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Halitosis and helicobacter pylori infection
A meta-analysis
Wenhuan Dou, MM, Juan Li, MM, Liming Xu, MM, Jianhong Zhu, PhD, Kewei Hu, MM, Zhenyu Sui, MM,
Jianzong Wang, MM, Lingling Xu, MM, Shaofeng Wang, MM
∗
, Guojian Yin, PhD
∗
Abstract
Background: Halitosis is used to describe any disagreeable odor of expired air regardless of its origin. Numerous trials published
have investigated the relation between Helicobacter pylori (H pylori) infection and halitosis, and even some regimes of H pylori
eradication have been prescribed to those patients with halitosis in the clinic. We conducted a meta-analysis to define the correlation
between H pylori infection and halitosis.
Objectives: To evaluate whether there is a real correlation between H pylori infection and halitosis, and whether H pylori eradication
therapy will help relieve halitosis.
Methods: We searched several electronic databases (The Cochrane Library, MEDLINE, EMBASE, PubMed, Web of Science, and
Wanfangdata) up to December 2015. Studies published in English and Chinese were considered in this review. After a final set of
studies was identified, the list of references reported in the included reports was reviewed to identify additional studies. Screening of
titles and abstracts, data extraction and quality assessment was undertaken independently and in duplicate. All analyses were done
using Review Manager 5.2 software.
Results: A total of 115 articles were identified, 21 of which met the inclusion criteria and presented data that could be used in the
analysis. The results showed that the OR of H pylori infection in the stomach between halitosis-positive patients and halitosis-negative
patients was 4.03 (95% CI: 1.41–11.50; P=0.009). The OR of halitosis between H pylori-positive patients and H pylori-negative
patients was 2.85 (95% CI: 1.40–5.83; P=0.004); The RR of halitosis after successful H pylori eradication in those H pylori-infected
halitosis-positive patients was 0.17 (95% CI: 0.08–0.39; P<0.0001), compared with those patients without successful H pylori
eradication. And the RR of halitosis before successful H pylori eradication therapy was 4.78 (95% CI: 1.45–15.80; P=0.01),
compared with after successful H pylori eradication therapy.
Conclusions: There is clear evidence that H pylori infection correlates with halitosis. H pylori infection might be important in the
pathophysiological mechanism of halitosis, and H pylori eradication therapy may be helpful in those patients with refractory halitosis.
Abbreviations: CBS =cystathionine b-synthase, CLO-test =campylobacter-like organism test, CSE =cystathionine g-lyase,
ENT =ears, nose, and throat, GERD =gastroesophageal reflux disease, H pylori =Helicobacter pylori, H2S =hydrogen sulfide, MM
=methyl mercaptan, UBT =urea breath test, VSC =volatile sulfur compounds.
Keywords: halitosis, Helicobacter pylori, meta-analysis
1. Introduction
The term halitosis or bad breath is generally defined to
describe any noticeable disagreeable odor of expired air
regardless of its origin.
[1]
The diagnosis of halitosis can always
be genuine halitosis, pseudo halitosis, and halitophobia.
[2]
As
a public social health problem, genuine halitosis is always
classified into physiological and pathophysiological illness,
which affects a significant number of people around the world.
Research reveals that nearly 50% of the adult population has
halitosis.
[3]
The cause of the halitosis is often considered to be found in the
oral cavity. It was found that 80% to 90% of patients with
halitosis was caused by oral conditions, defined as bad breath or
oral malodor.
[4]
Halitosis usually results from deep caries,
pericoronitis, periodontal disease, exposed necrotic tooth pulps,
peri-implant disease, imperfect dental restorations, unclean
dentures, tongue coating, mucosal lesions, and factors causing
decreased salivary flow rate.
[4]
The causative organisms from
halitogenic biofilm on the posterior dorsal tongue, and/or within
gingival crevices/periodontal pockets are usually gram-negative
anaerobic bacteria. The basic pathophysiological process is
microbial degradation of sulfur containing amino acid sub-
strates, for example, methionine, cysteine, and cysteine.
