Halitosis Case #17

From Partnership Operating Manual

To provide each Franchisee with the broadest level of knowledge, the Operating Manual contains numerous case reports each designed to emphasize one or more aspects of diagnosis and treatment. It is the goal of the National Breath Center’s franchise operation to create each franchisee as an expert from the outset of association. The Case Report here is an example of correlating the information given by the patient at the initial interview with the diagnostic information to obtain the correct diagnosis and treatment.

Case #17

This woman came in complaining of having bad breath for many years. She was particularly concerned about projecting her breath to others and had even “retired” because of it. Her other notable complaint was that she could “taste something from under her bridge.” Here are some photos from her initial visit:

case 17 tongue before
17 gauze before

Patient's Treatment Plan

17 treatment plan

Areas of Concern

  • Patient has excessive biofilm (see photo)
  • Her sulphur readings were not very high (See Oral Chroma image)
  • Her organoleptic was 5, with a distinct fecal odor
  • Most areas had bleeding on probing (See photos)

So, where was the odor coming from? Actually, all places - tongue, gums and under the bridgework as you will see.

The evidence we were relying on was the organoleptic score, the gauze tests, the photos of her tongue, and the somewhat high reading of methyl mercaptan.

Original Oral Chroma

17 oral chroma

The two notable items on this Oral Chroma are the levels of methyl mercaptan and dimethyl sulfide.

Since dimethyl sulfide is “blood born”” which indicates that it is coming from something systemically, not orally for the most part (although it can), she was instructed during the course of the consultation to begin probiotics as a dietary supplement. At that time, she had already related that she had constipation that was greatly alleviated by eating yogurt. This information led me to believe we were on the right track with possibly lowering the dimethyl sulfide.

Because the H2S was not high but the CH3SH was, it indicated that a large part of the problem was coming from the gum tissue. Note the photos of her bleeding points upon probing.

gums 1

The Treatment

So, we initiated treatment, eliminating tongue biofilm and doing SRP. Once we were finished with biofilm removal, this is what her tongue and gauze looked like. Note the “whitish” appearance of the tongue with all the biofilm removed. What you are seeing in the middle of her tongue is thick saliva. This is an indication that hydration is also important for her. Note the clean gauze devoid of biofilm.

17 tongue after
17 gauze after

After Treatment

However, there was still a slight organoleptic odor recorded as 1+ and it had a mild fecal smell.

As noted in the chapter on the Oral Chroma, a metabolic odor usually smells like faint garlic and onions. This cannot be detected organoleptically at the outset as the other odors of halitosis are much stronger and mask that smell. But after the biofilm is removed, these lesser odors can be detected.

oral chroma after

At the same completion visit we did another Oral Chroma and found this. Note the still high reading of CH3SH.

When I questioned her about how she thought she was doing with her breath at the completion visit, she related again that she still had a bad taste coming from under one of her bridges.

At the outset of treatment, due to the excessive bleeding on probing, it was impossible to tell if the CH3SH was due to food trapping under her bridgework (as she related) or from the subgingival bacteria, inflammation, and subsequent bleeding. (CH3SH is particularly higher in the subgingival tissues – see Oral Chroma)

Once the tongue and subgingival biofilm was removed and she had been irrigated multiple times subgingivally with the appropriate products, and taught how to self-irrigate, the bleeding from probing was minimal. Then, it was easy to conclude that it was the faulty bridgework that was the direct cause of the remaining bad breath, her bad taste, and the organoleptic finding.

Her next step in treatment was to remake the bridge that had been done in Peru about three years prior.

(As part of the obligations of the National Breath Centers to its Franchisees, support will be available for help with interpretation of diagnostic results for treatment planning. As an ongoing commitment, more cases and new findings will be added to the Manual.)


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