Evaluation of self-perceived halitosis and effective conditions in periodontology clinic applicants: A cross-sectional study

Abstract

Halitosis is defined as an unpleasant odor emanating from the oral cavity and has social and economic effects. Halitosis is a common complaint in individuals with periodontal disease, but limited data are available. The aim of this study is to evaluate self-reported halitosis and related conditions. It is a cross-sectional study using a questionnaire consisting of 10 questions on the self-perception of halitosis in patients who applied to the periodontology clinic. Five hundred nine individuals were included in the study. The relationship between individual-reported oral malodor and sociodemographic, medical history and oral hygiene variables was examined. Periodontal clinical parameters (plaque index, gingival index, and bleeding on probing) recorded in the patient forms of the individuals included in the study were evaluated. The prevalence of halitosis reported by the patients participating in the study is 34.2%. Factors that are significantly associated with self-perceived halitosis, low frequency of tooth brushing, increased degree of periodontal disease, regular drug use of patients, and low education level. Halitosis remains one of the main issues facing people in today’s world. As a result, dentists should play a bigger part in educating and alerting patients about oral malodor. There should be more public education regarding the causes of foul breath and potential treatments.

1. Introduction

Halitosis, halitosis, or oral malodor, is the expression describing the unpleasant odor emanating from the oral cavity. Halitosis can affect people’s social relationships and lives, and it can also be an indicator of some diseases.^[1] Its etiology includes non-oral causes such as smoking, alcohol and some foods, and oral or systemic causes.^[2] Generally, poor oral hygiene and intraoral conditions such as periodontitis are considered the most important cause (85%) for bad breath.^[1]

Acute necrotizing ulcerative gingivitis is one of the most significant reasons of foul breath, despite the fact that most forms of gingivitis and periodontitis can also contribute to it. Oral malodor can vary in intensity as a result of adult periodontitis, which is characterized by a gradual loss of periodontal attachment brought on by plaque. Strong oral malodors can result from aggressive periodontitis, which is characterized by a rapid loss of periodontal bone and related tooth movement. Lack of oral hygiene brought on by xerostomia (dry mouth) also has the potential to induce or exacerbate malodor, and some research indicates that wearing dentures can do the same, probably because of increased deposits on the tongue surface.^[3]

The prevalence of halitosis may be underestimated since some people are unaware of their poor respiratory conditions.^[4] According to a 2006 study by Al-Ansari et al on a sample of 1500 people, 25% of the population had halitosis.^[2] In addition, Liu et al studied 2000 people in China, and they discovered that 25% of them had halitosis.^[5]

Halitosis can have an impact on a person’s life, and it can also have psychological repercussions that result in social anxiety disorders that hinder social interaction.^[6] Productivity can be affected by halitosis, and the majority of sufferers express personal discomfort.

The aim of this study is to determine the prevalence of self-reported halitosis among patients at the periodontology clinic and to link oral hygiene practices to self-reported halitosis.

2. Materials and methods

The Necmettin Erbakan University Faculty of Dentistry Ethics Committee for Non-Pharmaceutical and Medical Device Clinical Research approved this cross-sectional study (Decision number: 2022/240). After signing the informed consent form, participants completed a survey that included demographic information and questions about how they perceived halitosis.

2.1. Population and sampling

Five hundred nine participants who chose to take part in the study and applied to our clinic for a variety of reasons were included in it. They did not have any medical, mental, or psychiatric conditions that would have made it impossible for them to respond to the survey questions. According to the power analysis results of the G Power program (G * Power 3.1 software; Heinrich Heine University, Düsseldorf, Germany); for logistic regression analysis, it was determined that a minimum of 509 samples were required in two-tailed analysis (two-tailed), 1.5 odds ratio, 0.05 margin of error (α), 0.20 effect value (pr), 0.95 power (1−β) level.