[5]
Bacterial metabolism of these kinds of amino acids leads to
metabolites including many compounds, such as volatile sulfur
compounds (VSC), for example, hydrogen sulfide (H
2
S), methyl
Editor: Natale Figura.
WD, JL, LX, and JZ contribute equally in this meta-analysis.
The authors have no conflicts of interest to disclose.
Department of Gastroenterology, The Second Affiliated Hospital of Soochow
University, Suzhou, Jiangsu Province, People’s Republic of China.
∗
Correspondence: Guojian Yin, Department of Gastroenterology, The Second
Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, People’s
Republic of China (e-mail: ygj234@163.com); Shaofeng Wang, Department of
Gastroenterology, The Second Affiliated Hospital of Soochow University, Suzhou,
Jiangsu Province 215004, People’s Republic of China
(e-mail: sfwang68@yahoo.com.cn).
Copyright ©2016 the Author(s). Published by Wolters Kluwer Health, Inc. All
rights reserved.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Medicine (2016) 95:39(e4223)
Received: 5 April 2016 / Received in final form: 29 May 2016 / Accepted: 20
June 2016
http://dx.doi.org/10.1097/MD.0000000000004223
Systematic Review and Meta-Analysis Medicine®
OPEN
1
mercaptan (MM, CH
3
SH), dimethyl sulfide, and skatole,
indole.
[6]
The main odorants implicated in intraoral halitosis
are MM and H
2
S.
[7]
About 10% to 20% of all genuine halitosis cases are attributed
to extra-oral diseases,
[5]
including upper and lower respiratory
tract disorders, gastrointestinal disorders, some systemic dis-
eases, metabolic diseases, medications, and cancer.
[4]
Some
authorities have reported that the ears, nose, and throat (ENT)
are the most common sites of origin of extra-oral halitosis,
[5]
and
it is well established that various ENT disorders and symptoms
may be a manifestation of gastroesophageal reflux disease
(GERD). Poelmans et al
[8]
showed that patients with suspected
GERD-related ENT symptoms had a high prevalence of
esophagitis and this was associated with better response to
antisecretory therapy. Moshkowitz et al
[9]
found that halitosis
was a frequent symptom of GERD and might be considered an
extra-esophageal manifestation of GERD. Struch et al
[10]
showed
clear evidence for an association between GERD and halitosis
and suggested treatment options for halitosis, such as proton
pump inhibitors.
It was Tiomny et al
[11]
who first showed the possible
connection between halitosis and Helicobacter pylori (H
pylori) infection in a case report. Since then, Hpylori
infection has been investigated with regards to a potential
relationship with halitosis in the past 20 years in many
studies, and inconsistent results from case reports, epidemio-
logical studies, randomized controlled trials, and quasir-
andomized controlled trials have been reported.
[7,11–29]
For
example, data from Ierardi et al
[13]
showed that Hpylori
eradication could resolve the symptom of halitosis. Serin
et al
[19]
showed that halitosis was a frequent and treatable
symptom of Hpylori-positive nonulcer dyspepsia and
suggested an Hpylorieradication therapy for those patients
with halitosis. However, on the contrary, in Tangerman study
no association between halitosis and Hpyloriinfection was
found and he concluded that halitosis always originated
within the oral cavity and seldom or never within the
stomach.
[7]
In order to clarify the possible relation between the H pylori
infection and the annoying halitosis, we conducted an exhaustive
review and meta-analysis of all the literatures related to this
subject to evaluate whether H pylori is a cause of halitosis and
whether eradication of H pylori can relieve it.
