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Delusional Halitosis

You think you have bad breath but you don’t. Or do you?

7 May 1999

By Mary Roach

When the key words for a journal article include “halitosis,” “odor judge” and “psychopathology,” you know you’re in for a diverting read. You especially know this when a fast skim reveals the sentence “…To assess the subjects’ scoring of a given foul odor, chicken-dung based fertilizer in aqueous suspension was presented … in an opaque sniff bottle.”

The author, one M. Rosenberg, ran an “oral malodor clinic” in Tel Aviv at the time, which was 1995. The aim of his research—and a fine aim it is—was to find out, in a scholarly, clinical, published-in-a-peer-reviewed-research-journal sort of manner, whether there is any conceivable way that human beings can accurately judge the smell of their own breath.

The dentist had begun to wonder. Day in and day out, patients would come to his clinic, claiming, as he put it, “to be able to smell their own malodor.” He set forth their techniques: The tried-if-not-true cupping of the hands over mouth and nose; the breathing beneath the blanket ploy; the smelling of the telephone mouthpiece or the dental floss; and the uncommon — and exotic — licking and subsequent sniffing of the wrist.

And so, with help from six dentist pals and financial support from the Tel Aviv University Authority for Applied Research and Development, Rosenberg gathered up 52 Israeli citizens, 43 of whom had claimed to have bad breath, and let them try a few of their tricks. He had them cup their hands over their mouth and nose. He had them lick their wrist (in, for unknown reasons, “a perpendicular fashion”). He also had them try one they hadn’t heard of. He had them expectorate into a petri dish that was then closed and allowed to incubate for five minutes at 37 degrees, centigrade, whereupon it was opened — and here we must pause to acknowledge the deft wording of what must surely stand as the most unsavory task ever asked of a research volunteer — and “presented for odor assessment.”

At the same time, the dentist himself, wearing the mantle of “odor judge,” would rate each subject’s breath himself. Our man Rosenberg smelled 52 open mouths, glistening wrists, and incubated saliva samples (and, lest we forget, a chicken dung-based fertilizer in an opaque sniff bottle).

What he found confirmed his suspicions. With the exception of the incubated spit technique, there was no significant correlation between the subjects’ ratings of their own breath odor and Rosenberg’s ratings of it. Assuming for the moment that few of us possess the technical expertise or constitutional wherewithal for incubated saliva sniffings, it would seem there is in fact no simple and accurate way to know if you have bad breath.

Which brings us to our final key word: “psychopathology.” Not knowing if one’s breath stinks can have hugely peculiar consequences. Not knowing leads to assuming, which, in a handful of instances, leads to a very specialized breed of hypochondria. Rosenberg’s references include a paper entitled “Delusional halitosis: Review of the literature and analysis of 32 cases.”

Delusional halitosis is one of the monosymptomatic hypochondriacal psychoses. If you had to choose one of these psychoses, you would definitely want to pick delusional halitosis. Why? Because your other options are: “delusional skin infestation by insects, delusion of internal parasitosis, delusion of the presence of small, seed-like objects under the skin, delusion of body disproportion, and phantom bite syndrome, wherein the patient has the persistent delusion that his dental bite is abnormal.”

On second thought, go with phantom bite syndrome. Delusional halitosis patients have been known to give up their careers because they can no longer face the embarrassment of their imaginary bad breath. They never go out. They attempt suicide. They abuse oral hygiene products. One possessed toothbrusher in the article went through 100 milliliters of toothpaste every four hours. The article told the story of a morose young student who would show up early to his classes, sit on the far periphery of the room, and insist that the students who came in afterward were avoiding the seats closest to him. Not one of the 32 cases, all of whom had come to the University of Benin Dental Hospital in Nigeria specifically seeking help for halitosis, had any perceptible breath odor. (A note of clarification: The patients in the study and the author of the article are all Nigerian. Nigeria has no special claims to halitosis or the cure thereof. It does, however, have an airport that does not maintain and administer effective aviation security measures. Another good reason not to go there seeking treatment for halitosis.)

I feel for those 32 Nigerians because I myself may be a sufferer of delusional halitosis (either that or nondelusional halitosis). It is a mild case, periodically aggravated by my stepdaughter crawling into our bed in the morning, putting her face right up next to mine, and saying, “Your breath STINKS.”

Fortunately for me, I live in the age of the Interscan Halimeter®. A Halimeter® is a technological rendering of Dr. Rosenberg’s nose. It measures the volatile sulfur compounds (VSCs) in a person’s breath. VSCs are the bad in bad breath. They come from decayed food in your gums or on your tongue.

The Halimeter® resides in the Bay Area Fresh Breath Center, which is an alter ego of the dental practice of Mat Kiisk, a man for whom the phrase “crossing your i’s and dotting your t’s” must bring its own private pain. I had envisioned the proprietor of the Fresh Breath Center as an icky sort of man, preying on the insecurities and delusions of the city’s dental paranoids.

Mat Kiisk is the nicest man in the world. Here is a man who will deplaque your tongue if you ask him; who doesn’t mind that his parents couldn’t be bothered to put the proper number of i’s and t’s in his name. He agreed to do the Halimeter® reading in a “journalistic” manner, meaning he didn’t charge me.

Only a couple of people visit the Fresh Breath Center every month. In part, it’s because Kiisk doesn’t advertise. Mostly, it’s because it’s embarrassing. It starts long before you walk in the door. I called 411 to get the Breath Center number and the operator said, “Breath as in bad breath?” In the waiting room, the receptionist passed my paperwork to her assistant saying loudly, “This is the Fresh Breath.” I can see why people go to Nigeria for this.

While Kiisk revved the Halimeter®, he told me some things about halitosis. People get morning breath because they’ve been mouth-breathing all night and their mouths are dried out and there’s no saliva to wash away the bits of food and dead mouth cells, which are what mouth bacteria break down into VSCs. You can get bad breath if you skip meals (Hunger Breath) or if you’re a woman about to get her period (PMS Breath). For most people — people with reasonably healthy gums — the tongue is the bigger problem. “It’s a shag carpet,” said Kiisk. I gave some thought to this. And while I would agree that my tongue is something you’d immediately want to rip up if someone had it installed on the floor of your apartment, I wasn’t getting far with the metaphor. Kiisk explained that tongues are covered with fine filaments. As in, trap debris, hard to clean.

Dirty tongues are not vacuumed but scraped. Kiisk dispenses Gentle Tongue Scrapers (“3) Stick out tongue …”) for the Breath Center crowd, which can be used with something new and interesting called Tongue Conditioning Gel. I tried brushing my tongue once, and it made me gag.

“It’s easier if you hum,” said Kiisk. “Don’t ask me why.” I didn’t.

The Halimeter® is about the size of a car tape deck and has a similar handle. (No doubt realizing the fun it might add to parties and picnics, the manufacturers made it portable.) Attached to this is a tube. Kiisk told me to put this tube into my mouth. A 56 appeared on the digital readout. Halitosis is in the range of 80 to 150. Anything over 150 is “advanced halitosis.” One Fresh Breath Center patient scored 400. Said Kiisk, “He was totally diseased out.” Kiisk gave him a referral to a periodontist, which he never followed through on. “So now he’s got denture breath.”

Next, Kiisk had me put the tube in the back of my mouth, warning me that the numbers were likely to go up. First the Halimeter® said 39. Then it said 82. Then it said 10. Kiisk confided that the technician had just been in to service the machine, which had had a loose wire. So maybe what the machine should really have said was 390. And maybe he gave me a Fresh Breath starter kit not because I’m a journalist doing a story on halitosis, but because I do in fact STINK.

The petri dish calls.