Hindawi

International Journal of Dentistry

Volume 2017, Article ID 8682010, 10 pages
https://doi.org/10.1155/2017/8682010

Research Article
Self-Reported Halitosis in relation to Oral Hygiene
Practices, Oral Health Status, General Health Problems, and
Multifactorial Characteristics among Workers in Ilala and
Temeke Municipals, Tanzania

C. M. Kayombo and E. G. Mumghamba

Department of Restorative Dentistry, School of Dentistry, Muhimbili University of Health and Allied Sciences (MUHAS),
P.O. Box 65014, Dar-es-Salaam, Tanzania
Correspondence should be addressed to C. M. Kayombo; cecywamax@yahoo.com

Received 20 July 2016; Revised 7 December 2016; Accepted 12 January 2017; Published 9 February 2017

Academic Editor: Gilberto Sammartino

Copyright © 2017 C. M. Kayombo and E. G. Mumghamba. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Aim. To assess self-reported halitosis, oral hygiene practices, oral health conditions, general health problems, sociodemographic
factors, and behavioural and psychological characteristics among workers in Ilala and Temeke municipals. Materials and
Methods. This was a cross-sectional descriptive study. Four hundred workers were recruited using a self-administered structured
questionnaire. Results. Self-reported tooth brushing practice was 100%, tongue cleaning 58.5%, dental flossing 4.3%, gum bleeding
on tooth brushing 79.3%, presence of hard deposits on teeth 32%, mobile teeth 15.3%, and self-reported halitosis (SRH) 48.5%. Tea
users were 95%, coffee users 75.8%, smokers 21%, and alcohol consumers 47%. The SRH was significantly associated with bleeding
gums, hard deposits, and mobile and malaligned teeth. Tongue cleaning and regular change of toothbrush were associated with low
prevalence of SRH (𝑃 < 0.001). Higher occurrence of SRH was significantly related to low education and smoking. Conclusion. Self-
reported halitosis was prevalent among workers and was significantly associated with bleeding gums, hard dental deposits, mobile
teeth, and smoking. All participants brushed their teeth and cleaned the tongue regularly but use of dental floss was extremely low.
Oral health education and health promotion are recommended.

1. Introduction causing personal discomfort and emotional stress. Previous

studies have reported that about 30% to 50% of the population
Oral hygiene is the practice of keeping the mouth and has experienced the problem of halitosis [3–5].
teeth clean to prevent dental problems, most commonly, Halitosis has been classified into three main categories:
dental cavities, gingivitis, periodontal (gum) diseases, and genuine, pseudo-halitosis, and halitophobia halitosis [6].
bad breath [1]. In genuine halitosis, the malodour intensity is beyond the
Halitosis, oral malodour, or bad mouth breath is a socially acceptable level. If halitosis is not perceived by others
universal medicosocial problem in all communities and refers but the patient persistently complains of its existence, it is
to the unpleasant odour that originates from the mouth or diagnosed as pseudo-halitosis. If after successful treatment
elsewhere [2]. Most of the times these three “terms” had of genuine halitosis or pseudo-halitosis the patient still com-
been used interchangeably in literature and likewise they plains of halitosis, the diagnosis is referred to halitophobia
have been adopted in the current report. The condition is [6]. A term psychosomatic breath malodour (halitophobia,
multifactorial in aetiology and may involve both oral and pseudo-halitosis) is used when breath malodour does not
nonoral conditions. exist in actual fact but the patient imagines and believes
Halitosis is a nuisance problem for many people around that he or she has breath malodour. Halitophobia cannot be
the world. It affects social interactions of people in daily life by objectively determined and is mostly associated with suicidal
2 International Journal of Dentistry

