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Year : 2022  |  Volume : 20  |  Issue : 3  |  Page : 293-297

Relationship between psychological status and self-perception of halitosis among young adults with moderation by oral health status in Bengaluru City: A cross-sectional study

Department of Public Health Dentistry, Government Dental College and Institute, Bengaluru, Karnataka, India

Date of Submission05-Apr-2022
Date of Decision24-May-2022
Date of Acceptance22-Jun-2022
Date of Web Publication12-Sep-2022

Correspondence Address:
R Sudha Rani
Department of Public Health Dentistry, Government Dental College and Institute, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_71_22

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Background: Halitosis is a term defining a common concern of individuals with a bad odor originating from their mouth. Halitosis is a symptom related to both somatic and emotional status. There is a need to investigate the relationship between psychological status and halitosis with the moderation by oral health. Aim: To assess the relationship between psychological status and self-perception of halitosis among young adults with moderation by oral health status (OHS). Methodology: A cross-sectional study was conducted among 160 self-perceived halitosis (SPH) and 160 halitosis suggestive (HS) young adults in Bengaluru city. Questionnaire for self-perception of halitosis and Symptom Checklist-90-Revised (SCL-90-R) questionnaire for psychological status were used. Halitosis was measured using organoleptic test. OHS was assessed using the World Health Organization Oral Health Assessment form for Adults, 2013. Independent t-test, Chi-square test, and multivariate linear regression were performed. A moderation analysis was carried out to examine the effect of OHS. The P < 0.05 was considered significant. Results: The mean age was 21.56 ± 1.84 years and 23.8 ± 1.93 years in the self-perceived halitosis and HS groups, respectively. Questionnaire for self-perception of halitosis majority of them experienced bad breath for the past 3 months; were hesitant to talk to others; felt uneasy; avoided social interaction, and the workplace was affected. The mean SCL-90-R score of SPH (291.46 ± 13.17) was significantly greater than HS (137.06 ± 25.09) (P < 0.001). Most of the participants in SPH had malodor and 50% had no odor in HS group. The mean Decayed, Missing, and Filled Teeth were 2.37 ± 3.92 and 1.87 ± 2.86 in SPH and HS groups, respectively (P = 0.19). The mean of teeth with gingival bleeding was significantly higher in SPH (3.46 ± 3.87) when compared to HS groups (1.61 ± 2.44) (P < 0.001). On multivariate linear regression, there was a significant relationship noted between the self-perceived halitosis group and SCL-90-R (R2 = 0.07; P < 0.001). In the moderation analysis, the effect of oral health and self-perception of halitosis was significant with psychological status. Conclusions: There is a relationship between the psychological status and self-perception of halitosis with moderation by OHS.

Keywords: Halitosis, organoleptic test, psychopathology, self-perception

How to cite this article:
Rani R S, Puranik MP, Uma S R. Relationship between psychological status and self-perception of halitosis among young adults with moderation by oral health status in Bengaluru City: A cross-sectional study. J Indian Assoc Public Health Dent 2022;20:293-7

How to cite this URL:
Rani R S, Puranik MP, Uma S R. Relationship between psychological status and self-perception of halitosis among young adults with moderation by oral health status in Bengaluru City: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2023 Nov 29];20:293-7. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2022/20/3/293/355894

  Introduction Top

Halitosis, also referred to as malodor, is a common oral health condition worldwide. It is a term habituated to define the presence of unpleasant or offensive breath emitted consistently from a person's mouth. Halitosis features a complex etiology with extrinsic and intrinsic causes. Extrinsic causes include tobacco, alcohol, some medications, and certain odoriferous foods, such as garlic and onion. Intrinsic causes could also be associated with both systemic and oral conditions, about 80%–90%, are generally associated with oral causes.[1]

Oral malodor is especially the result of the microbial metabolism of amino acids in local debris. Many of the main compounds that contribute to oral malodor are volatile sulphide compounds (VSCs) such as hydrogen sulfide, methyl mercaptan, and dimethyl sulfide. VSCs levels are typically been measured using an organoleptic test to gauge the extent of oral malodor in patients complaining of halitosis.[2]

