The association between halitosis and periodontitis: a systematic review and meta-analysis.

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.

Halitosis in young patients with chronic kidney disease: findings from a randomized controlled trial.

BACKGROUND: Chronic kidney disease (CKD) directly affects oral health. Yet data about halitosis in young CKD patients and the impact of dental prophylaxis is limited. Therefore, as part of this randomized clinical trial, halitosis in young CKD patients undergoing intensive or standard oral preventive procedures was to be explored. METHODS: Three volatile sulfur compounds (hydrogen sulfide, methyl mercaptan and dimethyl sulfide) were measured in 30 young patients with CKD (mean age 14.2 years; 16 males, 14 females). Breath samples were taken after 3 and 6 months and analyzed with selective gas chromatography (OralChroma). Tongue coating (Winkel Index) and clinical indices to determine local inflammation or oral hygiene (Papillary Bleeding Index and Quigley-Hein Index) were assessed. Within an extended anamnesis, patients and their mothers and nurses were questioned about the perceived halitosis. Corresponding quotes were noted verbatim. Patients were randomized to either intensive need-related oral health care measures (oral preventative program, OPP) or a one-stage standard prevention (treatment as usual, TAU). RESULTS: While there were no differences in volatile sulfur compound levels between TAU and OPP at the three time points of measurements (p > 0.05), there was a tendency towards a reduction in dimethyl sulfide and hydrogen sulfide of affected patients within the OPP group over time. Looking at potential differences between both groups with regard to tongue coating, significant differences were observed between baseline and 3 months after study start in the OPP group, and between baseline and 6 months after study start in the TAU group (p < 0.05). The burden of halitosis was frequently reported by patients' mothers and nurses. CONCLUSIONS: Young CKD patients regularly suffered from halitosis and dimethyl sulfide was its main source. Preventive measures mainly resulted in a reduction of tongue coating. TRIAL REGISTRATION: The German Clinical Trial Register (# DRKS00010580).

Investigating the prevalence of halitosis and its associated factors amongst the general population of Karachi, Pakistan.

Objective: To assess the prevalence of halitosis among the general population of Karachi, and to identify factors contributing to its occurrence. METHODS: 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.

Characteristics of extra-oral halitosis induced by functional constipation: a prospective cohort study.

Characteristics of extra-oral halitosis induced by functional constipation (FC) have never been revealed. To address this, this prospective cohort was conducted with 100 FC patients, who were divided into a halitosis group and a negative group. Organoleptic score (OLS) ⩾ 2 in nose breath was diagnosed as extra-oral halitosis. Concentration of overall volatile sulfur compounds (VSCs) measured by Halimeter, concentration of hydrogen sulfide (HS), methanethiol (MT), dimethyl sulfide (DMS) and their total amount measured by OralChroma in nose breath was recorded asC-VSC,C-HS,C-MT,C-DMS andC-sum respectively. We found that 82% (82/100) of the FC patients had extra-oral halitosis. However, only 12.5% (3/82) and 1.22% (1/82) of halitosis group were correctly diagnosed with the current diagnostic threshold ofC-VSC ⩾ 110 parts per billion (ppb) and ⩾150 ppb.C-VSC,C-DMS andC-sum were significantly higher in the halitosis group compared to the negative group (allP< 0.001), with ratios of about 2.2 times, 3.1 times and 2.1 times respectively.C-HS andC-MT were low and not significantly different between the groups. Positive correlations were observed among OLS,C-VSC,C-DMS andC-sum. The area under curve of receiver operating characteristics ofC-VSC, C-DMS andC-sum for predicting FC-induced halitosis was 0.909, 0.9073 and 0.962 respectively, with the threshold values of ⩾36 ppb, ⩾52 ppb and ⩾75 ppb respectively. Therefore, we conclude that: (1) DMS is the primary contributor to FC-induced extra-oral halitosis. (2) OLS, Halimeter and OralChroma are consistent in detecting FC-induced extra-oral halitosis. (3) The diagnostic threshold for Halimeter should be adjusted toC-VSC ⩾ 36 ppb and the diagnostic threshold for OralChroma should be set asC-DMS ⩾ 52 ppb for diagnosing FC-induced extra-oral halitosis.

