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ORIGINAL ARTICLE
Year : 2013  |  Volume : 4  |  Issue : 1  |  Page : 38-41

Is oral microbiological evaluation necessary in the management of psychological halitosis?


Department of Oral Surgery and Pathology, University of Benin, Benin City, Nigeria

Date of Submission06-Dec-2012
Date of Acceptance25-Apr-2013
Date of Web Publication20-Sep-2013

Correspondence Address:
Osawe F Omoregie
Department of Oral Surgery and Pathology, University of Benin, Benin City
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-6944.118536

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  Abstract 

Objective: Patients with psychological halitosis frequently receive treatment for genuine halitosis, including use of metronidazole and/or chlorhexidine mouthwash, without microbiological evidence of bacteria infection. This study aims to evaluate the role of oral microbiological assessment in the management of patients with psychological halitosis.
Materials and Methods: A 3-year prospective study in which patients diagnosed of psychological halitosis were routinely subjected to microbiological assessment of their tongue swabs. Psychological halitosis was subclassified as pseudohalitosis or delusional halitosis based on the patients' psychological score, oral microbiological findings, and initial response to counseling.
Results: Thirty-seven (12.9%) patients were diagnosed with psychological halitosis among the 287 patients seen during the study period. There were 28 (75.7%) males and 9 (24.3%) females, giving a ratio of 3.1:1. The peak age group was the 3 rd decade of life (n = 17, 45.9%) and the mean age was 36 ± 1.4 years. Most cultures yielded no growth (n = 15, 40.5%) and normal oral flora (n = 7, 18.9%) [p = 0.000]. The commonest associated bacteria were Klebsiella species (n = 4, 10.8%), mostly sensitive to gentamicin (n = 3, 8.1%) and Staphylococcus aureus (n = 4, 10.8%), mostly sensitive to augmentin, ofloxacin, and cefuroxime sodium (n = 3, 8.1%). The pseudohalitosis patients (n = 20, 54.1%) were mostly associated with a psychological score of 4 (n = 14, 37.8%) (P = 0.000). The delusional halitosis patients (n = 17, 45.9%) were mostly associated with a psychological score of 8 (n = 7, 18.9%).
Conclusion: A low prevalence of psychological halitosis was observed. Oral microbiological assessment was useful for diagnosis and counseling of the patients.

Keywords: Oral microbiology, psychological halitosis, psychological score


How to cite this article:
Omoregie OF, Akpata O. Is oral microbiological evaluation necessary in the management of psychological halitosis?. Indian J Oral Sci 2013;4:38-41

How to cite this URL:
Omoregie OF, Akpata O. Is oral microbiological evaluation necessary in the management of psychological halitosis?. Indian J Oral Sci [serial online] 2013 [cited 2019 Jun 18];4:38-41. Available from: http://www.indjos.com/text.asp?2013/4/1/38/118536


  Introduction Top


The dark, wet, and warm oral cavity is an ideal breeding ground for microorganisms that cause oral malodor in 90% of cases of genuine halitosis. [1] The tongue with its malodorous colony of bacteria shed epithelial cells, and decayed food is the primary odor hosts of all sites in the body. [2] More than 100 bacteria may be attached to a single epithelial cell on the tongue dorsum, whereas only about 25 bacteria are attached to each cell in other areas of the oral cavity. [3] Gram-negative anaerobic bacteria are the main cause of oral malodor, with over 300 bacteria species implicated to cause bad breath found in the dorsum of the tongue. [4] These bacteria degenerate proteinaceous substances and release offensive gases, such as dimethyl sulfide, hydrogen sulfide, dimethyl disulfide, and methyl mercaptan. [5]

The extent of oral malodor is indirectly assessed by the odor produced by microorganisms in vitro or by identifying the odor-producing microorganisms in vivo. The indirect methods of assessment include bacteria culture, direct bacterial smears, and enzyme assay. [6] However, patients with psychological halitosis often receive treatment for genuine halitosis, including use of metronidazole and/or chlorhexidine mouthwash, without clinical evidence of oral malodor or microbiological (culture) evidence of bacteria infection. These patients' persistent chronic bad breath complaint is often ignored by dental clinicians, instead of referring the patients to psychological specialist to assist in treatment of the patients' psychological disturbance manifesting as oral malodor. [2],[7] There is dearth of literature on the microbiological pattern associated with psychological halitosis in our environment; therefore, no spectrum of normal oral flora (microorganism) found in patients with psychological halitosis has so far been established. This study aims to evaluate the role of oral microbiological assessment in the management of patients with psychological halitosis.


