Relationship Between Halitosis and Periodontitis: a Pilot Study

Self-perceived halitosis and associated factors among university students in Dhaka, Bangladesh

BACKGROUND

Bad breath (halitosis) is a common problem affecting psycho-social wellbeing of young people. We aimed to explore the extent of self-perceived halitosis and associated factors among university students in Dhaka, Bangladesh.

METHODS

A cross-sectional study was conducted among university students from November 2021 to April 2022. Six private and two public universities were approached. A total of 318 participants were conveniently selected for the study. A self-administered questionnaire was used for data collection. Students unwilling to participate were excluded. Multivariable logistic regression analysis was used to examine factors associated with halitosis. Statistical analysis was conducted using Stata Version 17.

RESULTS

A total of 55.97% of students had self-perceived halitosis, with females (74.53%) having a significantly higher proportion than males (36.94%) (p < 0.001). A significantly higher proportion of halitosis was found among participants who were overweight ( 61%), had obesity (60.77%), smoked cigarette (46.79%), consumed alcohol (71.43%), lacked exercise (66.29%), were on unhealthy diet (57.35%), consumed coffee/tea (61.35%), breathed through mouth (64.60%), brushed tooth infrequently (85.71%), changed toothbrush after 6 months (77.42%), did not use toothpaste (94.74%), did not use/ sometimes used fluoride toothpaste (75.76%), lacked dental floss use (60.85%), did not use toothpick (62.87%), did chew or sometimes chewed sugar-free chewing gum (75.82%), did not clear / cleaned tongue sometimes (76.14%), did use mouth freshener regularly or occasionally (64.97%), did not use or used mouthwash sometimes (58.87%) were also associated with higher self-perceived halitosis (p < 0.05 for all). Students with gum bleeding, swollen gums, dry mouth, dental caries, food accumulation, and tooth sensitivity had a significantly (p < 0.05 for all) higher proportion of self-perceived halitosis (76.85%, 81.82%, 72.50%, 67.78%, 64.13% and 67.40%, respectively) compared to those without this problem. Being female (OR = 5.04; 95% CI: 2.01-12.62; p < 0.001), alcohol consumers (OR 7.35; 95% CI: 1.77-30.50; p = 0.006); not using sugar free chewing gum (OR = 0.25; 95% CI: 0.10-0.58; p = 0.001), lack of tongue cleaning (OR 4.62; 95% CI: 2.16-9.84; p < 0.001), and gum bleeding (OR = 7.43; 95% CI: 3.00-18.35; p < 0.001) were independently associated with halitosis on multivariable regression.

CONCLUSION

This study reveals a high proportion of self-perceived halitosis and relevant factors. There should be more public education on the causes of halitosis and potential management approaches.

The oral organ: A new vision of the mouth as a whole for a gerophysiological approach to healthy aging

This article brings a new perspective on oral physiology by presenting the oral organ as an integrated entity within the entire organism and its surrounding environment. Rather than considering the mouth solely as a collection of discrete functions, this novel approach emphasizes its role as a dynamic interphase, supporting interactions between the body and external factors. As a resilient ecosystem, the equilibrium of mouth ecological niches is the result of a large number of interconnected factors including the heterogeneity of different oral structures, diversity of resources, external and internal pressures and biological actors. The manuscript seeks to deepen the understanding of age-related changes within the oral cavity and throughout the organism, aligning with the evolving field of gerophysiology. The strategic position and fundamental function of the mouth make it an invaluable target for early prevention, diagnosis, treatment, and even reversal of aging effects throughout the entire organism. Recognizing the oral cavity capacity for sensory perception, element capture and information processing underscores its vital role in continuous health monitoring. Overall, this integrated understanding of the oral physiology aims at advancing comprehensive approaches to the oral healthcare and promoting broader awareness of its implications on the overall well-being.

Effects of Mint Oils on the Human Oral Microbiome: A Pilot Study

The oral microbiome is a diverse and complex ecosystem essential for maintaining oral and systemic health. Our study is the first to define the oral microbial community in Egyptian young adults and investigate the effects of natural antimicrobials on the oral microbiome. SuperMint (SM) is a proprietary blend of peppermint, Japanese mint, bergamot mint, and spearmint essential oils encapsulated in a tiny soft beadlet. This work aimed to evaluate the effects of SM beadlets on the oral microbiome. This study recruited twenty healthy participants. A baseline investigation of the oral microbiome of the selected participants was performed by collecting saliva and swab samples before treatment. Treatment included chewing four SM beadlets twice a day for 7 days, and then, post-administration saliva and swab samples were collected at the end of treatment. The oral microbiome samples were analyzed by the high-throughput amplicon sequencing of 16S rRNA gene fragments, and the community composition was determined. The results showed that the abundance of some microbial genera and families decreased after using SM, including Prevotella, Streptococcus, Neisseria, and Haemophilus. However, some genera showed inconsistent patterns. We also found that the subject's gender and SM usage were significantly associated with diverse microbial composition. The results suggest that SM treatment decreased the abundance of several bacteria associated with halitosis and periodontal diseases, such as Actinomyces and Streptococcus. Furthermore, Corynebacterium species increased and Streptococcus decreased after SM usage. More research is needed to fully understand the antimicrobial effects of mint oils and their potential applications in maintaining good oral health.

