‘Say Ahhh’: What do dentists, general medical practitioners and community pharmacists do about halitosis?

Abstract

Introduction: Halitosis is common and can have significant impact on quality of life. Current literature recommends multidisciplinary approaches. This paper explored the practice, knowledge and views of Australian general dental practitioners (GDPs), general medical practitioners (GMPs) and community pharmacists (CPs) on halitosis and interprofessional collaboration to manage halitosis. Methods: A mixed methods approach was used. Recruited GMPs, GDPs and CPs completed an online survey. A small number then participated in semi-structured follow-up interviews. Results: Sixty-six GDPs, 27 GMPs and 114 CPs completed the survey. Five from each group were interviewed. Sixty-eight percent of GMPs and 46% of CPs considered halitosis management part of their role despite the majority feeling that they had insufficient oral health training. Sixty-eight percent of GMPs, 86% of GDPs and 79% of CPs thought interprofessional halitosis care would benefit patients. Most participants admitted to feeling uneasy when starting conversations with their patients about halitosis. Most GDPs did not monitor their patients’ progress, and GMPs seemed comfortable in managing halitosis only when it had a systemic cause. Critically, the role of CPs in halitosis management was poorly understood. Conclusion: Most GDPs, GMPs and CPs find it challenging to manage patients with halitosis and are interested in working together. Improving health professionals’ knowledge and training will contribute to comprehensive interprofessional halitosis management.

INTRODUCTION

Halitosis or bad breath reportedly affects 6%–50% of the global population1., 2.. Associated social anxiety, low self-esteem, insecurity and isolation can have a significant, negative impact on quality of life1., 2..

Halitosis has many causes, and aetiologies can be broadly divided into two categories: genuine halitosis; and pseudo-halitosis2., 3., 4.. Genuine halitosis is detectable bad breath most commonly with an intra-oral cause, such as tongue coating, periodontitis and tooth decay; or less commonly with an extra-oral cause such as tonsillitis, gastrointestinal tract infections, diabetes, renal dysfunction and (in more sinister cases) cancers1., 2., 3., 4., 5., 6., 7., 8.. Pseudo-halitosis is rarer, has no detectable bad breath and is usually associated with a psychological origin2., 4., 5..

Differential diagnosis is critical to management, particularly of pseudo-halitosis in which patients are often misdiagnosed and receive treatments more suited for genuine halitosis, including tonsillectomy, medications to reduce stomach acid, and ear, nose and throat (ENT) surgery1., 9., 10., 11., 12.. Furthermore, extra-oral halitosis may be a marker for underlying systemic conditions that require timely treatments².

Current literature recommends multidisciplinary approaches to provide accurate diagnosis and follow-up management of halitosis1., 2., 4., 12.. Established multidisciplinary clinics, located predominantly in Europe, have been found to reduce time, frustration and risk of unwarranted treatments for patients1., 6., 10., 11., 12.. Despite the benefits, such approaches have not yet translated into practice in Australia.

The ‘Say Ahhh’ project is supported by the eviDent Foundation (a dental practice-based research network of the Australian Dental Association Victorian Branch and the Oral Health Cooperative Research Centre) and the Victorian Research Network (VicReN; a primary care practice-based research network of The University of Melbourne Department of General Practice). The overall project aims to improve halitosis management through collaborative care provided by Australian general dental practitioners (GDPs), general medical practitioners (GMPs) and community pharmacists (CPs). GDPs were chosen because most halitosis has intra-oral origins2., 3., 4.. However, studies also suggest that patients, particularly those in some rural and remote communities, are equally likely to consult the more affordable and accessible health professionals 1., 13.. Such patients often consult GMPs and CPs for oral health issues, such as bad breath, which may be perceived as trivial1., 14..

The ‘Say Ahhh’ project has three phases. Phase 1 investigated the practice and experiences of GDPs, GMPs and CPs in halitosis management and explored their attitudes towards interprofessional collaboration. Phase 2 focussed on exploring patients’ and clients’ perspectives on halitosis management. Phase 3 will use the information collected to inform a potential interprofessional care model to improve halitosis management.

This paper presents the findings of Phase 1.

AIMS

To explore the practice, knowledge and views of Australian GDPs, GMPs and CPs regarding halitosis and interprofessional collaboration to manage halitosis. Findings will inform the development of strategies to improve halitosis management through enhanced interprofessional collaborative care.

METHODS

Ethical considerations

This minimal-risk project was independently reviewed and approved by The University of Melbourne Human Research Ethics Committee (UoM HREC). The authors declare that the research was conducted in full accordance with the World Medical Association Declaration of Helsinki.

The plain language statement in the online surveys clearly informed participants that completion and submission of the online surveys would imply consent. Written consent was subsequently obtained from survey participants who expressed interest to be considered for follow-up interviews. This consent procedure was approved by UoM HREC.