Factors associated with halitosis reported by parents/caregivers in individuals with Down syndrome.

AIMS: Data on halitosis among individuals with Down syndrome (DS) are scarce. The aim was to evaluate factors associated with the occurrence of halitosis reported by parents/caregivers (P/Cs) in individuals with DS. METHODS AND RESULTS: A cross-sectional study was conducted in non-governmental assistance institutions in the State of Minas Gerais-Brazil. P/Cs have answered an electronic questionnaire with sociodemographic, behavioral and oral health data. Factors associated with halitosis were evaluated by multivariate logistic regression. The sample comprised 227 P/Cs (age 48.8 ± 13.2 years; 82.9% mothers) of individuals with DS (age 20.8 ± 13.5 years). The prevalence of halitosis in the total sample was 34.4% (n = 78) and its occurrence was associated: 1) in individuals with DS ≤18 years old (26.2%; n = 27)-negative perception of oral health (OR = 3.91); 2) in individuals with DS > 18 years (41.1%; n = 51)-gingival bleeding (OR = 4.53), absence of tongue brushing (OR = 4.50), negative perception of oral health (OR = 2.72). CONCLUSIONS: The occurrence of halitosis in individuals with DS reported by P/Cs was relevant and associated with dental factors, having a negative impact on the perception of oral health. Oral hygiene practices, especially tongue brushing, should be reinforced to prevent and control halitosis.

[Halitosis. Multidisciplinary approach]. / Khalitoz ­ mezhdistsiplinarnaya problema.

Halitosis is a common complaint among patients. Up to 50% of people worldwide claim to have persistent or intermittent bad breath. Often, bad breath not only disrupts the social life of patients, but is also a symptom of systemic diseases. An important step in the treatment of halitosis is the localization of the source and possible cause of the unpleasant smell. Most often, the problem of halitosis is solved by dentists, because intraoral halitosis accounts for up to 90% of all cases, but doctors of many specialties should deal with the differential diagnosis of its causes. This article considers the main causes of halitosis in patients with diseases of various organ systems.

Investigation of volatile sulfur compound level and halitosis in patients with gingivitis and periodontitis.

This study aimed to measure the levels of volatile sulfur compounds and investigate the occurrence of halitosis in patients with gingivitis and periodontitis. Additionally, the incidence rates of gingivitis and periodontitis in patients with halitosis were investigated. Through various statistical analyses, we attempted to determine the relationship between periodontal disease and halitosis. One-hundred-and-four participants (52 females and 52 males, mean age: 46.49 ± 16.03 years) were enrolled in this cross-sectional study, comprising 33 healthy controls, 43 patients with gingivitis, and 28 patients with periodontitis. Gas chromatography was used to measure hydrogen sulfide (H2S) and methyl mercaptan (CH3SH), which are representative VSCs. The VSC cut-off values for diagnosing halitosis were 65.79 ppb for women and 79.94 ppb for men. Total VSC level was significantly higher in the gingivitis than the healthy control group (186.72 ± 374.83 ppb vs. 19.80 ± 40.19 ppb, p = 0.035). There was no significant difference between the gingivitis and periodontitis (153.79 ± 278.51 ppb) groups. H2S level was significantly higher in the gingivitis (100.51 ± 183.69 ppb) and periodontitis (91.57 ± 132.06 ppb) groups than in healthy controls (14.97 ± 31.22 ppb), and CH3SH level was significantly higher in gingivitis group (29.31 ± 59.16 ppb) than in the healthy control (5.73 ± 14.10 ppb) (all p < 0.05). Halitosis was found in 3% of healthy controls and 39.5% and 42.9% of patients with gingivitis and periodontitis patients, respectively, making it significantly higher in the gingivitis and periodontitis groups than the healthy controls (p = 0.005). Conversely, among participants with halitosis, 53.1% had gingivitis, 37.5% had periodontitis, and 90.6 incidence had periodontal disease. Multivariate logistic regression analysis to predict the presence of halitosis, found periodontal disease was a significant predictor of halitosis (OR = 3.607, 95% CI 1.023-12.718, p = 0.046). Considering area under curve value for halitosis, the cut-off value of healthy control (H2S:61.5 ppb, CH3SH:3.5 ppb), gingivitis (H2S:50.0 ppb, CH3SH:6 ppb), and periodontitis (H2S:62.0 ppb, CH3SH:3.5 ppb) were (all p < 0.05). Our results emphasize the close and strong relationship between periodontal disease and halitosis through human clinical evidence based on the high co-occurrence rate of mutual diseases. Additionally, the presence of periodontal disease increased the probability of halitosis by 3.607 times. These results suggest that H2S can be used as a biomarker of halitosis in patients with periodontal disease.

