AWARENESS AND KNOWLEDGE OF

HALITOSIS AMONG GENERAL POPULATION

– A CROSS-SECTIONAL STUDY

JIDAM

“An Official Journal of IDA - Madras

Available online

To access & cite this article

Website: jidam.idamadras.com

ABSTRACT

BACKGROUND:

Halitosis or Oral malodor is defined as an

unpleasant breath odor and it is an important dental problem in which

the affected are not conscious of it, and it also causes individuals to

lose self-confidence and thus affecting their social life. It can also be

because of underlying systemic condition but most prominently it is

due to improper maintenance of oral hygiene.

AIM:

The study aims at assessing awareness and knowledge of

halitosis among general population and their perception of it.

METHODS AND MATERIALS:

A descriptive cross-sectional

study was conducted among 512 individuals of age 18-70 years through

online forums due to COVID 19 pandemic situation. A pre-validated

questionnaire with 22 closed ended question on Google forms were

circulated on social media platforms like WhatsApp, Messenger and

Instagram. The collected data was subjected to statistical analysis.

RESULTS: It was observed that 66% believed that halitosis was

related to oral hygiene and 68% believed that smoking and alcohol

consumption caused bad breath and 60% agreed that tongue coating

and food lodgment caused halitosis. About 64.6% stated that bad breath

affected their social life by reducing their self-confidence.

CONCLUSION:

Halitosis is the one of the unattractive aspects

affecting psychosocial interaction and relationship, it needs multiple

approach to treat. The result of the study indicates that awareness of

halitosis among general population is very high whereas knowledge on

prevention of halitosis is comparatively less.

KEY WORDS:

Halitosis, Bad breath, oral hygiene measures, oral

malodor, social life

JIDAM/Chennai/Volume:7/Issue:4/Pages 128 - 138/Oct-Dec 2020

128

Address for Correspondence:

Dr. Aruna.C, B.D.S.,

Junior Resident, Department of Public

Health Dentistry,

Thai Moogambigai Dental College

and Hospital, Chennai, Tamil Nadu,

India

Email id: arunaachandrasekar98@

gmail.com

Received

: 17.10.20

Accepted

: 11.11.20

Published

: 27.12.20

ORIGINAL STUDY

Dr.Vinita Mary.A, Dr. Kesavan. R, Dr. Aruna.C, Dr. Ashwini. R, Dr. Arunkumar.T.M,

Dr. Mohammed Azarutheen

Department of Public Health Dentistry, Thai Moogambigai Dental College and Hospital,

Chennai, Tamil Nadu, India.

DOI:1.37841/jidam_2020_V7_I4_01

JIDAM/Chennai/Volume:7/Issue:4/Pages 128 - 138/Oct-Dec 2020

Vinita et al : Awareness of halitosis

129

INTRODUCTION:

Halitosis is the term used to define an unpleasant

or offensive odour in expired air, regardless of

whether it originates from oral or non-oral sources

Microbial degradation in the oral cavity is the main

cause of oral malodour

. Oral malodour or halitosis

refers to unpleasant breath

Halitosis result from the release of volatile

sulfur compound (vsc

) through putrefactive activities

of predominantly anaerobic gram-negative oral

organisms

(3)

. In 90% of the cases, the causative factor

is located in the mouth such us deep caries lesion,

periodontal disease, oral infection, pericoronitis,

mucosal ulceration, food impaction, reduced

salivary flow, coated tongue and systemic diseases

like diabetic mellitus

Oral manifestation of diabetes

includes periodontal diseases, oral candidiasis and

dry mouth.

Extraoral causes of halitosis could be

disturbances in upper and lower respiratory tract,

metabolic diseases, medications, carcinoma, etc.

Halitosis can cause major social impact

on those who suffer from it affecting their daily life

causing embarrassment, reduced employment and

decreasing quality of life

. Also, habits like smoking,

tobacco use, alcohol, etc can trigger halitosis

A number of methods have been used to detect

the presence of halitosis either directly or indirectly.

Direct tests are organoleptic, gas chromatography

and indirectly it can be assessed by odour producing

microorganism or assessing their byproducts

invitro

and the BANA (N-benzoyl-DL-arginine-2-

napthylamide) test which uses of chemical sensors

Oral breath can be improved by scaling and root

planing and rinsing with chlorhexidine, essential

oils, chlordioxide, triclosan, amine-fluoride, H

toothpaste containing stannous fluoride, zinc or

triclosan

The aim and purpose of this study was to access

the awareness and knowledge of halitosis and

individuals’ attitude towards it.

