|Year : 2016 | Volume
| Issue : 3 | Page : 150-154
Prevalence of self-reported halitosis and associated factors among dental patients attending a tertiary hospital in Nigeria
Kehinde Adesola Umeizudike1, Olufemi Elijah Oyetola2, Patricia Omowunmi Ayanbadejo1, Grace Onyenashia Alade3, Priscilla Okhiabigie Ameh4
1 Department of Preventive Dentistry, Faculty of Dental Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Preventive Dentistry, Faculty of Dentistry, College of Health Sciences, Obafemi Awolowo University, Ile Ife, Nigeria
3 Department of Preventive Dentistry, Faculty of Dentistry, College of Health Sciences, University of Port Harcourt, Port Harcourt, Rivers, Nigeria
4 Department of Preventive Dentistry, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
|Date of Web Publication||14-Oct-2016|
Kehinde Adesola Umeizudike
Department of Preventive Dentistry, College of Medicine, University of Lagos, P.M.B. 12003, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Objectives: To determine the prevalence of self-reported halitosis among dental patients seen in a teaching hospital. Materials and Methods: This was a cross-sectional study that included 135 dental patients enrolled at the Oral Diagnosis/Periodontology Clinics of the Lagos University Teaching Hospital. Self-administered questionnaires were used to assess self-reported halitosis (oral malodor) in the subjects. Association between self-reported halitosis and sociodemography (age, gender, education, marital status, ethnicity, and religion) and intraoral findings (gingivitis, periodontitis, tongue coating, caries, and number of mobile teeth) was determined. Results: The prevalence of self-reported halitosis was 14.8% and was significantly associated with age of 40 years and above (P = 0.025), and male gender (P = 0.032). Subjects with gingivitis were 2 times more likely to have halitosis than those without gingivitis (odds ratio [OR] = 2.19 while subjects with tongue coating were 2 times more likely to have halitosis than those without tongue coating OR = 2.02. About 50% perceived halitosis by themselves, 25% by family and friends, and 20% from presumed actions of people around them. The majority (70%) of the patients perceived the halitosis from their mouths, 30% from their mouth and nose. Most (75%) of the subjects had perceived the halitosis for more than 4 weeks while only 3% had sought professional treatment. Conclusion: Older age of 40 years and above and male gender were the factors associated with self-reported halitosis in this study. The health-seeking behavior of the patients for the treatment of the halitosis was poor.
Keywords: Halitosis, Nigeria, prevalence, self-report
|How to cite this article:|
Umeizudike KA, Oyetola OE, Ayanbadejo PO, Alade GO, Ameh PO. Prevalence of self-reported halitosis and associated factors among dental patients attending a tertiary hospital in Nigeria. Sahel Med J 2016;19:150-4
|How to cite this URL:|
Umeizudike KA, Oyetola OE, Ayanbadejo PO, Alade GO, Ameh PO. Prevalence of self-reported halitosis and associated factors among dental patients attending a tertiary hospital in Nigeria. Sahel Med J [serial online] 2016 [cited 2022 Aug 13];19:150-4. Available from: https://www.smjonline.org/text.asp?2016/19/3/150/192398
| Introduction|| |
Halitosis, also known as oral malodor or bad breath, is a common reason for dental consultation. It is a term used to describe any disagreeable odor in the breath. It is an oral health condition that is reported to rank next to dental caries and periodontal disease as the cause of patient's visits to the dentist. It is characterized by emanating odorous breath that may be due to intra- and extra-oral causes. It has been documented that halitosis originates from the oral cavity in about 80–90% of the patients. This is not unlikely to be related to the myriad of microorganisms particularly the Gram-negative, anaerobic bacterial species which abound in large quantities especially on the dorsum of the tongue and periodontal pockets (in periodontal disease), thereby interacting with remnants of food debris. Many of these organisms have the ability to biotransform substrates into volatile sulfur compounds such as methyl mercaptan and hydrogen sulfide, some of which are assessed through organoleptic methods, in addition to a detailed history and oral examination.
Other predisposing factors for halitosis include poor oral hygiene, consumption of specific food types, tooth decay, tongue coating, oral carcinomas, disorders of the oral mucosa, use of tobacco products, reduced salivary flow, and wearing of denture appliances. Gingivitis, periodontitis, and tongue coating are the most frequent oral causes of halitosis. Extraoral causes include nasal sepsis, respiratory tract infections, gastroesophageal reflux disease, uncontrolled diabetes (acetone-like breath), and renal failure (uremic breath) among others.
