|Year : 2018 | Volume
| Issue : 4 | Page : 187-191
Prevalence of self-perceived halitosis, demographic factors and oral health care among defined groups of dental students in Iran
Mahin Bakhshi1, Maryam Tofangchiha2, Sedigheh Bakhtiari1
1 Department of Oral Medicine, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Oral and Maxillofacial Radiology, Dental School, Qazvin University of Medical Sciences, Qazvin, Iran
|Date of Web Publication||28-Aug-2018|
Dr. Sedigheh Bakhtiari
Department of Oral Medicine, Dental Faculty, Shahid Beheshti University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Aim: This study was to determine the prevalence of self-perceived halitosis and the associated factors regarding health care among dental students. Materials and Methods: This study was conducted on 225 dental students. Information form which contained demographic factors and habits (cigarettes and alcohol), self-perceived halitosis and health cares was filled by them. Then, the organoleptic test was done. People whose organoleptic test score was ≥2 were considered with halitosis. Statistical tests such as Chi-square, Mann–Whitney, and logistic regression modeling were used to examine the relationship between variables and halitosis and their severity. Results: Out of 225 patients enrolled, 127 were female and 98 were male. Mean age of patients was 21.72 years. A total of 151 patients (67.1%) suffered from halitosis (66.9% of women and 67.3% of men), which showed no significant difference between them. Self-perceived halitosis was 76.9%. Among patients, 43 (19.1%) smoked. The odds for halitosis in people who did not use mouthwash regularly were 2.03 times higher than those who used mouthwash (P = 0.029). Moreover, people who brushed their teeth once a day were more likely to develop halitosis than those who brushed more than twice a day (odds ratio [OR] = 2.73, P = 0.038). The odds for halitosis was 1.86 times higher in people who did not use floss than those who used floss (P = 0.07); although this difference was not statistically significant at the 0.05 level. The use of tongue scrap was not significantly associated with the halitosis (OR = 1.13, P = 0.71). Conclusion: Self-perceived halitosis was high (76.9%) in dental students. In more than 75% of students who had genuine halitosis, halitosis had a negative effect on their social relations.
Keywords: Halitosis, oral health care, prevalence, self-perceived
|How to cite this article:|
Bakhshi M, Tofangchiha M, Bakhtiari S. Prevalence of self-perceived halitosis, demographic factors and oral health care among defined groups of dental students in Iran. J Int Oral Health 2018;10:187-91
|How to cite this URL:|
Bakhshi M, Tofangchiha M, Bakhtiari S. Prevalence of self-perceived halitosis, demographic factors and oral health care among defined groups of dental students in Iran. J Int Oral Health [serial online] 2018 [cited 2022 Jan 28];10:187-91. Available from: https://www.jioh.org/text.asp?2018/10/4/187/240014
| Introduction|| |
Halitosis refers to unpleasant breath from the mouth, and it is divided into three categories: genuine halitosis, pseudo halitosis, and halitophobia., If there are no symptoms and the patient insists on having halitosis, it can be due to a disorder in a nervous system or results from halitophobia and pseudo halitosis. Halitophobia patients should be referred to a psychologist.,
Halitosis is a social-medical problem which significantly influences social relations and may lead to isolation. Several factors are involved in its development, which can be divided into three groups including intraoral factors, extra oral factors, and temporary factors. Its origin is intraoral in 80%–90% of cases.,,,, The main cause of halitosis which originates in the mouth is volatile sulfur components (VSCs), particularly hydrogen sulfide, methyl mercaptan and dimethyl sulfides produced by Gram-negative anaerobic bacteria.,, The role of the coated tongue has been established in the etiology of halitosis.,,, Extra-oral factors include respiratory and gastrointestinal problems, sinusitis and nasal polyps, kidney diseases, diabetic ketoacidosis, and side effects of some drugs. Temporary and transitory factors such as diet containing garlic, onions, and peppers, use of cigarettes and alcohol as well as morning bad breath can cause halitosis. For successful treatment of halitosis, it is necessary to know the exact etiology and the related factors.,,,
There are several clinical methods to assess halitosis, such as:
smelling breath directly which is a practical and reliable method to assess halitosis; this method is routinely used in clinical studies.,,
This assesses sulfide compounds of the oral cavity. Although other components except sulfur gases contributing to halitosis are not detectable by Halimeter, its results are consistent with organoleptic assessments.,,,
Gas chromatography shows higher potential and a broader range of materials and components than Halimeter; however, it cannot be used routinely in dental clinics due to special equipment and expert operators required.
