•  Acetone—diabetes or acetone, alcohol, phenol, or salicylate ingestion
   
  
•  Ammonia—some types of urinary tract infections, or kidney failure
   
  
•  Bitter almonds—cyanide poisoning
   
  
•  Cat’s urine—odor of cats syndrome (beta-methyl-crotonyl-CoA-carboxylase deficiency)
   
  
•  Celery—Oasthouse urine disease
   
  
•  Dead fish—stale fish syndrome (trimethylamine oxidase deficiency)
   
  
•  Fresh-baked bread—typhoid fever
   
  
•  Foul—tonsillitis, sinusitis, gingivitis, lung abscess, or dental cavities
   
  
•  Garlic—arsenic, phosphorus, organic phosphate insecticides, or thallium poisoning
   
•  Horse-like (also described as mouse-like or musty)—phenylketonuria
   
  
•  Rancid butter—odor of rancid butter syndrome (hypermethionemia and hypertyrosinemia)
   
  
•  Raw liver—liver failure
   
  
•  Sweaty socks—odor of sweaty feet syndrome (Isovalryl CoA dehydrogenase deficiency)
   
  
•  Sweaty socks—odor of sweaty feet syndrome II (Green acyldehydrogenase deficiency)
   
  
•  Violets—turpentine poisoning

That’s why we are recommending the use of a surge protector with your Halimeter^®.

Some good brands—available internationally—include:

•  APC
  
•  Belkin
•  Tripp-Lite

Generally, the most basic model should suffice.

APC offers an interesting white paper entitled “The Seven Types of Power Problems.”

Please contact us with any questions.

Good luck!

Here, then, are…    Interscan’s Seven Rules For Success With The Halimeter^®

1.     Treatment of oral malodor in your office is a practice-builder, not a get-rich-quick scheme in itself. Those with unrealistic expectations are bound to be disappointed.

As a practice-builder, treatment of oral malodor will attract new patients, and you can offer more services to existing patients. Plus, you can distinguish yourself from the crowd. The attractiveness of breath treatment is that it is inexpensive to get into, requires little doctor time, and promises a cure for the patient in virtually all cases. As a part of your overall marketing plan, it can truly help, but it is not your entire marketing plan

2.     Be wary of those who would sell you quantities of rinses and other therapeutic items, to dispense to the patient, at high markup. While some of these formulas are proprietary, many can also be obtained directly by the patient. Moreover, claims that aqueous rinses are not available in conventional retail outlets have been false ever since Crest^® introduced its Pro-Health Rinse.

3.     Note that proper technique for breath sampling involves taking three readings (automatically averaged by the Halimeter^®), and each reading should be preceded by a three-minute sample incubation time. As such, at least 11 minutes will be required.

Of course, most of this is NOT active time for the doctor or hygienist, and these procedures can be modified. Still, it does take time to get good scientific data, and this should be understood by both the practitioner and the patient.

4.     Take advantage of all the resources in our Experts’ Forum. Several doctors detail what they do in their successful practices, and Prof. Touyz’ clinical charts are still the best we’ve seen for oral malodor management.

5.     Since most oral malodor patients are suffering from some kind of gum condition, no special training is needed to treat the majority of cases of oral malodor. Just practice the good dentistry you are already practicing.

6.     Don’t be afraid to charge appropriately for your good work, and don’t forget to ask us about our free PR services. Over the years, we have gotten great publicity for many of our dentists, in local and national media.

7.     Finally, do not hesitate to contact us, with any service or marketing issue. Your success is our success!

BANA, short for N-benzoyl-DL-arginine-B-napthylamide, is a synthetic peptide that can be hydrolyzed only by these particular species. In the test, a chromogenic diazo reagent that reacts with one of the hydrolytic products of the peptide breakdown produces a blue color, and the intensity of this color determines whether it is a “positive” or “weak” reaction.

The test was developed by Walter J. Loesche et al., at The University of Michigan School of Dentistry.

The commercial chairside BANA test setup consists of the BANA test strips and an incubator. As of December, 2005, the incubator costs $300.00, and a pack of 20 test strips is priced at $120.00.

No doubt, the ability to quickly and inexpensively test for pathogenic oral bacteria is a significant breakthrough in periodontics, along with the recognition that “periodontal diseases are the result of an immunological response to specific bacterial challenges,” as one supplier\’s website puts it. This mirrors the revelation some years ago that most peptic ulcers were the result of a Helicobacter pylori infection—not spicy food, acid or stress—and could be best treated with antibiotics.