2.2. Questionnaire items

The 10-question survey was divided into 2 parts: the first asked about sociodemographic information such as age, gender, marital status, education level, and smoking status (current, former, or nonsmoker); the second asked about the presence or absence of medical conditions that were thought to be linked to bad breath, such as diabetes mellitus, kidney disease, gastrointestinal tract disorders, respiratory disease, chronic sinusitis, xerostomia, and drug use. Individuals’ oral hygiene habits were assessed using questions on how frequently they used a toothbrush, dental floss, miswak (a chewing stick), and mouthwash. In the final section of the survey, participants were asked whether they believed they had foul breath, how they learned they did (by self-report, dental diagnosis, or word of mouth from a relative or friend), and whether they had previously sought therapy for the issue.

The demographic and periodontal clinical data (plaque index, gingival index, bleeding on probing) from the study participants’ patient forms were evaluated.

2.3. Statistical analysis

Using the Windows version of IBM SPSS Statistics, version 23.0, statistical analyses for the study were conducted. For categorical data, the frequency and percentage are provided as well as the mean and standard deviation. The correlations between brushing practices, demographic factors, general health information, diagnosis and plaque, gingival index levels, and the presence of bleeding on probing in relation to halitosis were examined using the Pearson chi-square test and Fisher Exact test. The analysis of binary logistic regression was utilized to pinpoint key causes of bad breath. A value of P ≤ .05 was considered significant.

3. Results

Male participants in the study make up 34.6% of the total, while female participants make up 65.4%. Table 1 contains demographic information as well as the questions and their responses.

Table 1.

Participant general demographic information, smoking, and systemic diseases.

		f	%
Gender	Male	176	34.6
	Female	333	65.4
Marital status	Single	189	37.1
	Married	320	62.9
Educational Status	Primary school	173	34.0
	Associate degree	139	27.3
	License	197	38.7
Smoking	Yes	129	25.3
	No	380	74.7
Do you have diabetes?	Yes	37	7.3
	No	472	92.7
Do you have chronic sinusitis?	Yes	28	5.5
	No	481	94.5
Do you have xerostomia?	Yes	25	4.9
	No	484	95.1
Do you have kidney disease?	Yes	12	2.4
	No	497	97.6
Do you have gastrointestinal problems?	Yes	22	4.3
	No	486	95.5
Do you have breathing problems?	Yes	27	5.3
	No	482	94.7
Do you use regular medication?	Yes	135	26.5
	No	374	73.5
What is your tooth brushing frequency?	More than 1 per day	244	47.9
	<1 per day	193	37.9
	None	72	14.1
Do you use dental floss?	Yes	79	15.5
	No	429	84.3
Do you use miswak?	Yes	13	2.6
	No	496	97.4
Do you use mouthwash?	Yes	86	16.9
	No	423	83.1
Do you think you have bad breath?	Yes	174	34.2
	No	335	65.8
How did you find out that you have bad breath?	My family told	26	14.9
	My friends told	1	0.6
	Diagnosed by my dentist	2	1.1
	I noticed myself	145	83.3
Have you been treated?	Yes	70	13.8
	No	437	86.2

The patients’ self-reported halitosis prevalence is 34.2%. While 83.3% of the individuals who believed they had foul breath were aware of their own perceptions, 14.9% and 0.6% of them claimed to have received a diagnosis from a dentist, and 1.1% claimed to have received 1 from their relatives or friends. Only 70 of the 174 individuals with foul breath admitted to having sought therapy for the condition in the past (Table 1).

The correlation between teeth brushing practices and halitosis is seen in Table 2. When compared to people who brushed, miswaked, or flossed at least once a day, individuals who brushed their teeth less frequently or never did so reported a higher prevalence of self-perceived bad breath. Patients who reported using mouthwash daily had self-reported bad breath levels that were comparable to those of nonusers (Table 2).

Table 2.

The relationship between the presence of halitosis and the tooth brushing habit.

