Halitosis - how to approach the issue with my patients?

Use of Language

Addressing halitosis requires courage and self-confidence.  There are things you can do to make the conversation easier.  First and foremost, always let your patient know you are there to help.  Your choice of language can also influence how the conversation will be perceived. Small rhetorical tricks can help to make your discussion more pleasant. Speak in the first person and do not generalize: "I have the impression ... It seems to ME ...". This makes the conversation more personal and gives the patient the opportunity to express their opinion on the subject. Speak in the subjunctive ("could it be ..., would it be possible ...") and use modal particles or interjections like "maybe" and "perhaps", so statements are softened and appear less harsh.

Opening the conversation

An important question is who addresses the subject first - dentist, dental assistant or patient?

• It is of course easier if the patient brings up this sensitive topic first. If the impulse comes from the patient, there is very little danger of offending anyone.
  
  
• The issue of halitosis can also be integrated into patient history forms. This gives the patient an opportunity to assess him/herself and, if they suspect they have bad breath, they can bring it up during the consultation.
  
  
• Another option is for the oral health specialist to address the issue directly.  You may want to offer a separate halitosis consultation, independent of the dental check-up. Setting up a separate appointment will give you sufficient time to discuss this personal matter, and also set appropriate patient expectations. Prior to the halitosis consultation, you may want to ask the patient to complete a questionnaire, so as to better frame the problem.

Putting the patient at ease

Following are some recommendations to help the patient feel at ease while discussing the history of his/her problem.

• Position the treatment chair upright so that the conversation takes place "at eye level". This makes it easier to build trust and talk openly about intimate problems.
  
  
• Make sure the conversation can take place undisturbed from background activities and noise.
  
  
• Consider starting with an instrumental measurement before moving on to the subjective organoleptic measurement. This provides tangible results that the patient can understand, since they are objectively measured.
  
  
• You may want to start the conversation by discussing prevention of a bigger problem, positioning the solution firmly in the patient’s hands. This approach is based on the extensive experience of a dental hygienist and is written up in “Registered Dental Hygienist” (RDH) magazine [1].  If the hygienist noticed a breath odor, she would tell the patient something like: "John, as I am scaling this one area in your mouth, I'm noticing an odor. My worry is that this could affect your breath overall. Here are some suggestions that you can try to help prevent a bigger problem." She would then discuss tongue scraping, effective hygiene, mouth rinses, or whatever else she thought was appropriate for the patient's needs.   The patient was told delicately that the problem was nascent, and that he or she could manage it to avoid it becoming bigger (and by extension more embarrassing). Hence the hygienist is avoiding patient embarrassment by suggesting early treatment, rather than creating it.

Tips and Tricks for Periodontitis and Dry Mouth Patients

For both periodontitis and dry mouth patients, you may want to discuss early on, the potential for halitosis to set in. You can reassure patients (or alert them, if needed) that prevention is always the best path.   

If the patient has periodontal issues and has not followed through on treatment, discussing inflammation, infection, and the effect on breath can be a powerful motivator. Explain to your patients that the source of the problem needs to be addressed, and that nothing will perfectly mask or cover up the odor of a true infection. 

For patients suffering from dry mouth and related malodor that might be a byproduct of medications, one option is to “point the finger” at medications, and team up with your patient to help them solve the problem. Uncovering medication and medical treatments can take place during a medical history update, preceding the mouth even being opened.  With this approach, you can suggest hypothetically that there may be an issue to be verified, as opposed to reacting to a mouth that has been presented. This, may be better received by patients.

Summary

In order to ensure both therapeutic success and patient satisfaction, it is important for healthcare professionals to address halitosis in a confident and open manner. Make the patient feel at ease and let them know the problem is under their control and is manageable. When appropriate, encourage patient compliance by stressing the importance of prevention and early treatment.

Finally, reassure your patients that halitosis is not an isolated case but a common condition affecting 30% of patients or more [2]. If you are taking measurements, make it clear that measuring halitosis is a done via a clearly standardized procedure.