Research design

A mixed methods study design was used.

Quantitative data: online surveys

Three separate surveys were hosted on the online platform SurveyMonkey®, one for each of the three professional groups: GDPs, GMPs and CPs. The three anonymous surveys had between 22 and 25 questions each and were similar in format: six questions on demographics; four questions on professional education and training; 10–13 questions on current practice and attitudes about halitosis management; and two conclusion questions (Table 1). The questions were developed based on findings from a review of the literature and have yet to be validated. Each survey took approximately 10 minutes to complete.

Table 1.

Survey questions

GDP survey questions

Demographics

1. Your gender is: Male/Female

2. Your age is: under 30/31–40/41–50/51–60/over 60/If other, please specify

3. Your current primary workplace where you practise as a dentist is: public/private/other

4. Your current primary workplace is located in a community that is: metropolitan/rural/remote

5. The approximate number of hours you currently practise as a dentist in a week is: 0–10/11–20/21–30/31–40/more than 40

6. The number of years you have been practising as a dentist is: under 5/6–10/11–15/16–20/21–25/25–30/over 30

Education and training

7. Your dental training was received in: Australia/overseas

8. In your view, did you receive appropriate education and training in your dentistry course regarding non-oral causes of oral diseases? yes/no/not sure

9. How would you typically find information on oral health? You may select multiple options. internet/professional magazines/journals/your colleagues/other/If other, please indicate where

10. Would you welcome the opportunity for continuing education and training in oral diseases resulting from non-oral causes? yes/no/not sure

Current practice and attitudes

11. On average, how many patients would you see in a week who either present with or complain of bad breath? 0/1–10/11–20/21–30/31–40/more than 40

12. How comfortable are you to broach the subject of bad breath with a patient who has come to see you about other issues, who also has malodourous breath? very comfortable/comfortable/not comfortable/not comfortable at all

13. Are you aware of the following oral behaviours and/or conditions that could trigger halitosis? poor oral hygiene/eating certain foods/drinking alcohol/smoking/gingivitis/periodontitis/tooth decay/food trapping/dental infection (yes, no, not sure)

14. Are you aware of the following non-oral behaviours and/or conditions that could trigger halitosis? stress and anxiety/psychiatric disorders/lack of sleep/certain medications/respiratory tract infections/gastrointestinal tract infections/metabolic disorders such as diabetes/renal dysfunction/liver dysfunction (yes, no, not sure)

15. Have you recommended the following to patients with bad breath? drink plenty of water/brushing/flossing/mouthwashes/lozenges/other/If other, please specify (yes, no, can’t remember)

16. How often do you refer patients with halitosis to a pharmacist for the management of halitosis? always/often/occasionally/rarely/never

17. How often do you refer patients to a GP for the management of halitosis? always/often/occasionally/rarely/never

18. How often do you refer patients to other dental health professionals for the management of halitosis? always/often/occasionally/rarely/never

19. In your view, would better collaboration between GPs, dentists and community pharmacists benefit patients with halitosis? strongly agree/agree/neutral/disagree/strongly disagree

20. What are some suggestions you have to improve the management of patients with halitosis?

Conclusion of survey

21. Thank you very much for participating! Would you welcome the opportunity to be considered for an interviewed at a later stage to further explore your experience of managing patients with halitosis? yes/no/If yes, please provide your contact name, and email/postal address

22. Would you like to receive a brief report about the findings from this study when they are available? yes/no

GMP survey questions

Demographics

1. Your gender is: Male/Female

2. Your age is: under 30/31–40/41–50/51–60/over 60/If other, please specify

3. Your current primary workplace where you practise as a GP is: public/private/other

4. Your current primary workplace is located in a community that is: metropolitan/rural/remote

5. The approximate number of hours you currently practise as a GP in a week is: 0–10/11–20/21–30/31–40/more than 40

6. The number of years you have been practising as a GP is: under 5/6–10/11–15/16–20/21–25/25–30/over 30

Education and Training

7. Your medical training was received in: Australia/overseas

8. In your view, did you find the oral health and education components of your medical course thorough enough? yes/no/not sure

9. How would you typically find information on oral health? You may select multiple options.

internet/professional magazines/journals/your colleagues/other/If other, please indicate where

10. Would you welcome the opportunity for continuing education and training in oral health? yes/no/not sure

Current practice and attitudes

11. How confident are you in identifying the signs and symptoms associated with: halitosis/gingivitis/periodontitis/oral disease in general? (very confident, confident, not confident, not confident at all)

12. On average, how many patients would you see in a week who either present with or complain of bad breath? 0/1–10/11–20/21–30/31–40/more than 40

13. How comfortable are you to broach the subject of bad breath with a patient who has come to see you about other issues, who also has malodourous breath? very comfortable/comfortable/not comfortable/not comfortable at all

