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Associate Professor, Division of Periodontics, Department of Preventive Dental Science

ADDRESS CORRESPONDENCES 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


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.

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 21st 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).

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.

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 Presence of halitosis Halitosis found by your self Halitosis found by others Presence of dry mouth Presence of caries Presence of bleeding with brushing Occurrence of frequent ulceration

Yes 52% 50.3% 18.3% 50.9% 58.9% 51.4% 18.9%

No 28% 49.7% 81.7% 48.56 21.1% 48.6% 79.4%

Don't know 20% 0 0 0.54 % 20 % 0 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

Table II: Highest Peek of Halitosis Time halitosis is highest After waking up When hungry Mid-day During working hours Yes 61.7% 46.9% 31.4% 8.0% No 38.3% 53.1% 68.6% 92%

Table III: Correlation between Halitosis/ Timing and Medical history Time/ Medical history When tired When hungry During work When waking up Gingival bleeding Sinusitis Gastric disturbance Percentage 31.9% 59.4% 18.8% 78.3% 58% 25% 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 Daily brushing Daily flossing Frequency of taking teas Frequency of taking coffee Smoking Yes 58.9% 8.6% 38.3% 58.9% 5.1% No 40.6% 90.9% 18.9% 10.3% 94.9% Sometimes 0 0 42.9% 30.3% 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

Medical condition Gastric condition Sinusitis Anemia Allergies

Yes 25.1% 23.4% 14.3% 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 Dentist Physician Receiving treatment for halitosis Yes 20% 11.4% 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 Hesitation to speak to others Feeling anxious when being close to others Avoided by others Yes 34.9% 30.9% 12.6%

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 Diabetes Caries Periodontal Disease Gastric Disorders Percentage 14.9% 13% 13% 8%

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 selfperception 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).


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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