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Psychological and social impacts of halitosis: a review.

Introduction

Olfaction, which is the special sense of smell, has a role in the enjoyment and selection of food, defence and sexual behaviours especially in lower animal. Today it is widely recognised that the sense of smell is closely linked to our memory and basic emotions. Perception of odours in human olfactory system is thus important in the creation and conservation of social bonds, as they are loaded with cultural values (1). The olfactory, smelling experience is intimate, emotionally charged and helps to connects us with the world (2). The smell from mouth breath odour can consequently either connect or disconnect a person from his or her social environment and intimate relationships (2). The explanation is based on the fact that olfactory pathway input to various regions of limbic system such as the septal area, amygdala and hypothalamus; mediating the affective components of sensation associated with odours.

In the society, there is constant pressure to look and smell good; halitosis is undesirable. Halitosis is defined as noticeable unpleasant odour that emanates from the mouth which is objectionable to others (3). It is one of society's oldest and most troublesome social maladies and has been recorded in literature for thousands of years. It is caused by several intra- and extra-oral factors with volatile sulphur compounds being the major contributor of the unpleasant odour (4) and despite its frequency, it is often unaccepted.

Halitosis is a common and universal affliction suffered by many people irrespective of age, sex, social status. Over half of the population experience it but only one out of ten adults suffers from its severity that requires medical help (5). Halitosis has become a major health concern among the general public because it causes significant amount of social disharmony, embarrassment, frustration, despair and often leads toward social and professional isolation and marital problems (6). Bad breath is known to have a devastating effect on the daily social life of those who suffer from it (7) thus earning the title 'social life killer'. It is estimated to be the third most frequent reason for seeking dental aid, following tooth decay and periodontal disease (8). In western societies, embarrassment and discomfort are the main reasons for seeking professional care.

Because society quickly develops a negative towards those with halitosis, it can be a very influential factor in a person's life. Halitosis may be an important factor in social communication hence the origin of concern not only to due a possible health condition, but also psychological alterations leading to social and personal isolation (9). Halitosis is a condition that has health and social implications rendering it an area of oral science that spans medical and psychological issues. The social impact of halitosis is one of the reasons for so much research. In addition, its presence can indicate the existence of other pathologies that must be diagnosed and treated as soon as possible.

In recent years, dentists and doctors have turned more attention on the problems of halitosis sufferers, and a few have done halitosis social studies to find out more about how it affects the population. The subject of halitosis has received considerable attention over the past few years. Oral malodour clinics have been set up in different parts of the world, and the consumption of over-the-counter products to improve mouth odour has become a big business worldwide. There are enormous commercial interests at stake in keeping the public intolerant of bad breath, sometimes to the point of paranoia. In the year 2000, Americans spent over $700 million on mouthwash products and $625 million on breath mints and other mouth fresheners (10). People spend over 2 billion dollars per year buying products to mask halitosis (11) making it a source of an important profit industry worldwide.

The objective of this research is to comprehensively describe the psychological and social impacts of genuine and delusional halitosis.

Methodology

Internet articles on halitosis were obtained from medline and using Google search engine. All articles with psychological, and/or social implications, concerns and impacts of all types of halitosis were accessed and stored in CD-roms. The authors read the articles and analysed the impacts as psychological or social. Findings of the study.

These were classified into the following:

1. Social impact

A. Identification

B. Quality of life

C. Interpersonal relationship

I. Impact on marriage

II. Impact on love life

III. Impact on friendship

IV. Impact on daily social interaction

A. Reaction of other people to halitosis sufferers

B. Impact on schooling and career

C. Impact on employment and employability

D. Impact on religion

E. Abuse of oral care products

F. Halitosis and treatment seeking

G. Impact on friends and relatives

2. Psychological impact

A. Self-image, self-esteem, self-confidence

B. Happiness

C. Social phobia

D. Loneliness

E. Depression

F. Suicidal intents

G. Substance abuse

Halitosis is a common health problem which greatly affects activities of many people. One of the most intriguing problems regarding it is the apparent inability of knowing whether one has it, and to the extent. Many people emit bad breath without being aware of it and have to rely on others to inform them like a family member, friend, doctor or dentist. The reason is because it may be difficult for one to detect own smell thus incapable of measuring their own halitosis (12) Mentioning that someone has bad breath is considered unfriendly in some society while not mentioning has negative effects too. Some people may therefore, begin to shy away from the person affected in order to avoid the smell.

