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Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 120-124

Psychosocial effects of halitosis among young adults

Department of Public Health Dentistry, DMIMS (DU), Sharad Pawar Dental College and Hospital, Wardha, Maharashtra, India

Date of Web Publication30-Nov-2018

Correspondence Address:
Shravani G Deolia
Department of Public Health Dentistry, Sharad Pawar Dental College and Hospital, Sawangi, Wardha, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_23_18

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Background: One of the greatest and oldest taboos in our society is halitosis which is considered as a common dental condition and is suffered by many individuals around the world and dentists are usually the ones they turn to for their first professional help. Aim: This study aims to understand the psychological and the social effects of halitosis among young adults and to correlate their psychosocial effects with different level of halitosis. Materials and Methods: A cross-sectional descriptive study was performed on participants (n = 200; range 18–25 years) using a self-administered closed-ended questionnaire to detect the psychological and social effects of halitosis on individuals, and severity of their halitosis was checked using a device, FitScan® Breath Checker (Tanita Incorporation). A parallel was drawn between their psychosocial effects and severity of halitosis. Results: There were 94 (47%) males and 106 (53%) females used in this study. The age group used was 18–25 years and the younger age group showed a higher incidence of halitosis in relation to the older age group. About 44 (22%) patients out of the 200 gave a score of 0-Happy face on the device FitScan indicating that they were suffering from pseudohalitosis and not true halitosis. Both genders showed not much of difference with respect to the psychological impact of halitosis, however, social impact was seen more in females. Conclusion: This study revealed that pseudohalitosis is common among individuals and it restricts one's caliber. The social effects of halitosis are seen greatly in females, however, the psychological impact of halitosis is seen almost equally in both the genders.

Keywords: FitScan Breath Checker, halitosis, psychosocial effects

How to cite this article:
Deolia SG, Ali M, Bhatia S, Sen S. Psychosocial effects of halitosis among young adults. Ann Indian Psychiatry 2018;2:120-4

How to cite this URL:
Deolia SG, Ali M, Bhatia S, Sen S. Psychosocial effects of halitosis among young adults. Ann Indian Psychiatry [serial online] 2018 [cited 2023 Jan 31];2:120-4. Available from: https://www.anip.co.in/text.asp?2018/2/2/120/246530

  Introduction Top

Halitosis, oral malodor, bad breath, fetor ex-ore, or fetor oris are the terms used for describing an unpleasant odor which is emitted from an individuals' oral cavity consistently.[1] The unpleasant breath is due to odorous substances which can be of either extrinsic or intrinsic origin.[1]

Certain food items, tobacco products, alcohol, or some medical conditions constitute extrinsic causes. Intrinsic causes include systemic and oral conditions; however, 80%–90% cases are due to oral conditions such as poor oral hygiene, deep caries, infections of oral cavity, periodontal conditions, and ulcerations on the mucosa and majorly, tongue coating.[2] Tongue is considered as one of the major sites for oral malodor production, whereas periodontal diseases and other reasons constitute only a small fragment of the overall issue. Systemic conditions include chronic sinusitis, bronchitis, tonsillitis, hepatic disorders, renal disorders, diabetes, and gastroesophageal reflux disease.[1]

Halitosis is considered to be a symptom which is related to somatic as well as emotional status, and the psychological disorders are sturdily linked with the conditions of certain patients.[3] Hence, halitosis or bad breath can be clinically divided as true halitosis which can be either due to physiological (for instance morning halitosis) or pathological cause; pseudohalitosis where a person complains of bad breath even though he does not suffer from it. Patients who suffer from pseudohalitosis and also those with true halitosis may have a complementary psychological condition.[2] Perceiving one's own breath odor can be complex. The inability of an individual to tell whether he/she suffers from halitosis or not is known as bad breath paradox.[4]

Nowadays, several methods are used for detection of halitosis such as organoleptic testing, sulfide monitoring, gas chromatography, or chemical sensors.[2]

Foul odor from oral cavity is due to the bacteria which include Porphyromonas gingivalis, Fusobacterium nucleatum, and Prevotella intermedia[5]. These Gram-negative anaerobic pathogens can produce the odoriferous compounds also known as volatile sulfur compounds (VSCs), like methyl mercaptan, hydrogen sulfide, and dimethyl sulfide.[5],[6],[7]

The significance of personal image and interpersonal relationships is highlighted by current social norms. Unpleasant breath during communication can be a major setback and may affect an individual's social life and psychological health.[2]

Those individuals who suffer from halitosis generally make desperate attempts to hide or mask their problem using chewing gums, mints, repeated brushing, and rinsing of their oral cavity with mouthwashes.

This study was conducted to understand awareness about halitosis and stigma associated with it as well as sensitize the public to pseudohalitosis, which is more common than the actual condition. Personality development occurs in this age group and self-perception of bad breath, can make an individual inhibited in interpersonal interactions.[4],[7] Thus, public awareness needs to be created against this issue so as to minimize the problem caused while socializing.