Halitosis creates a high level of stress and anxiety and low levels of self-esteem as sufferers interact with others in their daily lives. It makes them less inclined to socialize with others and affects their professional lives. The impact of halitosis is very minute or deleterious. Halitosis can indeed become a robust limitation to interpersonal relationships.[3] Studies revealed the association of halitosis with physical and emotional states.[3],[4] Mental disorders are closely related to halitosis in certain subjects and have anxiety issues, and it is difficult for subjects to beat their anxiety.[5] In addition, anxiety and halitosis are correlated since anxiety states may increase the concentration of the volatile sulfide compound (VSC) resulting in halitosis. Patients who have suffered from halitosis and associated psychological problems for a protracted period are affected. This causes more serious psychological problems, forming a vicious circle.[4]

Poor oral health also affects social interactions and psychological status due to necrotic pulpal exposure, deep carious lesions, food impaction, oral infections, periodontal diseases, faulty restorations, reduced salivary flow, and poor oral hygiene practices including brushing and flossing.[6] The severity and stringency of dealing with oral health-related problems are immediately evident when considering oral diseases share the burden of causing oral malodor.[7] The importance of halitosis is heavily associated with its psychological and social impact along with oral health status (OHS).

Several studies were conducted to gauge self-reported halitosis among the adult population. The prevalence of self-reported halitosis was 23.3% among young adults, 20.7% among university students in China,[4] and 21.7% among dental students in India.[6]

The impact of halitosis on psychological status is particularly strong among younger people. However, there is scarce information about the moderation of OHS on psychological status in halitosis participants. Only a few studies have addressed self-perceived halitosis (SPH) among youth and their psychological concerns. Hence, this study was conducted to assess the relationship between psychological status and self-perception of halitosis among young adults with moderation by OHS in Bengaluru city. The hypothesis of the present study is self-perception of halitosis affects psychological status with OHS as a moderator among young adults.

  Methodology Top

The present cross-sectional study was conducted at the degree colleges in Bengaluru city, India from September 2021 to October 2021. This study was conducted in accordance with the Helsinki Declaration after obtaining ethical approval from the institutional ethical committee. Participants who attended degree colleges, if they sensed halitosis (self-perceived group) (n = 160) or were advised about the malodor by family members, or friends (suggested group) (n = 160) were recruited based on similar inclusion and exclusion criteria – inclusion criteria: participants aged 20–26 years with minimum of 20 natural teeth, had self-perception of halitosis/halitosis suggestive (HS), who can read and write English and Kannada; and exclusion criteria: participants with acute oral infections and nasal obstructions and made oral health assessments difficult. All the participants provided written informed consent.

The sample size was calculated using the mean and standard deviation of Symptom Checklist-90-Revised (SCL-90-R) scores between self-perception of halitosis and suggestive of halitosis group (0.48 ± 0.27 and 0.63 ± 0.41), respectively, from the previous literature,[8] and group sample sizes of 160 and 160 were needed to achieve 95% power with a significance level (α) of 0.05. All participants were instructed to refrain from smoking, drinking alcohol, and consuming any spicy foodstuff (such as onion and garlic), use of any kind of cosmetic, perfume, chewing gum, drops, mint, and mouth rinses on the day of clinical examination.

A self-administered questionnaire was designed for assessing self-perception of halitosis with 5-point Likert scale questions. A pilot study was carried out on 30 participants at degree college and appropriate modifications were made in the questionnaire. Face validity was evaluated before the start of the main study. Content validation was performed and the content validation index was 0.98. The internal consistency of the questionnaire was measured by Cronbach's alpha (0.80). These 30 participants were not included in the main study.