14. Are you aware of the following oral behaviours and/or conditions that could trigger halitosis? poor oral hygiene/eating certain foods/drinking alcohol/smoking/gingivitis/periodontitis/tooth decay/food trapping/dental infection (yes, no, not sure)

15. Are you aware of the following non-oral behaviours and/or conditions that could trigger halitosis? stress and anxiety/psychiatric disorders/lack of sleep/certain medications/respiratory tract infections/gastrointestinal tract infections/metabolic disorders such as diabetes/renal dysfunction/liver dysfunction (yes, no, not sure)

16. Have you recommended the following to patients with bad breath? drink plenty of water/brushing/flossing/mouthwashes/lozenges/other/If other, please specify (yes, no, can’t remember)

17. How often do you refer patients with halitosis to a pharmacist for the management of halitosis? always/often/occasionally/rarely/never

18. How often do you refer patients to a dentist for the management of halitosis? always/often/occasionally/rarely/never

19. How often do you conduct more investigations on patients with suspected non-oral causes of halitosis? always/often/occasionally/rarely/never

20. How often do you refer to specialists if you suspect non-oral causes of halitosis? always/often/occasionally/rarely/never/If referring, please specify to whom

21. In your view, is it within your role as a GP to manage patients with halitosis? yes/no/not sure

22. In your view, would better collaboration between GPs, dentists and community pharmacists benefit patients with halitosis? strongly agree/agree/neutral/disagree/strongly disagree

23. What are some suggestions you have to improve the management of patients with halitosis?

Conclusion of survey

24. Thank you very much for participating! Would you welcome the opportunity to be considered for an interviewed at a later stage to further explore your experience of managing patients with halitosis? yes/no/If yes, please provide your contact name, and email/postal address

25. Would you like to receive a brief report about the findings from this study when they are available? yes/no

CP survey questions

Demographics

1. Your gender is: Male/Female

2. Your age is: under 30/31–40/41–50/51–60/over 60/If other, please specify

3. Your current primary workplace where you practise as a pharmacist is: public/private/other

4. Your current primary workplace is located in a community that is: metropolitan/rural/remote

5. The approximate number of hours you currently practise as a pharmacist in a week is: 0–10/11–20/21–30/31–40/more than 40

6. The number of years you have been practising as a pharmacist is: under 5/6–10/11–15/16–20/21–25/25–30/over 30

Education and Training

7. Your pharmaceutical training was received in: Australia/overseas

8. In your view, did you find the oral health and education components of your pharmaceutical course thorough enough? yes/no/not sure

9. How would you typically find information on oral health? You may select multiple options.

internet/professional magazines/journals/your colleagues/other/If other, please indicate where

10. Would you welcome the opportunity for continuing education and training in oral health? yes/no/not sure

Current practice and attitudes

11. How confident are you in identifying the signs and symptoms associated with: halitosis/gingivitis/periodontitis/oral disease in general? (very confident, confident, not confident, not confident at all)

12. On average, how many patients would you see in a week who either present with or complain of bad breath? 0/1–10/11–20/21–30/31–40/more than 40

13. How comfortable are you to broach the subject of bad breath with a patient who has come to see you about other issues, who also has malodourous breath? very comfortable/comfortable/not comfortable/not comfortable at all

14. Are you aware of the following oral behaviours and/or conditions that could trigger halitosis? poor oral hygiene/eating certain foods/drinking alcohol/smoking/gingivitis/periodontitis/tooth decay/food trapping/dental infection (yes, no, not sure)

15. Are you aware of the following non-oral behaviours and/or conditions that could trigger halitosis? stress and anxiety/psychiatric disorders/lack of sleep/certain medications/respiratory tract infections/gastrointestinal tract infections/metabolic disorders such as diabetes/renal dysfunction/liver dysfunction (yes, no, not sure)

16. Have you recommended the following to patients with bad breath? drink plenty of water/brushing/flossing/mouthwashes/lozenges/other/If other, please specify (yes, no, can’t remember)

17. How often do you refer patients with halitosis to a GP for the management of halitosis? always/often/occasionally/rarely/never

18. How often do you refer patients to a dentist for the management of halitosis? always/often/occasionally/rarely/never/

19. Would you refer patients with halitosis to any other health professionals? yes/no/If yes, please specify who

20. In your view, is it within your role as a pharmacist to manage patients with halitosis? yes/no/not sure

21. In your view, would better collaboration between GPs, dentists and community pharmacists benefit patients with halitosis? strongly agree/agree/neutral/disagree/strongly disagree

22. What are some suggestions you have to improve the management of patients with halitosis?

Conclusion of survey

23. Thank you very much for participating! Would you welcome the opportunity to be considered for an interviewed at a later stage to further explore your experience of managing patients with halitosis? yes/no/If yes, please provide your contact name, and email/postal address

24. Would you like to receive a brief report about the findings from this study when they are available? yes/no

Qualitative data: semi-structured follow-up interviews

Survey participants were then selected to participate further in individual semi-structured interviews to explore their survey responses in more detail. The face-to-face or over-the-phone interviews were also similar in structure for the three groups of participants. They explored participants’ views and attitudes about halitosis management, particularly around interprofessional collaboration. The duration of the interviews was 20–30 minutes each.

