oral malodor and low carb article

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T he low carb diet craze has brought with it an unexpected sideeffect — bad breath. Called low carb oral malodor (LCOM), it iscaused by the breakdown of food that produces volatile organic

compounds (VOCs) and from bacteria on oral tissue. To nd solutions,a group of colleagues from the University Health Resources Group,Inc. and the University of Minnesota’s Clinical Dental Research Centerconducted a study to evaluate the effectiveness of a breath care systemon people with LCOM.

The supermarket shelves are full of products for people who havebeen swept up in the low carb diet craze. Has sacricing the morningbagel been worth it? The Atkins and similar diets require eating highamounts of protein and fat, which risks nutritional decits and otherside effects. These diets have been criticized by those who believe thatthe most efcient way to lose weight is through a well-balanced diet lowin 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-carbdiet. 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 hasbeen a resurgence of low carb dieting, with little scientic evidence tosupport the safety of the diets. Since 1980, the number of overweightU.S. adults age 20 and older increased from 46 to 65 percent. Americansspend $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 embarrassingcondition may be experienced sporadically and at different degreesdepending on how strictly the diet is followed, previous dispositionfor the condition, and oral hygiene. High protein diets cause more VOCs, and when carbs are decreased, the body turns to ketones thatare produced by burning fat. Ketoses build up, and VOCs are expelledthrough the breath, which produces an offensive odor.

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

The Effectiveness ofBreath Careon Low-Carb Oral Malodor

The low carb craze also indicates more emphasis on oral home care.




Breath Management

How would a high-protein, low carb diet contributeto oral malodor? Is the malodor associated with the diettemporarily, or does it develop into a chronic problem? Most subjects beneted from treatment and noticedsignicantly fresher breath. Results showed that controlgroups also experienced fresher breath, which wasmost likely attributed to the increased awareness of thecondition, which led to a more rigorous dental hygieneregimen.

LCOM is not likely caused by the passage of dietary proteins through the mouth, as there are not sufcientenzymes 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 aminoacids in the serum, which increases saliva. Although not yet documented in humans, high protein diets increase thelevels of urea in the saliva of animals. If there are increasedpeptides in the saliva, they will be readily available for theodor causing bacteria to use them. In order for a low carbdiet to be responsible for oral malodor, the body wouldexperience an increase in serum peptide and amino acidlevels.

Low carb diets favor loss of fat, but water may accountfor some of the initial rapid weight loss. This causesdry mouth that can contribute to bad breath. Duringprolonged fasting or adherence to a strict low carb diet,the metabolism shifts toward lipid breakdown as theenergy source, resulting in ketone bodies in the liver.Clinically, ketone body production indicates that lipidmetabolism has been accelerated, and the ketone bodiesserve as alternative fuel for tissues to spare carbohydrateand protein, and ketosis suppresses appetite to help keep weight off.

Brushing, tongue scraping and rinsing as part of theBreathRx® treatment kit proved to be benecial to thosesubjects who experienced LCOM, as well as chronic OM.Saliva contains many nutrients that can be fermented to VSCs and other noxious compounds, particularly if thesubjects are on a high-protein diet. When the saliva settlesin the crevices on the tongue and around the teeth forextended periods, OM can occur. The treatment kit used

in the study allowed for the mechanical removal of settledsaliva, as well as rinsing and expelling. During the study,some people did not experience improved breath. Thismay be the result of chronic halitosis that is characteristicof systemic diseases such as diabetes mellitus, chronic renalfailure, anaerobic infections, acid reux and xerostomia, as well as subject non-compliance.

Results from the study show that benecial results wereattained with all groups under treatment in a relatively short time with the use of the breath management starterkit, BreathRx.

The authors are afliated with University Health Resources roup, Inc., in Culver City, Calif. The corresponding author

s Sushma Nachnani, PhD, and she can be contacted at [email protected].

References

1. Greenman J, Dufeld J, Spencer P, Rosenberg M, Corry D, Saad S, Lenton P, Majerus G,Nachnani S, El-Maaytah M.

Study on the organoleptic intensity scale for measuring oral malodor. J Dent Res. 2004;83(1):81-5.

2. Young A, Jonski G, Rolla G. Combined effect of zinc ions and cationic antibacterial agents onintraoral volatile sulphur compounds (VSC). Int Dent J. 2003;53(4):237-42.