			Think you have bad breath?		Total	P
			Yes	No
What is your tooth brushing frequency?	More than 1 per day	n	59	185	244	.001
		%	24.20%	75.80%	100.00%
	<1 per day	n	81	112	193
		%	42.00%	58.00%	100.00%
	None	n	34	38	72
		%	47.20%	52.80%	100.00%
Do you use dental floss?	Yes	n	20	59	79	.078
		%	25.30%	74.70%	100.00%
	No	n	153	276	429
		%	35.70%	64.30%	100.00%
Do you use miswak?	Yes	n	3	10	13	.732
		%	23.10%	76.90%	100.00%
	No	n	171	325	496
		%	34.50%	65.50%	100.00%
Do you use mouthwash?	Yes	n	28	58	86	.727
		%	32.60%	67.40%	100.00%
	No	n	146	277	423
		%	34.50%	65.50%	100.00%

Bold value represents statistically significant result (P < .05). Values are expressed as n (%).

Pearson Chi-Square.

The medical diseases linked to halitosis are listed in Table 3. In comparison to patients without these medical history factors, patients with diabetes mellitus, chronic sinusitis, kidney disease, xerostomia, and any medication reported a higher prevalence of halitosis, whereas people with gastrointestinal system disorders and respiratory system diseases reported similar values.

Table 3.

Relationship between presence of halitosis and general health status.

			Think you have bad breath?		Total	P
			Yes	No
Do you have diabetes?	Yes	n	18	19	37	.054
		%	48.60%	51.40%	100.00%
	No	n	156	316	472
		%	33.10%	66.90%	100.00%
Do you have Chronic Sinusitis?	Yes	n	11	17	28	.558
		%	39.30%	60.70%	100.00%
	No	n	163	318	481
		%	33.90%	66.10%	100.00%
Do you have xerostomia?	Yes	n	11	14	25	.558
		%	44.00%	56.00%	100.00%
	No	n	163	321	484
		%	33.70%	66.30%	100.00%
Do you have kidney disease?	Yes	n	6	6	12	.242
		%	50.00%	50.00%	100.00%
	No	n	168	329	497
		%	33.80%	66.20%	100.00%
Do you have gastrointestinal problems?	Yes	n	8	14	22	.371
		%	36.40%	63.60%	100.00%
	No	n	165	321	486
		%	34.00%	66.00%	100.00%
Do you have breathing problems?	Yes	n	10	17	27	.748
		%	37.00%	63.00%	100.00%
	No	n	164	318	482
		%	34.00%	66.00%	100.00%
Do you use regular medication?	Yes	n	65	70	135	.001
		%	48.10%	51.90%	100.00%
	No	n	109	265	374
		%	29.10%	70.90%	100.00%

Bold value represents statistically significant result (P < .05). Values are expressed as n (%).

*Pearson Chi-Square.

According to Table 4, there was no discernible difference in the prevalence of self-reported halitosis between men and women. The difference between smokers and nonsmokers was also not statistically significant (P > .05). A considerably higher prevalence of self-perceived halitosis was observed by those with lower levels of education and by those who were not married.

Table 4.

The relationship between presence of halitosis and demographic characteristics.

			Think you have bad breath?		Total	P
			Yes	No
Gender	Male	n	62	114	176	.718
		%	35.20%	64.80%	100.00%
	Female	n	112	221	333
		%	33.60%	66.40%	100.00%
Marital status	Single	n	45	144	189	.001
		%	23.80%	76.20%	100.00%
	Married	n	129	191	320
		%	40.30%	59.70%	100.00%
Educational status	Primary school	n	84	89	173	.001
		%	48.60%	51.40%	100.00%
	Associate degree	n	45	94	139
		%	32.40%	67.60%	100.00%
	License	n	45	152	197
		%	22.80%	77.20%	100.00%
Smoking	Yes	n	45	84	129	.846
		%	34.90%	65.10%	100.00%
	No	n	129	251	380
		%	33.90%	66.10%	100.00%

Bold values represent statistically significant results (P < .05). Values are expressed as n (%).

*Pearson Chi-Square.

The prevalence of self-reported halitosis and their periodontal health were shown to be significantly correlated (Table 5) (P < .05). Individuals with poor periodontal health reported a higher prevalence of halitosis, compared to those with gingival health. As the participants’ periodontal health deteriorates, the participants’ judgments of halitosis rise.

Table 5.

The relationship between periodontal status and presence of halitosis.