MATERIALS AND METHODS:

STUDY SAMPLES:

A cross sectional study was conducted among

individuals aged 18 years and above in India. Due

to COVID-19 pandemic situation the study was

conducted using online platforms. A self-administered

pre-validated questionnaire was used to assess the

knowledge and awareness about halitosis. A pilot

study was conducted to validate the questionnaire

using 20 samples from the study population. The

internal consistency of the questionnaire was

adequate (Cronbach’s alpha = 0.70) and reliability

was assessed by test-retest and Kappa statistic

and the agreement was good (0.80). The face and

content validity of the questionnaire was carried

out by a panel of experts who assessed whether the

questionnaire items are adequately measuring the

concept intended to assess, and whether the items

are adequate to measure the domain of interest. The

first part of the questionnaire collected demographic

data of participants including socio economic status.

The second part of the questionnaire consisted of

substantive questions exploring respondent’s self-

perception and awareness of halitosis along with

their knowledge about causes and management

of halitosis. The questionnaire was prepared on

Google forms and circulated through social media

applications such as WhatsApp, Messenger and

Instagram. The rationale and purpose of the study

was explained as an introductory paragraph on the

Google forms and the participants were assured

that the data identifying the individual will be kept

confidential and the collected data will be used only

for research purpose. The total time taken by the

participants to complete the questionnaire was 5-6

minutes approximately. The link was kept open for

a period of 2 months, starting from 19

May 2020

to 18

July 2020 and Google form limiter was used

to avoid multiple responses by an individual. All the

individuals who responded the forms were included

in the study.

STATISTICAL ANALYSIS:

The data was analyzed using Statistical Package

for Social Sciences, IBM Corporation, SPSS Inc.,

Chicago, IL, USA version 21 software package

(SPSS). Descriptive statistics with frequency,

percentage, mean and standard deviation was

computed. Pearson chi-square test was used to assess

the statistical significance between genders and the

p≤0.05 is set as stastically significant.

RESULTS:

This study was conducted to evaluate the

awareness of halitosis among general population to

determine their knowledge. A total of 512 individuals

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Vinita et al : Awareness of halitosis

130

had responded to the questionnaire during the study

period.

66%

25%

SYSTEMIC DISEASE

Systemic disease No Yes
None of the above

Gender

Female

49%

Male

51%

GENDER

The age of the participants ranged from 18 to

70 years (Mean-36.94+8.436) and 253 (49.4%) were

females and 259 (50.6%) were males. About 66% of

the participants had stated that they had no systemic

diseases, and about 59 (11.5%) and 67 (13.1%) had

the habit of smoking and alcohol consumption,

respectively.

When asked about “whether bad breath was

related to oral hygiene”, 66 % believed that it was

related to oral hygiene and 63.7 % of the participants

believed that proper brushing and mouthwash will

reduce bad breath. When questioned about “whether

smoking and alcohol consumption can cause bad

breath”, most of the participants responded positively

and about 68.2 % believed that those habits may

cause bad breath. Most of the participants, 61.7%

agreed that systemic diseases can cause bad breath.

Among the participants, 62.1 % of the

participants thought food lodgments in teeth could

cause bad breath and 58.2 % of participants believed

food particles coating on tongue caused bad breath.

Majority of the participants, 52.9 % responded

that all of the mentioned options (i.e. oral infection,

dry mouth, medication) can cause halitosis followed

by oral infection (20.9 %), Dry mouth (14.3%)

medication (11.1%). Regarding the association of

halitosis to stomach problems and dental caries,

about 52.5 % and 55.1 % respectively, responded

positively.

Almost 64.6 % of the participants responded

that bad breath reduced their confidence level in

public, and about 60.7 % of the participants were

aware that uncleaned denture may also cause bad

breath. Among 63.3 % of the participants responded

to “I will advise them to have proper oral hygiene” to

the people experiencing halitosis.

When experience of bad breath was compared

between males and females, it was observed that

males had experienced bad breadth significantly

more often than females, (p=0.33) and significantly

a greater number of males had approached dentists

for treating bad breadth. It was observed that

significantly a greater number of females responded

QUESTION

OPTION

FREQUENCY

PERCENT

Have you ever experienced bad
breath?

Yes

203

39.6

192

37.5

Sometimes

117

22.9

TABLE 1: Distribution of participants according to knowledge and attitude towards halitosis

JIDAM/Chennai/Volume:7/Issue:4/Pages 128 - 138/Oct-Dec 2020

Vinita et al : Awareness of halitosis

131

Do you think BAD BREATH is
related to oral hygiene?

