December 26, 2020
One of the most common complains that patients present with is bad breath coming from the mouth. This condition is called halitosis. It can occur due to multiple reasons with the most common being poor oral health maintenance. The treatment ranges from thorough cleansing of the teeth (done by the dentist), using appropriate mouthwashes and toothbrushes, etc. However, many times a patient complains of bad breath but upon examination, no malodor is detected. This is called halitophobia.
Halitus is a Latin word meaning 'breath.' The word phobia means 'fear.' Halitophobia is thus a condition where patients feel that they are suffering from bad breath but so is not the case. It is more of a psychological condition than one with a dental origin. Halitophobia involves a certain level of obsession and compulsion that a patient develops with his or her breath. Despite this, halitophobia does not fall under the list of psychiatric conditions. It involves a range of features that might be associated with the patient. These include social anxiety, delusional disorder and olfactory reference syndrome. Social anxiety makes the patient concerned about his or her breath time and again. Delusions of having a bad breath has given halitophobia a synonym of delusional halitosis. Finally, olfactory reference syndrome is when not only the breath from the mouth, but the entire body odour is likely to be affected. Nearly 75% of cases of olfactory reference syndrome are associated with halitophobia.
The diagnosis of halitophobia is purely based on the symptoms that a patient presents with. A patient might give a history of excessive toothbrushing (prolonged time), frequent use of mouthwash, chewing gums and always carrying a perfume or deodrant in the pocket. They might maintain a distance from social communications and speak in a muffled voice. The patient avoids eating foods like onions, garlic, etc. that can emit strong odours from the mouth. Anxiety and depression of the patient can be assessed to know the severity of the condition.
Halitophobia's psychological factor triggers by certain factors. These include having a dry mouth, thirst and hunger that ignite distressing thoughts in the mind. Further triggers include a break in normal conversation when the patient thinks that the interruption occured due to the sniffing or anxious reactions of the person the patient is conversing with. Moreover, conversations that include topics related to breath and halitosis might as well make the patient nervous.
Treating halitophobia involves targeting the thought process of the patient. This is done through psychoeducation, cognitive behaviour therapy (CBT) and exposure with response prevention therapy (ERP). Let us have a look at each of these.
Psychoeducation: Psychoeducation is a framework of the treatment protocol that is explained to the patient. He or she is explained the importance behind psychologically combating halitophobia and the various treatment models can help in doing the same. It involves one-on-one conversation with the therapist who will make the patient realize about their unwanted fears.
Cognitive Behavioral Therapy (CBT): Cognitive means the process that leads to a perception or sensation. CBT is a treatment plan that helps in cognitive, physiological and behavioural enhancement of the patient. The patient is asked to jot down all the instances when he or she perceives the fear of bad breath. These instances are discussed with the therapist. In each session the therapist records the anxiety and depression scores. In the subsequent therapies the scores of anxiety and depression for each session are evaluated. The therapist would ask the patient to avoid any safety measures (maintaining distance while conversation, chewing gums, etc) whenever they find themselves in a situation of halitophobia. This would help them gain confidence in various situations.
Exposure with Response Prevention (ERP): This form of therapy is closely related to CBT. It involves not only forgetting past measures that one takes to combat individual situations but also learn the new ways through which the patient gets habituated to the fear-inducing situations. It is important to ensure that in each of the sessions the therapist takes a feedback from the patient regarding the ERP and CBT procedures.
There are times when patients may not be comfortable with ERP or CBT. In these cases certain drugs like fluvoxamine and risperidone can be prescribed. These drugs are Selective Serotonin Reuptake Inhibitor (SSRI). In other words, these are anti-depressants and often called "feel good hormones." In phobic patients, these drugs help by countering the emotion of fear. Even though they are likely to show a faster effect than CBT and ERP, they might show side-effects like dry mouth, constipation and blurry vision.
The end of the treatment is guaranteed by an air bag test. The patient is asked to exhale with their mouth in an odour-free bag. Once the bag is inflated completely, the air from the bag is squeezed out gradually in front of the patient. If the halitophobic patient responds normally, then it means he or she is acquainted with his or her breath.
Halitophobia needs to be addressed as soon as possible. A dentist can better the oral health status and reassure the patient that their oral hygiene is not the reason behind their bad breath. The main treatment of psychology is done by a therapist. The end of the patient's treatment is when they reach the optimal depression and anxiety level.