Studies have evaluated halitosis prevalence in different populations; these reports range from 22% to higher than 85%.,, Due to the limited epidemiological studies on halitosis in Iran, this study examines the prevalence of self-perceived halitosis and associated factors regarding health care among dental students.
| Materials and Methods|| |
This cross-sectional study was conducted on 239 dental students at all levels. Information form was filled by patients. Then, the organoleptic test was conducted by two evaluators for each sample. Information form included three main parts:
- Demographic factors: age, gender, smoking, and alcohol consumption
- Descriptive information of self-evaluated halitosis: The ability to smell breathing by hand-on-mouth technique, its intensity, how to notice of halitosis, its effect on social life
- Oral health: frequency of using a toothbrush, dental floss, mouthwash, and tongue scraper per day.
Before assessment, following instructions were given to participants and eligible patients were enrolled: not using antibiotics within 3 weeks before the assessment; not using pepper, garlic and onion 48 h prior to the assessment; not using aromatic substances 24 h before the assessment; avoiding coffee, alcohol and smoking 12 h prior to the assessment; not using oral mouthwash and chewing gum on the morning of the examination.,,,,
To avoid confusion of halitosis with morning bad breath, it was permitted to wash the mouth with water and eat breakfast on the day of the study. All measurements of the organoleptic test were done at 8:30–11:30 and at least 2 h after eating and drinking and routine oral hygiene. In addition, the 5-min break was given between the examinations (to restore the sense of smell in examiners).
Examiners had a natural sense of smell and avoided aromas, coffee, and foods-containing garlic, onions, peppers and aromatic toothpaste in examination days. Moreover, the examiners did not have cold and upper respiratory tract infections.
A sheet (50 cm × 70 cm) was placed between the patient and the examiner to stop them from seeing each other; a transparent tube (2.5 cm diameter and 10 cm length) was placed in the middle of the sheet. The patients were asked to close their mouth for 60 s without swallowing saliva. Then, they slowly exhaled air from the tube which was placed inside their mouth. Each examiner rated the smell from 0 to 5 after smelling. Finally, an average of the two reported rates was considered as halitosis score.,,
People whose organoleptic test score was ≥2 were included in the group with halitosis, and those whose organoleptic test score was 0 and 1 were included in the group without halitosis.,,
In order to calibrate two evaluators in the diagnosis of halitosis by using organoleptic test, calibration was done on ten samples that were selected randomly. To assess agreement between these two, the weighted kappa coefficient was calculated and the reported coefficient indicated a moderate and acceptable agreement between two people.
Halitosis was measured on a six-point scale including zero (without halitosis), 1 (barely perceptible), 2 (low), 3 (moderate), 4 (intense but tolerable), and 5 (intense and intolerable).
Statistical analysis was performed using SPSS for Windows (version 21.0; IBM Corp., Armonk, NY, USA). Descriptive methods were used for reporting results. The absolute and relative frequency of variables was reported. Statistical tests including Chi-square, Mann–Whitney, binary logistic regression model, and ordinal logistic regression were used to examine the relationship between variables and the presence or absence of halitosis.
| Results|| |
Out of 239 patients, 14 patients were excluded due to noncooperation. Out of 225 samples enrolled, 127 were women and 98 were men. The mean age of participants was 21.72 years (standard deviation [SD] =1.94) and ranged from 18 to 32 years. A total of 151 patients (67.1%) were suffering from halitosis; 85 (66.9%) women and 66 (67.3%) men had halitosis, which showed no significant difference (P = 0.947).