While it is true that any blue color indicates the presence of BANA-positive organisms on the test, the manufacturer does recommend that clinical judgment be used when interpreting test results, owing to variations in color intensity and how the color may be distributed across the strip. The manufacturer of the BANA test apparatus also states:

Evaluate weak reactions in the context of the patient’s history of periodontal disease and current clinical status as well as to the level of malodor that the clinician can detect.

Generally, a weak-positive result indicates the presence of low levels of bacteria capable of producing foul-smelling compounds. If the BANA test is only weak-positive, the clinician may choose to reinforce oral hygiene procedures.

Thus, this test that is touted by some as a inexpensive alternative to the Halimeter^® is asking the user to detect, using some other means, the level of oral malodor!

A few points can be made here

1.     Colorimetric testing, in general, is best suited to “go/no-go” determinations. Problems in interpretation will occur when results fall into the broad middle ground.

2.     We readily agree that a strong positive result is indicative of bacterial infection. Yet, how useful is a “go/no-go” measurement of bacterial infection in monitoring the progress of treatment of oral malodor?

3.     A simple “go/no-go” colorimetric test is no substitute for an analytical, numerical measurement of the concentration of volatile sulfur compounds—the very chemicals that cause bad breath. One cannot compare instrumental measurements in parts-per-billion to a visual color indication. If you want to measure oral malodor, then measure oral malodor, rather than extrapolate and approximate it via bacterial counts.

4.     Inexpensive colorimetric methods—the best are called “detector tubes”—have been available in the world of gas detection for many years, but have serious limitations. Those interested in analytical gas detection seek out companies like Interscan [shameless plug].

5.     We must also mention that there are cases of oral malodor not of oral etiology, and the BANA test will be of little benefit in these scenarios. With the Halimeter^®, the practitioner can measure volatile sulfur compounds in mouth, nose, and lung air, to isolate the source of the problem.

So… Is the BANA test a substitute for the Halimeter^®? As the old Hertz commercials used to say,”NOT EXACTLY!”

The implication being, of course, that it is wasteful and absurd to proceed as if there were every likelihood of a brain tumor, instead of just a plain old tension headache. And, if the aspirins do not help, tomorrow is another day, and then we can call in the cavalry.

While this argument makes sense—in a limited context—there is always the danger that the observer will discern the wrong disease, and then apply an inappropriate treatment. Indeed, misuses of empirical treatment are well-known in the world of infectious disease. Unfortunately, misuses are not unknown in the world of oral malodor.

Certain manufacturers of mouthrinses and tongue scrapers would have you believe that a shortcut to fame and fortune is dispensing these products, on an empirical treatment basis, to patients who present with chronic halitosis. While most of these products will provide some short-term benefit, they treat only the symptoms. Moreover, most of these products are readily available in non-dental settings, at retail or online.

Consider that fully 80% of patients who present with oral malodor have some sort of gum condition, and rinses and tongue scrapers are hardly cures for gum disease! Gum conditions respond to good dentistry—the kind you already practice.

With the Halimeter^®, you can determine the origin, as well as the severity of the halitosis, and monitor the efficacy of treatment. Should you encounter one of those rare malodor cases of non-oral etiology, the patient can be referred out. This, then is truly ethical, evidence-based dentistry, that can originate from a presumably humble case of chronic bad breath.

Click here to download a more commercial approach to this topic (as an Adobe Acrobat pdf file—41KB), also available as a printed flyer.

The vast majority of oral malodor originates with the anaerobic bacterial degradation of sulfur containing amino acids within the oral cavity, resulting in the emission of hydrogen sulfide (H₂S), methyl mercaptan (CH₃SH), and dimethyl sulfide (CH₃SCH₃), collectively referred to as volatile sulfur compounds (VSC).

The Halimeter^® responds to all three volatile sulfur compounds, and gives a reading of total VSC’s.

To be rigorous, the Halimeter does not respond equally to all three compounds, nor are all three compounds present in the same proportion in all patients—or even in the same patient—at all times. The relative amounts of these compounds are affected by diet, and the extent of anaerobic bacterial growth.

Elucidating the precise breakdown of the three compounds in an oral malodor sample requires a gas chromatograph, an instrument clearly beyond the scope of the typical dental office, and rare enough even in academic dental research settings. Fortunately, the additive reading provided by the Halimeter correlates extremely well with organoleptic panels of trained human olfactory evaluators, and compares admirably with chromatographic testing.

The Halimeter reads out in parts-per-billion (ppb) of volatile sulfur compounds.

