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Halitosis: A Review of the Literature on Its Prevalence, Impact and Control

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Halitosis is the offensive or disagreeable odour that may emanate from the mouth. In 80%-90% of cases, bacterial activities especially on the dorsum of the tongue are implicated. Current studies on halitosis accessed from electronic databases were appraised in the light of prevalence, impact and control of halitosis. Halitosis has a worldwide occurrence with a prevalence range of 22% to 50%. Due to the associated social and psychological effects, it should be taken seriously in all affected patients. Oral healthcare professionals ought to be well informed, because their office(s) are usually the first points of call for the affected patients.
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Akaji et al
Vol 12, No 4, 2014 297
REVIEW ARTICLE
Halitosis is an offensive or disagreeable odour
emanating from the mouth or hollow cavities of
the nose, sinuses or pharynx.71,73, 91 Other general
terms used to describe this unpleasant condition
are fetor oris, fetor ex oris, oral malodour, foul
breath or bad breath.2,18 Halitosis can be classied
as genuine halitosis, pseudo-halitosis or as halito-
phobia.35,94 Genuine halitosis is either physiologi-
cal or pathological in origin, while pseudo-halitosis
is the claim that halitosis exists when no objective
evidence can be found.35,94 In genuine halitosis,
bacterial activities in the oral cavity are implicated
in 80%–90% of cases.26,73 Researchers have de-
tected over 600 species of microorganisms in the
oral microbiota.33,36 These operate mainly by their
action on sulfur amino acids such as cysteine, cys-
tine and methionine to produce volatile sulfur com-
pounds (VSCs) such as hydrogen sulde (H2S), me-
Halitosis: A Review of the Literature on Its Prevalence,
Impact and Control
Ezi A. Akajia/Nkiru Folaranmib/Olufunmilayo Ashiwajuc
Summary: Halitosis is the offensive or disagreeable odour that may emanate from the mouth. In 80% –90% of cases,
bacterial activities especially on the dorsum of the tongue are implicated. Current studies on halitosis accessed from
electronic databases were appraised in the light of prevalence, impact and control of halitosis. Halitosis has a world-
wide occurrence with a prevalence range of 22% to 50%. Due to the associated social and psychological effects, it
should be taken seriously in all affected patients. Oral healthcare professionals ought to be well informed, because
their ofce(s) are usually the rst points of call for the affected patients.
Key words: control, halitosis, prevalence, prevention
Oral Health Prev Dent 2014;12:297-304 Submitted for publication: 17.08.13; accepted for publication:08.01.14
doi: 10.3290/j.ohpd.a33135
a Senior Lecturer and Consultant Public Health Dentist, Depart-
ment of Preventive Dentistry, College of Medicine, University of
Nigeria, Enugu Campus, Enugu, Nigeria. Study concept and de-
sign, the review of study materials, coordinated manuscript writ-
ing, proofread manuscript.
b Senior Lecturer and Consultant Orthodontist, Department of
Child Dental Health, College of Medicine, University of Nigeria,
Enugu Campus, Enugu, Nigeria. Reviewed study materials, proof-
read manuscript.
c Lecturer and Consultant Paediatric Dentist, Department of Child
Dental Health, College of Medicine, University of Lagos, Idi-Araba,
Lagos, Nigeria. Provided technical support, proofread manuscript.
Correspondence: Dr. Ezi A. Akaji, Department of Preventive Den-
tistry, College of Medicine, University of Nigeria, Enugu Campus,
Enugu 234, Nigeria. Tel: 234- 806- 956-5601.
Email: ezi.akaji@unn.edu.ng
thyl mercaptan (CH3SH) and dimethyl sulde
(CH3SCH3) as metabolites.2,18,24,57 Some micro-or-
ganisms and other conditions associated with hali-
tosis are listed in Table 1.
Various sites in the oral cavity serve as niches
for these bacteria, but the dorsum of the tongue
with its characteristic ssures and grooves is their
primary location.1,35,40,64,83,93,95 The tongue pro-
vides a suitable environment for the growth of
these organisms, as favourable redox potentials
are found in the deep crypts associated with the
structure of the tongue papillae.30 Quirynen et al61
demonstrated that tongue coating – whether pre-
sent alone or with periodontal inammation – was
associated with halitosis in more than 1200 of
2000 patients of a breath clinic. The aim of the
present study was to assess the prevalence of hal-
itosis, impact on the individual and the wider soci-
ety and the available control measures for this pub-
lic health issue.20 This review may be useful to oral
healthcare professionals in treatment planning de-
cisions and in providing information to share with
patients who are burdened with oral malodour.
DATA SOURCES AND STUDY SELECTION
Articles published between 1990 and 2012 from
the University of Nigeria electronic library and inter-
net-based publications were retrieved. The words
‘halitosis’ and ‘oral malodour’ were used as key
words for the electronic data search. Available full
Akaji et al
298 Oral Health & Preventive Dentistry
articles were accessed and stored on a CD-ROM.
Sorting was done to exclude all publications before
1990 while those from 1990 and 2012 were includ-
ed. The authors read the articles and extracted data
on prevalence, impact and control of halitosis. If any
author had more than one article on halitosis or its
correlates, the most suitable for each subheading
under focus was selected; this was done to accom-
modate as many authors’ views as possible.