Plutarch in Writing about morality (1911) writes about an incident involving Heron of Syracuse when informed about his bad breath by his doctor turned to his wife and said: "Why have you not told me before that my bad breath hurts you every time that I kiss you?" The wife answered "I've always thought that all men had this horrible odor". Identifying halitosis and informing the affected person. Individuals may have difficulty detecting halitosis themselves because the brain has the ability to suppress odours stemming from ourselves. Those affected are usually unaware of their condition possibly because of smell adaptation and habituation. Another explanation could be the pathways between the inhaled and exhaled air diverge because the expelled air from the mouth travels horizontally, whereas the air breathed in travels primarily vertically, thus a lowered chance of detecting the smell from the expelled air. For these reasons, the simplest and most effective way to know whether one has bad breath is to ask a trusted adult family member or very close friend. If the confidant confirms that there is a breath problem, he or she can help to determine whether is the bad breath is from the mouth and whether a particular treatment is effective or not (13).

However, it is difficult to tell a person about bad odour and suggestions are that one must consider his/her approach carefully by assuring the affected person that they are a normal human being. Then they can hopefully gradually slide into suggesting pointing out the problem. Furthermore, a friend can suggest that to the affected person may go for counseling or seeking medical help.

Impact on quality of life

Halitosis causes negative interference in social relationships which is one of the pillars of the quality of life. It can be truly demoralising, while its successful treatment leads to improved quality of life and well-being of individuals affected. It tends to be very embarrassing for the patients, making them feel insecure to relate to other people and decreases their life quality. The study of halitosis in a scientific basis is justified once it causes social restriction, decreases life quality and become a serious disease. The social impact of halitosis is one of the reasons for so much research. Most sufferers commonly say, 'It ruins my life', 'I sleep separately from my husband', 'It's like having cancer'.

Impact on marriage

Clinical experience has proven that some affected patients have more difficulties in getting married. It causes embarrassment, frustration and despair and often leading toward marital problems, partner rejection and marital disharmony. "In the Talmud," (a collection of ancient rabbinical writings that provide the basic underpinnings for the Jewish faith) bad breath is considered a serious disability, particularly regarding spouses: it states that bad breath is sufficient grounds for divorce! Throughout the world, bad breath continues to be a major impediment between couples. Since Israeli divorce law leans on religious courts, having a spouse with bad breath can, to this day, be cited as grounds for divorce (14).

George Orwell wrote that 'You can have affection for a murderer, but you cannot have affection for a man whose breath stinks.' (The Road to Wigan Pier, published 1937) According to Jewish law, if a husband dies without leaving children the widow is obligated to marrying the husband's brother (Deuteronomy 25:5-10). Only under special circumstances can the widow request to be exempted. In the case, in which both brothers have oral or nasal malodour, the wife could claim that she could tolerate the foul odour of her deceased husband but not of the prospective groom (14).

Impact on love life

Kissing is a normal thing for human beings. It is a demonstration of affection, a symbolic gesture of affirmation and bonding with another person. Halitosis makes one afraid to kiss as sometimes it may lead to rejection. For those who are unmarried, it can make dating very difficult as the other partner may find the smell unpleasant. It can be extremely damaging to opportunity for romance and intimate friendship. This has led to a proliferation of advertisements for mouthwash, considered a severe social impediment (15) to a rewarding love life, as it negatively affects one's appeal in intimate situations.

Impact on friendship

Halitosis has a devastating effect on a person's social life. Others avoid close contact with an afflicted person so they won't have to endure the smell. This makes close friendships very difficult. Bad breath can destroy already existing friendships and sexual relationships. Clinical experience has proven that patients affected with halitosis have more difficulties in making and maintaining friendships and relationships. It can even make some of your friends begin to move away if you don't do something to remedy the situation quickly.