Recruitment

Participants were recruited purposively via the Australian Dental Association Victorian Branch, the eviDent Foundation, the Victorian Research Network (VicReN), the Pharmacy Guild of Australia (Vic) and the personal networks of the researchers (including via professional conferences and closed professional Facebook groups). No sample size calculation or selection matrix was used to select participants for the survey as the objective of the survey was to elicit information broadly to provide descriptive statistics to describe the context. The surveys were open for completion for 5.5 months because of low response rates from GDPs and GMPs.

At the end of the survey, participants were asked to indicate interest and provide contact details to participate in individual semi-structured interviews. A selection matrix, based on age, gender, place of practice and years of professional experience, was used to select interview participants to ensure maximum variation and a broad representation of views.

Data extraction

SurveyMonkey® was used to collect data on every survey that was attempted, regardless of its status of completion. The follow-up interviews were either audio-recorded with participant permission and then transcribed or interview notes were taken if consent was not given.

Data analysis

Raw data and summary reports downloaded from SurveyMonkey® were used to produce descriptive statistics via Microsoft Excel (Microsoft Australia, Melbourne, Australia). All follow-up interview transcripts and notes were entered into NVivo, then interpreted, coded and analysed deductively for themes previously identified from reviewing the literature and inductively for new emerging themes. Initial coding of all transcripts was performed by one of the authors (CM). Another two authors (PL and ID) independently coded a sample of transcripts and the codes were cross-checked and compared. Themes were developed through an iterative process, including cross-checking through several rounds of discussion amongst the researchers to reach a consensus. Cross-checking and interpretation strategies at frequent round-table discussions by the research team ensured rigour of the qualitative analysis.

RESULTS

Survey results

Survey participants’ demographics

In total, 207 online surveys were submitted but only 189 were completed: 64 of 66 from GDPs; 24 of 27 from GMPs; and 101 of 114 from CPs. However, because of the relatively small sample size of the study, all surveys, regardless of the status of completion, were included in the analysis.

The overall sample had a larger number of male participants than female participants. Regarding GDP participants, 70% were male and 30% were female. There were a similar trend of male and female GMP participants – 59% and 41%, respectively. However, for CP participants, only 44% were male and 56% were female. The median number of years of practice was 26, 11 and 16 years for GDP, GMP and CP participants respectively. Most participants were in private practice, practised in metropolitan areas and worked part-time hours. The majority received their professional training in Australia (Table 2).

Table 2.

Survey participants’ demographics

Variable	GDPs (n = 66) (%)	GMPs (n = 27) (%)	CPs (n = 114) (%)
Gender
Male	46 (70)	16 (59)	50 (44)
Female	20 (30)	11 (41)	64 (56)
Years of practice
<5	5 (8)	6 (22)	28 (25)
6–10	9 (14)	5 (19)	14 (12)
11–15	7 (11)	4 (15)	12 (11)
16–20	5 (8)	2 (7)	6 (5)
21–25	6 (9)	3 (11)	10 (9)
26–30	7 (11)	2 (7)	11 (10)
>30	27 (41)	5 (19)	33 (29)
Practice setting
Public	15 (10)	5 (19)	34 (30)
Private	53 (80)	21 (78)	72 (63)
Practice location
Metro	55 (83)	24 (89)	76 (67)
Rural	11 (17)	3 (11)	38 (33)
Working hours (per week)
0–10	8 (12)	3 (11)	12 (11)
11–20	9 (14)	11 (41)	16 (14)
21–30	10 (15)	0 (0)	16 (14)
31–40	31 (47)	8 (30)	47 (41)
>40	8 (12)	5 (19)	23 (20)
Place of training
Australia	51 (77)	16 (59)	101 (90)
Overseas	15 (23)	11 (41)	11 (10)

CP, community pharmacist; GDP, general dental practitioner; GMP, general medical practitioner; Metro, metropolitan.

Education and source of information on oral health

More than half of GMPs (56%) and CPs (69%) reported that their training included insufficient oral health content, and most (67% and 91%, respectively) would welcome continuing education on oral health. Their most common source of information was the internet. Most CPs also obtained information from professional magazines and journals, whereas GMPs did not seem to access these resources.