PREVALENCE OF HALITOSIS
Halitosis is a problem that has plagued people for
thousands of years; it ranks third amongst the rea-
sons for patients’ visit to the dentist.14,24 It can be
detected organoleptically (i.e. by nose) and instru-
mentally using sulde monitors or gas chromatogra-
phy,57,66,68 ,96 although results of these different
methods do not always agree.15 The prevalence of
halitosis differs across the globe due to variations
in the perception of odours among people of differ-
ent races and cultures, absence of uniformity in
evaluation as well as a disparity between self-per-
ceived and clinically detected halitosis re-
ports.11,44,63 However, the overall prevalence ranges
from 22% to 50%, being higher when self-reported
than clinically detected.18,71 Table 2 shows the prev-
alences of halitosis extracted from some studies.
Tangerman and Winkel,88 in their assessment of
58 subjects without periodontal disease but with
complaint of malodour, found 10.4% of them with
halitosis from non-oral sources. They also repor ted
dimethyl sulde (CH3SCH3) and methyl mercaptan
(CH3SH) as the main VSCs associated with extra-
oral and intra-oral halitosis, respectively.12 In their
study on daily variation of oral malodour and related
factors in community-dwelling elderly subjects, Sam-
nieng et al72 found a signicant association between
the concentration of CH3SCH3 with systemic diseas-
es and routine intake of medications at all times of
measurements. Subjects with systemic disease and
routine intake of medicines (80.7%) tended to have
a higher concentration of CH3SCH3 than their coun-
terparts. Although halitosis from non-oral sources is
generally not common, records from a multidisciplin-
ary breath clinic show that the most frequent non-
oral source is in the ear, nose and throat area.21,22
IMPACT OF HALITOSIS ON THE INDIVIDUAL
AND SOCIETY
Halitosis has both medical and social aspects, the
latter being responsible for most of the concern in
recent times.9,19,73 Some phrases used to describe
it in the literature include social stigma,6 social
health problem,63 universal medico-social prob-
Table 1 Aetiological agents/conditions associated with halitosis
Bacteria in oral cavity
Other oral
contributory
factors Consumables (food and drugs) Non- oral sources
Treponema denticola, Porphyr-
omonas gingivalis, Porphyromonas
endodontalis, Prevotella interme-
dia, Bacteroides loescheii,
Enterobacteriaceae, Tannerella
forsythia, Centipeda periodontii,
Eikenella corrodens, Fusobacte-
rium nucleatum, Micromonas
micros, Campylobacter rectus,
Desulfovibrio and Eubacterium
spp.8,16,37,43,58
Tooth decay,
gingival
inammation,
poor oral
hygiene,
dental
abscesses
and presence
of dental
prosthe-
ses6,55
Drugs causing dry mouth
(xerostomia) – anti- cholinergics,
e.g. atropine, anti-depressants;
diuretics, e.g. furosemide;
anti-hypertensives, e.g. methyl-
dopa and captopril; analgesics,
e.g. codeine, methadone,
ibuprofen and piroxicam; anti -
histamines, e.g. brompheniramine
and diphenhydramin; some
cytotoxic agents, solvent
abuse45,58
Non- oral sources of halitosis
include ENT infections (acute
pharyngitis, purulent sinusitis, and
postnasal drip); bronchial and lung
disease (chronic bronchitis,
bronchiectasis, bronchial carci-
noma), liver diseases (cirrhosis),
kidney disorders (chronic renal
failure), metabolic disorders
(diabetes/diabetic ketoacidosis),
GIT disorders, e.g.
GERD11,45,58,84,91
Peptostreptococcus anaerobius,
Collinsella aerofaciens, Veillonella
spp., Selenomonas flueggei, and
Proteus mirabilis89
Dry mouth,
food impac-
tion areas in
between
teeth, oral
ulcerations,
oral malignan-
cies6,24,39,58,87
Onions, garlic, cof fee, alcohol,
cigarettes14,35,38 ,68,74
Other conditions linked with
halitosis: dehydration, old age,
anaemia, hypovitaminosis,
emotional stress, inammatory
autoimmune diseases and
obstruction of salivar y glands,
malignancy and irradiation for
head and neck cancers, multiple
sclerosis, menopause45,58
Atopobium pavulum, Eubacterium
sulci, Fusobacterium periodonti-
cum, Dialister spp., Solobacterium
moorei, certain uncharacterised
Streptococcus species29,33
Akaji et al
Vol 12, No 4, 2014 299
lem63 and social-life killer.9 Hence, it could consti-
tute a handicap leading to withdrawal from social
circles by affected individuals.24,34 Data analysed
from 465 patients who attended the halitosis clinic
at the University of Basel over a 7-year period re-
vealed that social life was affected in about 388 of
them.97 Sufferers of halitosis can also be plagued
with anxiety regardless of whether the condition is
real or imagined.4,75,90 Anxiety in this context is
mo re or l ess phobia-me diate d, leading to avoidance
of dental visits, poorer oral health and ultimately to
a heightened or real oral malodour.75 Clinicians ob-
served a trend among victims: behavioural practic-
es such as use of mints and chewing gum, mouth-
wash, sprays and dental oss, increased frequency
of toothbrushing and toothbrushing force were ap-
plied to mask bad breath.10,14,49,58 Thus, proper pro-
fessional guidance in employing some of these
practices is strongly encouraged to avoid unwanted
side effects, such as tooth-wear lesions and caries.