			Think you have bad breath?		Total	P
			Yes	No
Diagnosis	Gingival health	n	1	22	23	.001
		%	4.3%	95.7%	100.0%
	Gingivitis	n	111	268	379
		%	29.2%	70.8%	100.0%
	Periodontitis	n	62	45	107
		%	57.9%	42.1%	100.0%
Total		n	174	335	509
		%	34.2%	65.8%	100.0%
Plaque index		n	59	166	225	.001
		%	26.20%	73.80%	100.00%
		n	95	159	254
		%	37.40%	62.60%	100.00%
		n	20	10	30
		%	66.70%	33.30%	100.00%
Gingival index		n	57	181	238	.001
		%	23.90%	76.10%	100.00%
		n	108	149	257
		%	42.00%	58.00%	100.00%
		n	8	3	11
		%	72.70%	27.30%	100.00%
BOP		n	0	22	22	.001
		%	0.00%	100.00%	100.00%
		n	174	313	487
		%	35.70%	64.30%	100.00%

Bold values represent statistically significant results (P < .05). Values are expressed as n (%).

*Pearson Chi-Square.

4. Discussion

In order to assess the prevalence of self-reported oral malodor in patients enrolled in the department of periodontology at Necmettin Erbakan University and identify the risk factors for this disease, this study was carried out. A third of people said they had unpleasant breath. Additionally, those who brushed their teeth less frequently or not at all, did not floss, had dry mouth, or had systemic disease had considerably higher self-reported halitosis. However, in this study, there was no correlation between gender, oral hygiene practices, or smoking and self-reported halitosis.

The prevalence of oral malodor in this patient sample is 34.2%. Jassem M. El-Ansari et al in a study evaluating the self-reported prevalence and factors of halitosis in 1551 Kuwaiti patients, the prevalence of halitosis was 23.3%.^[2] Halitosis has a self-reported prevalence ranging from 22% to 40% in various populations.^[7,8] Certain population groups were studied in some research, which also revealed various prevalence percentages ranging from 7% to 50%.^[2,8–14] In a 2016 research of dental students, the prevalence of self-reported halitosis was found to be 21.8%.^[12] Another study on patients undergoing orthodontic treatment discovered a frequency of 41.2%.^[15] Studies that employ differing prevalence estimates imply that different criteria were applied, which may have had an impact on these prevalence rates.

Also, population characteristics can affect the results.

Although some studies have demonstrated that self-reported assessments can be highly erroneous, it was discovered that the self-estimated and clinical assessments of halitosis correlated well.^[8,11,16] Self-evaluation of halitosis has many limitations because it is a subjective assessment.^[9] The fact that it considers any offensive odor that has a detrimental effect on quality of life means that it is still clinically significant.^[17]

Numerous research have linked oral hygiene practices including brushing and flossing with self-reported bad breath.^[14,18,19] According to this study, which is in line with earlier research,^[2,20] cleaning teeth less frequently results in more instances of subjective bad breath. The Nalçaci et al study found that using the toothbrush less frequently than once a day was the factor most closely linked to self-perceived bad breath.^[21] According to Kayombo et al, a low prevalence of halitosis was connected with regular brushing and tongue cleansing.^[13]

Adult halitosis may be brought on by a number of conditions, including the use of drugs, drug use, hyposalivation, and sociodemographic and behavioral variables.^[22,23] In this study, like in the study by Moreno et al,^[24] participants who take regular medication have a greater rate of halitosis evaluation. Additionally, although it is not statistically significant, patients with systemic diseases have a higher frequency of halitosis. It is well known that some medications alter the onset of foul breath by decreasing salivation.^[23]

According to the findings of Saniya Setia et al’s study with dentistry students, women practiced superior oral hygiene and much less halitosis than men.^[25] According to Milanesi et al, women are 2.57 times more likely than men to report having unpleasant breath.^[12] Men are more likely than women to self-report having halitosis, according to some studies.^[26,27] However, there was no difference between the genders in the frequency of halitosis in several studies.^[11,28] Although there was no statistically significant difference between the assessments of halitosis in the male and female study participants, they are also very close to one another.

