self assessment of halitosis among diabetic saudi female patients

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SELF-ASSESSMENT OF HALITOSIS

AMONG DIABETIC SAUDI FEMALE

PATIENTS

NAHED ASHRI

Associate Professor, Division of Periodontics, Department of

Preventive Dental Science

ADDRESSCORRESPONDENCES TO:

Dr. N. Y. Ashri

Department of dental science

Division of Periodontics

College of Dentistry, King Saud University

P.O. Box 60169, Riyadh 11545

Telephone numbers:

Home 966-1-233-2720

Mobile 966-558-008-80

Fax 966-1-476-5357


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E-mail [email protected]

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mailto:[email protected]:[email protected]


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ABSTRACT

Aim: The purpose of this study was to assess self-perception of oral malodor

(Halitosis) in female diabetic patients and the impact of halitosis on their social life.

Methods: A self-administrated questionnaire was developed and distributed in the

diabetic clinics in four governmental hospitals. The questioner contained questions

about past medical history, oral habits, and self-perception of halitosis, in addition, to

questions about social and psychological impacts of halitosis.

Results: 175 female diabetic patients participated in this study by completing the

distributed questionnaire. Fifty two percent of participant were aware of having

halitosis, 50.3% of these had self-perception of halitosis while 18.3% were told by

others. Subjects with halitosis reported that the uppermost level of halitosis was

noticed at waking up 78.3%, followed by the time when they famished 59.4%.

Participant also reported having caries 58.9% and gingival bleeding 51.4%. Fifty eight

percent used the toothbrush daily but only 8.6% used the dental floss daily. Past

medical history included gastric disturbance 25%, sinusitis 23.4%, anemia 14.3%, and

allergies 19.4%. Twenty percent of subjects seek treatment for halitosis by a dentist,

and 11.4% consulted a physician, however only 11.4% reported receiving treatment.

Thirty four percent of participant reported that having halitosis had made them

hesitant to speak to others and 12.6% completely avoids others. Fifty two percent of

the subjects gave there own opinion about what is the cause for halitosis; diabetes

14.9%, caries 13.1%, 13% periodontal disease, and 8% gastric disturbance. It can be

concluded that self-perception of halitosis is high among female diabetic patients and

has relative effect on their social and psychological status. Further studies are needed

to document the prevalence of halitosis among diabetic patients.

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INTRODUCTION

Diabetes Mellitus (DM) is a chronic disorder characterized by hyperglycemia and

associated with major abnormalities in carbohydrate, fat, and protein metabolism (1). It is

one of the major public health issues facing the world in the 21 st century (1). It often goes

undiagnosed and compromises the oral health of an affected patient (1). Prevalence of (DM)

is about 3%-7% in the western countries (2). In Saudi Arabia, the incidence of DM is rapidly

increasing with prevalence of 2.55% - 5.32% among males and females respectively (3).

Diabetes Mellitus is associated with many complications affecting both physical and

psychological status of patient (4). One of those is periodontal disease which was found to be

of a high prevalence and severity in DM (5).

The relationship between DM and periodontitis were reported by several studies (5) (6) (7).

Yavuzyilmaz et al. 1996 found that alteration in the composition of whole saliva could be

associated with the increase in severity of PD in diabetic patients (8).

Halitosis is a common complaint that may periodically affect most of the adult

population (9) (10).In the large majority of cases, halitosis originates in the oral cavity as the

result of microbial metabolism (9) (10) (11).Sixty five percent to 85% of halitosis found to be

caused by periodontal disease (12). It was also found to be associated with systemic disease

as DM (13) (14) (15). Halitosis is caused by the high activity of bacteria and production of foul

smelling by products known as volatile sulfur compounds (VSC) (16)(17) (18).

Halitosis affects a large proportion of the population (19), and may be the cause of a

significant social and psychological handicap to those who suffer from it (20) (21). However

not all persons who have halitosis are aware of it (6).

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The aim of this study was to assess the self-perception of Halitosis in a sample of Saudi

female Diabetic patients and the social effect of Halitosis on their life.

MATERIALS AND METHODS

Patients under treatment in the diabetic centers in four different hospitals in Riyadh,

Saudi Arabia; King Abdul Aziz university hospital, King Khalid university hospital, The

Military hospital and the Security forces hospital were requested to participate in the study.

To assess self-perception and awareness of halitosis (bad breath) in Saudi female

diabetic patients, Arabic questionnaire was developed consisting of two parts. The first part

consisted of questions about the presence of medical illness, oral hygiene practice, their

consumption of coffee, tea, the presence of smoking habit, presence of caries, and finally

there awareness of having halitosis and whether treatment was seeked. The second part of

the questionnaire consisted of social and psychological consequence of halitosis if present.

A nurse was assigned in each hospital to distribute the forms to diabetic Saudi female

patients in the waiting areas and recollect them in 10-15 minutes and the opportunity for

verbal inquiry to assist in establishing rapport when ever patient were illiterate.

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RESULTS

One hundred seventy five Saudi female patients with diabetes agreed to

participate in the present study. Age range was 16-72 years old with the majority

58.3% ranging between 36 to 55 years old.