Other challenges that can ensue from halitosis
are low self-esteem and self-condence, hampered
intimate relationships such as dating and marriage,
decreased quality of life, unfullled career aspira-
tions, loneliness, depression, substance abuse,
dropping out of school, suicidal tendencies and di-
Table 2 Prevalence of halitosis extracted from some studies
Authors /
year Location Subjects/N
Typ e o f
assessment Prevalence report
Other observations /
conclusion
Odai et al,
201055 Benin city,
Nigeria
41 consecutive
patients attending a
halitosis clinic
Organoleptic
assessment
80.5% with genuine
halitosis
The most af fected
population was the age
group 60–69
Eldarrat et
al, 200824 Libya
498 student volun -
teers and of ce
workers
Self-perceived 44.4% in males and
54.2% in females
Halitosis was perceived
mostly upon awakening
Almas et
al, 20036Riyadh 481 dental students
(19 –24 years) Self-perceived 44% in males and 32% in
females
Smoking, dr y mouth and
tea consumption were
the other features
Mbodj et
al, 201147 Senegal 62 dental prostheses
users
Measurement
of VSCs using
halimeter
35.4% for all cases:
72.2% for xed denture
users and 27.3% for users
of removable dentures
Mean VSC level 157.7 ±
152.6 ppb was much
higher than the cut-off
point VSC ≥ 152.6
Arowojolu
and
Dosunmu,
20047
Ibadan,
Nigeria
255 consecutive
patients (16–74 years)
Organoleptic
assessment
14.5% among attendees
of the periodontology
clinic
Signicant differences
were found in the
prevalence of halitosis
according to age group,
oral hygiene status and
social class
Liu et al,
200642 China 2000 (15–64 years)
Organoleptic
assessment
and with
sulde monitor
27.5% by organoleptic
score
Tongue coating, peri-
odontal status and
plaque index had positive
associations with level of
oral malodour
Bornstein
et al,
2009a12
Switzer-
land
419 individuals
from Bern,
(18 –9 4 years)
Organoleptic
assessment
and VSC
measurement
28% had readings of ≥
75 ppb VSCs in their
breath (halimeter)
Weak correlation
between self-reported
with either organoleptic
or VSC measurement
Bornstein
et al,
2009b13
Switzer-
land
625 Army recruits
(18 –25 yea rs)
Compared
self-perceived
halitosis with
clinical data
20% prevalence of
halitosis
No correlation between
self-reported halitosis
and clinical measure-
ment was detected
Söder et
al, 200080 Sweden Swedish men/ 1681 Clinically rated
halitosis 41 (2.4%) prevalence
Signicantly higher
probing depth and
gingival index
Miyazaki et
al, 199551 Japan 2672 individuals aged
18 to 64 years
VSCs scores
with halimeter 6%–23%
Signicant link between
VSC values and tongue
coating status; periodontal
conditions were observed
Akaji et al
300 Oral Health & Preventive Dentistry
vorce.3,4,9 Ancient Hebraic texts (the Talmud) pro-
vided legal backing to broken marriages if one part-
ner had oral malodour and similar references were
found in writings from Greek, Roman, early Chris-
tian and Islamic cultures.73
The effect of halitosis goes beyond the immedi-
ate sufferer as relatives and friends also share in
the burden.9,19 Apart from the awkward scenario
created by the condition, relatives may need to re-
assure or counsel the sufferers about their bad
breath.9,55 Delanghe et al22 reported that more than
70% of the attendees at a Belgian breath clinic were
advised by others to seek treatment; in a suburban
health facility in Nigeria, 31.7% and 24.4% were in-
formed of the symptoms by friends and spouses,
respectively, before they visited the clinic.55 From
an economic point of view, productive hours are lost
while sufferers seek solutions to their predicament,
with a concurrent boom in the mouthwash indus-
try.9,55 This is evidenced by the $700 million dollars
spent on mouthwashes by Americans in 2000 and
more than $850 million dollars in the previous
years.52,67 Meningaud et al49 reported over 2 billion
dollars spent annually on products to mask halito-
sis. It can be concluded that a great deal of social,
psychological and economic resources are devoted
to halitosis both at the individual and community
levels, since its impact cuts across culture, religion,
race, sex and social taboos.63,73
PREVENTION AND CONTROL OF HALITOSIS
Halitosis, a condition with known microbial and bio-
chemical parameters, can be prevented and/or
controlled.2,41,44,85 Each case is treated differently
depending on its origin, making a holistic approach
necessary.53 Before a treatment plan can be devel-
oped for any patient, an accurate diagnosis based
on the patient’s history, physical examination, or-
ganoleptic assessment and evaluation of any la-
boratory tests must be made.48 Also, a review of
signicant aspects of the patient’s family and so-
cial history (such as dietary and smoking habits),
drug histories, illnesses, hospitalisations and sur-
geries are invaluable in reaching an appropriate di-
agnosis.48 In 1999, Miyazaki et al50 established
the recommended classication for halitosis with
the corresponding treatment needs:
TN-1: Explanation of halitosis and instructions
for oral hygiene (support and reinforcement of a
patient’s own self-care for further improvement
of his/her oral hygiene).
TN-2: Oral prophylaxis, professional cleaning and
treatment of oral diseases, especially periodon-
tal diseases.
TN-3: Referral to a physician or medical specialist.
TN-4: Explanation of examination data, further pro-
fessional instruction, education and reassurance.
TN-5: Referral to a clinical psychologist, psychia-
trist or other psychological specialist.