The aim of this study is to understand the psychological and social effects of halitosis among young adults between 18 and 25 years and also to evaluate the level of halitosis using a breath analyzer and correlating the psychosocial effects with level of halitosis.

  Materials and Methods Top

This was a cross-sectional descriptive study of young adults between the ages of 18 and 25 years visiting a private dental college in Maharashtra who perceived themselves as sufferers of halitosis. The study protocol was approved by the ethical committee and the hospital's institutional review board and an informed consent was obtained from the patients.

Study population

The study population comprised of 200 patients (male and female) selected by random sampling method. The sample size was calculated using a formula where the population proportion was equal to 0.5 and a confidence interval of 95% was used and a value of 384.16 was obtained. This value was then used to calculate the new sample size of 191.2 which was then rounded off to a sample size of 200 in total. The study was conducted in the outpatient department of oral medicine and radiology department for 2 months (March–April 2017). On an average, about 17–27 individuals with ages ranging from 15 to 35 and 60 to 65 reported with a complaint of bad breath daily, among which 1–4 individuals belonged to the age group of 18–25. All the participating individuals were explained the nature of the research project and they provided informed consent. The selected study participants who were on any ongoing antibiotic therapy or, any females who were pregnant at the time of the study were excluded.

Study design

A self-administered closed-ended questionnaire was prepared in Marathi by the authors. It was explained and administered to the patients who felt that they experienced halitosis. Since Marathi is the local language of the region, the questionnaire which initially was in English was then prepared in that language and validated. The contents of the questionnaire included demographics and questions related to the psychological and social impact of oral malodor on their daily lives. The 16 item 5 point likert rated questionnaire having 8 questions each on the psychological and social impact of halitosis was prepared based on a similar scale by Toka.[7] The scoring range was from 8 (minimum) to 40 (maximum). The scores ranging from 8 to 18 were interpreted as mild impact; 19–29 as moderate impact; and 30–40 as severe impact.

Malodor assessment

The severity of oral malodor in each patient was determined using FitScan® Breath Checker (Tanita Incorporation) which is an inventive palm-sized monitor that is easy to operate and detects the odor in seconds. It measures the presence of compounds responsible for breath odors (VSCs). The device is turned on by pulling the cap up which exposes the sensor. This switches on the digital display which flashes a countdown from 5 to 0 followed by START, which is when the patient has to breathe into the sensor keeping it at a distance of about 1 cm from the mouth for 4 s until it beeps. The thumb must be kept on to the chin so that the sensor is just in the right position. Almost immediately, the results are displayed in 6 levels, in the form of a number and face symbols, similar to the organoleptic method. A 0 reading means no odor (happy face), 1 is slight odor (content face), 2 is moderate odor (straight face), 3 is heavy odor (dissatisfied face), 4 is strong odor (sad face), 5 is intense odor (depressed face), and E is an error sign which indicates to try again. Participants scoring more than 2 on the device were deemed to have genuine halitosis.

Statistical analysis

Data collected was entered in Microsoft Excel 2010 (Developed by Microsoft Redmond, WA) and analyzed using StataCorp. 2005. Stata Statistical Software: Release 9. College Station, TX: StataCorp LP. Statistical tests included descriptive statistics for quantitative variables and Chi-square test for difference in proportions. P < 0.05 was considered as statistically significant.

  Results Top

[Table 1] shows the incidence and relation of pseudohalitosis and true halitosis among the 200 patients who were scanned using FitScan, out of which 199 (99.5%) patients thought they suffered from halitosis, but 44 (22%) patients got a score of 0.00 on the FitScan device indicating that they suffered from pseudohalitosis. Only one patient of the participating sample did not feel that he suffered from halitosis. Whereas, 155 (77.5%) patients were actual sufferers of halitosis showing scores between 1.00 and 5.00 (χ2 = 5.383; P = 0.864).
Table 1: The bad breath paradox: Incidence and relation of pseudohalitosis and true halitosis using FitScan scores

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[Table 2] shows the relation of FitScan score with the presence of bad breath apart temporary morning breath in patients who were scanned. 108 (54%) patients thought that they suffered from halitosis apart from temporary morning breath, but only 87 (43.5%) patients were true sufferers of halitosis (χ2 = 13.580; P = 0.193).
Table 2: Relation of FitScan score with the presence of bad breath apart from temporary morning breath

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[Graph 1] shows the correlation of halitosis with age and sex. As shown above, the patients falling in the younger age group showed a higher incidence of halitosis as compared to the older age group. About 106 (53%) patients suffering from halitosis were females.

[Table 3] shows the variation in psychological impact of halitosis in both the genders. No significant psychological impact of bad breath was observed in both genders with respect to their confidence, work performance, and oral hygiene practices as P > 0.05.
Table 3: Variations of responses pertaining to the psychological impact of halitosis among both the genders

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However, consciousness and a constant fear of bad breath were found more in females 63 (31.5%) compared to males 32 (16%) which was statistically significant (P < 0.01).

