From Bad to Good
Exactly an hour before I’m due to interview the experts at the new UCLA Fresh Breath-Halitosis Clinic, a terrifying thought strikes:
Suppose my breath is graded not just bad, but terrible. Dragon quality.
Just in case, I rebrush, refloss, rerinse--and do the yawn-and-sniff test en route.
Multiply my anxiety by 25 million--the number of U.S. adults who have, to put it charitably, a chronic oral odor problem--and it’s easy to understand why bad breath clinics are sprouting across the country.
Since 1993, when Philadelphia dentist Dr. Jon Richter opened the Richter Center for the Treatment of Breath Disorders, as many as 1,000 dentists nationwide--including about 100 in Southern California--have joined the anti-halitosis campaign, industry experts estimate. Some have opened specialty clinics; others market bad breath treatment as part of their private practice.
And more are poised to follow, if attendance at a recent UCLA symposium is any clue. “Scientific Frontiers in Oral Malodor” drew 110 participants.
What these dentists are after is in-your-face, day-after-day halitosis that can make even your nearest and dearest flinch.
And they’re tapping into an eager pool of customers, according to the folks who track our oral hygiene spending habits. “We estimate the market at retail level for mouthwashes, gargles and breath fresheners at $740 million a year,” says David Vladyka of Kline & Co., a New Jersey marketing consulting firm. Sales were flat in ‘94, he says, but began to rise again last year.
It’s no coincidence, of course, that the rise of fresh breath clinics is also occurring in the eras of cavity-free kids and managed care. Dentists see halitosis as both a new professional challenge and a fresh revenue-producing avenue.
“In the process of getting rid of bad breath, you are ridding your mouth of bacteria that can lead to gum disease and cavities,” says Dr. George Gholdoian, a Downey dentist who focuses on bad breath treatment and says the new niche can net dentists an extra $200,000 annually.
But not everyone is singing the praises of the new niche. “Every dentist’s office is in fact a bad breath center,” says Dr. Richard Price, a Newton, Mass., dentist and spokesman for the American Dental Assn. While he doesn’t condemn the centers, he sees them as “another way to market a practice,” adding: “I don’t know if they’re necessary.”
But many patients who show up at fresh breath clinics have been to their family dentist. They have tried home remedies without success, says Dr. Sushma Nachnani, a microbiologist and co-director of the newly opened UCLA clinic with Dr. Diana Messadi, a dentist. And they are nearly desperate to get rid of the odor.
Having bad breath “is one of those stigmas that is not visible,” says Jeanne Curran, professor of sociology at Cal State Dominguez Hills. Even so, she adds, it can make you feel like an outcast quickly, especially in the United States. “We believe we must smell sweet and clean,” she says. “Bad breath taints us. It’s like having flatulence or body odor.”
So it’s no surprise that about 50% of people with severe bad breath have social phobias, as Richter has found.
Or that consumers are paying dearly for an initial evaluation at a bad breath center, which costs $100 to $500 at Southern California clinics and sometimes includes follow-up care.
Bad breath treatment is generally not covered by insurance plans, Messadi notes, because insurers still view it as a cosmetic-only problem. In some cases, the costs of X-rays and basic exams are reimbursed, dentists say, but not other tests or products to combat the halitosis.
Taking a complete medical and dental history is the first step. While dentists used to believe that some bad breath originated in the stomach, most now concur that at least 80% of it comes from the mouth.
Richter pinpoints the root even more precisely: “Bad breath comes from the back of the tongue.”
Late last year, researchers writing in the Journal of the American Dental Assn. concurred: “The tongue plays an important role in the production of oral malodor.”
The bacteria that flourish in the dark, oxygen-deprived environment on the hinterlands of the tongue produce substances called volatile sulfur compounds, or VSCs. Research on VSCs dates from the ‘60s, but it wasn’t until the ‘70s or so that dentists began dubbing them the bad boys of bad breath. And only in the last few years have dentists begun to market bad breath treatments.
