Background: Oral Halitosis (OH) defined as unpleasant oral odor associated with physiological and pathological causes. It is generally accepted that oral cavity is the source of 90% of halitosis. The aim of our study was to assess the Incidence of oral halitosis in children and evaluate its associated factors.
Methodology: 60 parents respond to the developed questionnaire were distributed to a random selected school in Riyadh city, Saudi Arabia includes demographic data, general health, dental health and dietary habits for their child. Examination included plaque index, dental index (DMFT), and tongue coating and oral halitosis were obtained by organoleptic measurements. Statistical analyses included analysis of variance, frequency, cross-tabulations and Spearman’s rho coloration test.
Results: 55% of the participant had halitosis, a strong relation between halitosis and poor oral hygiene, correlations between several food types and oral malodor were evident.
Conclusion: increased awareness of the importance of oral hygiene and diet is important. Further studies should consider with a larger sample size.
Oral Halitosis (OH) defined as unpleasant oral odor that associated with physiological and pathological causes . OH ranked as the third most common reason for dental visits . Many terminologies have been used in literature as fetor oris , fetor ex-ore , fetid halitus  , oral malodor , bad breath , OH affects individuals socially creating personal discomfort, social embarrassment and anxiety, which leads to a severe problem causing halitophobia.
More than 50% of the society suffer from chronic halitosis [8,9]. Oral cavity is the source of 90% of halitosis and can be attributed to deep carious lesion, periodontal disease, impacted food, decreased salivary flow rate and mainly tongue coating . The remainder 10% originates from underlying systemic diseases such as diabetes mellitus , hypertension , chronic sinusitis , gastrointestinal tract disorders  and respiratory disease .
Microbial putrefaction of aminoacids such as cystine, cysteine, and methionine by enzymes will produce volatile sulphur compounds (VSCs) such as hydrogen sulphide (H2S), methyl mercaptan (CH3SH) and dimethyl sulphide [(CH3)2S] . Villa et al. found 42.6% had halitosis , Quirynen et al.  reported that 76% had oral causes, 43% caused by tongue coating, 11% had periodontal disease (gingivitis/periodontitis) and 18% had a combi
nation .Oral halitosis has been widely investigated in adults, only few studies have been carried out in children. The aim of the study was to assess the Incidence of oral halitosis in children and evaluate its associated factors [17-23].
Ethical consideration of this study was obtained from the Research Center of Riyadh Elm University. The sample comprised 60 healthy children randomly selected boys and girls aged from 4 to 6 years, any medically compromised or and any child with dental appliance were excluded from the study.
The study was done in to two stages
a. Stage one:
An Arabic version of a specially designed self-administered questionnaire, were randomly distributed to 100, out of which 60 questionnaires were returned and processed for data analysis, the questionnaire involved four major parts; consent form, demographic data (child age, gender, nationality, monthly income, relationship to the child), child general health , child dietary habits and child dental health.
b. Stage two:
A Complete dental examination was performed based on WHO criteria using disposable examination kit (mirror and explorer)
and pen light for the 60 children who retained the questionnaire.
The intensity of malodor was detected by the organoleptic
test, the child was asked to inhale through the nostril and hold his
breath for 1min then exhaled the air by the mouth directly on the
examiner, air is inhaled from 20cm. The scoring system is divided
into 6 point scale to measure the intensity of halitosis 0-no odor,
1-barely noticeable,2-slight but clearly noticeable, 3- moderate, 4-
strong, 5-exteremly strong.
One investigator was trained and calibrated against the lead
All statistical analyses were done using SPSS ver 22 data processing
software (IBM Corp, Armonk NY, USA). Apart from descriptive
statistics, Spearman’s rho correlation test was used to
determine the relationship between OH and influencing factors.
The probability values (P-value) of P<0.05 was regarded as significant.
60 subjects responded to the questionnaire; children aged 4
to 7 years with a mean age of 5.3±0.76. More than 60% of the children
thy had three meals per day, The frequency of consumption
of meals shows no significant difference p=0.721.
When oral hygiene factors were tested for any possible association
halitosis, there was a significant association between teeth
brushing and halitosis (p=0.020). Statistical significance using
Spearman test found when correlating OH with gummy candy
p=0.32, and garlic and onion p=0.013 (Table 1).
When oral hygiene was considered 69.2% reported brushing
their teeth, DMFT was scored from 0 to 10 in (Table 2) While the
relationship between OH and DMFT was found statistically insignificant
p=0.81 (Table 2).
The main aim of this study was to assess the incidence of oral
halitosis in children and evaluate its associated factors, in order to
predict the future health care needs in controlling and solving this
social and health problem. Oral halitosis is a noticeable condition
that has negative impact on the society. Oral halitosis may affect
the social life of the individual limiting his interaction with people,
which might lead to anxiety and social isolation. In our study
lack of oral hygiene has been implicated in an oral malodor. Our
study was aimed at evaluating the incidence of OH in children and
assessing the impact of several factors on oral halitosis. These factors
include diet (number of meals, type of food consumed, and
the frequency of consumption) and oral hygiene practices.
And Since oral malodor is an olfactory stimulus, direct smelling
of the exhaled air by judges is considered the most logical measurement
approach so According to Rösing et al organoleptic is
considered the gold standard method due to the capability of the
human nose to distinguish between pleasant or unpleasant malodor.
Using this method, we found 55% of our sample having OH.
Few studies have documented the prevalence of oral malodor
in children. Moreover, there are no data reported on the prevalence
of OH in children in Saudi Arabia nor studies done on the
effect of oral hygiene and diet on halitosis.
Oral halitosis affected more than 50% of our sample, Halitosis
is widespread in the study population, poor oral hygiene and diet
are significantly associated with halitosis. Tooth brushing alone
is not effective in solving halitosis, so tongue brushing should be
part of daily oral hygiene and should be included in the oral hygiene
instructions given. Also, health care providers should pay
more attention to health education regarding halitosis since halitosis
from an extra-oral origin can be the sign of an underlying
systemic disease. Therefore, it is substantiated to organize halitosis
consultations in a multidisciplinary setting, assembling periodontal
problems, and ear–nose–throat specialists, specialists in
internal medicine, and psychologists or even psychiatrists.