Volume 7, Issue 4 (12-2018)                   3dj 2018, 7(4): 137-144 | Back to browse issues page


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Malekzadeh M, Ezoji M, Maleki D. Knowledge and Practice of Dental Students in Guilan University about Halitosis: A Randomized Questionnaire-Based Cross-Sectional Study. 3dj 2018; 7 (4) :137-144
URL: http://3dj.gums.ac.ir/article-1-330-en.html
1- Assistant Professor, Periodontology Department, Dental Faculty, Guilan University of Medical Sciences, Rasht, Iran.
2- Doctor of Dental Surgery, Faculty of Dental, Guilan University of Medical Sciences, Rasht, Iran.
3- Dentistry Student, Student Research Committee, Dental Faculty, Guilan University of Medical Sciences, Rasht, Iran. , Dinamaleki74@gmail.com
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1. Introduction
Halitosis is a bad breath that comes from the oral cavity or nose and was first defined as a clinical condition by Howe in 1874 [1, 2]. Halitosis is classified into three main categories; true halitosis, false halitosis, fear of halitosis. In true halitosis, the severity of bad odor is beyond the level of social acceptance [3]. If the smell is not detected by other people, but the patient is constantly complaining about it, it is known as false halitosis and if, following a successful treatment of halitosis, the patient still complains of bad breath, the condition is classified as fear of halitosis [4]. 
Halitosis is one of the common causes of dental visits with a prevalence rate of 33% [5]. In the developed world, 8-50% of people perceive chronic recurrence of halitosis [6, 7]; however, only a limited number of patients refer to dentists seeking for treatment [7]. It is estimated that 85 million individuals suffer from halitosis [8]. Halitosis results from poor oral hygiene, inappropriate denture cleaning, reduced saliva flow, use of tobacco in any form, specific systemic conditions, deep caries lesions, periodontal disease, peri-implantitis, mucosal ulcers and food retention [4, 5]. The main compounds that lead to halitosis are Volatile Sulfur Compounds (VSCs), especially hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and dimethyl sulfide ((CH3)2S) [6]. 
Halitosis is considered as an obstacle in social communication and can reduce individual efficacy; thus, seeking for treatment is of importance. The use of mouthwashes reduces halitosis temporarily. However, products containing zinc or ascorbic acid had low efficacy, and chlorophyll-containing products were ineffective. Oral hygiene instructions, Scaling and Root Planning (SRP)and treating periodontal disease, restoring caries, closing open contact between teeth, treating irreversible pulpitis and extraction of semi-impacted molar teeth without a space to erupt are among the treatment methods of halitosis [9]. 
Maleki et al. investigated the knowledge of halitosis among general dentists working in Tehran. The results revealed that general dentists’ awareness of halitosis was relatively low [10]. Ashwath et al. surveyed the self-awareness of halitosis and oral hygiene habits among graduated dental students in India. Their results indicated a high awareness in this population [11]. Nunes et al. reported that 72% of dentists lack in responding to questions related to halitosis [12]. Regarding to the heterogeneity of findings, the necessity of conducting a study to assess the knowledge of students about halitosis is unavoidable.
2. Materials and Methods
This was a simple randomized, cross-sectional, questionnaire-based study on the knowledge and practice of dental students about halitosis in dental faculty of Guilan University of Medical Sciences (GUMS). Approval was taken from ethical committee of GUMS. The subjects were informed about the purpose and objectives of the study. They were also provided information about their voluntary participation and right to refusal. Those willing to participate in the study signed a written consent.
Students belonging to dental faculty of GUMS were Included in the study. Exclusion criteria were people unwilling for the study and incomplete questionnaires. The sample size was determined according to the similar study by Richard Ayodeji Adewole et al. (at 95% CI and considering the estimated of error of 7.5%) equal to 130 persons (Formula 1). 