The Readings

As was emphasized in the Knowledge Base article “The importance of proper breath sampling technique–with recommendations”, numerical readings can be greatly affected by variations in breath sampling technique. Please note that the interpretations discussed below are based on following the sampling technique described in that article.

Many practitioners have developed their own sampling techniques, some of which do not incubate the sample for as long as we recommend, and some of which might be more prone to dilution from the ambient air.

The question arises:  Are these sampling techniques “wrong”?

They are only wrong if one wishes to produce VSC readings conforming to the interpretations discussed below. However, if alternative sampling techniques are practiced with consistency, good results can be obtained, and will conform in a RELATIVE sense with our numerical scale. It is noted that alternative sampling techniques will usually produce lower readings

• Normal readings, for subjects with no oral malodor, are generally in the range of 80-140 parts per billion (ppb). Readings lower than this range are still indicative of no oral malodor, and are otherwise clinically inconsequential.
   
• At levels of 200-300 ppb, oral malodor is noticeable by an observer standing close to the patient.
   
• At 350-400 ppb, the odor is noticeable by an observer standing several feet away from the patient.
   
• At 500-700 ppb the odor is more noticeable not because it is “stronger,” but because it is more foul.
   
• At over 1000 ppb, the odor will linger for several minutes after the patient leaves the room. In many of these cases, odor will continue to emanate from the tongue during the entire sampling process, and the Halimeter reading will keep climbing, and may not truly peak, as the sample pump seems to draw more VSC’s off the tongue surface. Removal of the tongue coating should eliminate this phenomenon.

High readings can also be produced by interfering compounds, such as flavoring agents in mouthrinses, mints, and herbal teas. The Halimeter is reading in the parts-per-billion range, and some of these flavoring agents can be present at oral concentrations several orders of magnitude higher. This is one reason why we recommend that the patient should refrain from food, smoking, drinking (water is allowed), and oral hygiene for 3-4 hours before the testing.

If you wish to investigate the therapeutic effect of a rinse, or a procedure that may introduce a flavoring agent into the mouth, make sure that the patient rinses thoroughly with plain water, and allow sufficient time for the aromatic sensation to dissipate, before taking a Halimeter reading.

As with all biological parameters, Halimeter readings should be used not so much as absolute standards, but as relative indicators of a condition. That is, a normal blood pressure reading is said to be 120/80. While 180/110 would be an indication that the patient should seek further medical attention, a reading of 130/82 would not. Similarly, normal blood glucose level is said to be 100 mg/dl, but is better defined as a range of 70-115 mg/dl.

We stand ready to provide all the technical support you require. Let us know how we can help.

Many Halimeter^® users want to know what concentration of volatile sulfur compounds (VSC) constitutes a finding of \”bad breath. If the answer to this question is to have any consistency, it is clear that the method of obtaining the breath sample must not only be consistent, it must employ clinically proven techniques. Remember that the Halimeter\’s sensor will faithfully display the VSC concentration presented to it, but cannot compensate for a breath sample that has not been properly incubated, or that may have been diluted inadvertently.

By “incubation,” we mean that the patient\’s mouth has to be held closed, with breathing only through the nose, for a particular length of time, before the sample is taken. Ideally, the patient should also refrain from food, smoking, drinking (water is allowed), and oral hygiene for 3-4 hours before the testing.

Experience has shown that a sample incubation time of 3 minutes produces the best results, and beginning in October, 2002, Halimeters have been provided with an automatic countdown timer (counting down and displaying the seconds remaining) to facilitate this process. Users of older models can utilize commercially-available digital countdown timers.

Just before the timer times out, the patient is instructed to take a deep breath through the nose, and, with breath held, then place the straw (already connected to the Halimeter) into the mouth. The straw is placed as far back into the mouth as it can be, without touching any surface, and the lips are gently closed. Take care that the mouth is NOT closed tightly around the straw.  A very small gap is preferred.  The sampling begins.

Peak value should be reached in about 20 seconds, although in certain cases, it may take slightly longer. The newer Halimeters are provided with a 30-second sample timer, which starts, and then shuts off the sample data collection (even though the pump continues to run). The peak reading is automatically held in memory, and is averaged with two successive samples.

Again, experience has shown that taking three samples, recording the peaks, and then calculating the average provides maximum accuracy.

Users of older Halimeters, not equipped with the automation features, can still, of course, apply the same sampling protocol of…

• 3-4 hour pre-sampling abstinence by patient
• 3 minute sample incubation
• Deep breath, held breath, and proper straw insertion, with gently closed lips
• Record peak sample value
• Take three samples, calculate average peak

Rest assured that better sampling technique will produce better and more consistent results. For further information, please contact our service department.