Fifty two percent of participant reported that they have halitosis, from which

50% made self-diagnosis and 18 % were told that they have halitosis. Table I

Fifty percent of participant reported having dry mouth, 58.9% reported presence of

caries, 51.4% reported bleeding during brushing, and 18.9% reported frequent oral

ulceration. Table I

Table I: Self-Assessment Questions:

Question Yes No Don't know

Presence of halitosis 52% 28% 20%

Halitosis found by your self 50.3% 49.7% 0Halitosis found by others 18.3% 81.7% 0

Presence of dry mouth 50.9% 48.56 0.54 %

Presence of caries 58.9% 21.1% 20 %

Presence of bleeding with brushing 51.4% 48.6% 0

Occurrence of frequent ulceration 18.9% 79.4% 1.7 %

Participants were asked when they feel that they have the highest level of

halitosis during the day, 61.79 of subjects reported bad breath at awaking up, 46.9%

when hungry; and 8% at work. Table II.

However when cross tabulation was done between participant who actually

said that they have halitosis and time of highest peak of halitosis it was found that

31.9% of participant found halitosis worst when they are tired, 59.4% when they are

hungry, 18.8% at work, and 78.3% at waking up.

Fifty eight percent of participant who reported having halitosis have gingival

bleeding when brushing, 25% have sinusitis, and 24.6% reported having gastric

disturbance. Table III

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Table II: Highest Peek of Halitosis

Time halitosis is highest Yes No

After waking up 61.7% 38.3%

When hungry 46.9% 53.1%

Mid-day 31.4% 68.6%

During working hours 8.0% 92%

Table III: Correlation between Halitosis/ Timing and Medical history

Time/ Medical history Percentage

When tired 31.9%

When hungry 59.4%

During work 18.8%

When waking up 78.3%

Gingival bleeding 58%

Sinusitis 25%

Gastric disturbance 24.6%

Regarding patients habits, 58.9% of the participants drink coffee frequently,

38.3% drank tea with mint and only 5.1 are smokers. Fifty eight percent brush their

teeth daily and only 8.6% use dental floss regularly. Table IV

Table IV: Oral Hygiene Care and Different Habits

Question Yes No Sometimes

Daily brushing 58.9% 40.6% 0Daily flossing 8.6% 90.9% 0

Frequency of taking teas 38.3% 18.9% 42.9%

Frequency of taking coffee 58.9% 10.3% 30.3%

Smoking 5.1% 94.9% 0

Past medical history of participant included; sinusitis 23.4%, Gastric disturbance

25.1%, allergies 19.4%, and anemia 14.3%. Table V

Table V: Past Medical History

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Medical condition Yes

Gastric condition 25.1%

Sinusitis 23.4%

Anemia 14.3%

Allergies 19.4%

Limited numbers of participant seek treatment of halitosis; 20% seen by a

dentist, 11.4% went to a physician, of those only 11.4% received treatment for

halitosis. Table VI

Table VI: Treatment Of Halitosis

Seeking treatment of halitosis Yes

Dentist 20%

Physician 11.4%

Receiving treatment for halitosis 11.4%

The subject who reported having halitosis were asked to answer questions

regarding the social impact of halitosis on there life, 34.9% reported hesitation when

speaking to others, 30.9% reported being anxious and nervous when approaching

others, and only 12% had reported that they noticed being avoided by others.

Table VII.

Table VII: Responce to Effect of Halitosis on the Subjects Social Life

Questions Yes

Hesitation to speak to others 34.9%

Feeling anxious when being close to others 30.9%

Avoided by others 12.6%

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Causes of halitosis as it were expressed by 52.6% of participant included;

diabetes 14.9%, caries 13 %, periodontal disease 13%, and gastric disorders 8%.

TableVIII.

TableVIII: Causes of Halitosis

Cause Percentage

Diabetes 14.9%Caries 13%

Periodontal

Disease

13%

Gastric Disorders 8%

DISCUSSION

Halitosis is estimated to affect up to 50% of the adult population with varying

degrees of intensity and etiology (19) (22) (23). Halitosis is caused by several intra and

extra oral factors, including systemic diseases and disorders of the gastrointestinal

and/or upper respiratory tracts (24).

It is generally acknowledged that people suffering from halitosis are often

unaware of it (25), so the aim of the present study was to assess the awareness and self-

perception of halitosis in Saudi Female Diabetic Patients. Fifty two percent of

participant reported having halitosis, as judged by them self, which can be objective

according to the fact that those participant are also diabetic patient, and it was

reported in the literature that diabetic patients have diabetic ketosis where the breath

may smell of acetone from producing acetoacetic acids, hydroxybutyric acid, acetone

and other ketones (26) (27) (28).

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In addition, the participant reported having bleeding gums 51.4%, which is

indicative of presence of inflammation in the oral cavity, and poor oral hygiene

habits, where only 8.6% of patients floss regularly. All of these factors lead to oral

malodor as reported in literature (29) (30).

Patients in the present study who reported having halitosis also gave a past

medical history of dry mouth 50.9%, sinusitis 25%, and Gastric disturbance 24.6%, in

addition to caries 58.9%, bleeding gums 51.4 %, and frequent ulceration 18.3%.

Studies had reported local factors responsible for halitosis which include conditions in

the oral cavity and nasopharynx such as, poor oral hygiene(31)(11) (32) , chronic

periodontal disease(33) (34), caries(33)(34) (28), Ulcers(27) , and dry mouth(27) . Conditions in

nose and pharynx include sinusitis (33), Rhinitis, pharyngitis, tonsillitis, syphilitic

ulcers and tumors of the nose (33) (34) (28) (27).

It is thus appears that, in diabetic patients, all of these factors together could be

indicative of the presence of genuine halitosis among those patient, however further

investigations with a more objective evaluation should be done.

Summary and Recommendations

This study indicates a potential of halitosis with diabetes. Further studies and

investigations are needed to determine the actual prevalence of halitosis and the

clinical variability of halitosis among larger population of subjects with diabetes.

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self assessment of halitosis among diabetic saudi female patients

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