ORGANOLEPTIC AND HALITOMETRIC ASSESSMENTS DO NOT CORRELATE WELL IN INTRA-ORAL HALITOSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

The gold standard method for diagnosing oral halitosis is the subjective organoleptic measurement. Device-supported methods are also widespread worldwide. The challenges and safety concerns around performing organoleptic measurements during pandemics and the diversity of measuring device alternatives raised our clinical question: which halitometer is the most suitable for diagnosing halitosis?

METHODS

This systematic review was registered in PROSPERO (ID CRD42022320024). The search was performed on March 23, 2022 in the following electronic databases: MEDLINE, Embase, Scopus, Web of Science, and CENTRAL. Adult populations with or without halitosis were included, and patients with systemic diseases were excluded. Organoleptic (subjective) measurement and the device-supported (objective) methods were compared; the primary outcome was the correlation coefficient, and the secondary was the specificity and sensitivity of the devices. QUADAS-2 and QUADAS-C were used to evaluate the risk of bias in the studies. Random-effects meta analyses were performed on the outcomes, and the secondary outcomes were plotted on a common ROC plot.

RESULTS

A total of 1231 records were found in the 5 databases. After the selection process, 76 articles were eligible for the systematic review, and 14,635 patients were involved in the qualitative analysis. The pooled Spearman's correlation coefficient (c.c.) for sulfide monitors was 0.65; 95% CIs: [0.53-0.74]; I2 = 95%, P < .01. The pooled Spearman's c.c. for portable gas chromatographs was 0.69; 95% CIs: [0.63-0.74]; I2 = 12%, P < .01. The pooled Spearman's c.c. for gas chromatographs was 0.76; 95% CIs: [0.67-0.83]; I2 = 0%, P < .01.

DISCUSSION

None of the most commonly used halitometers proved to be significantly superior to the others. Halimeter and OralChroma measurements did not correlate well with the organoleptic level of oral halitosis in adults. Therefore, better halitometers need to be developed as an alternative to organoleptic measurements.

Oral microbiome as a co-mediator of halitosis and periodontitis: a narrative review

Objective

Halitosis or oral malodor is an unpleasant odor from the oral cavity. However, although patients with periodontitis often complain of halitosis, their relationship has not been fully elucidated. We reviewed previous literature based on the hypothesis that the relationship between halitosis and periodontitis is mediated by the oral microbiome.

Materials and methods

This narrative review sought to provide insight into the causative role of the oral microbiome in influencing halitosis and periodontitis. In addition, we tried to deepen knowledge related to the relationship between halitosis and periodontitis generated by the oral microbiome accumulated over the past 40 years.

Results

From 1984 to 2023, a total of 106 papers that carefully and scientifically dealt with halitosis and periodontitis were included in this narrative review. Based on previous results, halitosis and periodontitis were closely related. For decades, researchers have taken an intriguing approach to the question of whether there is a relationship between halitosis and periodontitis. Central factors in the relationship between halitosis and periodontitis include volatile sulfur compounds (VSCs), the oral microbiota that produce VSCs, and the inflammatory response.

Conclusions

Taken together, the more severe periodontitis, the higher the level of VSC in halitosis, which may be mediated by oral microbiome. However, the relationship between the occurrence, maintenance, and exacerbation of periodontitis and halitosis is not a necessary and sufficient condition for each other because they are complex interplay even in one individual.

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.

Effects of water flossing on gingival inflammation and supragingival plaque microbiota: a 12-week randomized controlled trial

OBJECTIVES

The effects of water flossing on dental plaque removal have been suggested, but its ecological impact on dental plaque microbiota needs further investigation. In addition, whether this plaque control measure by water flossing promotes the control of halitosis still needs clinical validation. The aim of this study was to evaluate the effects of water flossing on gingival inflammation and supragingival plaque microbiota.

MATERIALS AND METHODS

Seventy participants with gingivitis were randomly assigned to control (toothbrushing) and experimental (toothbrushing + water flossing) groups (n = 35). Participants were recalled at 4, 8, and 12 weeks, and their gingival index, sulcus bleeding index, bleeding on probing, dental plaque index, and oral malodor values were measured. The microbiota of supragingival plaque was further investigated using 16S rRNA sequencing and qPCR.

RESULTS

Sixty-three participants completed all revisits (control: n = 33; experimental: n = 30). The experimental and control groups exhibited similar clinical characteristics and dental plaque microbiota at baseline. Adjunctive water flossing effectively reduced the gingival index and sulcus bleeding index as compared to the toothbrushing control group. The water-flossing group showed reduced oral malodor at week 12 as compared to the baseline. Consistently, the water-flossing group exhibited altered dental plaque microbiota at week 12, characterized by a depletion of Prevotella at genus level and Prevotella intermedia at species level as compared to the toothbrushing control. In addition, the plaque microbiota of water-flossing group exhibited a more aerobic phenotype, while the control group was more anaerobic.