attempts [6, 7]. Genuine breath malodour from the oral cavity collection were eligible to participate. The workers were
contains volatile sulphur compounds (VSCs) particularly either self-employed or employed for pay. Only those who
hydrogen sulphide, methyl mercaptan, dimethyl-sulphide, consented were included in the study.
and organic acids [6, 8].
The causes for breath malodour (BM) are multifactorial 2.2. Data Collection Tool and Data Management. A self-
in that it may arise from dental plaque, bacterial products administered structured questionnaire that was formulated
from deep periodontal pocket, tongue, tonsils and pharynx, first in English and then translated into “Swahili,” the local
and rarely gastrointestinal tract [8]. Breath malodour is also language of the study participants, was distributed physically
associated with gingival bleeding on tooth brushing [9] by the researcher (CK) to all workers readily available on
and higher number of bleeding sites on probing [10]. Oral the study sites. No sampling was done. Recruitment of study
prosthetics such as acrylic dentures, especially when retained participants was done by registering consecutively every
in the mouth at night or are poorly and irregularly cleaned, consenting person at different work stations until the sample
can also produce a typical smell associated with candidiasis
size was attained. The questionnaire had open- and closed-
[11].
ended questions composed of inquiry items on sociodemo-
Nonoral causes for genuine breath malodour include
graphic characteristics, dental caries experience, oral hygiene
medical problems such as renal failure, cirrhosis of the liver,
and diabetes mellitus [3, 11, 12]. Although breath malodour practices, self-reported halitosis (SRH), periodontal diseases,
can originate from oral and nonoral sites, about 85% are general systemic health problems, and behavioural factors in
generally related to an oral cause [3, 11]. particular cigarette smoking and alcohol consumption (see
Major methods of analysing BM include organoleptic the questionnaire in the in Supplementary Material available
measurement (judges for BM), gas chromatography, and online at https://doi.org/10.1155/2017/8682010).
sulphide monitors [6, 13]. In addition to these methods, Data was entered into a computer and analysed using
clinical application of a questionnaire for diagnosis and Statistical Package for Social Sciences (SSPS) version 20.0.
treatment of breath malodour has been developed for use Frequency and cross-tabulation tables were generated. Data
[14]. transformation was undertaken and it included dichotomiza-
Poor oral hygiene not only is closely linked to various tion of some variables that had more than two options for
oral health problems but also has a significant effect on oral example, age (less than 30 years versus 30 years and above
malodour. Mechanical tooth cleaning, such as tooth brushing or at age group of 40 years and above compared to those
or interdental flossing, is an essential daily oral hygiene that were less than 40 years of age), level of education,
practice, but many articles have revealed that tooth brushing and type of education (primary education and lower versus
alone will not significantly reduce oral malodour [15]. On the secondary and higher education). The type of occupation
other hand, mouth rinsing and tongue cleaning can reduce of individuals was transformed, dichotomized, and recoded
VSCs levels [16]. as “indoor” versus “outdoor” workers. Chi-Square test or
The information on oral malodour in African countries Fisher’s Exact Test was used to detect associations given with
including East Africa particularly in Tanzania general pop- the Chi-squared (𝜒2 ) value truncated at two decimal points.
ulation is scarce. The prevalence of self-reported halitosis In all the analyses, the statistical significance level was set at
was 72% among adolescents in Temeke district [17], fourteen
“𝑃 < 0.05.” For the logistic regression analyses, a total of
percent among young women at maternity block in Muhim-
thirty-seven multifactorial characteristics were included in
bili National Hospital [9], and 44% in Muhimbili outpatient
“back-ward model” to determine their impact on the self-
dental clinic [18]. Most of the studied outpatients (66%)
at Muhimbili Dental Clinic were of the opinion that oral reported halitosis whether they had statistically significant
malodour was a problem in their society, and the majority contribution or not.
of these respondents (64.5%) were residents in Kinondoni
district [18]. 2.3. Ethical Considerations. This work was an elective study
The aim of the current study was to determine the which was part of the requirement for the doctor of dental
self-reported halitosis, oral hygiene practices, oral health surgery (DDS) undergraduate training at the Muhimbili
conditions, general health problems, and sociodemographic, University of Health and Allied Sciences (MUHAS). Ethical
behavioural, and psychological characteristics among work- clearance was granted by the Research and Publication
ers in Ilala and Temeke municipals. Committee of the School of Dentistry as empowered by
MUHAS Ethical Committee.
2. Materials and Methods
3. Results
2.1. Study Design, Place of Study, and Participants. This was
a cross-sectional descriptive study. The study was conducted 3.1. Study Participants. A total of 400 workers were recruited
in Ilala and Temeke municipals, Dar-es-Salaam, Tanzania, as study participants and aged 17–59 years (mean = 35.7±9.0)
which were readily accessible and thus conveniently selected years with the median of 34.5 years (Table 1). The level of
whereby rural areas were not part of this study. All workers education of the participants was primary (33%), secondary
found in business sites in particular the factories, garages, (38%), and college (24.3%) education. Only 4.8% had no
shops, offices, and schools on the day and time of data formal education.
International Journal of Dentistry 3