There is no globally accepted standard criterion used to define patients with halitosis that makes the actual prevalence to have a wide variation. The available evidence on the prevalence of halitosis suggests that it can affect people of all ages. While some authors believe that there is no sex predilection, others have reported a predilection for females. Halitosis is said to affect 2–87% among different populations. Epidemiological surveys report that moderate chronic halitosis may affect close to one-third of populations whereas severe halitosis may involve <5% of the population. A cross-sectional study among university students and their families in Brazil reported a prevalence of 15%, with halitosis being 3 times more likely in males than females and in those above 20 years old. A study among a Chinese population revealed 27.5% prevalence according to the organoleptic score. A more recent study among Italian subjects reported a prevalence of 19.39% for self-reported halitosis. In Africa, self-reported halitosis was reported to be 50% with a female preponderance among Libyan students and office workers. In Nigeria, few studies have documented the prevalence of halitosis.,, A prevalence of 14.5% was reported in patients seen at the Periodontology Clinic of the University College Hospital, Nigeria. A more recent study reported a comparable prevalence of 13% among Nigerian students in tertiary institutions in Lagos.
Halitosis is a source of concern to those affected and frequently causes embarrassment that may disrupt interpersonal social communication. The immense impact of halitosis on affected patients and its associated personal discomfort, low self-esteem, suicidal tendencies, and emotional distress has often led to the abuse or excessive use of mouthwashes, rinses, spray, chewing gum, or pills to mask the odor in searching for the way out of this distressing problem. Thus, halitosis is an oral health problem worth paying attention to by dental professionals, other health professionals and the society at large. Extensive studies on halitosis are necessary because it can be considered as one of the major factors that influence the quality of life of the patients, which is preventable, by means of simple oral hygiene. A survey of the prevalence of halitosis among dental patients will add to the knowledge of existing data and identify some of the associated factors for halitosis in these patients which will hopefully aid in formulating better treatment protocols for them. This study was therefore designed to critically explore the pattern of presentation of self-reported halitosis in a Nigerian population with the specific objective of determining its prevalence.
| Materials and Methods|| |
This was a cross-sectional descriptive study, in which 135 consecutive dental patients were enrolled from the Oral Diagnosis/Periodontology Clinics of the Lagos University Teaching Hospital. Consecutive patients attending the clinics who gave their informed consent were selected until the required sample size was attained. Self-administered questionnaires were distributed to them after obtaining their informed consent. It recorded information on their demography (age, sex, education, marital status, ethnicity, and religion) and their self-perception of halitosis (oral malodor). The duration of the self-perceived oral malodor was recorded as well as perceived aggravating factors. Clinical examination was carried out on all the respondents. The following periodontal indices were measured – the Simplified Oral Hygiene Index  and periodontal probing depth. The presence of gingivitis, periodontitis, tongue coating, and number of mobile teeth was recorded. Approval for the study was sought and obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital before commencing the study.
Statistical analysis was performed using Epi Info Statistical Software version 3.5.4 (2012). The results were presented as frequencies, means and standard deviations in tables and figures. Association between self-reported halitosis and sociodemography (age, gender, education, marital status, ethnicity, and religion) and intraoral findings (gingivitis, periodontitis, tongue coating, and number of mobile teeth) was determined by Pearson's Chi-square test. Analysis of variance (ANOVA) was used to compare differences between means, while Mann–Whitney test was applied where appropriate. Multivariate logistic regression analysis was used to determine the factors associated with self-reported halitosis. The level of statistical significance was set at P < 0.05.
| Results|| |
The study revealed that 14.8% (n = 20) of the subjects had self-reported halitosis [Figure 1]. Among this group, 75% (n = 15) had noticed the halitosis for >4 weeks, 20% (n = 4) for ≤4 weeks, and 5% (n = 1) did not respond. The majority (70%) of the patients perceived the oral malodor from their mouths while 30% from both their mouth and nasal cavity. Half (50%) of the respondents perceived the halitosis by themselves, with 25% by family and close friends [Figure 2]. There were statistically significant associations between self-reported halitosis and older age (P< 0.05) and male gender (P< 0.05), as reflected by the difference between those ≥40 years (26.2%) and <40 years (9.7%) as well as males (23.6%) versus females (8.8%) as shown in [Table 1]. Among the clinical indices, the mean mobile teeth was significantly associated with self-reported halitosis (P< 0.05) [Table 2] which was however not significant in a binary logistic regression [Table 3]. Clinical conditions including gingivitis, periodontitis, dental caries, and tongue coating were not significantly associated with self-reported halitosis (P > 0.05) [Table 3]. The duration of the self-reported halitosis was for at least 4 weeks in 75% of the respondents with halitosis and for <4 weeks in 20%. Only 5% (n = 1) did not respond. Only 3% (n = 4) of those reporting halitosis had sought professional treatment.
