effective “common” treatment against the causes of halitosis. 

Other Recommendations for Reducing Oral Malodor: 

  • Remove dentures at night and clean to get rid of bacterial buildup from food and drink.
  • Drink plenty of water and swish cool water around in the mouth. This is especially helpful to freshen “morning breath.”
  • Brush after every meal and floss, preferably twice a day.
  • Replace the toothbrush every two to three months.
  • Arrange regular dental checkups and cleanings.
  • Chew a handful of cloves, fennel seeds, or aniseeds. Their antiseptic qualities help fight halitosis-causing bacteria.
  • Chew a piece of lemon or orange rind for a mouth- freshening burst of flavor. (Wash the rind thoroughly first.) The citric acid will stimulate the salivary glands—and fight bad breath.
  • Chew a fresh sprig of parsley, basil, mint, or cilantro. The chlorophyll in these green plants neutralizes odors.
  • Suggest a 30-second mouthwash rinse that is alcohol-free. Mix a cup of water with a teaspoon of baking soda (which changes the pH level and fights odor in the mouth) and a few drops of antimicrobial peppermint essential oil. Do not swallow (Yields several rinses.)


Bad breath can be a serious issue. Surveys have shown that people find the oral odor to be a major turn-off, even more so than having stains on clothes, being bald, having yellow teeth, or acne. In some cases, it is a sign of a serious health issue.  As a dental professional it is important to gain the skills necessary to notice the signs, have the ability to have an open conversation about, and to treat this serious issue.