2. Methods
2.1. Search strategy
The Medical Ethics Committee of a 3-A hospital, the second
Affiliated Hospital of Suzhou University, Suzhou, China,
approved the study. Due to the review nature of the study,
informed consent was waived. A comprehensive, computerized
literature search was conducted in MEDLINE, PubMed, Web
of Science, and Wanfangdata from the beginning of indexing
for each database to December 2015, by 2 independent
investigators (GY and WD). Articles published in English and
Chinese were considered in this review. Search terms included:
“halitosis,”“bad breath,”or “malodor,”combined with
Helicobacter pylori,or“urea breath test.”The title and
abstract of eligible studies were then reviewed to exclude any
study that was irrelevant to the research question. After a final
set of studies was identified, the list of references reported in the
included reports was reviewed to identify additional studies.
We did not include data presented only as abstracts at
conferences.
2.2. Study selection and data extraction
Two review authors, Guojian Yin and Wenhuan Dou indepen-
dently assessed the abstracts of studies resulting from the
searches. Studies were included if they met the following criteria:
published as an original article; published as case reports, case-
control studies, cross-sectional studies, randomised/quasi-ran-
domised controlled trials, and comparative clinical experimental
trial; the relation between the incidence of halitosis and Hpylori
infection, or the incidence of halitosis before and after
eradication therapy of H pylori, were investigated in these
articles. Full text copies of any relevant and potentially relevant
studies, those appearing to meet the inclusion criteria, or for
which there were insufficient data in the title and abstr act to make
a clear decision, were obtained. The full articles were assessed
independently by 2 review authors and any disagreement on the
eligibility of included studies was resolved through discussion
and consensus.
2.3. Statistical analysis
All studies were grouped and analyzed on the basis of study
design: Hpyloriinfection rates in patients with or without
halitosis (group 1); Halitosis rates in patients with or without
H pylori infection (group 2); Halitosis rates in infected
halitosis patients after the treatment with or without successful
H pylori eradication (group 3); Halitosis rates in Hpylori-
infected patients before and after successful H pylori eradica-
tion (group 4).
The Cochrane Q-statistic and the I
2
-statistic were used to
assess statistical heterogeneity between studies, and an I
2
value
of >50% or a Pvalue <0.05 for the Q-statistic was taken to
suggest significant heterogeneity.
[30]
In the presence of heteroge-
neity, the random-effects model is recommended by the Cochrane
collaboration, because its assumptions account for the presence
of variability among studies.
[31,32]
As the included studies in each
subgroup were less than 10, the publication bias was not assessed
through Funnel plot or Begg test
[33]
and Egger tests in this
study.
[34]
All statistical tests were 2-tailed, and a probability level of P<
0.05 was considered significant. Results were presented in
accordance with the guidelines proposed by MOOSE.
[35]
ORs
(case-control studies, cross-sectional studies) and RRs (random-
ized controlled trials and quasi-randomized controlled trials, or
comparative clinical experimental trials) were used as the
reporting different risk estimates. All analyses were done using
Review Manager 5.2 software.
3. Results
The search strategy generated 115 citations, of which 57 were
considered of potential value. Thirty-six of these 57 articles were
subsequently excluded from the meta-analysis for various
reasons (21 studies were excluded by inclusion criteria, 10
reviews, 4 meeting abstracts/summaries, and 1 comment). No
additional article was included from the reference of the included
21 articles even after an overall and careful inspection of those
references. In the final analysis 21 articles (2 case reports, 1 cross-
sectional study, 13 case-control studies, 4 comparative quasi
clinical experimental trials, and 1 prospective nonrandomized
Dou et al. Medicine (2016) 95:39 Medicine
2
open-label trial) were included. Figure 1 shows the flow-sheet of
these studies and their classification by study design. Four
subgroups were further classified in the final meta-analysis.
The characteristics of the studies are shown in Table 1. The
publication dates of the studies included in the meta-analysis
ranged from 1992 to 2015. The 21 studies were ranked as
moderate quality. A total of 5062 participants were involved in
these studies (2312 participants in group 1, 2052 participants in
group 2, 128 participants in group 3, and 570 participants in
group 4).
3.1. Group 1 (n =7): H pylori infection rates in patients
with or without halitosis
Halitosis rates were associated with a statistically significant
increase of H pylori infection as shown by the random-effects
model: Overall OR is 4.03 (1.41–11.50) with P<0.05 (Fig. 2).