Yes

338

66.0

12.7

Maybe

107

20.9

Do you think proper brushing and
usage of mouth wash will reduce
BAD BREATH?

Yes

326

63.7

14.8

Maybe

110

21.5

Do you think smoking /alcohol
consumption can cause bad breath?

Yes

349

68.2

14.3

Maybe

17.6

Do you think BAD BREATH can
occur due to systemic diseases like
diabetes, liver disorder, gastric
problem, etc?

Yes

316

61.7

11.9

Maybe

135

26.4

Do you think food lodgement in
teeth can cause BAD BREATH?

Yes

318

62.1

16.6

Maybe

109

21.3

Do you think food particles
coating on tongue can cause BAD
BREATH?

Yes

298

58.2

14.3

Maybe

137

26.8

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Vinita et al : Awareness of halitosis

132

According to you, BAD BREATH
can be due to

Dry mouth

14.3

Improper
digestion

Internal
infection
in throat or
somewhere

Medication

11.1

Normal

Oral infection

107

20.9

Spicy foods
and ulcers

All of the
above

271

52.9

Do you think BAD BREATH
predominantly occurs among elderly
persons?

Yes

245

47.9

112

21.9

Maybe

148

28.9

Do you think BAD BREATH can be
caused from stomach problems?

Yes

269

52.5

102

19.9

Maybe

141

27.5

Do you think BAD BREATH can
occur due to dental caries?

Yes

282

55.1

19.1

Maybe

135

25.8

Do you think drinking plenty of
water can reduce BAD BREATH?

Yes

271

52.9

17.4

Maybe

152

52.9

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Vinita et al : Awareness of halitosis

133

Do you think BAD BREATH can
occur in a healthy individual also?

Yes

283

55.3

17.8

Maybe

129

25.2

According to you, what measures
can prevent BAD BREATH?

Brush

13.7

Floss

10.0

Mouthwash
and mouth
fresheners

133

26.0

All of the
above

258

50.4

Have you ever approached a dentist
for treating BAD BREATH?

Yes

166

32.4

261

51.0

Maybe

14.5

Do you think BAD BREATH can
decrease confidence level in the
individual?

Yes

331

64.6

14.8

Maybe

105

20.5

Do you think having good nutrition
can reduce BAD BREATH?

Yes

277

54.1

14.3

Maybe

153

29.9

According to you, at what interval
can an individual experience BAD
BREATH?

Daily

117

22.9

Early morning

157

30.7

Once in a
week

17.4

No idea

149

29.1

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Vinita et al : Awareness of halitosis

134

Do you think BAD BREATH might
be due to gum disease?

Yes

243

47.5

108

21.1

Maybe

161

31.4

Are you aware of any device to
measure BAD BREATH?

Yes

205

40.0

197

38.5

Maybe

104

20.3

Do you think that Uncleaned
dentures can cause BAD BREATH?

Maybe

311

60.7

16.2

Yes

118

23.0

What is your opinion of people with
BAD BREATH?

I will advise
them to have
proper oral
hygiene

324

63.3

I will continue
to be friendly
with them

14.1

I will ignore
them

12.9

None of the
above

9.8

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Vinita et al : Awareness of halitosis

135

QUESTION

OPTION

Gender

p-value*

Male

Female

0.033

Have you ever
experienced bad
breath?

Yes

110(21.5%)

93(18.2%)

83(16.2%)

109(21.3%)

Maybe

66(12.9%)

51(10.0%)

Have you ever
approached a dentist
for treating BAD
BREATH?

Yes

91(17.8%)

75(14.6%)

0.000

114(22.3%)

147(28.7%)

Maybe

51(10.0%)

23(4.5%)

What is your
opinion of people
with BAD BREATH

I will advise
them to have
proper oral
hygiene

145(28.3%)

179(35.0%)

0.003

I will continue
to be friendly
with them

39(7.6%)

33(6.4%)

I will ignore
them

44(8.6%)

22(4.3%)

None of the
above

31(6.1%)

19(3.7%)

Table 2. Comparison of gender according to knowledge and attitude towards halitosis

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Vinita et al : Awareness of halitosis

136

that they would advise a person with halitosis to have

proper oral hygiene.

DISCUSSION:

Oral malodour is a very common problem

among entire population. Self-assessment and

perception are the most important factor in both

controlling and diagnosing of bad breath

. This

study was undertaken to assess the knowledge and

awareness of halitosis among general population.

According to the present study, prevalence

and experience rate of bad breath was about 39.6% of

participants which was higher compared to the study

by Alshehri

(39%) and lower when compared to the

study by Fadhil et al

in which it was estimated to be

around 50%.