Table 1: Distribution of the study participants by age groups and not cleaning the tongue, they had more complains of SRH
sex. compared to those who cleaned their tongues (𝜒2 = 35.85,
Males Females Total 𝑃 < 0.001). The participants that had food stuck between
Age group teeth exhibited higher SRH than those without stuck food
𝑛 % 𝑛 % 𝑛 %
17–29 59 26.6 59 33.1 118 29.5 (𝜒2 = 6.16, 𝑃 = 0.013). Dental floss users to clean the spaces
between the teeth were very few (2.5%). Toothpick users
30–39 82 36.9 69 38.8 151 37.8
(19.0%) had higher SRH than nonusers (𝜒2 = 6.32, 𝑃 = 0.012),
40–49 59 26.6 37 20.8 96 24.0
and the same trend was observed between participants that
50–59 22 9.9 13 7.3 35 8.8
had teeth malalignment due to increasing space between
Total 222 (100) 178 (100) 400 (100) teeth compared to those without (𝜒2 = 9.28, 𝑃 = 0.002,
Table 4). Gum bleeding on tooth brushing resulted to more
complaints on SRH compared to those who had no bleeding
3.2. Self-Reported Halitosis in relation to Oral Hygiene Prac- (𝜒2 = 39.97, 𝑃 < 0.001). Hypertensive individuals had higher
tices, Oral Health Status, and General Health Problems. All SRH compared to those that had other systemic conditions
participants claimed to practice regular tooth brushing but (𝜒2 = 3.94, 𝑃 = 0.047, Table 4).
frequency of tooth brushing varies among individuals. Tooth Sociodemographic factors together with behavioural and
brushing once per day was 43% while twice or more per psychological characteristics in relation to SRH are shown
day was 57%. The prevalence of SRH was 48.5% and experi- in Table 5. The participants that had primary education or
enced in different times of the day and occasions (Table 2). less exhibited significantly higher proportion of SRH than
About one-fifth (21.7%) of the participants had different those that had secondary education or higher (𝜒2 = 14.99,
general medical conditions that include cardiovascular dis- 𝑃 < 0.001). Similar trend was evident among participants
eases (CVD) in particular heart problems and hypertension at age group of 40 years and above compared to those that
(8.5%), endocrine disorders especially diabetes (4.3%), and were less than 40 years (𝜒2 = 4.07, 𝑃 < 0.044). There were
other systemic conditions (Table 3). The participants that no significant differences in the prevalence of SRH between
had CVD that includes hypertension exhibited higher SRH males and females and likewise between the married and
than those that had other systemic conditions (11.3% versus singles.
5.8%, 𝜒2 = 3.91, 𝑃 = 0.048; table not shown). Among the A total of 157 out of 400 (39.2%) were outdoors workers
participants who brushed their teeth twice per day or more (casual labourers, drivers, security guards, garage people,
had lower proportion (36.0%) of SRH compared to those petty business persons, and porters) and 60.8% were indoor
(65.1%) who had brushed their teeth just once per day (𝜒2 = workers (managers, administrators, accountants, secretaries,
33.35, 𝑃 < 0.001). A total of 399 (99.75%) used plastic receptionists, office attendants, teachers, nurses, industrial
toothbrush (the participants who used plastic toothbrush engineers, and laboratory technicians). There were more
alone were 87%, both plastic as well as chewing stick 12.75%), outdoors workers that had SRH compared to indoor workers
and chewing stick alone only 1 person (0.25%). There was no (𝜒2 = 13.38, 𝑃 < 0.001). Likewise, SRH was higher among
significant difference in the occurrence of SRH between the smokers compared to nonsmokers (𝜒2 = 5.780, 𝑃 = 0.016).
participants who used both plastic toothbrush and chewing The participants that had opportunity to come closer to
stick compared to those who used plastic toothbrush alone. someone that had halitosis influenced them to an extent that
The SRH in relation to oral hygiene practices, oral health most of them perceived SRH than those that had not met
status, and general health/medical problems is shown in anyone with such situation (𝜒2 = 16.49, 𝑃 < 0.001).
Table 4. The SRH was higher among those who used the Among the 194 participants that had SRH problem, more
toothbrush for four months or more before changing it than two-fifth (41.3%) discovered it through gestures from
compared to those that used it for three months or less (𝜒2 = people near them when talking and 23.8% were informed by
13.93, 𝑃 < 0.001). All study participants used at least one their spouses (30.8) and relatives (23.8%, table not shown).
type of a dentifrice among the nine listed as available in the Furthermore, among those affected by SRH, 77.3% hesitated
shops which included Aha, Aloe vera, Chemi-dent, Chinese- to talk to other people, 41.2% tried to stay away from
brands, Close-up, Colgate, Sensodyne, Traditional herbs, other people, but also 54.1% thought that other people were
and White-dent. For ethical reasons these dentifrices were shunning away from them (Table not shown). Almost all
randomly coded as toothpaste (TP) type A-I. Toothpaste type (99.5%) of the participants that had SRH were bothered to
B and type E users had lower proportion of participants that an extent that it had affected them at work place (𝜒2 = 241.9,
had SRH as compared to nonusers 𝜒2 = 4.13, 𝑃 = 0.042 and 𝜒2 𝑃 < 0.001) as well as at home (𝜒2 = 273.1, 𝑃 < 0.001; Table 5).
= 5.42, 𝑃 = 0.02, respectively. Interestingly, some participants Use of chewing gum was significantly higher among the SRH
used charcoal (8.8%), ashes (1.5%), and/or sand (0.3%) to group compared to those without the problem (𝜒2 = 7.16,
clean their teeth. Among those who used charcoal, a higher 𝑃 < 0.01, Table 5). Self-treatment for SRH was attempted by
proportion of participants complained of SRH compared to 46.9% of the participants whereby 24.2% used chewing gums
those who did not use charcoal (𝜒2 = 4.55, 𝑃 = 0.033). and mouth-washes (31.4%), and 16.0% tried to seek doctor’s
The participants who brushed their teeth before going to advice. For the participants that had SRH, when asked, “are
bed had lower proportion of SRH than those who did not do you willing to be treated for SRH problem”, 95.9% responded
so (𝜒2 = 30.83, 𝑃 < 0.001). For those that had the habit of positively. The difference between those willing compared to
4 International Journal of Dentistry