Evidence of heterogeneity was shown between the studies: The I
2
was 89 and P<0.05. The random-effects meta-analysis was
therefore applied to minimize the effects of heterogeneity.
3.2. Group 2 (n =9): halitosis rates in patients with or
without H pylori infection
Hpyloriinfection rate were associated with a statistically
significant increase of halitosis as shown by the random-
effects model: overall OR is 2.85 (1.40–5.83) with P<0.01
(Fig. 3). Evidence of heterogeneity was shown between the
studies: The I
2
was 87.20 and P<0.05. The random-effects
meta-analysis was therefore used to minimize the effects of
heterogeneity.
3.3. Group 3 (n =3): halitosis rates in H pylori-infected
halitosis patients after the treatment with or without
successful H pylori eradication
Compared with the halitosis rates of those H pylori-infected
halitosis patients without successful H pylori eradication after the
treatment, the halitosis rates of the patients with successful H
pylori eradication were lower with a statistical significance:
overall RR is 0.17 (0.08–0.39) with P<0.0001 (Fig. 4). There
was no evidence of heterogeneity between the studies (the I
2
was
11.00 and P>0.05). The fixed-effects meta-analysis was
therefore chosen to assess the overall RR effects.
3.4. Group 4 (n =5): halitosis rates in H pylori-infected
patients before and after successful H pylori eradication
Compared with the halitosis rates in those H pylori-infected
patients before the successful H pylori eradication, it was lower
after successful H pylori eradication therapy with a statistical
significance: overall RR is 4.78 (1.45–15.80) with P<0.05
(Fig. 5). There was evidence of heterogeneity between the studies:
the I
2
was 90 and P<0.05 suggesting evidence of heterogeneity.
Figure 1. The flow sheet of the studies and the corresponding classification by study design.
Dou et al. Medicine (2016) 95:39 www.md-journal.com
3
Table 1
The characteristics of the included studies in this meta-analysis.
Author/year of
publication/country Study design Study type
Age, y, mean
or range Male, %
Case
number Halitosis test
H pylori test
(location)
Eradication therapy
of H pylori UGID
ENT
diseases
Oral
diseases
Tiomny et al/1992/
Israel
Suggest a new explanation for halitosis based
on clinical experience of H pylori
eradication
Case report Unknown 50.0 4 Obvious to family members,
family physicians and
gastroenterologists)
RUT/UBT /
Histology
(stomach)
Double-drug for 4 weeks
(bismuth+ metronidazole)
Yes Unknown Unknown
Ierardi et al/1998/
Italy
Investigate the effects of H pylori eradicate
therapy on halitosis
Comparative
quasiclinical
experimental trial
45.3 (17–70) 50.0 58 Halimeter/ Organoleptic
(researcher)
UBT/histology
(stomach)
Double-drug (omeprazole + amoxicillin)
for 14 days, and Triple-drug
(omeprazole+ clarithromycin +
metronidazole) for 10 days in
cases of eradication failure
Chronic
dyspeptic
patients
No No
Gasbarrini et al/
1998/ Italy
Evaluate the prevalence of H pylori
infection and gastrointestinal symptoms
in patients with IDDM
Case-control 35 ±11 43.1 116 Questionnaire (patients) UBT (stomach) —Unknown Unknown Unknown
Gasbarrini et al/
1999/ Italy
Compare the H pylori eradication rate in a group
of IDDM H pylori infected patients and in a
control group of infected dyspeptic patients
Comparative quasi
clinical
experimental trial
39±12 58.1 31 Questionnaire UBT (stomach) Triple-drug for 7 days for IDDM
patients (pantoprazol + amoxicillin +
clarithromycin)
Unknown Unknown Unknown
Shashidhar et al/
2000/USA
Evaluate safety and efficacy of triple-drug
eradication therapy in symptomatic children
with H pylori infection
Prospective,
nonrandomized,
open-label trial
11 (1–25) 40.6 32 Questionnaire RUT/histology
(stomach)
Triple-drug for 2 weeks (lansoprazole
+amoxicillin + clarithromycin)
Yes Unknown Unknown
Werdmuller et al/
2000/The
Netherlands
Compare the clinical presentations in relation to
HP infection in a consecutive series of
patients for gastroscopy
Case-control 50 (22–87) in H pylori
positive patients; 46
(13–83) in H pylori
negative patients
46.5 404 Questionnaire Histology, Culture and
Gram stain, RUT, and
ELISA (stomach)
—No Unknown Unknown
Hoshi et al/2002/
Japan
Investigate the relationship between
gastrointestinal conditions and halitosis
Case-control 44.7 (21–77) in H
pylori-positive patients;
33.8 (18–67) in H pylori
negative patients
73.9 46 Organoleptic UBT (stomach) –Unknown Unknown Unknown
Serin et al/2003/
Turkey
Investigate the frequency of halitosis before and
after eradication therapy in patients with H
pylori-positive non-ulcer dyspepsia.
