by Sushma Nachnani, PhD, Elizabeth Magallanes, Nancy Boonsawas, and Michelle Wu

The Effectiveness of
Breath Care
on Low-Carb Oral Malodor
The low carb craze also indicates more emphasis on oral home care.

T
he low carb diet craze has brought with it an unexpected side
effect — bad breath. Called low carb oral malodor (LCOM), it is
caused by the breakdown of food that produces volatile organic
compounds (VOCs) and from bacteria on oral tissue. To find solutions,
a group of colleagues from the University Health Resources Group,
Inc. and the University of Minnesota’s Clinical Dental Research Center
conducted a study to evaluate the effectiveness of a breath care system
on people with LCOM.
The supermarket shelves are full of products for people who have
been swept up in the low carb diet craze. Has sacrificing the morning
bagel been worth it? The Atkins and similar diets require eating high
amounts of protein and fat, which risks nutritional deficits and other
side effects. These diets have been criticized by those who believe that
the most efficient way to lose weight is through a well-balanced diet low
in saturated fats, coupled with an active lifestyle.
The low carb craze began with an overweight middle-aged man
who was having trouble losing weight and happened upon a low-carb
diet. Surprisingly it worked, and he wrote a book, Letter on Corpulence,
Addressed to the Public, by William Banting, in 1863.
Dr. Robert Atkins revived these theories in the 1970s, and there has
been a resurgence of low carb dieting, with little scientific evidence to
support the safety of the diets. Since 1980, the number of overweight
U.S. adults age 20 and older increased from 46 to 65 percent. Americans
spend $33 billion a year on weight loss solutions, and 37 percent of
people diet at any given time.
Low carb diets can lead to LCOM. This potentially embarrassing
condition may be experienced sporadically and at different degrees
depending on how strictly the diet is followed, previous disposition
for the condition, and oral hygiene. High protein diets cause more
VOCs, and when carbs are decreased, the body turns to ketones that
are produced by burning fat. Ketoses build up, and VOCs are expelled
through the breath, which produces an offensive odor.

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 Breath Management
If there are increased peptides in the saliva, they will be readily
available for the odor causing bacteria to use them. In order for a
low carb diet to be responsible for oral malodor, the body would
experience an increase in serum peptide and amino acid levels.
How would a high-protein, low carb diet contribute
to oral malodor? Is the malodor associated with the diet
temporarily, or does it develop into a chronic problem?
Most subjects benefited from treatment and noticed
significantly fresher breath. Results showed that control
groups also experienced fresher breath, which was
most likely attributed to the increased awareness of the
condition, which led to a more rigorous dental hygiene
regimen.
LCOM is not likely caused by the passage of dietary
proteins through the mouth, as there are not sufficient
enzymes to degrade proteins to the peptides for use by
odor-causing bacteria. Rather, it is theorized that high-
protein diets increase the levels of peptides and amino
acids in the serum, which increases saliva. Although not
yet documented in humans, high protein diets increase the
levels of urea in the saliva of animals. If there are increased
peptides in the saliva, they will be readily available for the
odor causing bacteria to use them. In order for a low carb
diet to be responsible for oral malodor, the body would
experience an increase in serum peptide and amino acid
levels.
Low carb diets favor loss of fat, but water may account
for some of the initial rapid weight loss. This causes
dry mouth that can contribute to bad breath. During
prolonged fasting or adherence to a strict low carb diet,
the metabolism shifts toward lipid breakdown as the
energy source, resulting in ketone bodies in the liver.
Clinically, ketone body production indicates that lipid
metabolism has been accelerated, and the ketone bodies
serve as alternative fuel for tissues to spare carbohydrate
and protein, and ketosis suppresses appetite to help keep
weight off.
Brushing, tongue scraping and rinsing as part of the
BreathRx® treatment kit proved to be beneficial to those
subjects who experienced LCOM, as well as chronic OM.
Saliva contains many nutrients that can be fermented to
VSCs and other noxious compounds, particularly if the
subjects are on a high-protein diet. When the saliva settles
in the crevices on the tongue and around the teeth for
extended periods, OM can occur. The treatment kit used
xxx • RDH/September 2005
in the study allowed for the mechanical removal of settled
saliva, as well as rinsing and expelling. During the study,
some people did not experience improved breath. This
may be the result of chronic halitosis that is characteristic
of systemic diseases such as diabetes mellitus, chronic renal
failure, anaerobic infections, acid reflux and xerostomia, as
well as subject non-compliance.
Results from the study show that beneficial results were
attained with all groups under treatment in a relatively
short time with the use of the breath management starter
kit, BreathRx.
The authors are affiliated with University Health Resources
Group, Inc., in Culver City, Calif. The corresponding author
is Sushma Nachnani, PhD, and she can be contacted at
sushman@worldnet.att.net.
References
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Nachnani S, El-Maaytah M.
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intraoral volatile sulphur compounds (VSC). Int Dent J. 2003;53(4):237-42.
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chemosensation. J Periodontol 1992; 63 (9): 790-6.
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7. Touyz LZ. Oral Malodor--a review. J Can Dent Assoc. 1993; (7): 607-10.
8. Rosenberg M, Editor. Bad Breath: research perspectives. Ramot Pub. Tel Aviv, 1995.
9. Tonzetich J. Production and origin of oral malodor: a review of mechanisms and methods of
analysis. J Periodontol, 1977;28:13-20.
10. Yaegaki K, Sanada K. Biochemical and clinical factors influencing oral malodor in periodontal
patients. J Periodontol, 1992; 63: 783-89.
11. Clark G, Nachnani S, Messadi D, CDA Journal 1997;25:2.
12. Waler S. On the transformation of sulfur-containing amino acids and peptides to volatile
sulfur compounds (VSC) in the human mouth. Eur J Oral Sci. 1997;105 (5 pt 2): 534-7.
13. Yaegaki K, Sanada K.: Volatile sulfur compounds in mouth air from clinically healthy subjects
and patients with periodontal disease. J Periodont Res 1992; 27:223-238.
14. Rosenberg M, Septon I, Eli I, Bar-Ness A, Gelenter, I Bremer, S Gabbay. Halitosis
measurement by an industrial sulfide monitor. J Periodontol. 1991;62:487-489.
15. Rosenberg M, Kulkarni GV, Bosy A, McCulloch CAG: Reproducibility and sensitivity of oral
malodor measurements with a portable sulfide monitor. J Dent Res 1991; 11:1436-1440.
16. Spielman AL, Bivona P, Rifkin BR. Halitosis: A common oral problem. N.Y. State Dent J
1996;63(10): 36-42.
17. Nachnani S, The effects of oral rinses on halitosis. CDA Journal,1997;25.
18. Westman EC, Yancy WS, Edman JS, Tomlin KF, Perkins CE. Effect of a 6-month adherence
to a very low carbohydrate diet program. Am J Med, 2002; 113:30-36.
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diets. Cleve Clin J Med, 2001; 68:761-774.
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 Breath Management
Editor’s Note: The following contains more information about
the study conducted prior to the writing of the preceding
article on oral malodor and “low-carb” diet plans.