Conversely, just over half (52%) of GDPs reported that they had received sufficient education on non-oral causes of oral diseases. Even so, most (96%) would welcome continuing education on the topic. They too preferred to obtain their information from journals, professional magazines, the internet and also from colleagues.

Levels of confidence with identifying oral conditions

GMP and CP participants were asked about their confidence when identifying signs and symptoms of different oral conditions. With halitosis, almost three-quarters (70%) of GMPs and more than half (56%) of CPs reported being ‘very confident’ or ‘confident’. Similarly, with gingivitis, almost three-quarters (71%) of GMPs and more than half (56%) of CPs reported being ‘very confident’ or ‘confident’. However, with periodontitis, under a half (48%) of GMPs and under a quarter (23%) of CPs reported being ‘very confident’ or ‘confident’. Overall, more GMPs (59%) than CPs (33%) were ‘very confident’ or ‘confident’ in identifying signs and symptoms of oral diseases in general.

Role in halitosis management

More than half (71%) of GDPs and (59%) CPs reported seeing 1–10 patients with halitosis every week. Despite this, only 46% of CPs reported that they felt managing patients with halitosis was within their role. This contrasted with half (50%) of GMPs reporting being consulted at all about halitosis but two-thirds (67%) reported that they felt halitosis management was within their role.

Knowledge about causes of halitosis

At least three-quarters (74%) of all three groups of participants reported being aware of oral triggers for halitosis, such as poor oral hygiene, eating certain foods, drinking alcohol, smoking, gingivitis, periodontitis, tooth decay, food trapping and dental infection. Less than two-thirds (61%) of CPs were aware that periodontitis could trigger halitosis.

Less than half (45%) of participants in all three groups reported being aware of stress and anxiety, psychiatric disorders and lack of sleep, as non-oral triggers for halitosis. At least two-thirds (68%) of participants reported being aware of other causes for halitosis, such as certain medications, respiratory tract infections, gastrointestinal tract infections and metabolic disorders. More GDPs (53%, 44%) and GMPs (70%, 67%) than CPs (17%, 25%) were aware that renal dysfunction and liver dysfunction could trigger halitosis.

Comfort in initiating conversation about halitosis with patients

Compared with the GDPs (66%), fewer GMPs (41%) and CPs (24%) reported to be ‘comfortable’ or ‘very comfortable’ in broaching the subject of halitosis with their patients.

Treatment recommendations for halitosis

The treatment most commonly recommended for halitosis, by 95% of GDPs, 85% of GMPs and 86% of CPs, was toothbrushing.

Referral practice

More GMPs (52%) than CPs (26%) reported that they would ‘always’ or ‘often’ refer their patients with halitosis to GDPs. This contrasted with fewer GDPs (9%) and CPs (7%) reporting that they would ‘often’ refer their patients with halitosis to GMPs; none reported they would ‘always’ refer. Similarly, fewer GMPs (11%) and GDPs (3%) reported that they would ‘always’ or ‘often’ refer their patients with halitosis to CPs.

Interprofessional collaboration in halitosis management

The majority of GDPs (86%), GMPs (68%) and CPs (79%) reported that they thought better collaboration between them would benefit patients with halitosis.

Interview results

Interview participants’ demographics

Twenty GDP, six GMP and 42 CP survey participants indicated interest in being interviewed. The selection matrix was then applied to achieve maximum variation. Of the 20 GDPs, seven met the selection matrix criteria and were invited; of these seven, two were unavailable and thus five were interviewed. Of the six GMPs, all were invited because of the small number; one was unavailable and thus five were interviewed. Of the 42 CPs, nine met the selection matrix criteria; of the nine, two declined, one was unavailable and six were interviewed. Unfortunately, the recording of the sixth CP interview was unclear and had to be omitted from the analysis. Demographic information of the final 15 interview participants is presented in Table 3.

Table 3.

Interview participants’ demographic information

Participant ID	Gender	Years of practice	Practice setting	Practice location	Place of training	Working hours (per week)
GDP1	Female	11–15	Private	Metro	Overseas	21–30
GDP2	Female	>30	Private	Metro	Australia	31–40
GDP3	Male	26–30	Private	Rural	Australia	>40
GDP4	Male	<5	Private	Metro	Australia	21–30
GDP5	Female	16–20	Private	Metro	Australia	31–40
GMP1	Male	26–30	Private	Metro	Australia	11–20
GMP2	Female	<5	Public	Metro	Australia	11–20
GMP3	Female	<5	Private	Metro	Australia	11–20
GMP4	Male	<5	Private	Metro	Australia	11–20
GMP5	Female	16–20	Private	Metro	Australia	11–20
CP1	Male	>30	Public	Metro	Australia	>40
CP2	Female	16–20	Public	Metro	Australia	31–40
CP3	Male	>30	Public	Metro	Australia	0–10
CP4	Male	26–30	Private	Rural	Overseas	31–40
CP5	Female	<5	Private	Metro	Australia	21–30

CP, community pharmacist; GDP, general dental practitioner; GMP, general medical practitioner; Metro, metropolitan.