[Table 4] shows the variation in social impact of halitosis in both the genders. Significant social influences were observed with regard to oral malodor in females.
Table 4: Variations of responses pertaining to the social impact of halitosis among both the genders

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More commonly, 34 females (17%) were likely to be embarrassed because of bad breath (P = 0.046). Furthermore, 33 females (16.5%) showed to have failed relationships owing to bad breath (P = 0.02). A difficulty in achieving academic goals was faced more by females, 37 (18.5%) (P = 0.004). In general, 69 females (34.5%) were more conscious of their bad breath (P = 0.001).

  Discussion Top

The aspects which were considered in our study while evaluating the psychosocial effects of halitosis were self-confidence, conversational and socializing skills, struggling to interact with opposite gender, academic endeavors, and employment opportunities.

True sufferers of genuine halitosis were considerably lesser than those who present with a complaint about it. This could be due to the perception that halitosis is subjective and self-evaluated by the patient.[4] 99.5% of participants in this study reported that they were suffering from halitosis, which affected their interactions with people.

Several studies report figures ranging from 74% to 90% when the same question was asked of their respective study populations.[8]

Only 22% patients got a score of 0.00 on the FitScan device indicating that they suffered from pseudohalitosis. Other supporting studies show that 20% of their participants were convinced that they were sufferers of bad breath (pseudohalitosis) even though the confirmatory test results were contradictory, that is, showed a FitScan score of 0.[3] This perception of pseudohalitosis in the given patients might be attributed to the olfactory delusion that they emanate a foul odor from their oral cavity, also reported by Iwakura et al., as imaginary halitosis based on others attitudes known as olfactory reference syndrome.[3],[6],[9]

Temporary morning bad breath was common grievance in 54% of patients who had participated in this study. Transient bad breath experienced in the mornings or after keeping one's mouth closed for a considerably long period or after a period of reduced salivary flow is a prevalent type of halitosis (physiologic halitosis) presenting with a high incidence.[2] The reduced salivary flow promotes anaerobic bacterial putrefaction contributing to oral malodor.[10]

The patients falling in the younger age group, 53.5%, showed a greater incidence of halitosis as compared to the older age group. Younger individuals become aware of the changes in their body due to puberty and are generally faced with peer pressure owing to their surroundings. Researchers have shown a strong correlation of halitosis with psychological traits such as depression, anxiety, paranoid ideation, and hostility.[3] These traits may promote a lack of motivation in maintaining one's oral hygiene further aggravating the problem.[3]

About 53% patients suffering from halitosis were females. Research has shown that a higher level of stress biomarkers has been found in the saliva of women which can account for such a result.[11] Women are more likely to experience emotional changes which have been shown to influence the levels of VSCs owing to bad breath.[9],[11] Menstrual cycle has also been attributed to affect epithelial desquamation, thereby causing increased halitosis or an increase in the number of bacteria in the oral cavity during menstruation. It is more often observed and supported by other research that females tend to seek medical help for such problems as compared to males.[3],[11]

No significant psychological impact of bad breath was observed in both genders with respect to their confidence, work performance, and oral hygiene practices. However, a significant number of females, 31.5% were more conscious and had a constant fear of halitosis. Most patients rated their oral malodor as mild which is probably the cause that the oral malodor did not have any adverse effects on their lives irrespective of their gender bias.[12]

A significant social impact of halitosis was observed in the study participants with contrasting responses for females and males. Females were more likely to be embarrassed because of bad breath. Higher number of females showed to have failed relationships due to bad breath. More number of females felt that they were unable to achieve their academic goals due to bad breath. Females were more conscious of their bad breath. The use of oral hygiene aids strongly influences an individual's social behavior and is particularly important for individuals who face insecurity about their oral malodor in social interaction.[13] This counterintuitive behavioral response is a manifestation of social insecurity and thus is a symptom of a fear of rejection or of social anxiety.[13],[14] These are attributed to be the negative effects of halitosis.[12] Relationship between social anxiety and halitosis has been investigated previously.[12] Females are more conscious about the oral odor while interacting with the opposite gender and seek treatment.[3] Bad breath is reported as a “social handicap” and leads the affected person to avoid socializing with others.[2],[15]

  Conclusion Top

Halitosis is a problem with multifactorial complexities and a patient reporting with this should be treated like an individual and not categorized. Self-estimation of oral malodor depends on an individual's perception and is a subjective finding unless proven objectively. A multidisciplinary approach should be employed while treating patients of halitosis, with genuine or perceived, providing a comprehensive cure to the problem, including improvement of a mental state of the patient. Based on the underlying cause, treatment may vary from motivating patients to maintain their oral hygiene, ultrasonic scaling, and restorations to specific treatments for underlying systemic conditions which contribute to halitosis. In cases where the patient experiences pseudohalitosis, proper detection using appropriate techniques and patient counseling is of an utmost importance. In cases when the patient experiences severe social anxiety due to the said issue, he/she maybe referred to a psychologist for further in-depth counseling. The results of this study reveal that self-perceived oral malodor is a potential cause of depression and social insecurity suggestive of its negative influence on social interactions, especially with the opposite gender. It additionally influences one's performance in workplace as well. However, failure to address and outline treatment options is a limitation of this study.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]

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