Methods and materials

For this random study, 54 people were enrolled in two categories:
groups 1and 2 received treatment, and groups 3 and 4 were the control
groups. Group 1 consisted of subjects with oral malodor (OM) who were
not on low-carb diets. Group 2 consisted of subjects with LCOM. Both
were treated with a breath care management starter kit called BreathRx
that included toothpaste, tongue spray and scraper, and mouth rinse.
They were told to use the products in three steps. First, subjects brushed
with the toothpaste. Second, they sprayed the back of their tongues and
immediately followed with the tongue scraper. Third, they swished with
the mouth rinse for 30 seconds. They were instructed to use the products
twice a day for six weeks.
The experimental procedure included a screening process, clinical
examinations, and OM diagnostic parameters. Each person signed an
informed consent statement, and completed a health and dental hygiene
habit questionnaire. The dental hygiene habit questionnaire asked the
participants to self-assess OM under 12 conditions, including physical,
mental, and temporal circumstances.
Figure 1 Subjects were asked to answer in the positive or the negative Final eligibility for the study was determined by several criteria.
in response to questions on regular dental hygiene maintenance. Data Subjects were screened for good health, at least 18 years of age,
presented here represents the number of individuals who performed willingness to comply with protocol procedures, an OJ score of at least
dental care as a percentage of the total group. A. Bar graphs
three on a five-point scale, and a minimum of 16 natural teeth including
representing individuals receiving treatment as compared to the control
four molars. Individuals underwent oral soft tissue assessment and were
group. B. Bar graphs representing individuals on low-carb diets with oral
malodor as compared to the control group. disqualified if they met any of the exclusion criteria. These included
gross oral pathoses, orthodontic devices, dentures, systemic diseases,
concomitant drug therapy, pregnant or lactating, periodontal disease or
gross oral hygiene neglect, smoker, prophylactic antibiotic coverage for
routine dental therapy, or using systemic antibiotics immediately before
the study.
The subjects were instructed not to brush, rinse, eat or drink anything
except water, use dental products or wear fragrances. This ensured
stable oral odor during baseline and follow-up evaluations. The OM
parameters included organoleptic judges (OJs), the Halimeter®, and a
spoon test. For the organoleptic assessment test, two trained OJs made
Figure 2 Subjects were asked to self-asses the level of oral malodor independent evaluations on each subject. OJs were trained based on an
experienced under 3 different conditions using a scale of 0-5, 5 being OM training program designed by University Health Resources Group,
of highest intensity. Inc. and the University of Minnesota, Clinical Dental Research Center.
Each subject was instructed to close his mouth for two minutes without
swallowing. The subject then breathed out gently, ten centimeters from
the OJ’s nose, for the assessment according to the five-point OM scale: 1
- None; 2 - Faint; 3 - Moderate; 4 - Strong; 5 - Extremely strong.
The balanced Halimeter instrument was used for all measurements to
Table 1
Average characterization of individuals in each treatment group
Characteristic Treatment Control Treatment-LCOM Control-LCOM
Sex (male/female) 63%/37% 66.7%/33.3% 50%/50% 58%/42%
Weight (lbs.) 174 147.6 170.75 192.8
Height (inches) 5’7.5” 5’7” 5’6” 5’7.5”
Age (years) 52 38 46 37