Halitosis can be predominantly reduced

by oral hygiene measures and in the current study

overall 66% believed that bad breath was related

to oral hygiene. On contrary it was lower when the

present study was compared to study by Yoko et al

(78.4%); higher when compared to study by Settineri

et al

(29.6%). The difference might be because most

of the individual in the present study were aware of

oral hygiene measures.

It is advocated that regular brushing twice

a day and mouth rinsing contributes to good oral

hygiene. In present study, about 63.7% of the

participants agreed to it. On the contrary, in a study

conducted by Azizah et al

a greater number of the

subjects, 77% believed that oral hygiene measures

prevented halitosis.

In the present study, 282 participants (55%)

agreed that bad breath can occur due to dental caries

and 107 (20.9%) of participants agreed that bad

breath can occur due to oral infections. Whereas in

the survey conducted by Bader et al

, in Saudi Arabia

in 2017 revealed that 64.6% of participants agreed

that presence of dental caries was one of the reasons

for halitosis and 79.4% of participants agreed that

halitosis was due to intra oral sources. The percentage

of participants who agreed that halitosis was due to

dental caries and oral infection was high compared

to the present survey. This may be because the

participants were more aware about factors leading

to dental caries.

The status of having other medical problems

was found to be significantly associated with

occurrence of long-standing breath malodor

with regards to this in the present study 61.7%

of the respondents agreed that systemic diseases

like diabetes, liver disorder and gastric problem

contributed to bad breath.

In the present study, tongue coating causing

bad breath was mentioned by about 58.2% of the

respondents which was higher compared to study

conducted by Azizah et al

(34.4%) and similar to the

study by Badar A

(57%). The possible explanation

for this might be as pointed by De Boever and

Loerche that uncleaned tongue is usually harbouring

periodontal bacteria such as prevotella intermedia,

porphyromnas gingivalis and fusobacterium that

were responsible for producing volatile sulphur

compounds that accounts for oral malodor from the

mentioned

Among the participants, about 52.5%

answered that stomach problem could also be the

reason for halitosis which was in accordance with

the study conducted by Nabila et al

(59%) but

lower from a study by Azizah et al(44.6%)

Also,

participants believed that medical condition such as

dry mouth (14.3%) and medications (11.1%) could

be the etiology and contributing factor. On the other

hand, in the study by Azizah et al

, it was higher,

31.4% for dry mouth and in the study by Settineri

et al

, 40% of the respondents answered that taking

medications such as immunosuppressant’s like

cyclosporine, tacrolimus and calcium channel

blockers like amlodipine, diltiazem could cause

halitosis.

The participants approaching dentists

for bad breath was 32.4% in the current study. On

contrary, study findings by Nabila et al

82.4% of

the respondents as agreed on seeking dentist opinion.

This disparity may be due to lack of knowledge about

treatment and prevention of halitosis in current study

individuals.

Most of the participants in the present study

i.e. about 64.6% agreed that bad breath reduced their

social life, but in the study by Badar A et al

(6),

only

36.3% responded so, whereas it was higher in a study

by Nabila et al

(71%). This implies that halitosis

can psychologically affects individuals’ social life.

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Vinita et al : Awareness of halitosis

137

Gum disease like bleeding gums while brushing

and other periodontal problem like periodontal

plaque and pocket also have impact on halitosis. In

the present study, 47.5% of the participants agreed to

it, and it was similar to a study by Rana et al

where

47.78% of males agreed so.

The limitation of the present study is that

it relies only on self-perceived data, and no clinical

examination was performed to assess the actual

presence of halitosis.

In this survey, the participants seem to

have appropriate perception on causes of halitosis

whereas the knowledge of precautionary measures

to prevent it was comparatively low. This disparity

can be overcome by more feasible methods to assess

bad breath and imparting knowledge about ways to

prevent it among the population.

CONCLUSION:

Halitosis is the one of the unattractive aspects

affecting psychosocial interaction and relationships

and it needs multiple approach to treat. Oral hygiene

habits such as brushing the teeth twice daily,

cleansing with mouthwash and usage of dental floss

can reduce the prevalence of halitosis. The result of

the study indicates that awareness of halitosis among

general population was high whereas knowledge

on prevention on halitosis was comparatively low.

Thus, each individual in the population should be

encouraged to gain knowledge about the prevention

of halitosis.

FINANCIAL SUPPORT AND SPONSORSHIP:

Nil.

CONFLICTS OF INTEREST:

There are no conflicts of interest.

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