Table 2: Self-reported halitosis in relation to time in a day when it is experienced more.

Problem with halitosis

Chi-square test
Time of a day Yes No
𝑛 % 𝑛 % 𝜒2 𝑃 value
After waking up 145 74.7 14 6.8 192.6 0.000
When talking to others 92 47.4 7 3.4 104.0 0.000
When fasting 90 46.4 3 1.5 113.1 0.000
During work 49 25.3 2 1.0 53.0 0.000
When thirst 40 20.6 5 2.4 33.1 0.000
In the afternoon 46 23.7 2 1.0 48.9 0.000
In the evening 43 22.2 1 0.5 48.0 0.000
At night 40 20.6 1 0.5 44.0 0.000
When tired 52 26.8 2 1.0 56.8 0.000
The whole day 88 45.4 4 1.9 106.4 0.000

Table 3: General medical conditions reported by the study participants.

General medical problems of the study participants 𝑛 %

Cardiovascular diseases: hypertension and heart problems 34 8.5
Endocrine disorders: diabetes, thyroid conditions 17 4.3
Respiratory tract (RT) system: tuberculosis (TB), RT infections, asthma 8 2.0
Central nervous system: headache, psychosomatic, and eye problems 11 2.8
Gastrointestinal tract problems 6 1.5
Genitourinary tract problems 2 .5
Musculoskeletal system: backache and joint problems, skin 9 2.3
No medical problem 313 78.3
Total 400 100.0