Interview themes

There are three overarching themes: current practice; health professionals’ self-perception of their role; and collaborative care.

Current practice

Four subthemes emerged when Interviewees were asked about their treatment of halitosis: starting the conversation; differential diagnosis; follow-up; and referrals.

• •Starting the conversation

Concern about compromising patient rapport was a key barrier to raising the topic of halitosis with patients who initially presented with other issues.

I wouldn’t be pushing it. I wouldn’t say, look, (your) breath is really bad. That’s a very, sort of, almost derogatory approach and the patient will be very put off. (GDP4, responded ‘comfortable to broach’ in online survey)

I don’t want to compromise the doctor–patient relationship by unexpectedly bringing up the topic of bad breath. (GMP5, responded ‘not comfortable to broach’ in online survey)

I think in a way it’s offensive to the patient that you’ve noticed and asked to manage their bad breath without them coming to see you about it. (CP4, responded ‘not comfortable to broach’ in online survey)

Inadequate oral health education affected some GMPs’ confidence to start such a conversation.

However, with dental issues, a little less confident given the lack of training in dental health. (GMP2, responded ‘not comfortable to broach’ in online survey)

On the other hand, some GMP participants regarded it as regular communication.

I feel like the idea of broaching it with somebody is really a communication skill and I have to deal with communication stuff all the time when I do clinical practice. (GMP4, responded ‘comfortable to broach’ in online survey)

Some GMP and CP interviewees felt that patients generally were self-conscious and reluctant to seek advice about bad breath.

People are frightened that it’s a socially unacceptable thing. (CP3)

• •Differential diagnosis

All participants said that the halitosis cases they encountered were mostly a result of oral issues, such as periodontitis or poor oral hygiene practices. When they could not find an obvious oral cause, most GDP and CP interviewees investigated non-oral causes, such as diet, and gastrointestinal and sinus-related issues.

It can come from the stomach… because of the acid in the stomach, and I will ask them if they’ve had reflux or look at issues with that. (GDP2)

I’ll ask if their tummy has been upset, it could be that… they’re having a bit of indigestion. (CP3)

• •Follow-up

Although GDP interviewees knew the benefits of follow-up, most did not monitor their patients’ halitosis management. They also reported not knowing how to monitor patients’ progress.

I have to say I haven’t really done much monitoring. It’s only patients coming back and saying they’ve still got the issue. (GDP5)

I’ve never actually done it. I’ve never really measured or, like, I wouldn’t know how to measure them except from my notes. (GDP1)

Most GMP interviewees followed up their patients only if the issue persisted or when there were test results to discuss. Otherwise, they usually recommended to patients to consult GDPs with no intention of following them up.

I’ll ask them to come back to me if the problem persists. If it’s something else that seems a bit more serious or they need to come back to get test results I’ll ask them to follow-up in perhaps a week or 2 weeks…. (GMP2)

Some CP interviewees similarly would simply advise patients to consult other health professionals after trying treatments available from the pharmacy.

I would just tell them if it doesn’t improve to see the doctor or the dentist, I wouldn’t say come back. (CP2)

• •Referrals

GMP and CP interviewees commonly referred their patients with halitosis to GDPs either because they felt GDPs are better trained or when the conditions were more serious.

The dentists are really the most equipped people to teach people how to maintain good oral hygiene, how to brush properly and how to floss properly. (GMP2, responded ‘often referred to a GDP’ in online survey)

I mean, they could have cavities, they could have some other dental issue that I just treat superficially, and it won’t go away, so we tell them to see a dentist. (CP2, responded ‘occasionally referred to a GDP’ in online survey)

Most GDP and CP interviewees referred patients to GMPs if they knew or suspected an extra-oral cause.

I’ll say, you have an infection you need to go to your doctor. (CP3, responded ‘occasionally referred to a GMP’ in online survey)

I find that a lot of patients on antidepressants have a dry mouth; it sometimes goes undiagnosed, so I refer them to the doctor or I put them on a <brand name> saliva substitute. (GDP1, responded ‘often referred to a GMP’ in online survey)

None of the GDP and GMP interviewees referred their patients with halitosis to a CP.

I’ve never thought to refer them to a pharmacist. What could the pharmacist do? Tell me what the pharmacist could do? (GDP3, responded ‘never referred to a CP’ in online survey)

Whilst I sometimes recommend products that would be available at a pharmacy, I don’t refer to a pharmacist. (GMP5, responded ‘never referred to a CP’ in online survey)

Health professionals’ self-perceptions of their role

All GDP interviewees said that they play a key role in halitosis management. However, they seemed to focus only on intra-oral halitosis.