Forty-three (19.1%) patients were smokers who smoked 1–20 cigarettes a day and 19 patients (8.4%) consumed alcohol. [Table 1] and [Figure 1] show the frequency of demographic variables and habits of patients with and without halitosis. About half of people gained score 3 in the organoleptic test. [Figure 2] reports the relative frequency of different degrees of the organoleptic score in men and women.
|Table 1: Frequency of demographic variables and habits of patients with and without halitosis|
Click here to view
|Figure 1: Relative frequency of demographic variables in people with and without halitosis|
Click here to view
|Figure 2: Frequency of different degrees of organoleptic scores in men and women|
Click here to view
Moreover, 173 patients (76.9%) were aware of halitosis and 74 patients (32.9%) had pseudo halitosis/halitophobia. In examining self-perceived halitosis, 52 patients (23.1%) could not smell their breath by hand-on-mouth, whereas 173 patients (76.9%) could.
In addition, 37 patients (16.4%) realized their halitosis in connection with others, 19 patients (8.4%) realized their halitosis by hint of others and 164 (72.9%) realized themselves. Five patients (2.2%) were not responsive. In relation to severity of self-perceived halitosis, 18 patients (8%) reported severe, 75 patients (33.3%) reported moderate, and 132 (58.7%) reported low severity. In relation to the effect of halitosis on social life, 189 patients (84%) reported no effect, and 36 patients (16%) reported an effect. More than half of people reported halitosis when waking up and 3.6% reported halitosis regularly throughout the day. Moreover, 52% of people with halitosis avoided talking with other people.
In relation to health care, 37.3% brushed once a day, and 62.7% brushed twice and more than twice a day; 28% used mouthwash, 70.2% used dental floss, and 28.4% used tongue cleaner. [Figure 3] shows the relative frequency of health-care factors in people with and without halitosis.
|Figure 3: Relative frequency of health care factors in people with and without halitosis.|
Click here to view
Binary logistic regression analysis showed that the odds for people who did not use mouthwash regularly were 2.03 times higher to develop halitosis than those who used mouthwash (P = 0.029). Moreover, people who brushed their teeth once a day were 2.73 times more likely to develop halitosis than those who brushed more than twice a day (P = 0.038). The odds for halitosis was 1.86 times higher in people who did not use floss than those who used floss (P = 0.07); although, this difference was not significant at the 0.05 level. The odds for halitosis was 1.13 times in tongue scrap nonusers than users (P = 0.71).
| Discussion|| |
Halitosis is a relatively common problem which considerably influences personal, professional, and social relationships. Hence, it is essential to evaluate its prevalence and self-perception of people to manage the problem. In this study, overall prevalence of halitosis was 67.1% and self-perceived halitosis was 76.9%; this high percentage of self-perceived halitosis may be due to the studied population which was dental students. Almas et al., Ashwath et al., and Setia et al. also studied dental students. In studies of Almas and Setia, the percentage of self-perceived halitosis was higher in men, while it was higher in women in studies of Ashwath et al. and Eldarrat et al.,
Aimetti et al. and Bornstein et al. found that the prevalence of halitosis based on organoleptic assessment was 53.51% and 85%, respectively. Hammad et al. reported the prevalence of halitosis at 78% and self-perceived halitosis at 20.5%. Lu et al. reported the prevalence of halitosis at 77.3% and self-perceived halitosis at 45%. Al-Ansari et al. reported self-perceived halitosis at 3.57%. The difference in assessment method, criteria used for measurement and definition of halitosis, lifestyle and culture can lead to difference in prevalence of halitosis reported in different studies.