Diagnosis, management and knowledge of halitosis among Polish and Lebanese dentists: Questionnaire-based survey.

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.

Is bad breath associated with dyspepsia? An association and an equivalence study.

Halitosis affects all populations worldwide. The presence of chronic halitosis may be related to a health problem. Patients with bad breath usually seek a gastroenterologist and, in some cases, invasive and expensive exams, such as digestive endoscopy, are performed to investigate the etiology of halitosis. This study aimed to investigate whether the prevalence of bad breath in patients diagnosed with dyspepsia (any pain or discomfort in the upper abdomen) is higher than or equivalent to that in non-dyspeptic patients. This is a cross-sectional study that included 312 patients from university hospitals in the city of Rio de Janeiro (141 dyspeptic patients and 171 non-dyspeptic ones). The presence of halitosis was defined based on different cutoff points. Association analyses were performed using a log-binomial model and 95% confidence intervals were calculated for the coefficients, adjusting for sex and age. The equivalence test (Westlake) was used to test the hypothesis of equivalence between the proportions of patients with bad breath in the two groups (dyspeptic vs. non-dyspeptic), considering an equivalence band of ± 15%. The prevalence of bad breath ranged from 30% to 64% according to the definition of bad breath. Dyspepsia was not associated with bad breath in any of the three definitions of bad breath (two specific ones and a sensitive one). The proportion of patients with marked bad breath was equivalent in patients with and without dyspepsia.

Use and Abuse of Electrocautery in Adenoidectomy Hemostasis.

Background and objectives: Bipolar electrocautery is commonly used to control bleeding after cold-instrument pediatric adenoidectomy, but the surgeon should be aware of the possible side effects. OBJECTIVE: The aim of our study is to investigate the effects of bipolar electrocautery when used for bleeding control at the end of an adenoidectomy procedure. Materials and Methods: We evaluated the effect of electrocautery on postoperative pain, velopharyngeal insufficiency symptoms, postoperative nasal obstruction, and rhinorrhea in a group of 90 children undergoing adenoidectomy in our ENT department over a period of 3 months. Results: After statistically analyzing the data, we found that the duration of postoperative pain, the duration of rhinorrhea and nasal obstruction, and the duration of painkiller administration, as well as the velopharyngeal insufficiency symptoms, were significantly longer in patients in whom electrocautery was used for hemostasis. A significantly higher incidence of posterior neck pain and halitosis (oral malodor) was noted in the patients in whom electrocautery was used for adenoidectomy hemostasis. Conclusions: Bipolar electrocautery use should be limited during pediatric adenoidectomy hemostasis because of the possible side effects: longer postoperative pain, prolonged nasal obstruction, rhinorrhea and velopharyngeal insufficiency, and halitosis. We noted some side effects that were specific to electrocautery use during adenoidectomy: posterior neck pain and oral malodor. Acknowledging the risk for these symptoms can help to alleviate the anxiety of both the parents and the patients regarding the expected postoperative outcomes.

Emotional and Social Impact of Halitosis on Adolescents and Young Adults: A Systematic Review.

