Application of the Fourth Level of Treatment: Intensive Therapy

Scenario: Carlos Suarez, a 36-year-old businessman, has scheduled an appointment specifically to discuss his bad breath. At a previous visit he revealed that he is so self-conscious about his bad breath, he turns his head when talking to others to avoid breathing directly on them. Carlos tells you that he has been examined by both an ear, nose, and throat (ENT) specialist and a gastroenterologist (GI) to see if they could determine the cause of his breath odor. The specialists could not find any physical cause for his complaint, and both had recommended he see a dentist. This is his third appointment in your office for breath evaluation. At the previous two visits, unpleasant breath odor could not be detected by either sensory assessment (smell) or when using the Halimeter® (an electronic device that measures sulfur levels in breath). Carlos was asked to return for another assessment when he believed his breath was extremely offensive. Carlos’s oral, sensory, and Halimeter assessments have just been completed.

Hygienist: “Carlos as you can see, all three of the Halimeter® readings are low today. Actually, the highest number recorded by the digital monitor is only 43 parts-per-billion. These readings are similar to those recorded at your last two appointments.”

Patient: “I really can’t believe it!”

Hygienist: “Well, neither I nor the other hygienists were able to detect any offensiveness in your breath. In fact, I actually find your breath has a rather pleasant smell.”

Patient: “Pleasant! Your nose must be broken. I feel like my breath is really bad today.”

Hygienist: “What is it that makes you think your breath is so offensive?”

Patient: “I just know it is. I can just tell. When I lick my wrist and smell it, it’s terrible.” Carlos licks his wrist and then smells his wrist. “Yuck that’s terrible!” He extends his wrist for the hygienist to smell.”

Hygienist: “Carlos, I don’t smell any offensiveness on your wrist. In fact, I have never been able to detect any bad breath from you, and all your Halimeter® readings have been low. Even with you not brushing this morning. Has anyone ever told you your breath was bad?”

Patient: “Well, no. But I know it is; even when I turn my head to avoid breathing directly on people, they still turn their heads away from me.”

Hygienist: “Carlos, have you ever considered the fact that when you turn your head away from people, they might think that you’re responding to their breath, so then they become self-conscious and turn away from you?”

Patient: “Gee, I never thought about that. Is that what you think is happening? Do you think it’s all in my head?”

Hygienist: “Carlos, I’m willing to acknowledge your concern is real, I’m just saying the problem may not be real. I’m just not finding the evidence to substantiate your concern.”

Patient: “Do you think I’m nuts?”

Hygienist: “No. I don’t think you’re nuts. I’m simply saying, based on the clinical evidence that’s been collected, my assessment is that your breath is not offensive. Do you think it’s possible the problem may not be as bad as you think it is?”

Patient: “Well, I don’t know what to say. The ENT and GI specialists couldn’t find anything wrong either. I’m starting to wonder if I am nuts!”

Hygienist: “Carlos, I’m not certain what to say either; you’ve had two medical specialists in addition to myself each tell you your breath is not offensive. Yet, it seems as though nothing the specialists or I say can convince you your breath is okay. My concern is the negative effect your anxiety about your breath is having on you as a person. You’ve told me it’s affected how you interact with others and you avoid talking directly to people.”

Patient: “Do you think I should see a shrink?”

Hygienist: “If a counselor reassured you your breath is okay would you believe them?”

Patient: “Well…there must be some reason I’m so worried about it.”

Hygienist: “I agree with you Carlos; there must be some reason for your concern. If you were my brother, I would encourage you to meet with a “Well…I need to do something because this is really bothering me.”

Hygienist: “Do you have access to counseling services through your medical provider? Otherwise, we can refer you to several clinicians who specialize in this area.”

Patient: “My medical coverage provides for counseling services. I’ll check with them and try to set something up.”

Hygienist: “Carlos, I really believe that’s the best route to take.”


The foregoing example illustrates the transition into the fourth level approach using the P-LI-SS-IT model. While Carlos’ problem is most likely due to either a compulsive disorder (halitophobia28) or a phenomenon referred to as “delusional halitosis.”29 This is a psychiatric disorder referred to as one type of olfactory reference syndrome (ORS). Treating halitophobic patients in the dental practice can be extremely challenging. Fortunately, these cases are the exceptions and most breath odor can be treated in the general practice.42,43 This level may also include those patients’ whose bad breath is multi-factorial in nature including both oral and non-oral components. For example, patients with periodontal disease, who are taking medications, and/or who have medical conditions that exacerbate bad breath. When the specific suggestions that work for the majority of patients are not effective for a particular patient’s problem, then it is time for highly individualized intensive therapy.

Intensive therapy involves an in-depth assessment of the patient’s specific situation in order to develop a highly individualized comprehensive therapeutic program unique to them. Clinicians with appropriate training in the etiology of and treatment modalities for oral malodor could initiate such treatment. Otherwise, this is the point at which you would refer patients for appropriate treatment elsewhere. The important point to keep in mind is we have an ethical responsibility to first try to resolve patients’ problems from within the brief therapy approach.