In terms of awareness and oral health, education level is a crucial factor.^[29] Additionally, greater oral hygiene may be linked to improved oral health knowledge and habits, which would lead to a decrease in the occurrence of oral health issues.^[24] Higher rates of self-perceived oral malodor were reported by subjects with less education than by those with a college degree.^[30] A greater education level was linked to less self-reported halitosis, according to another study.^[24] Similar to the literature, the prevalence of reporting halitosis in this study was lower among people with higher education levels.

Self-reported foul breath was significantly linked to smoking, according to Kayambo et al.^[13] Teshome et al in 2021, it was revealed, in line with earlier studies, that oral halitosis is more common in smokers, with smokers having a higher risk of developing halitosis than nonsmokers.^[31] It was discovered that the sample taking part in the study had a low smoking rate and that there was no statistically significant correlation between smoking and self-perceived halitosis. It was discovered that assessments of halitosis in smokers and nonsmokers were rather similar.

According to Silva et al, people with periodontitis had a 90% higher incidence of self-reported halitosis than people in good health.^[32] In this study, gingival health was associated with lower levels of halitosis, whereas periodontal disease was associated with higher levels of halitosis. The association between halitosis and bleeding, gingival index scores, and plaque index scores in recorded periodontal diagnosis and probing were examined in this study. Halitosis and the severity of periodontal disease were revealed to be significantly correlated by the evaluation.

Our research was carried out in a single hospital and may not necessarily represent the broader community in the area. Our study’s most significant flaw is that it only took into account the patients’ perceptions of their own self-reported levels of halitosis. In addition sinusitis problems, respiratory problems, diabetes and dry mouth can cause bad breath. Sometimes these are noticeable to people, while sometimes individuals may not notice them. In our study, the necessary equipment could be used to compare the bad breath that individuals know with the real bad breath. This is another limitation of our study. However, unlike other studies, it was conducted with patients who came to the periodontology clinic. There are limited number of studies on this subject in our country. Actually, it is important to come to a clinic where conditions that may cause bad breath will be treated, but it is interesting that many people come to the clinic because bad breath is not the reason. The fact that a human perceptible malodor truly indicates the presence of this illness makes this approach remain crucial for therapeutic usage. Furthermore, no special tools are required to diagnose self-reported foul breath. Our study’s findings demonstrated that whether someone has halitosis or not, they are most likely to notice it in themselves and their relatives. The dentists’ reported rates are the lowest. The fact that most people forego dental care and visits to the dentist could be the cause of this. Dentists should especially detect the presence of bad breath and plan treatments to eliminate the causative factor, and increase the awareness of the patients. Sinusitis problems, respiratory problems, diabetes and dry mouth can cause bad breath. Sometimes these are noticeable to individuals, while sometimes individuals may not notice them. In our study, the necessary equipment could have been used to compare the bad breath individuals know with the real bad breath.

4.1. Clinical relevance

4.1.1. Scientific relevance of the study

Halitosis is a complex problem that adversely affects the quality of life of those who suffer from it. Although there are many studies on this subject, the studies generally carried out with dentistry students. There are very few studies evaluating the prevalence of halitosis, which come to the periodontology clinic for any reason.

4.1.2. Principal findings

Our study reveals the situations in which self-perceived halitosis is relevant. Periodontal diseases, regular drug use, inadequate oral hygiene, low education level, advanced age, marital status, increase in plaque index-gingival index scores, and presence of bleeding on probing are factors associated with halitosis.

4.1.3. Practical implications

Halitosis is an important health problem that affects people’s social relationships and lives. In planning the treatment of the disease, the underlying causes should be learned first.

Acknowledgments

The authors thank HK for his assistance with statistical calculations and for providing Statistical Consulting.

Author contributions

Conceptualization: Ozkan Sen Dilek.

Data curation: Ozkan Sen Dilek, Durmaz Esra Nur.

Formal analysis: Ozkan Sen Dilek.

Methodology: Ozkan Sen Dilek.

Writing – original draft: Ozkan Sen Dilek, Durmaz Esra Nur, Saraç Fatma.

Writing – review & editing: Ozkan Sen Dilek.