  Materials and Methods Top


Ethical approval was obtained from the Hospital Ethical Committee to perform a 3-year (September 2009-May 2012) prospective study involving patients diagnosed with psychological halitosis; characterized by complaint of chronic bad breath, without clinical oral malodor (based on three judges/doctors examination of oral odor for all the patients, and volatile sulfur compound (VSC) screening was reserved for delusional halitosis cases) [7] and a high psychological score using a 30-question modified halitosis questionnaire [Table 1] (the questionnaire followed by clinical examination were used to determine the patients oral health status and to exclude oral and extra-oral etiological factors associated with genuine halitosis). [8] The present study was performed in the Department of Oral Pathology/Medicine, University of Benin Teaching Hospital, Benin City, Nigeria. The selected patients were routinely subjected to microbiological assessment (microscopy, culture, and sensitivity [MCS]) of the patients' tongue coating obtained with a wooden spatula and smeared on swab stick. Psychological halitosis was further subclassified as pseudohalitosis or delusional halitosis based on the following factors:
Table 1: The questions that assesses psychological component in the halitosis questionnaire

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  • The patients' psychological score (0 = normal, 1-3 = borderline, 4-10 = psychological condition)
  • Oral microbiological findings of no growth or normal flora
  • Initial good response to counseling (during weekly visits for at least 2 weeks for all the patients) following antimicrobial therapy for those with cultured microorganism (s) (diagnosed as pseudohalitosis) or persistent complaint of bad breath/poor response (diagnosed as delusional halitosis).
The data collected were analyzed and subjected to Pearson's chi square correlation of the variables, with confidence level set at 95% and P < 0.05 was considered significant.


  Results Top


Thirty-seven (12.9%) patients were diagnosed with psychological halitosis among the 287 patients seen during the study period. There were 28 (75.7%) males and 9 (24.3%) females, giving a ratio of 3.1:1. The peak age group was the 3 rd decade of life (n = 17, 45.9%) and the mean age was 36 ± 1.4 years [Table 2]. The mean duration of the bad breath complaint on presentation was 6 (±7) years and the mean psychological score was 6 (±1.9) [Table 3].
Table 2: Age distribution of the patients

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Table 3: Oral microorganisms cultured from tongue swabs of the patients

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Most cultures yielded no growth (n = 15, 40.5%) and normal oral flora (n = 7, 18.9%) (P = 0.000). The commonest associated bacteria were as follows: Staphylococcus aureus (n = 5, 13.5%), most cases were sensitive to augmentin, ofloxacin, and cefuroxime sodium (n = 4, 10.8%); Klebsiella species (n = 4, 10.8%), most cases were sensitive to gentamicin (n = 3, 8.1%); Haemophilus influenza (n = 3, 8.1%), all the cases were sensitive to imipenem [Table 3] and [Table 4]. The pseudohalitosis patients (n = 20, 54.1%) were significantly associated with a psychological score of 4 (n = 14, 37.8%) (P = 0.000). The delusional halitosis patients (n = 17, 45.9%) were mostly associated with a psychological score of 8 (n = 7, 18.9%) [Table 4].
Table 4: Summary of sensitive antibiotics to cultured oral microorganism in tongue swabs of the patients

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  Discussion Top


Yaegaki and Coil [2],[9] and Murata et al., [10] classified halitosis into genuine halitosis (subdivided into physiological and pathological types), pseudohalitosis, and halitophobia (psychosomatic halitosis), whereas in a recent Nigerian study, Uguru et al., [11] classified halitosis into genuine halitosis and delusional halitosis (subdivided into pseudohalitosis and halitophobia). Other reports [12],[13],[14] from Nigeria agree with Yaegaki's classification of halitosis, and delusional halitosis was also substituted for psychosomatic halitosis or halitophobia. However, both pseudohalitosis and delusional halitosis were referred to as subtypes of psychological halitosis in this study and the diagnostic criteria for each subtype was similar to those earlier used in Yaegaki's classification of halitosis. [2]

A low prevalence (12.9%) of psychological halitosis was observed in this study compared with previous reports. [11],[15] The predilection of the condition for males and the third decade of life in this study also agree with the findings in the previous studies. [11],[13],[15] This group of persons represents the highly productive workforce of most societies, but they appear to be more susceptible to the psychosocial handicap associated with psychological halitosis. The long duration of bad breath complaint observed in most of the patients before presentation for treatment suggests that these patients may have been unaware of where to seek help, or perhaps the patients may have been poorly managed and they resorted to 'doctor shopping', thereby prolonging the period of suffering from this condition. [2],[9] This, together with other predisposing psychosomatic factors, may have contributed to the severe psychological problem found in these patients, as shown by the high mean psychological score 6 (±1.9).