Dental clinicians may implement the TN-1 modality
as treatment of physiologic halitosis; TN-1 and TN-2
apply to oral pathological halitosis, while TN-1 and
TN-4 would sufce for pseudo-halitosis.50,94 Treat-
ment of extraoral halitosis should be performed by
a physician or medical specialist in line with TN-3,
while treatment of halitophobia should be by a clin-
ical psychologist, psychiatrist or psychologist (TN-
5).50,94 TN-2 procedures entail mechanical reduc-
tion of tongue coating as well as gingivitis and
periodontitis therapy.50,59 Some clinicians have ad-
vised adequate oral hygiene at home: toothbrush-
ing, ossing and moderate tongue scraping or
brushing using an infant toothbrush or a small
tongue brush to remove the microbial causal
agent(s).53,54,85 Chemical agents and use of natural
ingredients such as mouthrinses containing chlor-
hexidine, triclosan, cetylpyridinium chloride, essen-
tial oils or hydrogen peroxide could also be pre-
scribed.18,35,64 Metal ions, e.g. stannous, zinc and
copper ions, are useful in controlling halitosis
through their anti-plaque properties, that is, by the
oxidation of either thiol groups in the sulfur-contain-
ing precursors of VSCs or the odoriferous substanc-
es themselves to non-volatile substances.35 Chlor-
ine dioxide is another antibacterial mouthwash that
may be used against oral malodour.28,79 Two sepa-
rat e cli nica l tri als b y the s ame r esea r ch gr oup f ound
it effective as an oxidant in both healthy and af-
fected subjects for the control of oral malodour.77,78
Other agents against halitosis include bacterio-
cin-producing microorganisms (probiotics) such as
Streptococcus salivarius K12 and Lactobacillus sali-
varius WB21.16,32,46 Here, the objective is to pre-
vent re-establishment of undesirable bacteria,
thereby limiting the re-occurrence of oral malodour
over a prolonged period, since probiotics are keen
competitors of oral malodour bacteria.11 Herbal
and natural products have also been advocated for
the control of halitosis.31,62,76,81,82, 86 Green tea
mouthwash containing green tea extracts demon-
strated an appreciable effect among 60 patients
with gingivitis who had at least 80 ppb VSCs in
mouth air. The reduction in malodour observed was
Akaji et al
Vol 12, No 4, 2014 301
Table 3 Summary of some interventional data on prevention and control of halitosis
Authors/
year Study design Strategy used Results
Effectiveness of the
method
Odai et al,
201055
Prospective study of 41
consecutive patients
given clinical interven-
tions
Scaling and polishing;
restorations of cavities and
replacement of dentures
Reduced bacterial load in
patients’ mouth
Satisfactory outcome in 90.2%
of cases
Rösing et
al, 200970
Double blind crossover
study involving 14
subjects (20–35 years)
with healthy periodon-
tium
Use of 2 chewing gums as
masking agents measured in 2
series: 1st without and 2nd
after a mouthrinse c ontaining
cysteine
VSCs production was same for
both over time in the 2 series,
largest reduction (71% to 52%)
observed after 5 and 15 min
VSCs production diminished
after chewing gum; reduction
enhanced by cysteine rinses.
Effect was not sustained; only
served as a temporary
measure
Faveri et
al, 200625
Blinded crossover
study involving 19
volunteers
Tongue scraping and interdental
cleaning done thrice a day for 7
days, then washouts
Reduced VSCs in morning
breath in subjects with healthy
periodontium
In periodontally healthy
subjects, tongue scr aping was
an impor tant method of
reducing halitosis
Pedrazzi
et al,
200456
Crossover trial
involving 10 healthy
subjects (20–50 years)
Efcacy of 2 methods for tongue
cleaning – toothbrush and tongue
scraper were compared through
a handheld sulde monitor
The tongue scraper yielded a
75% reduction in VSCs, while
the toothbrush only achieved a
45% reduction in VSCs
Tongue scraper performed
better in reducing the
production of VSCs
Quirynen
et al,
200260
Experimental study
involving 16 dental
students who rinsed
with one of the 3
solutions in a
randomised order
Rinsing with CHX-Alc, CHX-CPC-
Zn, or AmF/SnF2 mouthrinse,
used twice daily for 1 week
Zinc cations added to CHX
mouthrinse yielded 40%
reduction in VSC, 80%
reduction in organoleptic
expired ratings
Sulfur binding to zinc produced
an enhanced effect of halitosis
reduction
Carvalho
et al,
200417
Randomised double-
blind crossover study
involving 12 dental
students
Use of 4 different mouth rinses
twice daily without mechanical
plaque control
Reduced VSCs formation. Best
result using 0.2% CHX, then
0.12% CHX + triclosan+
essential oils then CPC
Benecial impact of mouth
rinses on VSCs even in
absence of mechanical plaque
control
Van
Steen-
berghe et
al, 200192
Double-blind ran-
domised study
involving 12 (aged
21–23 years) medical
student volunteers
Randomised daily rinse with 1
of the following: CHX, CHX- NaF
or HX-CPC-Zn
CHX-CPC-Zn was more
effec tive in reducing organo-
leptic scores and sulde
monitoring readings
Benecial effect on halitosis
althoug h the mode of action
was unclear
Shinada
et al,
201078
Randomised double-
blind crossover,
placebo-controlled trial
involving 15 male volun-
teers (19–38 years)
Divided subjects into 2 groups
that rinsed with either mouth-
wash cont aining chlorine dioxide
(ClO2) or placebo mouthwash
without ClO2 for 7 days
Concentrations of VSCs
decreased for those who used
the experimental mou thwash
for 7 days; plaque and tongue
coating also decreased
Further investigations on
long-term effects of ClO2 and
its effect on periodontal
diseases and plaque accumula-
tion are needed
Feng et
al, 201027
Randomised con-
trolled, single-blind,
3- or 4-period
crossover investigation
involving 100 subjects
aged 19–62 years
Brushing with stannous- contain-
ing sodium uoride (NaF )
dentifrice in 4 independent
trials
The stannous-containing NaF
dentifrice showed greater
breath benets through
reduction of VSCs compared
to the negative control
dentifrice
Halitosis reduced at all three
points analysed, stannous-
containing NaF dentifrice
provided additional, simultane-
ous cosmetic and therapeutic
oral health benets
Burton et
al, 200616
Recruitment of 23
subjects (18–69 years)
from a population who
asserted they had
halitosis
Replacement of bacteria implicat-
ed in halitosis by S . salivarius
K12. A 3-day CHX mouthrinsing
followed at intervals with
lozenges containing S. salivarius
or a placebo
85% and 30% of S. salivarius
and placebo groups,
respectively, showed
substantial reduction of the
implicated bacteria.