I think most of the things we find… are dental cause, that we can usually treat….(GDP3)

Although most GMP interviewees felt that halitosis management was within their professional role, they did not feel confident or adequately trained to manage intra-oral halitosis.

If it is something like sore throat, tonsillitis causing halitosis, I feel fairly confident managing that; however, with dental issues a little less confident given the lack of training in dental health. (GMP2, responded ‘maybe within role’ in online survey)

Nevertheless, some GMP interviewees reported that they routinely perform basic oral examinations, provide basic dental advice, prescribe short-term treatments and refer patients to GDPs.

I’d start by taking a history, examine and have a look in their mouth, probably smell their breath… start them on antibiotics, give them some painkillers and I just looked up the details of the community dental clinic and organised for them to be seen by the clinic. (GMP 4, responded ‘within role’ in online survey)

Most CP interviewees also felt that halitosis management was within their professional role. They stressed that their accessibility was an advantage and they could provide advice, patient education, referral and medication review.

I think that we are the easiest person to talk to, people come in off the street, and they talk to us…In minor issues which is someone has had a bit of oral thrush, someone has had low-grade gingivitis or something like that, we have treated it with antiseptic type washes or rinses. (CP3, responded ‘within role’ in online survey)

One CP described the role of CPs in identifying misdiagnosis. He spoke about his experience of redirecting a patient for a second opinion who was later diagnosed with oral cancer.

It [oral cancer] had been missed twice by the GMP. Unfortunately, things do slip through the system, even today, as clever as everyone is so yeah, and that’s where I think CPs do have a role. (CP3, responded ‘within role’ in online survey)

Collaborative care

All interviewees agreed on the idea of interprofessional collaboration. Their views are organised under two subthemes: barriers; and facilitators for collaborative care.

• •Barriers for collaborative care

Most GMP interviewees noted that GDPs work in isolation from other health professionals because of factors such as geography and incentives.

The geography is definitely one of the barriers in that they are not co-located, 90% of dental care occurs in the private setting and those clinics are often in isolation… I feel a bit sad to say this, but there’s also not much incentive. So, the Medicare incentive, there’s an incentive for doctors to collaborate with pharmacists, for example, through medicine reviews. There’s not that between doctors and dentists. (GMP4, responded ‘agree’ for collaboration in online survey)

GDPs in general thought that GMPs and CPs were inadequately trained to manage halitosis. Most GMPs or CPs agreed.

Doctors, I think a lot of them don’t know much about the mouth. (GDP2, responded ‘strongly agree’ for collaboration in online survey)

I assume the pharmacists probably lack awareness of, you know, what dental things can cause bad breath. (GDP3, responded ‘strongly agree’ for collaboration in online survey)

When I went through medical school, we did not cover much about oral health outside of things such as oral cancers and ulcers. (GMP5, responded ‘strongly agree’ for collaboration in online survey)

Some interviewees noted that initiating an additional conversation about halitosis would prove difficult in an already-short GMP consultation.

It [collaboration] is very hard to do, especially with the doctors. I don’t think the doctors spend a lot of time with patients. (GDP1, responded ‘strongly agree’ for collaboration in online survey)

Some GMP and GDP felt that halitosis management is outside the role of CPs.

I feel it’s more of a dentist/doctor kind of thing. (GMP5, responded ‘strongly agree’ for collaboration in online survey)

• •Facilitators for collaborative care

Education on oral health and resources that provide a referral algorithm were seen as important facilitators.

Learning about bad breath, knowing the causes, the role for investigations, when to investigate, the red flags, how to go about managing the case with both lifestyle and pharmacological things. (GMP3, responded ‘strongly agree’ for collaboration in online survey)

Educational program for pharmacists to know when to refer or what to look for. (CP2, responded ‘agree’ for collaboration in online survey)

I think it would be handy to have like a summary table and it says these are the likely factors causing, and then mark those relevant as ‘for doctor referral’ or ‘refer the investigation to another health care practitioner.’ (GDP4, responded ‘agree’ for collaboration in online survey)

Most interviewees discussed the potential benefits of effective interprofessional communication.

Would be good if there’s a network online where doctors, dentists and pharmacists could communicate more. Knowing what dental clinics are available, public and privately, within where I work, how much it costs and what the wait time is. (GMP4, responded ‘agree’ for collaboration in online survey)

Some interviewees described the value of raising community awareness.