Comparative quasi
clinical
experimental trial
38.2 (20–70) 46.6 148 Questionnaire (both the
patients and their
relatives)
Histology (stomach) Triple-drug eradication therapy
for 14 days
No No No
Candelli et al/2003/
Italy
Investigate the effects of H pylori infection on
gastrointestinal symptoms in young DM1
patients
Case control 14.8 ±5.6 (6–21) 54.5 121 Questionnaire UBT (stomach) —Without known
peptic ulcer
disease
Unknown Unknown
Li et al/2005/China Analyze the clinical characteristics of dyspeptic
symptoms in patients
Case-control 49.5 (OD patients); 45.6
(FD patients)
70.3 in OD
patients;
54.4 in FD
patients
239 as OD;
543 as FD
Questionnaire Under endoscopy
(stomach)
—Yes Unknown Unknown
Adler et al/2005/
Argentina
The correlation between halitosis and H pylori
infection on the mouth and the stoma
Case-control 56.5 (24–74) 32.4 124 Halimeter PCR (stomach) —Yes Unknown Yes
Katsinelos et al/
2007/Greece
investigate the incidence and long-term outcome
of halitosis before and after eradication
therapy in patients with FD and H pylori
Comparative quasi
clinical
experimental trial
40.7 ±10.9 55.6 18 Questionnaire (both the
patients and their
relatives)
UBT/histology
(stomach)
Triple-drug eradication therapy for 10
days and quadruple-drug therapy
for 10days in cases of eradication
failure
Antral gastritis (mild
61.1% and
moderate 38.9%)
No No
Chen et al/2007/
China
Investigate the relationship between halitosis
and H pylori infection
Case-control 37 (18–64) 22.0 50 Organoleptic UBT/histology
(stomach)
—Unknown Unknown No
Suzuki et al/2008/
Japan
Study the relationship between oral H pylori
infection and halitosis
Case-control 45.3 ±15 42.0 326 Gas chromatography PCR (saliva) —No Unknown Yes
Lee et al/2009/Korea To evaluate the effect of Korea red ginseng
on H pylori-associated halitosis
Case report 47.7±10.4 (16–72) 44.3 88 Halimeter UBT (stomach) Triple-drug eradication therapy for 7
days or Red ginseng for 10 weeks
FD Unknown No
Tangerman et al/
2012/ The
Netherlands
Evaluate the possible relation between H pylori
and halitosis
Case-control 60 (H pylori +);
52.9 (H pylori -)
63.6 (H pylori +);
47.3 (H pylori -)
78 Organoleptic CLO-test /Histology/
culture (stomach)
—Yes Unknown Unknown
Dore et al /
2012/Italy
Examine the role of H pylori in gastrointestinal
symptoms in children
Cross-sectional sero-
epidemiologic
study
Unknown (6–15) Unknown 1741 Questionnaire (both the
children and their
relatives)
ELISA (stomach) —Unknown Unknown Unknown
Chen et al/2012/
China
Explore the relation between halitosis
and H pylori infection
Case-control 49.7 (halitosis + UGID);
41.6 (halitosis); 47.3
(normal control)
55.2 165 Questionnaire UBT (stomach) —Yes Unknown Unknown
Yilmaz et al/2012/
Turkey
Compare the presence of H pylori infection in
children with and without halitosis
Case-control 8 (3–15) in halitosis
patients; 8 (3–15) in
control group
50 108 Organoleptic Stool antigen test
(stomach)
—Unknown No No
HajiFattai et al/2015/
Iran
Relationship of halitosis with Gastric H pylori