Various studies have used questionnaire for measuring halitosis. Results of these studies are less reliable than present study due to lack of organoleptic test,,,, while Bornstein et al., Lu et al. and Hammad et al. used both organoleptic test and Halimeter; therefore, the results of these studies are relatively more reliable and repeatable than the present study.,, However, Halimeter mainly measures compounds containing sulfur. Aimetti et al. and Talebian et al. used both organoleptic test and chromatography gas. Although chromatography gas is relatively reliable and highly repeatable than organoleptic test, no significant relationship was observed between the organoleptic test and chromatography gas.
In the present study, 19.1% of participants were smokers, out of which 81.4% had halitosis; effect of smoking was significant on halitosis (P = 0.027). Cigarette smoke contains active sulfur components which can lead to halitosis. In addition, smoking causes dry mouth and periodontal disease which can worse halitosis. In studies of Lu et al., Al-Ansari et al., Almas, Aimetti et al., Setia et al., as this study, the effect of smoking was significant on halitosis.,,,, Other studies did not examine the role of smoking in halitosis or it was not significant.
In this study, most reports were related to halitosis after waking up (51.6%), which can be attributed to the reduced saliva flow during sleep and lack of physiological activities related to teeth cleaning. In studies of Setia et al., Eldarrat et al., Lu et al. and Almas et al., as this study, most of the reports were related to halitosis after waking up.,,,
In this study, 16% of participants believed that halitosis was influential on their social life; Eldarrat et al. reported this at 12%. In fact, halitosis can affect social life, and the person with bad odor can avoid social activities. In this study, the main problem caused by halitosis was avoiding to talk with people; Lu et al. reported an inability to communicate with people as the main problem of halitosis.
In this study, there was no significant relationship between the frequency of brushing and halitosis; however, logistic regression analysis showed that people who brushed once a day were 2.8 times to develop halitosis than people who brushed equal 2 or more than twice a day. In studies of Almas, Aimetti et al. and Eldarrat et al., the frequency of brushing was not significant, which is consistent with the current study.,, Al-Ansari et al. reported that the frequency of brushing was significant. In logistic regression analysis, brushing less than once a day had the highest and strongest relationship with halitosis. Unlike this study, Lu et al. and Bornstein et al. reported a significant relationship between the frequency of brushing and halitosis.,
The current study reported a significant relationship between not using mouthwash and halitosis (P = 0.047); 71% of people who did not use mouthwash had halitosis. Anaerobic bacteria in the mouth, particularly on the dorsum of the tongue, produce VSCs which cause halitosis. Mouthwashes temporarily eliminate these bacteria and halitosis. Consistent with this study, Ashwath et al. found a significant relationship between not using mouthwash and halitosis. In various studies, not using mouthwash was not significantly related to halitosis.,,,
In this study, there was no significant relationship between flossing and halitosis (P = 0.075); this is consistent with some studies.,, However, Al-Ansari et al. found a significant relationship between flossing and halitosis.
This study found no significant relationship between the tongue cleaner and halitosis (P = 0.765), which is consistent with Aimetti et al. and Eldarrat et al., Inconsistent with the current study, Ashwath et al. and Lu et al. found that tongue cleaner significantly reduced halitosis.,
| Conclusion|| |
Self-perceived halitosis was high (76.9%) in dental students. In more than 75% of students who had genuine halitosis, halitosis had negative effect on their social relations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mokeem SA. Halitosis: A review of the etiologic factors and association with systemic conditions and its management. J Contemp Dent Pract 2014;15:806-11.
Özen ME, Aydin M. Subjective halitosis: Definition and classification. J N J Dent Assoc 2015;86:20-4.
Dudzik A, Chomyszyn-Gajewska M. Pseudohalitosis and halitophobia. Przegl Lek 2014;71:274-6.
Hammad MM, Darwazeh AM, Al-Waeli H, Tarakji B, Alhadithy TT. Prevalence and awareness of halitosis in a sample of Jordanian population. J Int Soc Prev Community Dent 2014;4:S178-86.
Hughes FJ, McNab R. Oral malodour – a review. Arch Oral Biol 2008;53 Suppl 1:S1-7.