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 Breath Management
assess the mouth, throat and posterior tongue regions. For the Halimeter
reading in the mouth, one end of a drinking straw was attached to the
instrument, and the other end was inserted approximately one-half inch
into the subject’s mouth, with the lips gently touching the straw. The
subject was instructed to breathe through the straw until a volatile sulfur
compounds (VSC) reading was reached and recorded.
For the spoon test, the back of the tongue was scraped with a plastic
spoon. An OJ assessed the odor after five seconds, 10 centimeters from
his or her nose, according to the five-point scale.

Results and statistical analysis

Figure 3. Shaded areas in the pie charts represent subjects who
reported on eating habits and diet.
Figure 4 Organoleptic measurements were made at the initial
assessment and at the 6-week follow-up period. The assessments were
rated on a scale of 0-5, with 5 being equal to maximum intensity.
Figure 5. Halimeter measurements were made at the initial assessment
and at the 6-week follow-up periods. All assessments were performed
using one machine for the duration of the study.
There were more males in all groups. However, there was a higher
number of females in the LCOM groups, supporting the idea that women
are more prone to dieting than men (Table 1). All groups had consistent
age, height, and weight and brushed their teeth regularly, but did not
practice consistent use of a tongue cleaner. This suggests that tongue
cleaning is an important issue to address when investigating the causes
of OM (Figure 1). Individuals reporting regular dental check-ups and
regular flossing ranged between 30 and 40 percent in all groups, with
a higher percentage of individuals rinsing in the OM treatment groups
(70 percent) than the LCOM treatment groups (20 percent). This is
reasonable considering that OM is a chronic condition, whereas LCOM
is transitory, correlating to why the LCOM groups do not have mouth-
rinsing regimens. Groups with LCOM had a lower self-assessment of
their level of OM throughout the day, suggesting that OM is less severe
in transitory cases compared to chronic cases (Figure 2). LCOM groups
consumed more dairy and vitamins. For all groups, about half of the
subjects reported consuming alcohol on a regular basis, and about
three-quarters reported consuming spicy foods regularly (Figure 3).
Means were compared using one-way analysis of variable methods.
The non-parametric distributions/medians were compared using the
Kruskal-Wallis (KW) test based on ranks. The KW test is the same
as the Wilcoxon rank sum test. Since the organoleptic score is only
semi-continuous, the non-parametric KW p-value is more appropriate.
Generally, the nonparametric KW approach is more conservative
because it does not assume a Gaussian (normal) distribution.
For OJ results (Figure 4), the statistically significant difference
between the OM and control groups was -2.800 (p< 0.001), and the
mean difference between the LCOM and control groups was -2.673 (p<
0.001) (Table 2). Similar results (p= 0.000) were obtained using the
non-parametric KW test for both groups. For the Halimeter( test (Figure
5), the mean difference between the OM and control groups was -
47.920 (p=0.047). The difference between the low carb and control
groups was -16.190 (p= 0.500). Similar results were obtained with the
KW test. For the spoon test, mean difference for the OM group and the
control group was -2.140 (p <0.001). Mean difference for the low carb
and control group was -1.5714 (p=0.0012).

Table 2
Mean and P Values of Breathrx and LCOM Groups
Group VS Group Mean P value
Group 1 Breathrx Group3 control -2.8 <.001
Group 2 LCOM Group 4 LCOM- control -2.6 <0.001

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