3. Nachnani S. Oral Malodor: A Brief Review CDHA Journal 1999; 14 (2): 13-15.4. Survey conducted at ADA reveals interesting trends. Dent Econ 1995;6.5. Preti G, Clark L, Cowart BJ et al. Non oral etiologies of oral malodor and altered

hemosensation. J Periodontol 1992; 63 (9): 790-6.6. Rosenberg M. Clinical assessment of bad breath: current concepts J Am Dent Assoc. 1996;

127(4): 475-82.7. Touyz LZ. Oral Malodor--a review. J Can Dent Assoc. 1993; (7): 607-10.8. Rosenberg M, Ed itor. 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

nalysis. J Periodontol, 1977;28:13-20.10. Yaegaki K, Sanada K. Biochemical and clinical factors inuencing oral malodor in periodontalpatients. 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

ulfur 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

nd 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

easurement by an industrial sulde monitor. J Periodontol. 1991;62:487-489.15. Rosenberg M, Kulkarni GV, Bosy A, McCulloch CAG: Reproducibility and sensitivity of oral

alodor measurements with a portable sulde 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 d iet program. Am J Med, 2002; 113:30-36.19. Blackburn GL, JC, Morreale S. Physician’s guide to popular low-carbohydrate weight-loss

iets. Cleve Clin J Med, 2001; 68:761-774.

If there are increased peptides in the saliva, they will be readily

available for the odor causing bacteria to use them. In order for alow carb diet to be responsible for oral malodor, the body wouldexperience an increase in serum peptide and amino acid levels.



Breath Management


assess the mouth, throat and posterior tongue regions. For the Halimeterreading in the mouth, one end of a drinking straw was attached to theinstrument, and the other end was inserted approximately one-half inchinto the subject’s mouth, with the lips gently touching the straw. Thesubject was instructed to breathe through the straw until a volatile sulfurompounds (VSC) reading was reached and recorded.

For the spoon test, the back of the tongue was scraped with a plasticspoon. An OJ assessed the odor after ve seconds, 10 centimeters fromhis or her nose, according to the ve-point scale.

Results and statistical analysisThere were more males in all groups. However, there was a higher

number of females in the LCOM groups, supporting the idea that womenare more prone to dieting than men (Table 1). All groups had consistentage, height, and weight and brushed their teeth regularly, but did notpractice consistent use of a tongue cleaner. This suggests that tongueleaning is an important issue to address when investigating the causes

of OM (Figure 1). Individuals reporting regular dental check-ups and

regular ossing ranged between 30 and 40 percent in all groups, witha higher percentage of individuals rinsing in the OM treatment groups70 percent) than the LCOM treatment groups (20 percent). This is

reasonable considering that OM is a chronic condition, whereas LCOMis transitory, correlating to why the LCOM groups do not have mouth-rinsing regimens. Groups with LCOM had a lower self-assessment ofheir level of OM throughout the day, suggesting that OM is less severein transitory cases compared to chronic cases (Figure 2). LCOM groupsonsumed more dairy and vitamins. For all groups, about half of the

subjects reported consuming alcohol on a regular basis, and abouthree-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 theKruskal-Wallis (KW) test based on ranks. The KW test is the sameas the Wilcoxon rank sum test. Since the organoleptic score is onlysemi-continuous, the non-parametric KW p-value is more appropriate.Generally, the nonparametric KW approach is more conservativebecause it does not assume a Gaussian (normal) distribution.

For OJ results (Figure 4), the statistically signicant differencebetween the OM and control groups was -2.800 (p< 0.001), and themean difference between the LCOM and control groups was -2.673 (p<0.001) (Table 2). Similar results (p= 0.000) were obtained using thenon-parametric KW test for both groups. For the Halimeter( test (Figure

), the mean difference between the OM and control groups was -47.920 (p=0.047). The difference between the low carb and control

roups was -16.190 (p= 0.500). Similar results were obtained with theKW test. For the spoon test, mean difference for the OM group and theontrol group was -2.140 (p <0.001). Mean difference for the low carb

and control group was -1.5714 (p=0.0012).

Figure 3. Shaded areas in the pie charts represent subjects whoreported on eating habits and diet.

Figure 4 Organoleptic measurements were made at the initialassessment and at the 6-week follow-u eriod. The assessments wererated 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-u eriods. All assessments were erformedusing one machine for the duration of the study.

Ta e 2Mean and P Values of Breathrx and LCOM GroupsGroup VS Group Mean P valueGroup 1 Breathrx Group3 control -2.8 <.001Group 2 LCOM Group 4 LCOM- control -2.6 <0.001

oral malodor and low carb article

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