ORIGINAL ARTICLE Evirgen and Kamburo álu
Effects of Tongue Coating and Oral Health on Halitosis Among Dental Students Şehrazat Evirgena/Kıvanç Kamburoğlub Purpose: To assess halitosis and determine the relationship between halitosis and tongue scores, periodontal status and DMFT among dental students. Materials and Methods: The study comprised 268 (178 female, 90 male) dental students. Halitosis was measured using a Halimeter and the organoleptic method. Halitosis was diagnosed with a mean volatile sulphur compounds (VSC) level of ≥125 ppb and an organoleptic measurement of ≥ 2 on a 0- to 5-point scale. Tongue scores were obtained using a tongue coating index (TCI), periodontal status was measured and assessed using the Community Periodontal Index of Treatment Needs (CPITN) and DMFT indices were calculated. Results: Halitosis occurred at higher rates among male students than female students (83% vs 71%, P = 0.02). No differences were found in halitosis rates among students in different academic years (P = 0.6) or age groups (P = 0.6). A relationship was found between halitosis and tongue scores (P < 0.001) and between halitosis and mean CPITN scores (P = 0.004). The mean DMFT was 4.02 (SD = 3). No relationship was found between halitosis and DMFT index (P = 0.5). Conclusion: Halitosis was prevalent among dental students. Given their responsibilities for diagnosing and improving oral health, they may benefit from increased awareness of the problem and encouragement to improve their own oral hygiene, especially male students. Key words: CPITN, dental students, DMFT, Halimeter, halitosis, tongue scores Oral Health Prev Dent 2013;11:169-173 doi: 10.3290/j.ohpd.a29361
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alitosis is the term used to define an unpleasant or offensive odour emanating from the oral cavity, regardless of whether it originates from oral or non-oral sources (van den Broek et al, 2008). Halitosis of oral origin is associated with poor oral hygiene, dental plaque, dental caries, gingivitis, stomatitis, periodontitis, tongue coating and oral carcinomas (Attia and Marshall, 1982). Non-oral causes of halitosis may include disturbances of the upper and lower respiratory tract, gastrointestinal-tract disorders, systemic diseases and metabolic disorders (Porter and Scully, 2006). However, the most common source of bad breath in individuals with good oral hygiene and healthy periodontal tissue is the posterior dorsum of the tongue (Messadi and
a
Lecturer, Oral Diagnosis and Radiology Department, Faculty of Dentistry, Ankara University, Ankara, Turkey.
b
Associate Professor, Oral Diagnosis and Radiology Department, Faculty of Dentistry, Ankara University, Ankara, Turkey.
Correspondence: Dr. Şehrazat Evirgen, Medical Park İzmir Hospital. Yeni Girne Bulvarı 1825 St. No:12 Karşıyaka, İzmir, Turkey. Tel: +90232-3670585, Fax: +90-232-3670559. Email:
[email protected]
Vol 11, No 2, 2013
Submitted for publication: 11.03.12; accepted for publication: 22.06.12
Younai, 2003). Some people may perceive bad breath that is not noticeable to oral health care professionals or others. This condition is referred to as ‘pseudohalitosis’ and results in a considerable amount of over-treatment (Seemann et al, 2006). Oral malodor occurs as a result of the degradation of organic substrates by anaerobic bacteria, which produces a range of malodorous molecular components, the most extensively studied among them being the volatile sulphur compounds (VSCs). Organoleptic assessment is still the gold standard for diagnosis of bad breath; it is easy to perform and requires no extra apparatus. However, the evaluation has a degree of subjectivity, and training and calibration are necessary to improve objectivity and reproducibility within and between examiners. Measurement of volatile sulphur compounds (VSC) – in particular, hydrogen sulphide (H2S), methyl mercaptan (CH3SH) and dimethyl sulphide [(CH3)2S] – by a portable sulphur monitor (Halimeter) is a common method used to diagnose oral malodour as an adjunct to organoleptic measurement (Vandekerckhove et al, 2009).