Impact on daily social interaction

The impact can be minute or very deleterious; it can have a big effect on their social life and what other people think about them. Bad breath can indeed become a strong limitation to interpersonal relationships, leading those who suffer from it to avoid any close contact with other people. Some people go so far as to avoid social events, keep what are thought as safe distances from others or bending their head slightly when talking to people and even talk sideways when engaged in conversation. Some cover their mouth while talking.

Those afflicted with bad breath often experience heightened anxiety in social settings, avoiding face-to-face encounters and gatherings in tight quarters with the knowledge that their breath is off-putting. This may cause them to avoid such occasions and restrict their ability to lead fulfilling social lives.

A person, who knows he or she has bad breath uses defence techniques; may become withdrawn or anti-social, avoid social gatherings and social relations with others at all costs to prevent further embarrassment. They never go out. This affects a person's well-being. People suffering from halitosis will also create a social barrier between themselves and their friends, relatives, partners or colleagues at work. 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 may make them less inclined to socialize with others, affect their professional lives as they intermingle with co-workers.

A survey reported that 34% of participants that have halitosis had made them hesitant to speak to others and 12.6% completely avoids others (16). Halitosis can be considered as a crippling social problem (17), a social impediment that causes social disharmony, social embarrassment and social barrier between themselves and their friends, relatives, partners or colleagues at work.

It can cause negative effects on a person's relationship, whether they are personal, social or business acquaintances. Halitosis will make the sufferer not want to be in close proximity to anyone, worried about travelling on the tube and hate being in lifts with people.

An article told the story of a morose young student who would show up early to his classes, sit on the far periphery of the room, and insist that the students who came in afterward were avoiding the seats closest to him (18).

Reaction of other people to halitosis sufferers

Unfortunately, individuals are unaware of their own odour as it cannot be smelled by oneself nor seen like an image in a mirror. Since smells and odours have such a high ability to produce emotional responses, defense tactics such as negative body language may be used around people with bad breath.

Typical ways on how people try to avoid and protect themselves against the bad smell without informing the person is by actions and body language like people opening windows, people trying discreetly to hold their noses, moving away, making excuses for not having to talk at close quarters. People step back from you when you are talking to them, or they avoid direct contact with you and people standing well back when you talk to them. People around the sufferer of this disorder tend to shy away. People often laugh at bad breath.

Impact on schooling& career

Students with delusional halitosis report poor academic performance (19). Some gave up schooling (20). Delusional halitosis patients have been known to give up their careers because they can no longer face the embarrassment of their imaginary bad breath. Professional development in careers in patients affected with halitosis is often seriously stunted. Halitosis also narrows opportunities for career advancement among sufferers. Failures in selected endeavors, excuse for past failure, or fear for future failure are consequence of the perceived oral malodour

Impact on Employment and Employability

More than a few people have been denied employment, failed in business and relegated to low social status because of it. If you are job-hunting, it can dissuade prospective employers from hiring you. Halitosis can be extremely damaging to your opportunity for employment in a position that involves speaking to others. Having halitosis in the workplace can lead to uncomfortable moments with coworkers due to self-consciousness at meetings, luncheons and other periods of direct interaction. It can one's destroy employment prospects and promotion. Delusional halitosis can become a full-blown phobia and can begin to interfere with one's job, become an excuse for poor work performance. Some who have this phobia avoid work and eventually lose their job.

Impact on Religion

In Antiquity, having a fragrant breath meant exhaling the sweetness of life and asserting the purity of a person's soul. Buddhist monks in Japan recommended teeth brushing and tongue scraping before the first morning prayers. "In the Talmud," priests with bad breath are prohibited from carrying out holy duties. Interestingly, one treatment that was suggested for priests was "to place a pepper in his mouth," to enable the priest to continue with his duties (14). In the Talmud also: "It is forbidden to chew mastic on Sabbath, yet it is permitted for the prevention of oral malodour."

The Islamic theology emphasizes the importance of the siwak (a special device for cleaning the mouth), recommending its use during the Ramadan starving period in order to prevent halitosis. Islam also stresses fresh breath in the context of good oral hygiene. The prophet Mohammed is said to have thrown a congregant from the mosque for having the smell of garlic on his breath (21).