Each participant was initially instructed to complete the questionnaire, which consisted of three parts; the first part contained the participant's demographic data. The second part included self-reported questions in halitosis and SCL-90-R[9] questionnaire. The third part included an assessment of organoleptic score and clinical assessment of oral health using the WHO pro forma 2013.[10]

Organoleptics – the evaluation of oral malodor was performed using Breath Alert™ (BA). BA was used according to the manufacturer's instructions and disinfected after each use. The device was shaken four or five times before each use to eliminate any residual odors. A “beep” was emitted on pressing the button on the device, and a second “beep” was emitted when the participants blew into the frontal air entrance (air flow passage). After a third ''beep,'' the breath odor was measured and scored on a scale of 0–5 points (0 – no odor, 1 – slight odor, 2 – moderate odor, 3 – heavy odor, 4 – strong odor, 5 – intense odor, and E – error please try again). When the letter ''E'' appeared, indicating an error, the procedure was repeated. A score ≥1 was considered indicative of halitosis.

To compare the differences in sociodemographic and oral malodor in the self-perception of halitosis and HS groups, an independent sample t-test and Chi-square test were applied. An independent sample t-test was used to compare the self-perception of halitosis and HS groups in terms of the SCL-90-R total score and scores of the nine domains. A higher score indicated more obvious neurological symptoms and more serious psychological problems. The relationship was investigated among each SCL-90-R, OHS, and self-perceived halitosis using multiple linear regression analysis. The data were analyzed using the SPSS version 25.0 (IBM Corp., Armonk, NY, USA), and P < 0.05 was considered statistically significant. For the moderation analysis, self-perceived halitosis (SPH) as independent variable (IV), psychological status as dependent variable (DV), and OHS as moderator were included. The required statistical analyses were done using structural equation modeling software such as IBM's SPSS Amos version 23 and replicated with the PROCESS macro module developed by Hayes, [11,12] which includes the Johnson–Neyman technique for probing regions of significance.[13]

  Results Top

The present study included a total of 320 participants (160 participants each for the self-perceived halitosis and HS groups). There were statistically significant differences in the sociodemographic variables such as age, gender, and socioeconomic status (SES) between the two groups. Majority of the participants visited a dentist for more than a year, and the reason being decayed teeth, brushed twice daily, and received filling has treatment (P < 0.001) [Table 1].
Table 1: Intergroup comparison of sociodemographic information, oral hygiene behavior, and practices

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There was a significant difference in oral malodor scores between the self-perceived halitosis and HS groups (P < 0.001) [Table 2]. There was no significant difference for Decayed, Missing, and Filled Teeth (DMFT) and pocket and significant difference was found for gingival bleeding in the study groups [Table 3].
Table 2: Intergroup comparison of diagnostic test results and oral health status

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Table 3: Intergroup comparison of oral health status

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Among self-perception of halitosis participants, majority (51.9%) experienced bad breath for the past 3 months; 30.6% never had a clinical examination; 56.9% had hesitation to talk to other people; 60.6% felt uneasy whenever someone was nearby; 37.5% did not like to meet other people; 68.1% was avoided by other people due to bad breath; 46.3% personal life and 64.4% social life/workplace was affected.

The psychological scores of various domains among self-perceived halitosis group and HS group are compared in [Table 4]. The SCL-90-R total scores were significantly higher in self-perception of halitosis group when compared to HS group. Among the nine domains, depression and psychotism exhibited high mean scores in both groups [Table 4].
Table 4: Intergroup comparison of mean scores of Symptom Checklist-90-Revised domains

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Age, gender, SES, DMFT, gingival bleeding, pocket, self-perceived halitosis, and presence of halitosis were found to be significant predictors of psychological status explaining 7.3% (R2 = 0.073) of variability [Table 5].
Table 5: Multivariate linear regression results of the relationship between Symptom Checklist-90 Revised and oral health status in self-perception of halitosis participants

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The moderation model consisted of self – perceived halitosis (SPH) as IV and psychological status (SCL-90-R) as DV with OHS as the moderator [Figure 1]. After applying the PROCESS procedure for the SPSS of Hayes, the overall moderation model had significant effects F = 4.48, P < 0.001, and the whole interaction was significant: confidence interval = 3–15. Therefore, we further used the Johnson–Neyman technique to probe for interaction and identify ranges of value of the moderator for which the interaction effect is significant.
Figure 1: Moderation analysis for OHS and SPH predicting SCL-90-R and their interaction effect using originally scaled scores. OHS: Oral Health Status, SPH: Self-Perception of Halitosis, SCL-90-R: Psychological status (Symptom Checklist-90-Revised). **P < 0.01, ***P < 0.001

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  Discussion Top

Halitosis is one of the most frequent complaints when a patient visits to a dentist. It has a negative impact on the psychology of individuals due to the social stigma related to it.[13] The present study attempted to understand the moderation of OHS on the psychological status of subjects with self-perception of halitosis.