those not willing to be treated was highly significant (𝜒2 = characteristics as well as behavioural and psychological fac-
318.82, 𝑃 < 0.001). tors. The logistic regression model process went through
many steps whereby at each step some of the variables were
3.3. Self-Reported Halitosis in relation to Previous Tooth removed from the model and the final step with few variables
Extraction. The SRH was higher among participants that had that were maintained in the model with Odds ratio (OR),
had tooth extraction than in those who had no extraction (𝜒2 95% confidence interval (CI), and Probability (𝑃) value in
= 4.72, 𝑃 = 0.03, table not shown). Likewise, the same trend three decimal points (Table 6). In this table, it can be seen
was seen among those that had tooth extraction due to dental that a closer interaction with someone that had halitosis was
caries compared to those that had extraction of teeth without significantly associated with more than four times likelihood
tooth decay (𝜒2 = 8.77, 𝑃 = 0.003). to declare SRH (OR: 4.19, CI 1.61–9.69, and 𝑃 = 0.003)
compared to an individual that had never met anyone with
3.4. Knowledge on the Origin of Halitosis. Those participants a problem of halitosis. Also those participants that hated
that experienced SRH thought that the problem was due to the type of job they were doing had more than two times
bleeding gums on tooth brushing (70.1%), not brushing the likelihood to declare SRH (OR: 2.31 (CI 1.02–5.21), 𝑃 = 0.044)
teeth well (67.0%), holes on teeth (decayed teeth) (41.8%), and than the ones, for example, who had interesting jobs. Those
dry mouth (20.1%). who were married were less likely to report SRH than those
who were single (OR: 0.54, (CI 0.31–0.94), and 𝑃 = 0.031).
3.5. Logistic Regression Analyses. The binary logistic regres- Also participants at the level of primary education and lower
sion analyses of the multifactorial characteristics related to were less likely to report SRH than those that had higher
self-reported halitosis among the participants are shown in level of education from secondary school and above. The
Table 6. Multifactorial characteristics (dichotomized) that participants that had poor oral hygiene in particular those
were considered and entered in the binary logistic regression not brushing their teeth before bed as well as those not
back-ward model were those dealing with halitosis in the cleaning the tongue were less likely to assert SRH compared
bivariate analyses above (Tables 4 and 5) in relation to oral to their counterparts, OR: 0.36, (CI 0.21–0.60), and 𝑃 < 0.001
hygiene practices, oral health status, and sociodemographic and OR: 0.51, (CI 0.30–0.88), and 𝑃 = 0.016, respectively.
International Journal of Dentistry 5

Table 4: Bivariate analysis: self-reported halitosis in relation to oral hygiene practices, oral health status, and general health problems.

Self-reported halitosis
# Whole sample (𝑛 = 400)
Multifactorial characteristics Yes No Chi-square value 𝑃 value
𝑛 % 𝑛 % 𝑛 %
Oral hygiene practices
Brushing once or less/day 172 43.0 112 57.7 60 29.1 33.36 0.000
Use of chewing stick 51 12.8 29 14.9 22 10.7 1.64 0.201
Changing toothbrush 245 61.2 137 70.6 108 52.4 13.93 0.000
Not using charcoal to clean teeth 365 91.2 171 88.1 194 94.2 4.55 0.033
Not brushing before breakfast 20 5.0 10 5.2 10 4.9 0.02 0.890
Not brushing after breakfast 380 95.0 182 93.8 198 96.1 1.12 0.291
Not brushing before bed 213 53.2 131 67.5 82 39.8 30.84 0.000
Uses toothpaste type TP-B 142 35.5 80 41.2 62 30.1 5.42 0.020
Uses toothpaste type TP-H 101 25.2 32 16.5 69 33.5 15.30 0.000
Uses toothpaste type TP-E 326 81.5 166 85.6 160 77.7 4.13 0.042
Tongue cleaning 166 41.5 110 56.7 56 27.2 35.85 0.000
Use of toothpick 76 19.0 27 13.9 49 23.8 6.32 0.012
Oral health status
Dental hard deposits 128 32.0 93 47.9 35 17.0 43.98 0.000
Food impact between teeth 322 80.5 166 85.6 156 75.7 6.16 0.013
Bleeding gums on tooth brushing 316 79.0 179 92.3 137 66.5 39.97 0.000
Decayed teeth (not yet treated) 184 46.0 104 53.6 80 38.8 8.778 0.003
Loose/mobile teeth 61 15.2 46 23.7 15 7.3 20.87 0.000
Increasing space between teeth 171 42.8 98 50.5 73 34.5 9.28 0.002
Dry mouth 65 16.2 30 15.5 35 17.0 0.17 0.679
General health problems
Hypertension 43 10.8 27 13.9 16 7.8 3.94 0.047
Diabetes 21 5.2 10 5.2 11 5.3 0.01 0.934
Other health/medical problems 87 21.8 47 24.2 40 19.4 1.34 0.244
#
Each condition presented in this table has basically “Yes and No” alternatives with numerical values corresponding to each individual situation. Only the
numerical values corresponding to “Yes” have been presented in this table and the counterpart alternative “No” numerical values have been left out. For
example, for the use of chewing stick “Yes versus No,” only the numerical values for “Yes” have been presented in this table while the ones corresponding to
“No” have been left out.