140 subjects were selected by stratified random sampling technique. Data was collected using a self-structured questionnaire which had three parts. The first consisted of demographic questions. 
The second was designed to assess the knowledge of subjects on halitosis. Initially, 31 questions were considered. Based on Content Validity Ratio (CVR) index, only 13 questions satisfied the significance level (by Lavashe table (CVR≥0.6)) and the rest were removed. Based on Content Validity Index (CVI) index, all the remaining questions survived (CVI higher than 0.90). To assess the reliability of the remaining questions, two forms consisting of the 13 questions were provided to 15 randomly selected subjects, simultaneously. These subjects were not included in the study. The correlation between the two investigated forms was strong (based on Pearson’s correlation coefficient). The reliability of the questionnaire was above 95%.
Based on the correct answers, students who scored 0-6 were categorized by inadequate knowledge, 7-10 scores were considered as moderate knowledge and 11 to 13 were considered as having good knowledge about halitosis. The third, aimed to evaluate the students’ oral hygiene status and included 15 questions which were chosen based on other studies. These questions were answered as yes or no or open answers. Data were analyzed using SPSS v. 20. For continuous variables, mean and standard deviation were computed. Analysis of Variance (ANOVA), t-test, Chi-Squared test, Pearson’s correlation coefficient and Spearman correlation coefficient were performed. 
3. Results
140 questionnaires were collected from dental students of GUMS to evaluate their knowledge and oral hygiene status. The demographic data is presented in Table1. Analysis of the second part of the questionnaire revealed that the incorrect answer was mostly given to the question No. 8 (79.8) and question No. 11 (67.1). Mean±SD was 6.94±2.07 (moderate knowledge). The lowest and highest scores were 2 and 12, respectively (Table 2). The frequency of correct and incorrect answer to each question is presented in table 3.
The third part of the questionnaire evaluated the students’ oral hygiene status. The answers to the questions are reported in table 4. Interestingly, students using chlorhexidine mouthwash had a higher knowledge score of halitosis than those not using the mouthwash (P=0.047). Comparing the first and second part of the questionnaire; it is revealed that knowledge score had no significant relationship with gender and marital status. However, as students are in higher academic grades, their information about halitosis increases; students in the fifth, sixth and complementary years had significantly more information than the third and fourth-year students (P>0.0001).
Comparing the first and third part of the questionnaire revealed that the difference of oral hygiene status had no significant relationship with different marital status. However, in terms of gender, the frequency of recognizing an approach to evaluate the smell of the breath (P=0.049), the frequency of tooth brushing (P=0.021), using chlorhexidine mouthwash (P=0.042), smoking (P=0.001), and cleaning the tongue with a tongue brush (P=0.042) were statistically significant; females reported better oral hygiene, compared to males. Investigating the same frequency in terms of academic grade indicated significant difference in the use of chlorhexidine mouthwash (P=0.049); students with higher academic grade used CHX mouthwash more frequently. 
4. Discussion
Epidemiological studies in European societies have suggested that out of every four people, one person is suffering from halitosis, and approximately 6% of all individuals suffer from their unpleasant mouth smell [1]. halitosis is one of the reasons why people visit dental clinics and is a multifactorial condition requiring expert assessment and treatment by a dentist, and if necessary, by a physician, a psychologist, and pharmacotherapy [11]. Vasconcelos et al. [13] stated that the methods for controlling halitosis should include eliminating bacterial agents and improving the quality of oral hygiene.
 In the present study, there was no significant relationship between marital status, and halitosis; this finding is consistent with other studies. [10, 14]
The results showed that females had a better oral hygiene status compared to males. These findings are in line with the findings of Khami et al. [15], Al Omari [16], and Peker [17] investigations. Ashwath [11] also stated that females had a significantly better performance in using oral detergents, toothbrushes, and dental floss. Additionally, Bhat [18] stated that 100% of women used toothbrushes daily, However, in the study of Khaled Almas et al. [18], men were more likely to seek for halitosis treatment.
The current study claims that those who used chlorhexidine mouthwash had a higher knowledge score about halitosis which is in consistent with the study of Khami et al.[15]; who detected a significant correlation between the level of knowledge about halitosis and tooth brushing and dental visits however is not in accordance to Peker’s [17] and Bhat’s [18].
Higher academic grade was found to have a significant relationship with the higher knowledge of students in the current study. Khalil et al. [14] stated that with the increment of dentists’ experience and employment record, their knowledge about halitosis increases. also, Khami et al. [15] reported that senior students had more knowledge, compared to junior students which is confirmed by the current study. 
Khaled Almas et al. [18] reported that 44% of male students and 32% of female students had a good knowledge about halitosis. Population of their study included medical and dental students; thus, the cause of higher awareness in their study could be the higher knowledge of medical students about the non-oral causes and other halitosis-related diseases as well as more experience and training on this subject. However, Maleki et al. [10] reported that the mean knowledge score of dentists using a 15-item questionnaire were 8.1 which was categorized as a low knowledge. Also, Khalil et al. [14] stated that with the increment of dentists’ experience and employment record, their knowledge about halitosis increases [13]. also, Khami et al. reported that senior students had more knowledge, compared to junior students which is confirmed by the current study [14]. 
Khaled Almas et al. reported that 44% of male students and 32% of female students had a good knowledge about halitosis [15]. Population of their study included medical and dental students; thus, the cause of higher awareness in their study could be the higher knowledge of medical students about the non-oral causes and other halitosis-related diseases as well as more experience and training on this subject. However, Maleki et al. reported that the mean knowledge score of dentists using a 15-item questionnaire were 8.1 which was categorized as a low knowledge [10]. Also, Khalil et al. stated that 81% of dentists had very low knowledge about the causes and the detection approaches of halitosis [13]. The present study revealed that the knowledge and practice of dental students were moderate about halitosis; it can be due to inadequate educational focus on halitosis. Practical university courses about etiology, diagnosis and treatment of halitosis are required.


5. Conclusion
The mean knowledge score of students about halitosis was moderate. knowledge score and oral hygiene status had no significant relationship with marital status. Despite females having a significant better oral hygiene compared to males, the knowledge score about halitosis had no relation with gender. Students with higher academic grades, had significantly higher knowledge score about halitosis and maintained a significant better oral hygiene by using CHX mouth wash more frequently. 
Ethical Considerations
Compliance with ethical guidelines
All ethical principles were considered in this article. The participants were informed about the purpose of the research and its implementation stages; they were also assured about the confidentiality of their information; Moreover, They were allowed to leave the study whenever they wish, and if desired, the results of the research would be available to them.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors contribution's
All authors contributed in preparing this article.
Conflict of interest
The authors declared no conflict of interest.


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Type of Study: Original article |
Received: 2018/05/18 | Accepted: 2018/10/10 | Published: 2018/12/1

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