Bacteriocin-producing S.
salivarius given after mouth-
wash treatment reduced VSCs
levels – randomised clinical
studies needed to validate the
result
Iwamoto
et al,
201032
Recruitment of 20
patients who
complained of halitosis
at the clinic within a
period of 14 months
2.01 x 109 Lactobacillus
salivarius WB21 and 840m g
xylitol t ablets were dissolved in
the mouth daily. Evaluation af ter
2 to 4 weeks was done at the
same time of day for each
subject
Oral malodour parameters
signicantly decreased at 2
weeks in the subjects with
physiological halitosis. The
scores of an organoleptic test
and bleeding on probing
decreased at 4 weeks the
subjects with oral pathologic
halitosis
Oral administration of probiotic
lactobacilli primarily improved
physiological halitosis and also
showed benecial effects on
bleeding on probing from the
periodontal pocket
Abbreviations: CHX = chlorhexidine (0.2%); CHX-Alc = 0.2% chlorhexidine- alcohol mouthrinse; CH X-CPC-Zn = 0.05% CHX + 0.05% cetylpyridinium
chloride + 0.14% zinc lactate mouthrinse; AmF/SnF = an amine uoride/stannous uoride (125 ppm F-/125 ppm F -) containing mouthrinse; CPC
= cetylpyridinium chloride; CHX-NaF = 0.12% chlorhexidine + 0.05% sodium uoride; CHX-C PC-Zn = 0.05% chlorhexidine + 0.05 cetylpyridinium
+ 0.14% zinc lactate; VSCs = volatile sulfur compounds.
Akaji et al
302 Oral Health & Preventive Dentistry
linked to the ability of the green tea catechins to
transform VSCs to non-odorigenic substances;
they were especially anti-microbially active against
P. gingivalis.62 Other herbal agents, such as Euca-
lyptus extract in chewing gum and extracts of me-
dicinal herbs – e.g. Scutellariae radix, Phellodendri
cortex, Moutancortex and Magnoliae cortex – had a
masking effect on oral malodour.31,86 Each of these
has been used to develop a gargle solution which
produced a positive outcome on halitosis. Palatal
muco-adhesive formulations containing herbal ex-
tracts also alleviated oral malodour for few hours
up to one day.81,83 These muco-adhesive formula-
tions reduced VSC scores to an extent comparable
to that of chlorhexidine and zinc mouthrinses.
Finally, it is advised that diagnosis of pseudo-hali-
tosis or halitophobia be made with caution; abnor-
mal oral deposits, carious teeth and other oral con-
ditions which suggest genuine halitosis must rst be
ruled out.5,23 Evaluation of the psychological predis-
position of such patients is invaluable; thus, the
TN-5 regimen is advised.94 For halitosis from non-
oral sources, a multi-disciplinary approach is indicat-
ed as prescribed by TN-3.50,94 Referrals to special-
ists such as otolaryngologists, gastroenterologists
or mental health specialists should be done once
possible oral contributors are excluded.5,21,41 Since
existing data show that patients’ response to treat-
ment is enhanced by educating the public and
healthcare personnel (especially dental clinicians),21
it is imperative to convey correct information on hali-
tosis both at the individual and public level. Undoubt-
edly, this will dispel some myths about halitosis and
aid in the prevention and control of the condition.
Some interventional studies on prevention and con-
trol of oral malodour are summarised in Table 3.
CONCLUSIONS
Halitosis is a public health issue which leads to social
embarrassment as well as decreased quality of life
and may be an indication of systemic diseases or seri-
ous conditions in the nasopharynx, oropharynx, hy-
popharynx, larynx and oesophagus. However, the ma-
jority of cases are of oral origin. It is prevalent worldwide,
affecting the individual and society, but in most cases
it can be controlled. Due to the associated social and
psychological effects on the individual, halitosis needs
to be handled with great care and should be taken seri-
ously by the dentist and dental hygienist. Where neces-
sary, interdisciplinary management should be initiated
as early as possible after the diagnostic process.
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... The social effect of dental caries includes toothache, tooth loss and bad breath (Akaji, 2014). The outcome of the social effect of dental caries is the inability to pronounce or talk, the inability to chew, sleep disruption due to pain and difficulty in breathing especially for those who use the mouth to breathe (Pakpour et al., 2017). ...