|Table 3: Binary logistic regression for predictors of Self-reported halitosis|
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| Discussion|| |
Halitosis is a common oral problem that should be taken seriously in all affected patients because it affects not only the physical aspects of human health but also the social, psychological, and emotional wellbeing of individuals.,, Studies have shown lack of confidence, stress, depression, and anxiety in affected people , Furthermore, there appears to be an increasing prevalence of this worrisome condition. Our study showed that 20 of 135 patients perceived halitosis, representing a prevalence of 14.8%. This finding is similar to the reports of Settineri et al., Nadanovsky et al., Arowojulo and Dosumu, and Arinola and Olukoju  who reported 19.39%, 15%, 14.5%, and 13%, respectively. However, this is far lower than the range of 22–84% reported in the literature in other studies.,,,,,,, The present study was hospital-based and considering the poor attitude of patients in this part of the world seeking preventive dental care, these factors may have resulted in the underestimation of its prevalence. There are varying reports on the sex distribution of patients with halitosis in the literature. The present study showed a male predilection. This is in agreement with the reports of Eldarrat et al. Odai et al., and Vali et al. On the contrary, some other studies showed a female predilection , and in some studies, no predominant gender.,,
The prevalence of halitosis has been found to increase with age.,,, In our study, we also observed similar trends with the prevalence of halitosis among the older individuals above 40 years being significantly higher than in those below 40 years. Old age is associated with dry mouth, impaired immunity, and reduced oral functions., These factors may predispose the individual to oral infections such as periodontitis and gingivitis that have been identified as contributory local causes of halitosis.
There is paucity of information about the average time lag between the onset of symptoms in individuals with halitosis and the time of presentation in the clinic for care. In our study, we found that majority (75%) of the patients presented in the clinic after a minimum of 4 weeks from the onset of symptoms. This may not be unconnected to the general attitude of patients to oral care especially in a developing country like ours where the majority tend to seek treatment only when there is an obvious/noxious dental problem  or when the disease has become overwhelming. It could be inferred that many people with mild halitosis may not be too eager to seek care immediately as this may not directly affect their daily activities. Such people are more likely to seek dental care when the condition is accompanied by social embarrassments.
Several reports show an association between inflammatory oral lesions (such as gingivitis and periodontitis) and halitosis.,,, Unlike these studies, this relationship was found not to be statistically significant in this study. However, subjects with halitosis had significantly higher mean number of mobile teeth than those without self-reported halitosis. Tooth mobility is one of the important clinical signs of periodontitis and may indicate advanced periodontitis. This is not surprising and is supported by the literature which reports an association between periodontitis chronic  or aggressive  and oral malodor. It could be explained by the effects of the products of Gram-negative, anaerobic bacteria in periodontitis. The statistical significance observed between the mean number of mobile teeth and self-reported halitosis in the present study may be attributed to the sensitivity of tooth mobility as an indicator of advanced periodontitis. This is because the stages of periodontitis, that is, mild, moderate, or severe were not indicated in the study. Interestingly, subjects with gingivitis and tongue coating had 2 times the likelihood of developing halitosis. Also, other uncommon predisposing factors for halitosis in this environment such as stress, anxiety, and depression were not explored in the present study. Considering the increasing prevalence of halitosis in this part of the world, it is therefore imperative for dentists, particularly periodontologists, and oral medicine specialists to be up to date about their knowledge of halitosis and be familiar with appropriate management protocols that will ensure appropriate patients' evaluation and treatments especially in hospital settings with limited resources.
| Conclusions|| |
Self-reported halitosis was found to be an oral health problem in about fifteen percent of the patients. Despite their oral health condition, majority of them failed to seek professional advice and treatment. There is a need to increase the awareness of such patients on the availability of treatment options.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Akaji EA, Folaranmi N, Ashiwaju O. Halitosis: A review of the literature on its prevalence, impact and control. Oral Health Prev Dent 2014;12:297-304.
Rösing CK, Loesche W. Halitosis: An overview of epidemiology, etiology and clinical management. Braz Oral Res 2011;25:466-71.
Rayman S, Almas K. Halitosis among racially diverse populations: An update. Int J Dent Hyg 2008;6:2-7.
Scully C, Greenman J. Halitosis (breath odor). Periodontol 2000 2008;48:66-75.
