Influence of tobacco smoking on the development of halitosis

Background

Halitosis is the general term used to describe any disagreeable odor in exhaled air, regardless of whether the odorous substances originate from oral or non-oral sources. Previous research has strongly associated tobacco smoking in the development of halitosis, as it increases the synthesis of toxic volatile sulfur compounds in diseased periodontal pockets. In this review, we summarize the etiopathology and epidemiology of halitosis as well as the current evidence on the impact of smoking by means of a meta-analysis.

Methods

PubMed and Embase were searched to identify publications that reported halitosis in smokers and nonsmokers. Meta-analyses were performed if a sufficient number (n ≥ 3) of articles were available that evaluated the same outcome.

Results

The meta-analyses showed that there was an increased risk of halitosis in current smokers versus nonsmokers (odds ratios). These results were consistent both in fixed and random effects models. Even though the interstudy heterogeneity was high (I2 = 91%), sensitivity analysis by limiting the number of studies yielded similar results, with no-to-moderate heterogeneity (I2 = 0-65%). The analysis comparing ever smokers with never smokers showed no significant difference in the risk of halitosis in ever smokers. The same effect was observed when upon stratifying the analyses on the basis of ascertainment of halitosis (self-reported or measured by a Halimeter).

Conclusions

Halitosis is a common condition which can affect the quality of life of those affected. The results from this literature review and meta-analysis show that current smokers are more likely to suffer from halitosis, even if they are less likely to report it.

Clinical Trial Evaluating Quality of Life in Patients with Intra-Oral Halitosis

Halitosis is considered to be extremely unattractive in the context of social interactions. The main research objective of this study was to evaluate whether intra-oral halitosis may impact patients’ quality of life (QOL). One hundred generally healthy adult participants complaining about oral malodor and diagnosed with intra-oral halitosis were enrolled in this study. For halitosis diagnosis, a gas chromatography (GC) analysis by the Oral Chroma portable device was used. QOL assessment was based on the Short Form 36-item Health Survey (SF-36). The respondents had the highest scores in the physical functioning (PF), activity limitations caused by emotional problems (RE) and activity limitations caused by physical problems (RP) domains, and the weakest in the general health perception (GH), vitality (VT) and emotional wellbeing (MH) ones. The total volatile sulfur compounds (VSCs) level was negatively correlated with SF-36 domains. The SF-36 domains’ scores decreased the higher the level of VSC was. The respondents assessed their QOL to be at its best in physical functioning and activity limitations caused by emotional and physical problems and the worst in general health perception, vitality and emotional wellbeing. The strongest correlation between halitosis and decreased QOL was found in the social functioning (SF), vitality, emotional wellbeing and general health perception domains.

A Literature Review and Framework Proposal for Halitosis Assessment in Cigarette Smokers and Alternative Nicotine-Delivery Products Users

Halitosis is a health condition which counts cigarette smoking (CS) among its major risk factors. Cigarette smoke can cause an imbalance in the oral bacterial community, leading to several oral diseases and conditions, including intraoral halitosis. Although the best approach to decrease smoking-related health risks is quitting smoking, this is not feasible for many smokers. Switching to potentially reduced-risk products, like electronic vapor products (EVP) or heated tobacco products (HTP), may help improve the conditions associated with CS. To date, there have been few systematic studies on the effects of CS on halitosis and none have assessed the effects of EVP and HTP use. Self-assessment studies have shown large limitations owing to the lack of reliability in the participants' judgment. This has compelled the scientific community to develop a strategy for meaningful assessment of these new products in comparison with cigarettes. Here, we compiled a review of the existing literature on CS and halitosis and propose a 3-layer approach that combines the use of the most advanced breath analysis techniques and multi-omics analysis to define the interactions between oral bacterial species and their role in halitosis both in vitro and in vivo. Such an approach will allow us to compare the effects of different nicotine-delivery products on oral bacteria and quantify their impact on halitosis. Defining the impact of alternative nicotine-delivery products on intraoral halitosis and its associated bacteria will help the scientific community advance a step further toward understanding the safety of these products and their potentiall risks for consumers.