... Some people have bad breath but are not aware and they do not acknowledge having it (denied halitosis) (WHO, 2015). A study by Akaji showed that 28% of patients complaining of bad breath did not have clinical signs of bad breath (Akaji et al., 2014). Studies have shown varied levels of bad breath in different regions of the world with 42% in Japan, 23.6 % in Korea, 32% in Switzerland, 53.5% in Italy and 22.8% in Saudia Arabi (Nomura et al., 2019;Kim et al., 2016;Grieshaber et al., 2022). ...
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... disorders (diabetes mellitus), Gastrointestinal 8 disorders (gastroesophagal reflux disease). Halitosis is a universal medico-social problem in all communities of the world; a common complaint for both genders irrespective of age, social status, race 9 or nationality. ...
... 15 As in the present study, Sedky NA, 2015 reported that a high percentage of respondents identified dentists as the best professionals to treat halitosis, in contrast to a Portuguese study in which 21 gastroenterologists were most frequently selected. In this study, halitosis was seen to have a huge negative impact on one's confidence and this is in agreement with the recent review of Akaji et al., 8 2014 which emphasized the importance of controlling bad breath because it has serious impact on social life of those affected by the condition. In their study on attitudes towards individuals with halitosis among the Dutch general population, de 22 Jongh et al. documented that halitosis or bad breath was reported to be a strong 'downer' when meeting a person for the first time. ...
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Background: Halitosis is a universal medico-social problem in all communities of the world. Objective: Aimed to find out the level of knowledge, attitude and practice of clinical students towards halitosis.Materials and Method: This was a cross-sectional study conducted to assess the perception towards halitosis among clinical students in the University of Benin. The inclusion criteria included; any student who was eligible to give consent for the research and, those that consented to participate in the study. Data from the questionnaires was analyzed using the IBM statistical package for Scientific Solutions (SPSS) version 21.0.Results: A total of 80 clinical students were assessed on the perception of halitosis. The age group between 21-25 years accounted for the highest proportion with 49 (61.3%) of the respondents. On knowledge of halitosis, 78 (97.5%) of the respondents reported to have heard about halitosis. Concerning the source of halitosis, 79 (98.8%) agreed that it is due to oral conditions. Concerning the most qualified health professional to treat halitosis, 79 (98.8%) agreed that is the dentist. About 75(93.8%) believe that halitosis can be treated and that if not treated, can lead to loss of confidence 76 (95%) and poor academic performance 39 (48.8%).Conclusion: The knowledge and attitude of clinical students towards halitosis was good but their practice towards halitosis was not so encouraging and as such, there is need for more dental education towards routine oral health practices so that the clinical students can be an effective role model to the general populace.
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Halitosis is defined as the presence of an unpleasant odor in exhaled air, regardless of its cause. In most patients with halitosis, the condition causes embarrassment and interferes with social interactions and daily life. Furthermore, bad breath can be a sign of an underlying disease. Understanding the factors and causes that lead to halitosis and its manifestations could facilitate proper management of this condition. To properly diagnose and treat patients, healthcare professionals, including primary care physicians and dental professionals, must be familiar with the etiology and appropriate management of the disease. Consequently, this review aims to provide practitioners with up-to-date information on the etiological factors of halitosis to facilitate the establishment of preventive measures and provide accurate diagnosis and management.
... This malodor is essentially due to the presence of chemical compounds in the exhaled air, mainly volatile sulfur compounds (VSCs) in oral pathologies and volatile organic compounds (VOCs) in the majority of extraoral causes. 1 In the literature, reported prevalence of halitosis varies largely from study to study. This variation is due to many factors, such as its perception, definition, classification, and lack of a standard assessment method and diagnosis. ...
... [4][5][6] Studies suggest that in 70% of cases, genuine halitosis originates from the oral cavity. 1,7 The most common reason is tongue coating (around 43% of all cases). [7][8][9] In addition, it was shown that when VSCs are accompanied by VOCs, the origin of the halitosis will most likely be extraoral (10-20% of cases). ...
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Background: Halitosis (fetor ex ore, malodor, bad breath) is defined as an unpleasant odor coming from the oral cavity, regardless of the cause: local or systemic. It affects 22-50% of the population worldwide, leading to a significant decrease in the overall quality of life, and can have oral and extra-oral etiologies. There is an increased interest in the management of halitosis. Objectives: This study aims to evaluate the patient-dentist communication on halitosis, the dentists' knowledge about the management and etiology of halitosis, and the treatment options used by dentists who practice in Poland and Lebanon. Material and methods: An online questionnaire was sent to both Lebanese and Polish dentists using Google Forms (Google LLC, Mountain View, USA). In total, 205 dentists completed the questionnaire, of which 100 practiced in Poland (group P) and 105 practiced in Lebanon (group L). A multivariate analysis was conducted to determine differences between both groups and to identify parameters that could influence a dentist's management of halitosis. Results: According to the questionnaire, 86% of group P members and 65.7% of group L members reported communicating with patients about halitosis. Regarding the knowledge of halitosis, 78% of dentists in group P and 85.7% of dentists in group L reported that there is a classification for halitosis. A significant majority of dentists in both groups revealed not having any tool to measure halitosis (67.6% and 68% from group P and group L, respectively). Conclusions: This study confirms the need for improved communication skills in Polish and Lebanese dentists, as well as for education on the subject among dentists in both countries, and for standardization in diagnosis, treatment modalities and management of halitosis.