Filippi A, Müller N. Real and psychological halitosis – Findings, diagnoses and outcomes of a halitosis clinic. Schweiz Monatsschr Zahnmed 2006;116:129-35.
Soares L, Tinoco E. Prevalence and related parameters of halitosis in general population and periodontal patients. OA Dent 2014;2:4.
Nadanovsky P, Carvalho LB, Ponce de Leon A. Oral malodour and its association with age and sex in a general population in Brazil. Oral Dis 2007;13:105-9.
Liu XN, Shinada K, Chen XC, Zhang BX, Yaegaki K, Kawaguchi Y. Oral malodor-related parameters in the Chinese general population. J Clin Periodontol 2006;33:31-6.
Settineri S, Mento C, Gugliotta SC, Saitta A, Terranova A, Trimarchi G, et al.
Self-reported halitosis and emotional state: Impact on oral conditions and treatments. Health Qual Life Outcomes 2010;8:34.
Eldarrat A, Alkhabuli J, Malik A. The prevalence of self-reported halitosis and oral hygiene practices among Libyan students and office workers. Libyan J Med 2008;3:170-6.
Arowojulo MO, Dosumu EB. Halitosis (Fetor oris) in patients seen at the periodontology clinic of the University College Hospital, Ibadan – A subjective evaluation. Niger Postgrad Med J 2004;11:221-4.
Arinola JE, Olukoju OO. Halitosis amongst students in tertiary institutions in Lagos State. Afr Health Sci 2012;12:473-8.
Bosy A. Oral malodor: Philosophical and practical aspects. J Can Dent Assoc 1997;63:196-201.
Domingos P, Abreu A, Dantas A, Oliveira A. Halitosis: Limiting the quality of life. Rev Odontol Univ Cid São Paulo 2011;23:171-81.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.
Spielman AI, Bivona P, Rifkin BR. Halitosis. A common oral problem. N Y State Dent J 1996;62:36-42.
McKeown L. Social relations and breath odour. Int J Dent Hyg 2003;1:213-7.
Setia S, Pannu P, Gambhir RS, Galhotra V, Ahluwalia P, Sofat A. Correlation of oral hygiene practices, smoking and oral health conditions with self perceived halitosis amongst undergraduate dental students. J Nat Sci Biol Med 2014;5:67-72.
Hammad MM, Darwazeh AM, Al-Waeli H, Tarakji B, Alhadithy TT. Prevalence and awareness of halitosis in a sample of Jordanian population. J Int Soc Prev Community Dent 2014;4 Suppl 3:S178-86.
Bornstein MM, Kislig K, Hoti BB, Seemann R, Lussi A. Prevalence of halitosis in the population of the city of Bern, Switzerland: A study comparing self-reported and clinical data. Eur J Oral Sci 2009;117:261-7.
Ashwath B, Vijayalakshmi R, Malini S. Self-perceived halitosis and oral hygiene habits among undergraduate dental students. J Indian Soc Periodontol 2014;18:357-60.
Odai C, Azodo C, Osazuwa-Peters N, Obuekwe ON. Characteristics and treatment outcome of patients with halitosis at a suburban health facility. Int J Biomed Health Sci 2010;6:181-90.
Vali A, Roohafza H, Keshteli AH, Afghari P, Javad Shirani M, Afshar H, et al
. Relationship between subjective halitosis and psychological factors. Int Dent J 2015;65:120-6.
Miyazaki H, Sakao S, Katoh Y, Takehara T. Correlation between volatile sulphur compounds and certain oral health measurements in the general population. J Periodontol 1995;66:679-84.
Cortelli JR, Barbosa MD, Westphal MA. Halitosis: A review of associated factors and therapeutic approach. Braz Oral Res 2008;22 Suppl 1:44-54.
Locker D. Dental status, xerostomia and the oral health-related quality of life of an elderly institutionalized population. Spec Care Dentist 2003;23:86-93.
Umeizudike KA, Ayanbadejo PO, Taiwo OA, Savage KO, Alade GO. Utilization of dental services by administrative workers in a tertiary health institution in Lagos, Nigeria – A pilot study. Nig Q J Hosp Med 2014;24:86-90.
Alebiosu CO. Detrimental effects of late referral for dialysis. Afr J Health Sci 2001;8:89-92.
Morita M, Wang HL. Association between oral malodor and adult periodontitis: A review. J Clin Periodontol 2001;28:813-9.
Porter SR, Scully C. Oral malodour (halitosis). BMJ 2006;333:632-5.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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