Background and Objectives: Halitosis is a condition characterized by unpleasant breath smell that is starting to receive serious scientific attention, considering it reflects on people's social and personal life. While most studies focus on the prevalence of halitosis, its medical etiology, and the psychological impact on adults, there is a lack of evidence regarding the social impact of halitosis on the younger population. Therefore, this systematic review aimed to observe the social and emotional impact that halitosis has on adolescents and young adults. Materials and Methods: The review followed the PRISMA protocol, and four electronic databases (Scopus, Scholar, Web of Science, and ProQuest) were searched. From a total of 593 studies retrieved, only 6 were included in the study after assessing the eligibility criteria. Results: The main results showed that the levels of self-reported halitosis ranged from 23.1% to 77.5%, with an average of 44.7%, indicating a significant heterogeneity among the studies reporting this issue. Adolescents and young adults who experienced bad breath were feeling more anxious and depressed according to the non-standardized questionnaires and the standardized questionnaires (OHIP-14 and SCL-9-R). The respondents were isolated from social interactions and consequently had lower self-esteem and impaired quality of life. Conclusions: The conclusions drawn indicate the need for action on a medical level, as well as on a psychological level, in order to improve people's oral health and help them navigate through the difficulties of maintaining social interactions as they live with halitosis.

Evaluation of halitosis parameters in patients undergoing head and neck radiotherapy.

OBJECTIVES: To assess halitosis parameters using OralChroma™ and the correlation with salivary flow, oral hygiene index, radiation dose, and tongue-coating index among irradiated head and neck cancer patients compared to patients without cancer. MATERIALS AND METHODS: This cross-sectional study enrolled irradiated and non-irradiated patients divided into two groups. Hydrogen sulfide, methyl mercaptan, and dimethyl sulfide (DMS) levels were measured using a gas chromatograph, and sialometry was performed. The tongue-coating index and simplified oral hygiene index were also assessed. RESULTS: Thirty-eight patients were allocated to each group. Volatile sulfur compound levels were above the thresholds in both groups. Non-irradiated individuals showed higher levels of hydrogen sulfide and dimethyl sulfide. Patients with asialia had an inexpressive tongue-coating index and increased dimethyl sulfide levels. A decrease in salivary flow rate was followed by a significant increase in volatile sulfur compound levels. Higher doses of radiation to the submandibular salivary glands were associated with higher concentrations of sulfide and methyl mercaptan. CONCLUSIONS: Head and neck radiotherapy may be important in the development of halitosis. Irradiated patients with asialia presented insignificant lingual biofilm. Consequently, lower levels of volatile sulfur compounds were detected in this group. Asialia, a severe radiation-induced hyposalivation, impacted the levels of DMS (extraoral origin).

Aetiology and associations of halitosis: A systematic review.

Halitosis is a term that refers to an unpleasant or foul odour originating from the oral cavity that can be caused by either intra-oral or extra-oral factors. Despite the fact that halitosis has multifactorial aetiology, intra-oral factors play a significant role in the majority of cases. This systematic review assesses halitosis's intra-oral and extra-oral associations. An electronic search through MEDLINE (PubMed), Google Scholar and the Wiley Online Library was conducted to identify relevant manuscripts. A keywords-based search was performed, using the terms 'halitosis', 'bad-breath', and 'oral malodour causes and aetiology'. Articles published from January 2014 to December 2020 were included. We selected studies evaluating the intra-oral and extra-oral factors that induce oral malodour, as well as the factors associated with systemic diseases. Eighty to ninety percent of halitosis is caused by intra-oral factors, with coated tongue, periodontal diseases and poor oral hygiene practices being the principal factors. Ten to twenty percent of halitosis is induced by extra-oral factors associated with systemic diseases. Multiple factors can cause halitosis, but most of the aetiology is intra-oral. Increased medical awareness is needed to determine the actual pathophysiological process of oral malodour in otherwise healthy individuals.

Study on the Efficacy and Safety of Oral Care in ICU Patients Based on Meta-Analysis.