Likewise, those that had oral health problems like bleeding disparity is justified by the subjectivity of the diagnostic
gums on tooth brushing or had dental hard deposits were less criteria, assessment methods, and sampling techniques [20].
likely to claim having SRM compared to those without those In the present study the overall prevalence of halitosis
conditions, OR: 0.21, (CI 0.10–0.41), and 𝑃 < 0.001 or OR: was approaching fifty percent; this is almost similar to the
0.32, (CI 0.18–0.57), and 𝑃 < 0.001, respectively. results reported in Qassim, Saudi Arabia [21], is also lower
in comparison to study done in Kinondoni [22], but at the
4. Discussion same time is higher than the findings reported in other
populations especially Brazil [23] and USA [20]. As far as
Halitosis is a common problem among general population oral hygiene practices are concerned all participants practiced
and evidences reveal that it forms about 85% of all complaints tooth brushing and this could suggest that people had
when considering extraoral origins and psychological types knowledge on how to take care of their oral cavities. However,
[19]. In many studies, including ours, the assessment of this cannot be taken for granted that they were practicing
halitosis relies on the subject’s self-perception. Many profes- tooth brushing correctly, the subject matter that was beyond
sionals do not consider this method to be reliable because it the scope of this study. It is known that adequate oral hygiene
is subjective, and obviously, the method is not standardized measures may reduce or treat people suffering from halitosis
among participants. Although the method presents several or protect them from it [24]. Consistent with the previous
problems and may be objectionable to the dentist, it is the one studies [25, 26], lower frequency of tooth brushing in the
that most closely resembles daily situations in which halitosis current study was related to higher occurrence of halitosis.
is detected [20]. The prevalence of halitosis, according to Longer use of a tooth brush more than three months was
the studies published, is between 2% and 44% and this associated with higher occurrence of halitosis and this could
6 International Journal of Dentistry

Table 5: Bivariate analysis: self-reported halitosis in relation to sociodemographic, behavioural, and psychological factors.

Self-reported halitosis
# Whole sample (𝑛 = 400)
Multifactorial characteristics Yes No Chi-square value 𝑃 value
𝑛 % 𝑛 % 𝑛 %
Sociodemographic factors
Sex: male 222 55.5 114 58.8 108 52.4 1.62 0.203
Age group: 40 years and above 131 32.8 73 37.6 58 28.2 4.07 0.044
Education level: primary or low 151 37.8 92 47.4 59 28.6 14.99 0.000
Marital status: married 280 70.0 144 74.2 136 66.0 3.21 0.073
Rest place: at home 181 45.2 170 87.6 11 5.3 273.1 0.000
Business place: at work 164 41.0 156 80.4 8 3.9 241.9 0.000
Work environment: outdoor 157 39.2 94 48.5 63 30.6 13.38 0.000
Behavioural factors
Coffee: user 303 75.8 143 73.7 160 77.7 0.85 0.356
Tea: user 380 95.0 183 94.3 197 95.6 0.36 0.551
Alcohol: consumption 188 47.0 97 50.0 91 44.2 1.36 0.243
Cigarette: smoker 83 20.8 50 25.8 33 16.0 5.78 0.016
Chewing gum: user 256 64.0 137 70.6 119 57.8 7.16 0.007
Oral health facility: previous attendance 214 53.5 117 60.3 97 47.1 7.02 0.008
Psychological factors
Met someone with halitosis 45 11.2 9 4.6 36 17.5 16.49 0.000
Do not like the job being done 45 11.2 20 10.3 25 12.1 0.33 0.563
Willing to have a dental check-up 43 10.8 15 7.7 28 13.6 3.58 0.059
#
Each condition presented in this table has basically “Yes and No” alternatives with numerical values corresponding to each individual situation. Only the
numerical values corresponding to “Yes” have been presented in this table and the counterpart alternative “No” numerical values have been left out, for example,
sex (male: “Yes,” and female: “No”) and therefore numerical values corresponding to female have been left out.