Halitosis has been documented as far back as the Bible, along with the attempted remedies for treating it. Chapter 37 of the book of Genesis mentions ladanum (mastic), a resin derived from the Pistacia lentiscus tree, which has been used in Mediterranean countries for breath freshening for thousands of years. One of the first recordings pertaining to halitosis is in the Bible where Job (19:17) regretted: "My bad breath is unbearable to my wife ..." (1). In the larger biblical context, bad odours are allegories for Divine displeasure. When the Israelites in Egypt complain to Moses and Aaron about worsening their lot with Pharaoh, they complain that their leaders have literally "caused their smell to be repugnant" in the eyes of Pharaoh (Exodus 5:21).

In Christianity, the devil's supreme malignant odour smelled of sulfur, and it was presumed that sins produced a more or less bad smell. This association is complex, as the predominant smell in halitosis is often volatile sulphur compound.

The Hindus consider the mouth as the body's entry door and, therefore, insist that it be kept clean, mainly before prayers. The ritual is not limited to teeth brushing, but includes scraping the tongue with a special instrument and using mouthwash.

Abuse of oral care products

Individuals often engage in time-consuming compulsive behaviors in an attempt to alleviate their perceived mouth odour which includes excessive use and abuse, oral hygiene products like breath mints, mouthwashes, chewing gum, or internal breath fresheners. Those who suffer from breath halitophobia usually tire themselves out to hide bad breath by constantly brushing their teeth, chewing gum, sucking sweets and mints.

One patient with toothbrusher went through 100 milliliters of toothpaste every four hours (18). Delusional halitosis patient may take toothbrush and toothpaste to work with me and brush their teeth up to 10 times a day.

A case of halitosis due to abuse of tetracycline has been reported in the scientific literature (22).

Halitosis and Treatment seeking

With this awareness, people pay higher attention to the disorder, and those who are affected try to get rid of it. Majority of patients, usually look for help in traditional medicine, chewing gum, and non-medical advice first and these strategies are reported to be unsuccessful. The strong evil-smelling odour from the mouth of the patient has an affect on the examiner and made the oral examination excruciating.

Those with imaginary halitosis may respond to reassurance or behavioural psychotherapy but usually refuse to visit a psychological specialist, because they cannot recognize their condition as psychosomatic.

They never doubt that they have offensive oral malodour. Hence, they are unhappy with the dental clinician who tells them they do not have the condition. Some clinicians may hesitate to refer such patients to a specialist, and the patients may then start "doctor shopping" (23).

Proper treatment of halitosis can give good results, restoring a healthy, confident smile to many a patient's face. Patient's satisfaction with halitosis oral hygiene therapy leads to improvement in social life (24). Ineffective treatment leads to multiple visits to the dentist or going to another doctor "doctor shopping.", and to ultimately to withdrawal from social activity.

Some patients look for halitosis treatment due to relatives/friends warnings. It has to be considered the level of confidence in the information given by relatives/friends. Experience show that some cases have been mistreated due to biased information given by an unhappy consort.

Impact of halitosis on relatives and friends

Sufferers are frequently well aware and conscious of the reaction that their condition causes on others. It is also embarrassing for relatives and friends of people who have halitosis. A feature common among halitosis sufferers is the continual seeking reassurance from relatives and friends that there is no odour. Chewing gum the whole time and incessant use of oral care products can be annoying thus making your spouses, friends and strangers uncomfortable.

Halitosis hinders the personal lives of those who suffer from it. They have been known to avoid intimate displays of affection with spouses or children due to the discomfort the malodour of their breath might cause.

Psychological Impact of Halitosis

Halitosis creates difficult psychological issues in the daily affairs of those with the condition. In fact, it is the wear and tear on one's psyche that presents the greatest problem.

Self-image, Self-esteem, self-confidence and social phobia

Social rules highlight the importance of personal image in interpersonal relationships. Body image, self-image and social relations mesh, interact and impact upon each other. Breath odour is public as it occurs within a social and cultural context and personal as it affects one's body image and self-confidence. Breath odour is a dynamic and interactive aspect of the self-image. Bad breath is detrimental to one's self-image and confidence, causing social, emotional and psychological anxiety (25). It can negatively affect the individual's personal, social and business relationships, leading to poor self-esteem or self-worth and increased stress. Sufferer have poor self image thus leading to serious relational problems and social communication, and ultimately to social isolation.

