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Speaker 1: From bad hair, to bad breath. Halitosis is a tricky problem for us GP's, not because
we're particularly prone to it, you understand, but because we're often the last port of call
for desperate patients. People complaining of persistent bad breath often end up coming
back to their GP after their dentist has checked their mouth and various specialists who have
looked at their throats, lungs and stomach. So, what can the GP add if there is no abnormality
to find? Well, the first thing he or she can do is actually check that their patient has
bad breath. Offering to smell someone's breath can be embarrassing for both parties but it's
essential, as I discovered when I met Tim Hodgson, Consultant in oral medicine at the
Eastern Dental Hospital in London.
Tim Hodgson: I think the most important thing to say to these individuals is, "Is it there
or is it not?" And you've got to be very careful how you say it cause often these people are
coming to you with a problem that they feel is real. And then, if you turn immediately
around to them and say, "This is not real", you can run into problems. But I think it's
very important within the first discussion to smell the breath cause that's the gold
standard test, and if they haven't got bad breath you can say at that moment in time
they don't have halitosis but it is possible that in times previously that they had. And
it's often the case that people have halitosis, address their gum health.
S1: And gum health being the most common cause of it?
TH: Yeah. And after that they're left with this perception that they've still got halitosis
even though they've corrected the cause. And that's sometimes reinforced by family members,
friends and relatives. And often they come along with a very considered construct that
people on their bus or on the Tube are turning away from them or covering their face or won't
talk to them directly because they feel they've got bad breath. And they look, almost looking
for people who are avoiding them because of their bad breath.
S1: And that reinforces their notion that they've got bad breath.
TH: Yeah, it reinforces and helps build a construct in their own head.
S1: As a rough guide, what sort of proportion of people that you see here with halitosis
would, in your mind, not necessarily have a real problem but have a perceived problem?
Are they a significant minority?
TH: I would say probably 80% of patients referred with halitosis to our service don't have halitosis.
S1: Do they believe you when you smell their breath and say, "Look, I can't smell anything".
TH: Some do, and others don't.
S1: Working along side Tim Hodgson at the Eastern Dental Hospital is clinical psychologist,
Claire Daniel.
Claire Daniel: For some of these people, they may well have had halitosis in the past so
they've set up this way of thinking is... We work in a cognitive behavioural way which
basically looks at the way in which people think, they way in which they feel, what they
do and the physical symptoms and how they all interact. So, this patient in the past
may well have had halitosis. They've set up this belief system thinking about their breath,
maybe they're focusing on their breath. And as Tim said, they've had past experiences
of people reinforcing that they've got halitosis. Now, even if the halitosis disappears some
patients may well remain quite anxious about that and so they will keep on focusing on
the potential symptoms. And they become very biased in the way in which they see and hear
information so they become very focused on the negative stuff that will reinforce their
beliefs and will sort of ignore the other bits of information that may well support
a more helpful, more realistic way of thinking about their situation.
S1: So, when a doctor or a dentist tells them that they haven't got bad breath, they'll
say, "Well, that's not true or I haven't got my bad breath today but, trust me, I had it
yesterday because I saw someone in the pub wince".
CD: Yes, absolutely. So, it's either, "Well yes, it's okay today but it wasn't yesterday
or it won't be tomorrow". But also, some people initially will be reassured by somebody saying
they haven't got bad breath but, as we know, reassurance is for people who believe they
have medical difficulties can only be short-lived for most people. So, they'll feel very reassured
in the consulting room and then will go home and their whole belief system will trigger
again, maybe reinforced by the people. So, their anxiety maintains.
S1: Looking at this from the outside, Tim's got perhaps the easy part of the job when
he says, "Look, I don't think you have halitosis", and he then does the referral to you.
CD: Absolutely.
S1: And you've got to do something about it. It's quite a complex problem so what can you
do and how successful might you be?
CD: Yeah, it's very complex. Cognitive behavioural therapy is an anxiety about health in general,
we don't set out to tell people that they're wrong. We set out to try and help people understand
what's going on. So, we don't just talk about their physical reported symptoms. We'll talk
about the way in which they're interpreting things, they way in which they're thinking
about things, and how those interpretations actually may be unhelpful. They might seem
helpful to the patients, like go to the doctor, go to the dentist, focus on their breath to
check, maybe clean their teeth, but in the long term they can be very unhelpful and maintain
the problem. So, we help people to take a broader outlook on their situation. We don't
tell them what it's not, we help them to understand what it could be and then we help them to
develop evidence to support what it could be rather than maybe what it's not.
S1: And practically, what is involved and how often do you see them?
CD: So, we'd see people maybe every week, every two weeks.
S1: Is this one-on-one?
CD: Yes, one-on-one, for this particular condition. One-on-one, so one patient with one psychologist
for about 50 minutes about, on average about eight times.
S1: And in terms of success rate, how effective is it?
CD: I would say, we do help... With particularly halitosis, we probably help about 80-90% of
people.
S1: That's pretty good.
CD: But I wouldn't... But then it's a continuum, we might help some people just a little bit.
And I think with things like anxiety about health, it's a life-long issue. We're not
just going to suddenly stop people's anxieties. It's about helping them to live with uncertainty
and live with a degree of anxiety about their condition. So, they'll still have times when
they think their breath smells.
S1: Clinical psychologist Claire Daniel. Just time to tell you about the next Inside Health
when I will be investigating the side effect of cancer treatment...