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Recent research suggests that H2S induces apoptosis in human periodontal ligament cells and human gingival fibroblasts, which may play an important role in periodontal tissue damage and periodontal disease. Under these aetiological conditions, periodontal pathogens play a key role in the production of H2S (Zhang et al, 2009). In many countries, the Community Periodontal Index of Treatment Needs (CPITN) is used to evaluate periodontal conditions and treatment needs (Kawamura et al, 1993), whereas the DMFT index, another oral health assessment criterion, is calculated by evaluating decayed, missing and filled permanent teeth (Miyazaki et al, 1995). The Tongue Coating Index (TCI) is used to assess the degree of tongue coating (Morita and Wang, 2001). Dental students are expected to be good role models for their patients. The aim of this study was to assess the prevalence of halitosis among dental students at the Ankara University Faculty of Dentistry and to compare differences in halitosis values by sex, gender and years of study. The study also assessed the relationship between halitosis and tongue coating scores, CPITN and DMFT.
MATERIALS AND METHODS The study comprised 268 students of the Faculty of Dentistry at Ankara University. The present study was approved by the ethics committee of Ankara University. Demographic information obtained included gender and year of study. Organoleptic scores were obtained by a trained, calibrated judge and non-organoleptic measurements were obtained using a portable Halimeter bad-breath detector (Model RH-17k, Interscan; Chatsworth, CA, USA). Examiner calibration was achieved by smelling methyl mercaptan solutions at different concentrations as described by the Japan Bureau of Environmental Health (Shimura et al, 1996). Subjects were asked to refrain from eating any meal that might generate a strong odour on the day prior to and the morning of the test date. Subjects were also asked to refrain from smoking, wearing scented personal care products, toothbrushing, oral rinsing and eating immediately prior to the visit. Examinations were performed between 9 and 11 AM. Halitosis was evaluated according to the standard definition by Rosenberg et al (1991a, 1991b). Halimeter measurements were taken according to the manufacturer’s instructions. Maximum VSC values were recorded in ppb from a direct reading of
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the digital display monitor. VSC readings were taken from the mouth three times and averaged. For the organoleptic measurements, subjects were instructed to close their mouths for 30 s and then exhale briefly through the mouth at a distance of 10–20 cm from the nose of the judge. Oral malodour research commonly relies on a 6-point scale developed by Rosenberg et al (1991a) to measure odour intensity: 0; no malodour (odour concentration below the threshold of detection); 1: barely noticeable odour; 2: slight odour; 3: moderate odour; 4: strong odour; 5: extremely strong odour (concentration appears close to saturation). Halitosis was diagnosed if the mean VSC level was ≥125 ppb and the organoleptic measurement was ≥2. Tongue scores were obtained using the TCI, a visual assessment that scores the amount of coating according to the following criteria: 0: no visible tongue coating problem (normal tongue); 1: coating covering less than one-third of the tongue dorsum surface, 2: coating covering less than two-thirds of the tongue dorsum surface; 3: coating covering more than two-thirds of the tongue dorsum surface (Morita and Wang, 2001). For tongue coating scores, the examiner was previously calibrated by assigning tongue coating scores of 287 patients. Periodontal status was measured by a single examiner using a CPI probe and assessed according to the CPITN. Measurements were taken of index teeth in each sextant and the highest score was recorded as the CPITN score for each subject, as follows: 0: no sign of disease; 1: bleeding; 2: calculus; 3: shallow pockets of 4–5 mm; 4: deep pockets of 5–6 mm or more (Kawamura et al, 1993). The DMFT index was calculated by dividing the sum of the numbers of decayed, filled and missing teeth by the number of patients examined. Data analysis was conducted using the software SPSS 11.0 (SPSS; Chicago, IL, US) with a significance level of 95%. Chi-square tests were used to assess relationships between halitosis and age, gender and academic level. Spearman’s correlation coefficient was used to assess the relationship between halitosis and tongue scores, the Mann-Whitney Utest was used to assess the relationship between halitosis and CPITN and the t-test was used to assess the relationship between DMFT and halitosis.
RESULTS Table 1 shows the gender and academic year of the 268 dental students included in the study. Halito-
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sis was more prevalent among male than female students (P = 0.02, Table 1). No difference (P = 0.6) was found in halitosis prevalence by academic year; however, fifth-year students had the highest rate of halitosis and first-year students the lowest (Table 1). Of the 268 VSC measurements, 42% were