In the present study, participants with self-perception of halitosis had significantly poor psychological status, when compared to HS group. The main problem focused on depression and psychotism which are in agreement with previous literature.[2],[4] Another study reported that self-perception of halitosis may lead to more negative manifestations of depression, paranoia, and interpersonal sensitivity.[5] Although different instruments were adopted, the reported psychological problems of participants with self-perception of halitosis were matched, and impacts were detected on anxiety, depression, and interpersonal sensitivity.

In halitosis, prime diagnostic importance is in the identification of poor oral hygiene, periodontal diseases, and various systemic illnesses. The problem of oral malodor has been shown to originate in the oral cavity, where conditions favor the retention of anaerobic bacteria. Having a low perception of one's OHS would be linked with dental anxiety.[13]

OHS was not assessed in earlier studies. In our study, dental caries experience was higher in the self-perceived halitosis group compared to HS group. Dental caries experience might have influenced the participants' self-perception in halitosis. The prevalence of gingival bleeding was higher in the self-perceived halitosis group and the prevalence of periodontal pocket was similar in both self-perceived halitosis and HS groups. Perception of halitosis can be attributed to gingivitis rather than periodontal pockets.

Multivariate linear regression explained the variability of psychological status on oral health and self-perception of halitosis, nevertheless the physiological mechanism that explains the moderation of oral health in the relationship between self-perception if halitosis and psychological status is not clear. Except for depression, which is claimed to reduce the immune response in the development of periodontal disease,[15] there is diminutive information in the literature to explain a direct involvement of OHS in the development of psychological problems. It is more rational to assume that psychological problems influence oral health through oral behavior practices. Following the hypothesis, this study examined the data for evidence of moderation of oral health in the relationship between psychological problems and self-perception of halitosis. The effect of self-perception of halitosis alone was not significant, but there was a significant effect on psychological status moderated by oral health and self-perception of halitosis together.

Besides the statistical evidence, there are also other rationales for the moderation model. As previously mentioned, psychological problems caused by self-perception of halitosis can physically influence oral health practices. However, it is not clear from the present study and requires further investigation.

There are a few limitations of the present study; first, the cross-sectional study design does not allow assessment of causality between the study variables. However, the study results are suggestive of possible associations between these variables. Second, biases inherent in self-reporting questionnaire studies such as response bias and social desirability bias might be found in this study. However, the participants have assured anonymity. Third, the study was conducted on college students and the results of the current study may be generalizable to a similar population. Further longitudinal studies are required to assess the complexity of halitosis and its association with the psychological status along with moderation of OHS.

  Conclusions Top

Within all the limitations, the psychological status of self-perception halitosis participants was significantly worse, when compared to HS group. The main problems were in the domain of depression and psychotism. The negative psychological impact was related to the severity of self-perception of halitosis; furthermore, it shows this relationship is moderated by OHS. Therefore, apart from the physiological treatment for halitosis, the psychological status of halitosis patients should be carefully evaluated and psychological intervention should be considered.

Authors contribution

Sudha Rani R: Conceptualization, Data curation, Formal analysis, Software, Investigation, Writing – original draft. Manjunath P Puranik: Conceptualization, Methodology, Validation, Supervision, Writing – review and editing. Uma S R: Supervision, Writing – review and editing.


The author would like to express her gratitude to her supervisors, Dr. Manjunath P Puranik and Dr. Uma S R who guided her throughout this research work. The author would also like to thank her colleagues who supported her and offered deep insights into the study and last but not least all the study participants and head of institutions who were zealous and cooperative throughout the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Azodo CC, Osazuwa-Peters N, Omili M. Psychological and social impacts of halitosis: A review. J Soc Psychol Sci 2010;3:74-92.  Back to cited text no. 3
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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