Table 6: Binary logistic regression analyses of the multifactorial characteristics related to self-reported halitosis among the study participants.

95%
Multifactorial characteristics 𝐵 S.E. Odd’s ratio Confidence 𝑃 value
interval
Psychological factors
Met someone with bad mouth breath 1.43 0.46 4.19 1.61–9.69 0.003
Hating the type of work one is doing 0.84 0.44 2.31 1.02–5.21 0.044
Sociodemographic factors
Married −0.61 0.28 0.54 0.31–0.94 0.031
Low level of education −0.57 0.28 0.56 0.33–0.97 0.040
Oral health status
Have dental problem −0.95 0.27 0.39 0.23–0.65 0.000
Have dental deposits on the teeth −1.13 0.29 0.32 0.18–0.57 0.000
Gum bleeding on tooth brushing −1.59 0.35 0.21 0.10–0.41 0.000
Have loose tooth in the mouth −0.69 0.41 0.50 0.22–1.11 0.090
Oral hygiene practices
Not brushing teeth before bed −1.03 0.27 0.36 0.21–0.60 0.000
Not cleaning the tongue −0.67 0.28 0.51 0.30–0.88 0.016
Not using toothpaste type TP-E −0.76 0.34 0.47 0.24–0.91 0.025
Not using toothpaste type TP-H 0.53 0.31 1.70 0.93–3.12 0.058
Not brushing after breakfast 1.00 0.58 2.72 0.87–8.50 0.085
𝐵: regression coefficient and SE: standard error.
International Journal of Dentistry 7