... Halitosis, often described as foul breath odor, significantly impacts individuals beyond its physical manifestations. Emerging from various oral and systemic issues, such as inadequate plaque control and gastrointestinal problems, halitosis is fueled by odoriferous components, mainly volatile sulfur compounds (VSCs) produced by oral bacteria within the oral cavity through the enzymatic reaction [1]. The repercussions of halitosis extend far beyond physical discomfort, profoundly affecting social interactions, self-esteem, mental well-being, relationships, work productivity, and sense of belonging [2]. ...
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Background Halitosis appears to have significant impacts on quality of life, necessitating reliable assessment tools. The Halitosis Associated Life-Quality Test (HALT) has been validated in various populations, but not among Thai people. While HALT provides a valuable foundation, there is a need for a culturally adapted and expanded instrument for the Thai context. Consequently, this study aimed to develop and validate a comprehensive questionnaire for assessing halitosis-related quality of life in Thai populations, incorporating a Thai version of HALT (T-HALT) as a core component. Materials and methods This cross-sectional study involved 200 dental patients at Mahidol University. The original HALT was translated into Thai using forward-backward translation. Cultural adaptation and psychometric properties of T-HALT were evaluated through multiple approaches. Content validity was ensured through expert reviews, while face validity was assessed by patient feedback. Reliability was examined via test-retest and internal consistency measures. Criterion and discriminant validity was evaluated by correlating T-HALT scores with self-perceived halitosis and volatile sulfur compound (VSC) measurements, respectively. VSCs were quantified using the OralChroma™ device, which analyzes breath samples collected directly from patients’ mouths. Construct validity was assessed through exploratory (EFA) and confirmatory factor analysis (CFA), providing insights into the questionnaire’s underlying structure. Results T-HALT demonstrated excellent internal consistency (Cronbach’s alphas = 0.940–0.943) and test-retest reliability (ICC = 0.886). Criterion validity was supported by a significant correlation between T-HALT scores and self-perceived halitosis (r = 0.503, P < 0.001). Discriminant validity was confirmed by the absence of a significant correlation between T-HALT scores and VSC levels (r = 0.071, P = 0.32). EFA revealed a four-factor structure, which was subsequently confirmed by CFA. However, Items 1 and 7 were excluded due to poor standardized factor loadings. Conclusion T-HALT demonstrates good reliability and validity for assessing halitosis-related quality of life in Thai populations. It performs well as a unidimensional measure, but its multidimensional application requires modifications. Future research should validate a modified version excluding Items 1 and 7 across diverse Thai populations, potentially enhancing its cultural specificity.
... Halitosis, usually defined as an offensive or unpleasant odor emanating from the breath [1][2][3], has a worldwide prevalence ranging from 22 to 50% [4], and is the third most common reason for individuals to seek dental treatment, ranking only behind periodontitis and dental caries [5]. It can have a serious impact on an individual's quality of life. ...
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Objectives The purpose of this systemic review and meta-analysis was to explore the association between halitosis and periodontitis in observational studies. Materials and methods A systematic search covered PubMed, Web of Science, Embase, Scopus, and Cochrane Library until August 18, 2023. Nine observational studies (585 cases, 1591 controls) were analyzed using Stata 17, with odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses considered halitosis assessment methods. Results The review found a positive association between halitosis and periodontitis. Significant differences were observed with organoleptic test (OR = 4.05, 95% CI: 1.76, 9.30, p < 0.01) and volatile sulfur compound readings (OR = 4.52, 95% CI: 1.89, 10.83, p < 0.01). Conclusions A positive association was observed between halitosis and periodontitis, supported by significant differences in both organoleptic and volatile sulfur compound readings. However, conclusive findings are limited by statistical heterogeneity, emphasizing the need for additional research. Clinical relevance Understanding the halitosis and periodontitis association is clinically significant, informing potential interventions for improved oral health. Further research is vital to refine understanding and guide effective clinical strategies, acknowledging the limitations in current findings.
Article
A BSTRACT Background Reducing the levels of oral microbials, including Streptococcus mutans , Candida albicans , and Lactobacilli sp., would provide the prevention of dental caries and oral illness. Aims To assess the antimicrobial effectiveness against oral pathogens of oral care products that contain urginea maritima extract (UM) extract, including lozenges, mouth spray, and mouthwash. Methods The skin irritation test was conducted on each product compared with controls in healthy participants (n = 10) by the 24-hour closed obstruction patch test. The elimination of oral pathogens in participants (n = 30) before and after product usage (as per the instruction) was assessed using a modified dip slide test. Result The physical appearance and stability of oral care products were almost preferable. When added to oral care products for oral health maintenance, the cariogenic bacteria S. mutans, Candida species, and Lactobacilli species have been found to exhibit antimicrobial activity.
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Objective: To assess the prevalence of halitosis among the general population of Karachi, and to identify factors contributing to its occurrence. Method: The cross-sectional study was conducted from March to July 2022 in Karachi after approval from the ethics review board of Dow University of Health Sciences, Karachi, and comprised the adult population of Karachi. Data was collected online using a questionnaire that was piloted before its link was distributed through social media platforms. The questionnaire evaluated the association of demographic features with self-perceived halitosis on the basis of which factors predictive of halitosis were determined. Data was analysed using SPSS 26. Results: Of a total of 342 subjects, 182(53%) were females and 160(47%) were males. There were 141(41$) subjects aged 18-25 years, and 166(48%) were graduates. Overall, 240(70%) subjects reported to have self-perceived halitosis. Age, monthly household income, niswar and tea consumption, irregular use of dental floss and tongue cleaning were associated with higher incidence of halitosis (p<0.05). Carrying water bottle while outside was associated with decreased halitosis (p=0.007). Symptoms of gastroesophageal reflux disease, sinusitis, asthma, diabetes, hypertension and mental stress were associated with halitosis (p<0.05). Higher monthly household income and daily use of dental floss predicted lower odds of halitosis (p<0.05). Conclusion: Maintaining good oral hygiene and hydration reduced, while comorbid conditions increased the probability of halitosis. Key Words: Halitosis, Sinusitis, Gastroesophageal, Tongue, Hypertension, Asthma, Tea.