CONCLUSIONS

Daily water flossing can effectively alleviate gingival inflammation and reduce oral malodor, possibly by depleting oral anaerobes and altering the oral microbiota to a more aerobic phenotype.

CLINICAL RELEVANCE

Water flossing adjunctive to toothbrushing effectively alleviated gingival inflammation, representing a promising oral hygiene practice to promote oral health.

CLINICAL TRIAL REGISTRATION

The trial was registered in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/showprojen.aspx?proj=61797 , #ChiCTR2000038508) on September 23, 2020.

Comparison of clinical indices with halitosis grading in chronic periodontitis: A randomized control trial

Background

Oral malodor is a major periodontal complaint, but the best method for assessing the halitosis grade is still undefined. The primary objective of the study was to detect the halitosis grade in the exhaled breath using the three distinct techniques and to compare the readings with different clinical indices to find out the best method of halitosis grading.

Materials and Methods

A total of 90 patients with chronic periodontitis having oral malodor were included in the study. The subjective assessment of the exhaled breath (halitosis grading) was done by three different methods; using a handheld portable Tanita FitScan sulfide monitor, by Halitox toxin assay, and by organoleptic (Sniff test) method. The findings were then compared with the clinical parameters of poor oral hygiene like plaque index (PI), gingival index (GI), gingival bleeding index (BI), and pocket depth (PD) to detect the best method of halitosis grading.

Results

The mean age of the patients included was 38.23 ± 8.83 (mean ± standard deviation) years. The median value of halitosis grading as obtained by Tanita FitScan was 3.0 (95% confidence interval as 2 and 4) which was then compared with clinical indices (PI, GI, BI, and PD) and the results were statistically significant (P < 0.05), whereas the other two techniques of halitosis grading gave insignificant results.

Conclusion

The results confirmed that the halitosis grading done using Tanita FitScan sulfide monitor is more appropriate with respect to clinical indices when compared with the other two techniques.

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.

Impact of facemasks on the mouth as an emerging dental concern: A survey among residents of Karachi

Background

The illness known as "mask-mouth syndrome," which is brought on by constantly covering one's mouth and nose with a mask, was particularly prevalent among healthcare personnel. The covid-19 pandemic, however, had far-reaching effects on people's daily lives all around the world, to the point where mask use became practically mandatory. With Covid-19 posing a new threat to dental health, this study aims to assess the public's awareness of the issue and investigate how wearing a facemask affects oral hygiene.

Methods

Cross-sectional research was conducted at Karachi's Jinnah Medical & Dental College. From February to May of 2022, it was carried out in the Dental Opd. A survey of 400 people was conducted, representing a cross-section of society in terms of age, gender, occupation, and other criteria. The poll had 11 closed-ended questions. The data was analyzed using SPSS 24. Descriptive analysis was used to examine the responses.

Results

Men made up 44.5% (n = 174) of responses and women 56.5% (n = 226). Mean participant age was 27.31, ranging from 18 to 50. 99% (n = 396) of respondents wear masks. 48% (n = 192) of participants were uncomfortable using facemasks. Disposable face masks were voted the best option by 60.5% of respondents (n = 242). Negative effects or conditions brought on by mask use, such as halitosis (47.3%, n = 189) and dehydration (64.3%, n = 257).

Conclusion

Mask-mouth syndrome can occur as a result of using a face mask for prolonged periods of time. Mask benefits outweigh the danger of mask mouth syndrome.

Dental Status and Periodontal Health of Patients with Phenylketonuria in Latvia

Objectives

Phenylketonuria (PKU) is an autosomal recessive inherited disorder of phenylalanine metabolism resulting from a deficiency of phenylalanine hydroxylase. The aim of this study was to evaluate the dental status and periodontal health of PKU patients in Latvia.

Material and Methods

Forty-five PKU patients and age/sex-matched controls were recruited for this cross-sectional study. Their anamnestic data, periodontal health and dental status were assessed by one experienced dentist.

Results

Dental and periodontal clinical evaluation revealed that the median number of filled teeth was significantly smaller among PKU patients compared to the control group (p=0.021). PKU patients had a significantly larger median number of carious teeth than their healthy counterparts (p<0.001). Significant differences between the PKU and control groups were observed for several oral hygiene indices (p<0.001): Silness-Löe plaque index, OR=29.3 (95% CI: 3.7-232.4); CPITN index, OR=35.2 (95% CI: 4.5-278.3); Greene-Vermillion index, OR=10.2 (95% CI: 2.8-38.0); calculus removal necessity, OR=12.3 (95% CI: 3.3-45.4).

Conclusion

Dental status and periodontal health of PKU patients was found to be significantly inferior compared to healthy controls. This is likely due to the regular consumption of PKU formula and the difficulties which mentally and/or physically disabled PKU patients experience with their oral hygiene. To prevent tooth decay and periodontal disease, PKU patients should visit a professional oral hygienist every three to six months. Furthermore, they should adopt the habit of rinsing their mouth with water immediately after consuming PKU formula to counteract the acidity in their oral cavity.