be explained by the fact that cleaning effectiveness of the include faulty dental restoration sites, sites of food impaction,
bristle brushes diminishes with time of use and that changing and abscesses [37]. In the current study the halitosis was
the toothbrush after every use leads to decrease of microbes significantly higher among those who had food impaction
responsible for plaque formation [27]. The toothbrush has a between teeth compared to those who had none and concurs
significant role to reintroduce microorganisms into the oral with previous study in Nigeria [38].
cavity [27, 28]. Since it is not feasible to change the toothbrush Similar to the SRH study in Kuwait [25] and Turkey [39]
every day, it is recommended as a sound practice to change participants that had lower level of education in the current
the toothbrush at least after every three months [29]. study in Temeke and Ilala municipality had higher prevalence
The tongue is said to be the most common source for of halitosis and might be explained by the low level of
halitosis within the oral cavity [20]. In the current study the understanding in such groups. Self-reported halitosis in those
halitosis was significantly higher among those who did not over 30 years of age was higher than those under 30 although
clean the tongue compared to those who did and this concurs the difference did not reach a statistically significant level;
with previous reports [23, 30]. The possible explanation is that in a way it shows an inclination to previous studies which
the uncleaned tongue usually harbours periodontal bacteria reported significantly higher SRH in those over 30 years of
such as Prevotella intermedius, Porphyromonas gingivalis, and age than those less than 30 years [21, 40, 41]. In current study,
Fusobacterium species that are responsible for producing halitosis was not associated with sex and similar findings had
volatile sulphur compounds (VSC) that account for halitosis been reported in Turkey [39], Thailand [40], and Saudi [42];
[30]. however, opposite findings show that males were affected
In the current study, participants who brushed their teeth more than females in Brazil [23], Poland [26], and Saudi
before going to bed had significantly lower prevalence of Arabia [43] and vice versa that females were more affected
halitosis than those who did not brush their teeth before than males in Italy [44].
going to bed. It may be considered that a major reduction in Halitosis can have a distressing effect that may become a
microbial plaque before going to bed will result into a lower social handicap and the affected person may avoid socializing
total number of the microbes responsible for halitosis and [35]. In this study, almost all subjects that had halitosis
its intensity bearing in mind that one microbe in 24 hours admitted that it interfered with their social life and sig-
multiplies after every 3 hours and ends up in totaling into 254 nificantly was noted at home, in the evening and at night
[31]. A multitude of microorganisms of different species are and these parameters suggest personal discomfort and social
present in the oral biofilms as it is estimated that 1 mm3 of embarrassment [22]. Patients with SRH chose to share this
dental plaque weighing about 1 mg, more than 108 bacteria, problem with friends, relatives, and others more frequently
may be counted [31]. There are reports showing that the than with health professionals [40]. In the present study, self-
dentifrice containing triclosan and copolymer in a sodium treatment was found to be higher than the one reported in
Saudi Arabia [43]. About a quarter of the participants in the
fluoride/silica base reduces the number of VSC-producing
current study used chewing gums and mouth-washes for self-
bacteria [32] and that the concentration of triclosan in
treatment of halitosis. Chewing gum has been reported to
plaque biofilm inhibits the growth of bacteria and therefore
have the ability to significantly increase salivary flow rate,
retards the return of halitosis [33]. Therefore, the use of raise the plaque-pH levels, and improve halitosis [32]. Most
certain toothpastes, especially fluoridated toothpaste, should of the participants that had halitosis in the current study
be recommended for not only dental caries prevention but were using chewing gum and similar observation has been
also managing halitosis [32]. Use of some dentifrices in reported by Fadhil and Mugonzibwa [18].
the current study was associated with lower prevalence of Among the participants that had SRH, an interesting
halitosis and this is in a way in line with what has been observation was that some (a small proportion) were not
reported elsewhere [33, 34]. Periodontal diseases and dental willing to be treated for their problem. The reason for this
caries are potential factors contributing to halitosis [35]. is not known but it can be speculated that dental fear might
Gum bleeding on tooth brushing and hypertension were be the contributing factor as is a common phenomenon in
associated with higher prevalence of halitosis in the study the world as more than 25% of patients avoid visits and
population and putrefaction of the blood in the gingival treatments, and approximately 10% reach phobic levels of
sulcus or periodontal pocket might be the possible expla- anxiety [45]. Most of those with halitosis were willing to
nation for the observation [11]. Furthermore, high blood be treated. This is a good sign that most of those affected
pressure might contribute to pumping of more blood to the want to eliminate the embarrassing problem but, on the
gingival sulcus or periodontal pocket area and thus they other hand, needs to ring bell to the practitioners to be well
are more readily available for putrefaction. Self-reported equipped to manage adequately both the genuine and even
presence of decayed teeth in the present study was associated the psychological halitosis [46].
with high prevalence of halitosis and corroborates with Tin- Smoking has been defined as an extrinsic cause of
Oo and coworkers study in Malaysia [36] but is contrary oral halitosis [47]. In the current study smokers showed
to Eldarrat et al. findings in Libya [35]. Essentially any oral significant association with halitosis similar to other previous
site in which microbial accumulation and putrefaction can reports [23, 44, 48]. Smoking has been implicated to decrease
occur may be an origin for halitosis. In addition to the olfactory sensitivity [43] and this might have a negative
most common intraoral sites for halitosis production (the impact that it may limit the identification of self-reported
tongue, interdental, and subgingival areas), other foci may halitosis.
8 International Journal of Dentistry

Alcohol ingestion may result in transient halitosis because Acknowledgments

some substances can cause xerostomia and alcoholic bever-
ages are known to produce volatile compounds, acetaldehyde, Part of this study, especially the data collection and data entry
and other odorous by-products by oxidation of alcohol in into the computer, was funded by the Muhimbili University
the mouth and liver [49]. However, similar to previous of Health and Allied Sciences (MUHAS) and the Ministry of
studies [22, 40], participants who consumed alcohol showed Education, Vocational Training, Tanzania, as “elective study”
no association with self-reported halitosis. Contrary to our of the author (C. M. Kayombo).
findings, it has recently been reported that alcohol intake
could be considered as an important predictor for halitosis References
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