Article
Recently, there has been an increased self-awareness of halitosis post the COVID-19 pandemic due to the continuous wearing of masks. Oral malodor, often known as foul/bad breath, is a foul odor that arises from the oral cavity. Numerous etiologic factors cause breath malodor, of which tongue coating is the most common intraoral cause. Extra-oral etiology, such as lung infections, diabetes, and kidney diseases, also plays a significant role. Halitosis is caused by anaerobic bacteria producing volatile sulfur compounds subsequent to protein degradation in the mouth. Intraoral etiology is the most common cause that can be efficiently treated with proper oral hygiene, mechanical, and chemical plaque control methods. Extra-oral etiology requires referral to a medical specialist. However, psychological causes such as halitophobia necessitate consultation with a clinical psychologist. Persistent oral malodor has a negative impact on social interactions and decreases the oral health-related quality of life. A literature search of review articles, systematic reviews, and studies on halitosis, using the mesh terms etiology, diagnosis, and management, was carried out using PubMed and Google Scholar search engines. This review addresses the basic concepts of oral malodor, its causes, pathophysiology, and management.
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Breath malodour is a condition that has health and social implications. The origin of breath malodour problems are related to both systemic and oral conditions. The advice of dental professionals for treatment of this condition occurs with regularity since 90% of breath odor problems emanate from the oral cavity. This paper provides a comprehensive review of the etiology of breath odor, its prevalence, diagnosis, and treatment strategies for the condition. Citation Sanz M, Roldán S, Herrera D. Fundamentals of Breath Malodour. J Contemp Dent Pract 2001 Nov;(2)4: 001-017.
Article
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Oral malodor is a common problem among general population and evidences reveal that it forms about 85% of all bad breath. Bad breath can have a distressing effect that may become a social handicap and the affected person may avoid socializing. The condition is multifactorial in etiology and may involve both oral and non-oral conditions. Volatile sulphur compounds (VSC), namely hydrogen sulphide (H2S) and methyl mercaptan (CH3SH) are the main cause of oral malodor. These substances are by-products of the action of bacteria on proteins. Gram-positive bacteria produce little or no malodor; most Gram-negative bacteria are potent producers of odoriferous compounds. Treatments corresponding to the causes of oral malodor include mechanical or chemical tongue cleaning, periodontal disease treatment, oral hygiene instruction and mouth rinses or mouthwashes.
Article
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ABSTRACT: Background: It is estimated that approximately 85% of all halitosis cases have their origin within the mouth; of these, 50% are caused by tongue residues. Previous studies have established that hydrogen sulfide and mercaptans are the primary components of halitosis. Thus, tongue cleaning gains importance as a means for halitosis management. Methods: This investigation compared the efficacy of two mechanical methods for tongue cleaning through a handheld sulfide monitor. This crossover trial was carried out with 10 healthy subjects, 20 to 50 years old. Before the baseline measurement of the volatile sulfur compounds (VSCs), the subjects were instructed to refrain from any tongue cleaning method for 48-hours. The 10 participants were then placed in one of two groups (five each): 1) first week: new tongue scraper, second week: soft-bristle toothbrush; 2) first week: toothbrush, second week: tongue scraper, with a 48-hour wash-out period between each week. Results: The baseline measurements were compared with those of the end of each week using the Dunn method (=0.01). The tongue scraper showed a 75% reduction in VSCs, while the toothbrush only achieved a 45% reduction in VSCs. Conclusion: Although the tongue coating was removed by both methods, the tongue scraper performed better in reducing the production of volatile sulfur compounds (VSCs). J Periodontol 2004; 75(7):1009-1012. Accepted for publication on November 21 2003.
Book
Public health is a key concern of modern dental practitioners as they continue to play a vital role in the health of populations across the world. The second edition of Essential Dental Public Health identifies the links between clinical practice and public health with a strong emphasis on evidence-based medicine. Fully revised and updated for a second edition, this textbook is split into four parts covering all the need-to-know aspects of the subject: the principles of dental public health, oral epidemiology, prevention and oral health promotion, and the governance and organization of health services. Essential Dental Public Health is an ideal introduction to the field for dentistry undergraduates, as well as being a helpful reference for postgraduates and practitioners.
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Halitosis is an offensive odour emanating from the oral cavity and it is a common clinical condition. The purpose of this study is to emphasize the importance of the correct diagnosis of the type of halitosis in order to achieve a successful management. The four cases reported in this study revealed that a cause of the halitosis can be found most of the time following thorough examination. Elimination of the cause or source of the mal-odour eventually eliminates the halitosis. Dental practitioners should therefore be cautious in making a diagnosis of pseudo-halitosis and halitophobia which are very rare conditions and they should patients should be referred for expert management. Key words: Halitosis, Halitophobia, Pseudo-halitosis, management, diagnosis