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Introduction
Halitosis is a common social condition that affects a considerable portion of the general population. The prevalence of halitosis is close to 50% in some populations.1 This oral condition may cause embarrassment, depression and make relationships more difficult.2 Some studies have investigated whether the psychological profile of patients might have some influence on the complaints about halitosis, or even on halitosis itself.3 , 4 In a study that included 1,052 participants and self-reported halitosis, Sentiner et al.5reported that poor oral hygiene and general anxiety were associated with halitosis.
Halitosis is divided into intraoral, extraoral, pseudohalitosis and halitophobia. Intraoral halitosis, responsible for 85% of the cases of halitosis, is subdivided into physiologic (genuine) halitosis or pathologic halitosis.1 Extraoral halitosis occurs when malodor appears with no oral cause, as in the case of pulmonary causes. Both patients with pseudohalitosis and halitophobia present with complaints of halitosis, but without any diagnostic evidence of malodor.
This study determined the prevalence of halitosis in the group of enlisted individuals and the emotional impact of this oral condition on their lives, and correlated findings with sociodemographic factors.
Methods
Every year, all 18-year-old male Brazilians undergo medical and dental examinations by the army medical services because of mandatory enlistment for military service for all that reach that age.
This study selected 2,224 male recruits that joined the Brazilian Army in the city of Pelotas, RS, Brazil. After having their health assessment (medical and dental examination) completed by physicians, participants completed a questionnaire, applied by trained interviewers, and underwent an anthropometric examination. The questionnaire contained questions about their systemic health, oral health, halitosis, and demographic data. This study was conducted in association with a dermatology investigation. In questions about halitosis, the enlisted men were asked about their concern about breath and issues that might indicate the psychological impact of halitosis and the factors associated with it.
The questionnaire had four questions about the impact of halitosis that addressed the emotional impact of halitosis. The questions about psychological aspects were:
Did you use any product to hide unpleasant mouth odor in the last 4 weeks?
Did you seek any specialized treatment in the last 4 weeks?
Did your breath make you feel worried in the last 4 weeks?
Did you feel tense, irritated, depressed, embarrassed and/or ashamed, have smiling difficulties, difficulties in dating, feel uncomfortable talking to others or avoid the company of others because of your breath in the last 4 weeks?
The statistical analysis was made using the Statistical Package for Social Sciences (SPSS), and the sample was described using univariate frequency distribution. A chi-square test was used to analyze the association of self-perceived halitosis and sociodemographic data.
This study was approved by the Ethics Committee of Santa Casa de Misericórdia de Pelotas, RS, Brazil (protocol no. 028/2008). Participants' confidentiality was guaranteed. Written and verbal informed consent to participate in the study was obtained from all participants.
Results
Of the 2,274 individuals interviewed, 457 attempted to disguise their oral malodor (20.09%). The correlation of this data with household income was significant (0.020). Individuals with an income above four minimum wages had the highest prevalence in disguising malodor (22.5%). There was no significant association with education (p = 0.146). Seventy-five individuals (3.29%) sought specialized treatment, but household income did not affect outcomes (p = 0.91). Nevertheless, individuals with up to 5 years of schooling sought specialized treatment in a much higher proportion than those with 5 to 8 years and those with more than 8 years (p = 0.001).
Our results also revealed that 274 people were worried about their oral malodor (12%). Of these 274, 104 felt tense and 48, depressive; 192 were ashamed; 71 avoided the company of others; 198 did not feel comfortable talking to others; 85 had difficulty smiling; 82 reported difficulties in dating. The concern with oral malodor was associated with income and level of education. Individuals with an income of two or more minimum wages, as well as those with fewer than 5 years of schooling, reported greater concern with oral malodor. Associations were significant (p < 0.001). Table 1 shows the emotional impact of halitosis on patients according to the first three questions.
Table 1 Effect of education and household income on the emotional impact of halitosis, n (%)
| Yes to question 1 | p | Yes to question 2 | p | Yes to question 3 | p | |
|---|---|---|---|---|---|---|
| Total family income | ||||||
| Up to 2 minimum wages | 105 (17.6) | 0.020 | 17 (2.9) | 0.91 | 95 (15.8) | p < 0.01 |
| Between 2 and 4 minimum wages | 155 (19.4) | 31 (3.9) | 95 (11.9) | |||
| More than 4 minimum wages | 197 (22.5) | 27 (3.1) | 84 (9.6) | |||
| Total | 457* | 75 | 274 | |||
| Level of education | ||||||
| Up to 5 years | 26 (18.4) | 0.146 | 13 (9.2) | 0.001 | 31 (22.0) | p < 0.01 |
| 5 to 8 years | 196 (19.0) | 34 (3.3) | 138 (13.4) | |||
| Over 8 years | 236 (21.5) | 28 (2.5) | 105 (9.5) | |||
| Total | 458 | 75 | 274 |
* One missing.
Discussion
In our sample of 2,224 individuals, 274 (12.0%) were concerned about their oral malodor, which is a common complaint among the general population,6 found in a considerably larger percentage than halitosis itself; that is, there is a greater number of patients complaining about halitosis than suffering from it.7
This may be explained by the fact that it depends on a subjective evaluation of patients with halitosis. In a study3 carried out with 38 participants that answered a questionnaire and underwent periodontal examination and organoleptic evaluation of halitosis, participants were not able to correctly associate their halitosis with periodontal parameters and organoleptic evaluations. In another study,8 165 participants were classified as neurotic, with neurotic tendency, with a tendency to normal and without neurosis (normal), and the percentage of halitosis was high in this neurotic group. A halimeter and gas chromatography were used to classify individuals into five levels of halitosis. The author concluded that the psychological condition of the patients might be related to the degree of halitosis and their clinical characteristics. A Brazilian study7 also found a high prevalence of psychological distress in patients with halitosis. This conclusion might have been reached because patients with halitosis reported higher levels of depression than those with pathological halitosis. In addition, the authors suggested that halitosis might be exacerbated in depressed patients because many lack motivation to maintain adequate oral hygiene. Our questionnaire has not been validated, but some cause and effect relations may be considered. Some patients with halitophobia reported halitosis because of their degree of depression. Although some authors agree about the reliability of the self-assessment method used in our study, some individuals might be reporting greater halitosis.4 This is one of the limitation of this type of study, particularly because no other assessment method was used.