Validation of the Brazilian version of the Halitosis Associated Life-Quality Test (HALT)

The present study aimed to validate (cross-culturally adapt and test psychometric properties) the Brazilian version of the Halitosis Associated Life-Quality Test (HALT). A process of translation and cross-cultural adaptation was conducted by a group of dental researchers. The first draft of the Brazilian Portuguese version was pre-tested on a sample of 33 individuals leading up to the final version of the questionnaire. The Brazilian version of the HALT (B-HALT) was applied to 100 individuals with halitosis (organoleptic score ≥ 2) and 100 individuals without halitosis (organoleptic score < 2). Exploratory factor analysis (EFA) was performed to evaluate the dimensionality of B-HALT. Cronbach's alpha (α) and interclass correlation coefficient (ICC) were used to measure its reliability. For convergent validity, Spearman's correlation was conducted between the B-HALT and the organoleptic scores. The discriminant validity was evaluated through the Mann-Whitney and Kruskal-Wallis tests. EFA confirmed the unidimensionality of B-HALT, which has also demonstrated excellent internal consistency (α = 0.96) and test-retest reliability (ICC = 0.93). There was a positive correlation between B-HALT and organoleptic scores (r = 0.33; p < 0.001). B-HALT was able to discriminate between the groups with and without halitosis measured by the organoleptic method (p < 0.001) and self-reported halitosis (p < 0.001). B-HALT has demonstrated to be a reliable and valid tool to evaluate the oral health-related quality of life associated to halitosis in Brazilian adults.

Oral Health-Related Quality of Life and Associated Factors in Brazilian Adolescents

This study aimed to assess the impact of oral health on the quality of life of adolescents. A cross-sectional study was performed with students from public and private schools from Passo Fundo, Brazil. All students were aged between 15 and 19 years old. The proportional random sample consisted of 736 adolescents from 20 schools. A structured questionnaire was applied, and an oral examination was performed, counting the number of teeth. Oral health-related quality of life was assessed by OHIP-14. Associations between quality of life and associated factors were analyzed. The mean OHIP-14 score was 7.25. Age, ethnicity and studying in a public school were associated to the OHIP-14 score. Tooth loss (p=0.79) was not associated with quality of life. Additionally, questions related to appearance, such as whether teeth appearance bothers the adolescent (p=0.68) were not associated with quality of life. Attending a public school (OR=1.63; CI95%: 0.98-2.70) and self-reported halitosis (OR=1.48; CI95%: 1.01-2.16) were strongly associated to higher impact on quality of life. It was concluded that socioeconomic conditions and halitosis were associated to higher impact on quality of life of adolescents.

Factors Associated with Halitosis in White-Collar Employees in Shanghai, China

Objective

To investigate the factors associated with halitosis in Chinese white-collar employees.

Materials and Methods

Subjects in three randomly selected office buildings in Shanghai, China, were enrolled in this cross-sectional study using cluster random sampling. Oral malodor was assessed by measuring volatile sulfur compounds (VSCs) with a portable sulfide monitor. Subjects’ oral health, including dental caries, periodontal status, and tongue coating, was evaluated clinically. A questionnaire was used to obtain information about participants’ demographic characteristics, oral hygiene habits, and health behaviors.

Results

Of the 805 subjects invited to participate in this study, 720 were enrolled (89.4% response rate). Data from these subjects were used for statistical analyses. The prevalence of halitosis was 33.2%. In the final regression model, halitosis was significantly related to tongue coating thickness, periodontal pocket depth, no food consumption within 2 hours prior to oral examination, and less intake frequency of sweet foods.

Conclusions

In this Chinese white-collar population, tongue coating and periodontal disease were associated with halitosis. Oral hygiene education should be provided at the population level to encourage the maintenance of oral health and fresh breath. Consumption of sweet foods may reduce VSC production, although this finding requires further investigation.

Oral prophylaxis and its effects on halitosis-associated and inflammatory parameters in patients with chronic periodontitis

OBJECTIVE

A controlled clinical trial was conducted to evaluate the effects of oral prophylaxis on halitosis-associated, immunological and microbiological parameters.

METHODS

Thirty subjects were included in this controlled clinical trial (patients with generalized chronic periodontitis and controls without clinical attachment loss; each n = 15). Before oral prophylaxis and 14 days after (including tongue cleaning) volatile sulphur compounds (VSC), organoleptic scores and a tongue coating index were evaluated. The levels of IL-1β, IL-8, IL-10 and MMP-8 were measured in GCF, and also major periodontal pathogens were detected. Data were statistically analysed using anova and paired t-test.