Infection
Case-control 34.29 ±13.71 45.45 44 Organoleptic test RUT (stomach) —Unknown No No
Zaric et al/2015/
India
Eradication of gastric H pylori ameliorates
halitosis and tongue coating
Case-control 19–78 42.86 98 Organoleptic test Nestde-PCR Triple-drug eradication therapy
for 7 days
With dyspeptic Unknown Unkonwn
CLO-test =Campylobacter-like organism test (a rapid urease test), ELISA =enzyme-labeled immunosorbent assay, ENT=ear-nose-throat, FD =functional dyspepsia, H pylori =Helicobacter pylori, IDDM =insulin-dependent diabetes mellitus, OD =organic dyspepsia, PCR =polymerase
chain reaction, RUT =rapid urease test, UBT=urea breath test, UGID =upper gastrointestinal disease.
Dou et al. Medicine (2016) 95:39 Medicine
4
The random-effects meta-analysis was therefore chosen to
minimize the effects of heterogeneity.
4. Discussion
The exact pathophysiological mechanism of halitosis is not
clear. The possible relationship between Hpyloriinfection
and halitosis was first suggested by Marshall et al
[36]
in 1985.
The potential relation between halitosis and Hpyloriinfection
was further found by Tiomny et al
[11]
through a study of the
effects of Hpylorieradication therapy on halitosis. Since then,
a lot of studies have been focused on this controversial
subject.
In 2002, Hoshi et al
[17]
proved that the intensity of malodor of
mouth air was higher in H pylori-positive patients than in H
pylori-negative patients, and the levels of H
2
S and dimethyl
sulfide in mouth air were also significantly higher in the H pylori-
positive patients than in the H pylori-negative patients. In 2005,
Adler et al
[37]
showed that the detection of H pylori by
histopathology in the gastric biopsies was positive in 80.43%
patients with halitosis and only 6.41% patients without halitosis
(P<0.01). However, all these studies were carried out in the
adults, the outcomes of the studies in the children were on the
contrary. No statistical significance was reached between
halitosis-positive children and halitosis-negative children by
Dore et al
[25]
and Yilmaz et al.
[27]
Figure 2. H pylori infection rates in patients with or without halitosis.
Figure 3. Halitosis rates in patients with or without H pylori infection.
Figure 4. Halitosis rates in H pylori-infected patients with halitosis after treatment with or without successful H pylori eradication.
Dou et al. Medicine (2016) 95:39 www.md-journal.com
5
In this meta-analysis, we took all these studies into account
without considering the differences of age or sex between them.
The results showed that the OR (random model) of H pylori
infection between halitosis-positive patients and halitosis-nega-
tive patients was 4.03 (95% CI: 1.41–11.50; P=0.009). We also
did the meta-analysis of the risk of halitosis in the H pylori-
positive patients versus H pylori-negative patients. The results
showed that the OR (random model) of halitosis between
H pylori-positive patients and H pylori-negative patients was
2.85 (95% CI: 1.40–5.83; P=0.004).