Eldarrat A, Alkhabuli J, Malik A. The prevalence of self-reported halitosis and oral hygiene practices among Libyan students and office workers. Libyan J Med 2008;3:170-6.
Lu HX, Tang C, Chen X, Wong MC, Ye W. Characteristics of patients complaining of halitosis and factors associated with halitosis. Oral Dis 2014;20:787-95.
Quirynen M, Dadamio J, Van den Velde S, De Smit M, Dekeyser C, Van Tornout M, et al.
Characteristics of 2000 patients who visited a halitosis clinic. J Clin Periodontol 2009;36:970-5.
Aimetti M, Perotto S, Castiglione A, Ercoli E, Romano F. Prevalence estimation of halitosis and its association with oral health-related parameters in an adult population of a city in North Italy. J Clin Periodontol 2015;42:1105-14.
Cortelli JR, Barbosa MD, Westphal MA. Halitosis: A review of associated factors and therapeutic approach. Braz Oral Res 2008;22 Suppl 1:44-54.
Ashwath B, Vijayalakshmi R, Malini S. Self-perceived halitosis and oral hygiene habits among undergraduate dental students. J Indian Soc Periodontol 2014;18:357-60.
] [Full text]
Van Tornout M, Dadamio J, Coucke W, Quirynen M. Tongue coating: Related factors. J Clin Periodontol 2013;40:180-5.
Pratibha PK, Bhat KM, Bhat GS. Oral malodor: A review of the literature. J Dent Hyg 2006;80:8.
Faveri M, Hayacibara MF, Pupio GC, Cury JA, Tsuzuki CO, Hayacibara RM, et al.
A cross-over study on the effect of various therapeutic approaches to morning breath odour. J Clin Periodontol 2006;33:555-60.
Slot DE, De Geest S, van der Weijden FA, Quirynen M. Treatment of oral malodour. Medium-term efficacy of mechanical and/or chemical agents: A systematic review. J Clin Periodontol 2015;42 Suppl 16:S303-16.
Zürcher A, Laine ML, Filippi A. Diagnosis, prevalence, and treatment of halitosis. Curr Oral Health Rep 2014;1:279-85.
Kapoor U, Sharma G, Juneja M, Nagpal A. Halitosis: Current concepts on etiology, diagnosis and management. Eur J Dent 2016;10:292-300. [Full text]
Al-Ansari JM, Boodai H, Al-Sumait N, Al-Khabbaz AK, Al-Shammari KF, Salako N, et al.
Factors associated with self-reported halitosis in Kuwaiti patients. J Dent 2006;34:444-9.
Akaji EA, Folaranmi N, Ashiwaju O. Halitosis: A review of the literature on its prevalence, impact and control. Oral Health Prev Dent 2014;12:297-304.
Rosenberg M, Knaan T, Cohen D. Association among bad breath, body mass index, and alcohol intake. J Dent Res 2007;86:997-1000.
Almas K, Al-Hawish A, Al-Khamis W. Oral hygiene practices, smoking habit, and self-perceived oral malodor among dental students. J Contemp Dent Pract 2003;4:77-90.
Setia S, Pannu P, Gambhir RS, Galhotra V, Ahluwalia P, Sofat A, et al.
Correlation of oral hygiene practices, smoking and oral health conditions with self perceived halitosis amongst undergraduate dental students. J Nat Sci Biol Med 2014;5:67-72.
Bornstein MM, Stocker BL, Seemann R, Bürgin WB, Lussi A. Prevalence of halitosis in young male adults: A study in Swiss army recruits comparing self-reported and clinical data. J Periodontol 2009;80:24-31.
Talebian A, Tazhibi M, Semyari H, Iranpoor R, Talebian H, Oreizy SM, et al.
Clinical evaluation of 222 Iranian patients with halitosis. J Breath Res 2008;2:017015.
[Figure 1], [Figure 2], [Figure 3]