After a dentist obtains the history and briefs the patient on what’s known about bad breath, the next step is testing with a halimeter, a small monitor that measures levels of VSCs. A straw connected to tubing, in turn connected to the monitor, measures exhaled air from the mouth and nostrils.
It’s impossible to quote a perfect halimeter score. “Every halimeter is different,” UCLA’s Nachnani says, because the readings are affected by calibration differences and the immediate environment. At UCLA’S clinic, 50 is considered a good reading.
But Dr. Rudy Salda-mando, a general dentist who opened the Beverly Hills Fresh Breath Centre within his practice about a year and a half ago, says he doesn’t get concerned until a patient’s halimeter reading passes 100.
A single halimeter reading is never enough, experts caution. “Most people with bad breath have episodes of it,” Richter says. “It varies tremendously.” Time of day, diet and general health all contribute to breath odor or the lack of it. (Other oral problems, such as abscesses and poor dental hygiene, can contribute to the odor, as can sinusitis, tonsil infections, postnasal drip, gum disease and diseases such as diabetes and liver failure.)
Besides the halimeter, there is a variety of other tests, none for the fainthearted. Patients may be asked to lick their wrist and then smell it. Or, the dentist may use a spoon to scrape the tongue and then examine and smell the specimen.
Patients are urged to bring along loved ones, because dentists have found them valuable sources of information about just how bad the breath is.
Once the evaluation is completed, the patient is given a detailed game plan to attack the halitosis--an intensive oral hygiene program at home coupled with careful follow-up at the dentist’s office.
At the crux of home treatment programs are mouthwashes, toothpastes and gels with chlorine dioxide, a substance that breaks down the VSCs.
Although manufacturers, distributors and breath clinic dentists tout the benefits of chlorine dioxide, there are no published scientific studies on chlorine dioxide products and their long-term effects on chronic halitosis, Messadi says. “UCLA is planning to do studies,” she adds.
Meanwhile, the American Dental Assn. has adopted a jury-is-still-out stance. “We’ll be interested in any scientific studies [researchers] have,” says a spokesman about the chlorine dioxide products.
Besides the chlorine dioxide products, tongue scrapers are vital to a good home care program, bad breath experts say. The devices have been a staple of oral hygiene programs overseas but are just catching on here.
One style looks like a miniature windshield scraper. Another is a plastic strip, about half an inch by 10 inches in length, that is looped and inserted into the mouth to scrape the tongue.
Oral irrigators, which help direct a stream of warm water and mouth rinse toward the teeth and gum tissue, are sometimes recommended.
Costs for the special toothpastes and mouthwashes are $15 or $20 a month, dentists say. The oral irrigator is about $130; tongue scrapers sell for just a few dollars.
Some dentists send patients to pharmacies to pick up supplies; others serve as distributors for the chlorine dioxide products, thus boosting profit potential.
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Exactly how big a potential sparks debate. Gholdoian, the Downey dentist, says the profit possibility is high, noting that billing $2,000 a day in bad breath treatments and products is not unusual for him. Others familiar with the business say a small dental practice could expect to net an extra $2,000 or $3,000 a month from providing halitosis care; larger practices, more.
Those are just the direct profits. “The patients we see for bad breath tend to be irregular dental office visitors,” says Dr. Tom Davies, a dentist who opened his Brighter Breath Treatment Center in Dove Canyon near Mission Viejo two years ago. But once their breath problems clear up, he says, “72% of breath patients are converted into dental patients.”
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Dentists who provide halitosis care point to delighted patients such as Halayne Karroll, a Los Angeles personal manager who sought help from Salda-mando, her regular dentist. “I always had a problem with my breath,” says Karroll, who sought help after her husband and her hairdresser both mentioned it. “The difference is unbelievable,” she says of her breath after treatment. “I’d back off when talking to someone before.”
Not all of Salda-mando’s patients are so open. Karroll was the only one of four to go public. One patient, a lawyer, was worried about the effects a published interview on bad breath would have on his future business.
But then, even dentists can turn shy about halitosis. During a break at the UCLA conference, all 110 participants were offered a free halimeter test, and Nachnani kept careful track of those who accepted the offer.
All three of them.