Previous microbiological studies [16],[17] have demonstrated the presence of bacteria in tongue coating as the cause of genuine halitosis in the patients studied, and antimicrobial approaches (mechanical and chemical) were useful in the reduction of halitosis in these patients. [18],[19] Conversely, in the present study, microbiological evaluation of tongue swabs from the patients studied showed that psychological halitosis was significantly related to absence of bacteria and normal oral flora in the culture. Therefore, oral microbiological assessment may be a useful evidence to exclude bacteria infection in the diagnosis of psychological halitosis. Although, some of the patients' cultures showed bacteria infection, most of the bacteria were reported among normal flora in the oronasal mucosa and facial skin. [20],[21] Only Klebsiella species, Citrobacter species, and Enterobacter species are the bacteria (Enterobacteriaceae) previously associated with genuine halitosis. [22],[23],[24],[25] Other uncommon bacteria associated with psychological halitosis in this study were Haemophilus influenza, Streptoccocus pneumonia, Staphyloccocus aureus, and Pseudomonas aerogenosa. Therefore, we recommend, based on the findings of the present study, that the spectrum of normal oral flora should be broaden for patients with psychological halitosis in this center.

However, the patients with microbiological evidence of bacteria infection were treated with the sensitive antibiotics. Afterward, the patients' follow-up/counseling visits in the clinic were useful for subdividing the patients with psychological halitosis into pseudohalitosis and delusional halitosis. [2] Antimicrobial therapy for the cultured bacteria, suspected to be normal flora in the patients with psychological halitosis, was used as a palliative measure to elicit good initial response during counseling of the patients with pseudohalitosis. Similarly, response to treatment by patients with pseudohalitosis was also reported by Yaegaki et al., [2] as a criterion for the diagnosis of this condition. The patients diagnosed of delusional halitosis gave poor response to treatment and were recommended for halimeter screening (for VSC), [7] personality assessment (with mental health questionnaires), and joint counseling sessions by dentists and mental health experts. In contrast to previous study by Uguru et al., [11] most of the patients in the present study had mild form of psychological halitosis and were diagnosed of pseudohalitosis. It appears that some studies may have included the patients with pseudohalitosis among the delusional type without proper clinical assessment. This may be the reason for the higher prevalence of delusional halitosis earlier reported. [11],[15]

In conclusion, a low prevalence of psychological halitosis was observed in this study compared with previous reports. Oral microbiological evaluation of the patients with psychological halitosis was significantly related to the absence of bacteria and normal oral flora in the cultured tongue swabs. Therefore, it is recommended as a useful evidence for excluding bacteria infection in the diagnosis of psychological halitosis. Antimicrobial therapy for bacteria associated with psychological halitosis, was useful as a palliative measure to elicit good initial response during counseling of the patients with pseudohalitosis.

 
  References Top

1.Borden LC, Chaves ES, Bowman JP, Fath BM, Hollar GL. The effect of four mouthrinses on oral malodor. Compend Contin Educ Dent 2002;23:531-6, 538, 540, 548.  Back to cited text no. 1
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2.Yaegaki K, Coil JM. Examination, classification and treatment of halitosis; Clinical perspectives. J Can Dent Assoc 2000;66:257-61.  Back to cited text no. 2
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20.Michael GN, Russell N. Normal microbial flora of the human body: Oral Microbiology and Immunology. Philadelphia; W.B. Saunders Company, Harcourt Brace Jovanovich Inc; 1988. p. 135-44.  Back to cited text no. 20
    
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23.De Boever EH, Loesche WJ. Assessing the contribution of anaerobic microflora of the tongue to oral malodor. J Am Dent Assoc 1995;126:1384-93.  Back to cited text no. 23
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24.Kleinberg I, Codipilly M. The biological basis of oral malodor formation. In: Rosenberg M, editor. Bad Breath: Research Perspective. Tel Aviv, Israel: Ramot Publishing, Tel Aviv University; 1995. p. 13-39.  Back to cited text no. 24
    
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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