RESULTS

Supragingival plaque and calculus removal with combined tongue cleaning was able to reduce significantly (P < 0.05) the VSC values in both groups (no significant differences between both groups). Two weeks after periodontal debridement, the VSC values were observed in the periodontitis group, but not in the control group, similar to the baseline values. The difference between the groups was statistically significant (P < 0.05). Only a repeated prophylaxis session in the periodontitis group was able to reduce VSC values significantly in comparison with baseline (P < 0.05). Organoleptic scores (10 and 30 cm) were significantly different (P < 0.05) between both groups before and after the treatment. Periodontal pathogens and host-derived markers were not significantly affected by a single prophylaxis session.

CONCLUSIONS

Oral prophylaxis may result in a significant decrease in VSC values. However, in periodontal diseases, a more complex treatment seems to be necessary.

Characteristics of patients complaining of halitosis and factors associated with halitosis

OBJECTIVES

To describe the characteristics of patients who visited halitosis clinic and to investigate the factors that may associate with halitosis.

MATERIALS AND METHODS

Nine hundred and eleven patients, who visited halitosis clinic for consultations, underwent organoleptic tests and volatile sulfur compound (VSC) measurements with a portable sulfide monitor. The oral health of patients, including dental caries, oral hygiene, and gingival inflammation status, was assessed. Questionnaires were used to obtain information on demographics, oral hygiene practices, and dietary habits.

RESULTS

Of the 911 patients, more females than males visited the clinic. Patients' age ranged from 18 to 82 years (mean ± s.d.: 40.8 ± 14.1). Almost 30% of patients had complained of halitosis for over 5 years before looking into treatments. Approximately half of the patients self-perceived that they were unable to get close to others. Around 77% of patients had halitosis. Results of multiple logistic regressions for organoleptic scores and VSC values showed that tongue coating and tongue scraping were significantly associated with halitosis (P < 0.05).

CONCLUSIONS

Among these Chinese patients, over three-quarters of patients had halitosis, and negative impacts on social communications were observed. Tongue coating was the most important factor responsible for halitosis.

Does concern about halitosis influence individual's oral hygiene practices?

OBJECTIVE

The objective of this study was to assess whether the concern about halitosis influence oral health attitude and practices among young literate adults in Nigeria.

MATERIALS AND METHODS

This cross-sectional survey of 400 randomly selected temporary camp resident adults in Anambra state, South Eastern Nigeria was conducted using a modified version of the Hiroshima University-Dental Behavioral Inventory questionnaire.

RESULTS

Out of the 400 questionnaires distributed, only 294 were filled and returned giving an overall response rate of 73.5%. Half (50.0%) of the participants in this study expressed concern about halitosis. The participants that expressed concern about halitosis were mostly in the 25- to 27-year-old age group, females, known smoker, regular dental floss, and mouth wash users, had incorrect tooth brushing knowledge, brushed teeth more frequently and more forcefully, had no previous dental treatment, prefer symptomatic dental visit, experienced gingival bleeding, expressed worry about the color of their gingiva and teeth but were satisfied with the dental appearance.

CONCLUSION

Data from this study showed that concerns about halitosis-triggered behavioral reaction in oral self-care practices namely tooth brushing frequency, tooth brushing force, mouth wash, and dental floss use. Also revealed were poorer oral health and lower preventive dental visit practices among participants concerned about halitosis. There is need for improved public knowledge and awareness about halitosis by the dentist in Nigeria.

Halitology (breath odour: aetiopathogenesis and management)

This article reviews the aetiopathogenesis of halitosis (oral malodour) and management. Halitosis is any disagreeable breath odour. In most patients, the odour originates from the oral cavity. In some patients, it has an extra-oral aetiology and, in a few, metabolic anomalies are responsible. In other patients complaining of malodour, this is imagined rather than real. Volatile sulphur compounds (VSCs) and other elements appear largely responsible for the malodour. Predisposing factors include poor oral hygiene, hyposalivation, dental appliances, gingival and periodontal disease and mucosal disease. The first step in assessment is objective measurement to determine whether malodour is present. If present, the oral or extra-oral origin should be determined, because the latter requires medical investigation and support in therapy, as is also the case where the malodour is imagined rather than real. Oral malodour is managed largely by oral health improvement, plus use of one or more of the wide range of antimalodour therapies, and sometimes also with use of a malodour counteractive. Emergent treatments include probiotics and vaccines targeted against causal micro-organisms or their products.