Once a halitosis sufferer is armed with the knowledge of his or her condition, extreme stress and worry generally ensues, and they seek whatever remedy might work. Until one is found, however, their daily lives are severely affected. Halitosis can be debilitating to one's self esteem and emotional well-being.

Clinical experience has proven that patients affected with halitosis have more difficulties in gaining self- confidence. In 75% of the cases reviewed, decreased self-confidence and insecurity in social and intimate relations led clients to seek treatment at the specialized breath odour clinic.

Halitosis can produce low self-esteem, social phobias, depression, loneliness and even anger and further deep seated psychological problems. Person also presents physical and mental restrictions that can interfere in aspects of speech, social relations and self-esteem.

Happiness

Halitosis is a constant source of unhappiness to sufferers because it restricts their ability to lead fulfilling social lives. The only treaty about halitosis was written in 1874 by Howe. This author affirms that the importance of offensive breath derives from the fact that it becomes a constant source of unhappiness to the patient, and gets even worse when it destroys communication among friends and the pleasures of social contact.

Loneliness, depression and suicide

HALITOSIS + LONELINESS = DEPRESSION

Halitosis may result in loneliness due to social withdrawal and increased difficulties in making and maintaining friendships and relationships. This disorder is often accompanied by shame, embarrassment, significant distress, social avoidance disorders, social phobia and social isolation (26). Personal unhappiness, low self-image, loneliness and an inability to lead socially rewarding lives, may all interact to produce depression in halitosis patients. The problem of halitosis will be doubled by psychological trauma leading to depression. The sufferers from this problem will be isolated from the society.

Many people emit bad breath for years without being at all aware of it. Others greatly overestimate their own oral malodour and are consequently prone to obsessive behaviour, avoid social interactions, and may even contemplate suicide (18,27-30). They attempt suicide. There unfortunately have even been documented cases of suicide stemming from a halitosis problem (23).

Substance Abuse

Some halitosis sufferers may turn to the habits of smoking and/or alcoholism in order to mask the bad breath, and may even become addicted. These substances however only temporarily mask the bad breath, and their use in the treatment of halitosis should be discouraged. Worse still, smoking increase the production of some of the volatile sulphur compounds that cause halitosis, and cigarette smoke itself contains thousands of volatile substances. An early reference to halitosis caused by smoking stated: "Herein is ... a great contempt, that the sweetnesse of man's breath, being a good gift of God, should be willfully corrupted by this stinking smoke"' (31).

Conclusion

Halitosis is a cause of a significant social and psychological disability and handicap. It is clear that bad breath is considered a serious problem not only from a medical standpoint but also relating to psychological, social harmony and sanctity. It is very important for relevant healthcare professionals to have a rational approach in halitosis investigation, because the causes are many, the patients are usually frustrated and good results mainly depend on attacking the origin of the problem. Proper treatment of halitosis will help individuals improve not only their health but their social lives as well.

Recommendations

The first patient visit should, therefore, systematically include examination of the paranasal cavities and throat to avoid unnecessary time loss and frustration (32). Halitophobia could develop quite innocently, through a minor breath problem so optimum care at initial contact is paramount. Consultation hours for halitosis should be added for patients with pseudo halitosis and build up corresponding interdisciplinary contacts. Seeing the importance of halitosis to the individuals and the amount of time, money and energy expended, it is important that the scientific community do its best to help individuals who suffer from oral malodour or its related psychosis.

Halitosis is a very sensitive subject for most people, so some research should be done about how to successfully communicate with others regarding difficult topics such as these.

Acknowledgement

Authors are grateful to Prof. M. A. Ojo for his input and guidance on the preparation of this presentation.

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* Azodo CC, *Osazuwa-Peters N, **Omili M

* Department of Periodontics, University of Benin Teaching Hospital Benin City

** Prison Medical Centre, Abuja.

Email: (Corresponding author) clementazodo@yahoo.com
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Author:Azodo, C.C.; Osazuwa-Peters, N.; Omili, M.
Publication:Journal of Social and Psychological Sciences
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Date:Jan 1, 2010
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