The effectiveness and safety of oral care in Intensive Care Unit (ICU) patients by meta-analysis are explored. According to the research direction of the effectiveness and safety of oral nursing in ICU patients, the corresponding literature studies are retrieved in literature databases and meta-analysis is performed. A total of 17 Chinese and English literature studies are included, and the literature has no obvious publication bias. The experimental results show that the improvement effect of dry mouth and halitosis in the improved group is significantly higher than that in the traditional group, and the dry mouth score, plaque index, and complications such as oral mucosa infection, oral mucosa damage, and halitosis are significantly reduced in the improved group, and the differences are statistically significant (P < 0.05). Improved oral care can significantly improve the symptoms of dry mouth and halitosis in ICU patients, quickly remove dental plaque and effectively reduce the incidence of complications such as halitosis, oral mucosal infection, and oral mucosal damage. Improved oral care is an effective and safe ICU nursing program.

Criticism of the organoleptic examination for the diagnosis of oral halitosis.

Due to the fact that only a human can judge the objectionability of an odor, organoleptic examination (sniffing and scoring oral odor) was used as a reference standard of oral halitosis measurement. However, there are several problems that make the diagnostic value of organoleptic examination questionable. There is no universally accepted, precise definition, standardization or calibration in organoleptic examination, including scoring, scaling or safety protocols. Standardization, calibration, reproducibility, reliability, objectivity, specificity, accuracy and sensitivity of organoleptic measurements are doubtful. It is extremely subjective, emotional, instinctive, intuitive, speculative, hedonic and highly flexible. In addition, it is found to be repulsive, primitive and moreover even shame is experienced by patients and examiners. Non-standard protocols on pre-measurement, scoring, scaling, and training processes may cause misinterpretation or misdiagnosis since it depends on the examiner's emotional mood, gender, ethnicity, odor detection spectrum, threshold and even climatic conditions. It is not the gold standard, and not even considered standard. It is difficult to recognize, identify or focus on a particular gas among thousands in the breath. Organoleptic examination may not be necessary due to it not being a good diagnostic tool for halitosis. There may be an infection risk for sniffers or patients. Moreover, female examiners may have disadvantages in olfactory accuracy during organoleptic examination since menstruation, pregnancy and menopause may alter their odor sensation. In addition, age limits the reliability of examiners due to age-related smell loss. According to the psychophysics laws, the human nose can recognize odors logarithmically. There is no reason to think that scoring the oral malodor by sniffing the mouth of the patients obtains sufficient evidence for the diagnosis of halitosis. Portable multi-gas detectors and electronic noses, can be suggested as an alternative instead of sniffing patients. This is the first paper in the literature to criticize organoleptic examination, revalue its health risks and inconsistencies in assessment protocols.

Revisiting Standard and Novel Therapeutic Approaches in Halitosis: A Review.

Halitosis, or bad breath, is an oral health problem characterized by an unpleasant malodor emanating from the oral cavity. This condition can have different origins and causes a negative burden in social interactions, communication and quality of life, and can in uncommon cases be indicative of underlying non-oral non-communicable diseases. Most cases of halitosis are due to inadequate oral hygiene, periodontitis and tongue coating, yet the remaining proportion of cases are due to ear-nose-throat-associated (10%) or gastrointestinal/endocrine (5%) disorders. For this reason, the diagnosis, treatment and clinical management of halitosis often require a multidisciplinary team approach. This comprehensive review revisits the etiology of halitosis as well as standard and novel treatment that may contribute to higher clinical success.

Etiology of halitosis in pediatric dentistry.

Halitosis has become a major concern, as it is the third most common reason for dental visits and affects individuals across all ages, genders, and ethnicities. Only a few limited studies have explored the prevalence and etiology of halitosis in the pediatric population. Therefore, the aim of this review was to identify the etiological factors influencing the widespread occurrence of halitosis in pediatric dentistry in order to guide therapy based on the identified causes, thereby improving children's quality of life. The etiology of halitosis is multifactorial; however, in most cases, halitosis is associated with the oral cavity. It can also be related to otorhinolaryngological and respiratory or even gastric diseases. Although halitosis in children is widely associated with poor oral hygiene, we cannot rule out other possible causes, such as otorhinolaryngological and respiratory causes.