You know to educate the public about halitosis, via a social media campaign, because it might encourage people to see someone regarding those issues. (CP2, responded ‘agree’ for collaboration in online survey)

DISCUSSION

Although halitosis is common, it remains a stigma¹⁵. Current literature indicates that health professionals were not communicating effectively with patients about halitosis; however, the contributing factors had not been explored⁵. Our study finds that a key barrier was concern over compromising the rapport with patients by broaching a potentially embarrassing subject. Raising community awareness would help to destigmatise halitosis and facilitate diagnosis and management. Barnett et al.¹⁵ similarly suggested that promoting oral health in the community would improve outcomes for patients with oral concerns.

Another factor is level of education and training received. Most GMPs and CPs felt that they were not trained adequately in oral health. Barnett et al.¹⁵ also found that the professional training of GMPs and CPs in Australia lacked oral health content. Interestingly, even though GDPs are trained specifically in dental health, and proportionately more GDPs in our study were comfortable raising the topic of halitosis with their patients, there were still GDPs who were not.

International studies have suggested that health professionals, in general, lack awareness of the different causes of halitosis1., 10., 11., 12.. Seeman et al.⁶ found that three-quarters of patients attending a German halitosis clinic had received a prior incorrect diagnosis which led to unnecessary procedures, such as gastroscopy and ENT surgery. Most participants in our study, on the other hand, seemed to be aware of both oral causes and common extra-oral causes of halitosis. Further research, with a larger sample size, is required to explore this Australian aspect in greater detail.

Unlike other research which found that GMPs self-identify to be more suitable than GDPs for managing halitosis¹⁶, our study suggests that GDPs were regarded as the health professionals with the most training in oral health and GMPs and CPs commonly referred patients to them. GDP participants themselves, likewise, felt confident and competent to manage intra-oral halitosis. Such trust and confidence is supported by literature which states that GDPs are the practitioners most proficient in managing intra-oral halitosis⁶.

Conversely, GDPs and CPs in our study did not refer to GMPs frequently because extra-oral causes of halitosis are less common¹⁰. GMP participants were confident in managing halitosis with an extra-oral origin, such as sinus and gastric issues, although most were not aware of other causes, such as anxiety and psychiatric disorders.

Most health professionals interviewed in our study, including GDPs, did not seem to monitor patients’ progress with halitosis treatment. Barnett et al.¹⁵ similarly found that doctors did not follow-up with patients who were referred to a dentist, even though follow-up is critical to ensure correct diagnosis and treatment review to achieve optimal outcomes.

Our results suggest that CPs were often consulted by patients with halitosis. CP participants emphasised their accessibility as a primary health-care provider to contribute to managing a non-life threatening, but important, condition, such as halitosis. However, GDPs and GMPS seem to have limited understanding of a CP’s role. Our findings also suggest that isolation of the dental profession from medical and pharmacy professions is another key barrier to working together. Participants acknowledged that a lack of interprofessional communication affects continuity of care and patient outcomes. This is supported by research from Barnett et al.¹⁵ that describes such non-communication as problematic. Multidisciplinary continuing education and professional development on topics of common interest, such as halitosis, are necessary to instil an understanding and appreciation of the role of different health professionals and to promote effective interprofessional communication, collaboration and referral pathways.

Despite halitosis being a common condition, most health professionals, including dental health professionals, find it challenging to initiate a conversation about the topic with patients or monitor patients’ progress. A lack of oral health training affects GMPs’ and CPs’ confidence and competence to manage patients with halitosis. Collaboration between health professionals would improve patient outcomes, and GDPs, GMPs and CPs are interested in working together to manage halitosis. Raising community awareness is key to destigmatising halitosis and reducing the barriers for patients to seek treatment. Educating and training health professionals by enhancing undergraduate and graduate professional curricula and promoting multidisciplinary professional development programmes are critical in promoting interprofessional collaboration and providing patients with optimal care.

To the best of our knowledge, this study is the first to explore the multidisciplinary management of halitosis by GDPs, GMPs and CPs in an Australian setting. It is also the first study – nationally or internationally – to explore CPs’ views on halitosis management, which is important as CPs are arguably the most accessible primary health professionals. Our findings contribute to the limited literature currently available about halitosis management in Australia and will inform the content of professional development for health professionals and the development and implementation of an interprofessional collaboration model.

The mixed methods approach used in this study has enabled an in-depth exploration of the topic area. Our recruitment strategy and our subsequent selection of participants for follow-up interview achieved maximum variation. These processes were designed to ensure that a broad representation of views was explored. Nevertheless, the overall small survey numbers, particularly the low survey participation by GMPs, needs to be taken into consideration when interpreting and generalising our findings.

Acknowledgements

We would like to acknowledge the eviDent Foundation and VicReN who provided advice during research development and access to networks for recruitment. We thank the six, first-year dental students at Melbourne Dental School who assisted with the research, and our dental, medical and pharmacy colleagues who provided insight into the surveys and interviews that greatly assisted the research. Our study did not receive any financial support.

Competing interest

The authors declare no competing financial or non-financial interest in relation to the research conducted.