But how does H pylori infection produce halitosis. By assessing
the VSC produced by 3 strains of H pylori (ATCC 43504, SS 1,
and DSM 4867) in broth cultures mixed with different sulfur-
containing amino acids in vitro, Lee et al
[38]
showed that H pylori
was capable of producing H
2
S and MM. Although the
production of VSC by H pylori was a little bit different among
different strains of H pylori and different sulfur-containing amino
acids, it was still the direct evidence that this microorganism can
contribute to the development of halitosis. It was suggested that
the VSC produced in the gastrointestinal tract could diffuse into
the lung air after being carried to the lungs via blood.
[17,39]
Yoo
et al
[40]
found that erosive changes in esophagogastroduodenal
mucosa were strongly correlated with increased VSC levels,
suggesting that H pylori-associated eroded and inflamed mucosa
might aggravate halitosis by making VSC diffusion much easier
into blood. It was also shown that in accordance with higher
levels of VSC produced in patients with erosive mucosal changes
and ulcerative changes, the enzymes cystathionine b-synthase
(CBS) and cystathionine g-lyase (CSE) prerequisite for VSC
generation were obviously highly induced.
[40]
On the contrary,
Hoshi et al
[17]
found that although levels of H
2
S and dimethyl
sulfide in mouth air were significantly higher in H pylori-positive
patients than in H pylori-negative patients, which meant H pylori
did have some relation with halitosis, but no significant difference
was observed in the exhaled breaths between the 2 groups, which
indicated the higher production of VSC in upper gastrointestinal
tract might be not the main source of halitosis. Although the role
of H pylori infection in the pathophysiological mechanism of
halitosis and the increase of VSC level is not clear, it may still be a
frequent contributor to the production of halitosis.
The oral HP infection has also been under investigation in the
past. In1989, H pylori was found in dental plaque by bacterial
culture.
[41]
In 1991, Desai et al
[42]
showed that H pylori was
detected in dental plaque and in gastric antral and body mucosa
in 98%, 67%, and 70%, respectively, of 43 consecutive patients
with dyspepsia. In 1996 in a group of 100 dyspeptic subjects,
H pylori was detected by campylobacter-like organism test
(CLO-test) in saliva, dental plaques, and gingival pockets in 84%,
100%, and 100% of cases and by the culture in 55%, 88%, and
100%, respectively. The presence of H pylori determined by urea
breath test (UBT) in the stomach in these subjects was 60%.
[43]
Whether the H pylori infection in the oral cavity correlates with
halitosis is not clear, further detailed investigation is needed.
In this meta-analysis we also evaluated the effect of Hpylori
eradication therapy on halitosis. The results showed that the RR
(fixed model) of halitosis after successful Hpylorieradication in
the stomach in those Hpylori-infected halitosis-positive patients
was 0.17 (95% CI: 0.08–0.39; P<0.0001), compared with those
patients without successful H pylori eradication. We also did the
meta-analysis of the halitosis rates in Hpylori-infected patients
before and after successful H pylori eradication therapy.
The results showed that the RR (random model) of halitosis
before successful H pylori eradication therapy was 4.78 (95%
CI: 1.45–15.80; P=0.01), compared with the patients after
successful H pylori eradication therapy. These results all favor
successful Hpylorieradication therapy to treat those patients of
halitosis.
Interestingly, in 2011, Shalchi et al
[26]
took an further
comparative quasiexperimental clinical trial study of 33 halito-
sis-positive patients without oral diseases (17 H pylori-positive
patients and 16 H pylori-negative patients). All patients received
2-week’sH pylori eradication therapy regardless of H pylori
infection. She found that the RRs of halitosis resolution in H
pylori-positive group over H pylori-negative group were 2.8 and
3.3 respectively, and H pylori eradication could resolve halitosis
in a majority of patients. It was suggested that H pylori might be a
probable rather than a possible cause of halitosis.
In conclusion, there was a clear correlation between H pylori
infection and halitosis. H pylori might be a common contributor
to the production of halitosis. In those refractory halitosis-
positive patients without any oral/ENT/systemic diseases,
H pylori eradication therapy in the clinic may be helpful.
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Figure 5. Halitosis rates in H pylori-infected patients before and after successful H pylori eradication.
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