23088618800ISSNE: 3006-094XP: 3105-0786مجلة علوم طبّی غالبMJhttps://mj.ghalib.edu.af/index.php/mj12503154033500دورۀ دوم، شمارة دوم، خزان و زمستان 1404، صص13-29121285-22225000پوهنتون غالبشیوع هالیتوزیس در مریضان مبتلا به پریودنتیت: یک مرور سیستماتیک و متاآنالیز485775115570005079316112162004932680983260041361469168400324358076590002420424943700014203009222100سید اسحق امین۱، سینا همایونی۱، محمد رضا زاهد۱، فیروز عزیزی۱، محمد علی یوسفی۱، سید محمد امینی۱۱. دیپارتمنت عمومی، پوهنزی/ دانشکدة ستوماتولوژی، پوهنتون/ دانشگاه غالب، هرات، افغانستان. چکیده اطلاعات مقالهزمینه و هدف: هالییتوزیس یا بوی بدن دهان ۲۲ تا ۵۰ درصد بزرگسالان جهان را مبتلا میسازد که پریودنتیت یا التهاب انساج پریودنتال به عنوان یک عامل اتیولوژیک مهم برای هالیتوزیس محسوب میشود. با وجود اینکه همبستگی آماری بین آنها ثابت شده است، شیوع گزارش شده در مریضان مبتلا به پریودنتیت دامنه وسیعی (۳۷٪ تا ۸۱.۷٪) داشته که ناهمسانی میتودولوژیک را نشان میدهد. تاکنون هیچ میتاآنالیز با استفاده از سنجشهای عینی ترکیبات گوگردی فرار (VSC)، شیوع تجمیعی را کمّیسازی نکرده است. روش تحقیق: بر اساس دستورالعملهای PRISMA ۲۰۲۰، بهطور سیستماتیک پایگاههای PubMed، Cochrane، Wiley و Google Scholar را در بازه سالهای ۲۰۰۰ تا ۲۰۲۵ جستجو کردیم. مطالعات مشاهدهای که هالیتوزیس را با روشهای عینی (کروماتوگرافی گازی/ مانیتورهای سولفید) در مریضان مبتلا به پریودنتیت گزارش کرده بودند، وارد مطالعه هذا شدند. خطر سوگیری با استفاده از ابزار هوی (Hoy) ارزیابی شد. متاآنالیز با مدل اثرات تصادفی انجام شد و برای بررسی منابع ایجاد کننده ناهمسانی، تفسیر و تحلیل کیفی صورت گرفت. یافتهها: نه مطالعه (529 مریض ) مورد تحلیل قرار گرفت. شیوع تجمیعی هالیتوزیس (95% CI: 46.6–75.4%) 62.0%بود، اما ناهمسانی قابلتوجهی وجود داشت I² = 85.77%) ، τ²=0.53، p<0.001 ). تحلیل کیفی چند منبع مهم ناهمسانی را شناسایی کرد: اول، معیارهای تشخیصی پریودنتیت (طبقهبندی 2018 AAP/EFP در مقایسه با آستانههای (PD؛ دوم، روشهای سنجش ترکیبات گوگرد فرار (کروماتوگرافی گازی در مقایسه با مانیتورهای سولفید)؛ سوم، آستانههای تشخیصی VSC (140-80 ppb)؛ چهارم، ناسازگاری در ارزیابی پوشش زبان (WTCI در 4 مورد از 9 مطالعه استفاده شده بود).نتیجهگیری: تقریباً دوسوم مریضان مبتلا به پریودنتیت دچار هالیتوزیسِ تأییدشده به صورت عینی هستند. ناهمسانی بالا مانع از ارائه یک برآورد قطعی از شیوع هالیتوزس در مریضان نام برده، میشود. مسئله اخیرالذکر بیان گر این است که پروتکلهای تشخیصی استاندارد در زمینه موضوع ضرورت است. نوع مقاله: مروری تاریخ دریافت: 05/02/1404تاریخ پذیرش: 10/06/1404تاریخ نشر: 31/06/1404شناختنامة نویسندة مسؤول:سید اسحق امیندیپارتمنت عمومی، پوهنحی/ دانشکده ستوماتولوژی، پوهنتون/ دانشگاه غالب، هرات، افغانستان6307483285400sayedeshaq.amin@ghalib.edu.af کُد اختصاصیِ مقاله/ DOI:https://doi.org/10.58342/ghalibMj.V.2.I.2.2واژهگانِ کلیدی: هالیتوزیس، بوی بد دهان، پریودنتیت، ترکیبات گوگرد فرّار.ارجاع به این مقاله: امین س ا، همایونی س، زاهد م ر، عزیزی ف، یوسفی م ع، امینی س م. شیوع هالیتوزیس در مریضان مبتلا به پریودنتیت : یک مرور سیستماتیک و متاآنالیز. [اینترنت]. 22 سپتامبر ۲۰۲5. [تاریخ برداشت]؛ 2(2): 29- 13: https://doi.org/10.58342/ghalibMj.V.2.I.2.2558399553700 این مقاله تحت مجوز بینالمللی Creative Commons Attribution ۴ International License ثبت میباشد.1210567937600GHALIB UNIVERSITYGHALIB MEDICAL JOURNAL MJhttps://mj.ghalib.edu.af/index.php/mj12407901905000Vol. 2, Issue. 2, Autumn and winter 2025, pp.13- 292349505207000ISSNE: 3006-094XP: 3105-0786Prevalence of halitosis in patients with periodontitis: a systematic review and meta-analysis1045845152400060544813619500467931529790003765467384870023010193434500885770-350600 136525019494500Sayed Eshaq Amin1*, Sina Homayouni 1, Mohammad Reza Zahid 1, Firooz Azizi 1, Mohammad Ali Yosofy1, Sayed Mohammad Amini 1General Department, Faculty of Dentistry, Ghalib University, Herat, Afghanistan. Article Information AbstractType: ReviewReceived: 25/04/2025Accepted: 01/09/2025Published: 22/09/2025*Present address and corresponding author:Sayed Eshaq Amin.General Department, Faculty of Dentistry, Ghalib University-Herat, Herat, Afghanistan. 4445731500 sayedeshaq.amin@ghalib.edu.af DOI: https://doi.org/10.58342/ghalibMj.V.2.I.2.2Background: Halitosis or bad breath affects 22-50% of adults globally, with periodontitis being an important etiological factor for halitosis. Despite established associations, the reported prevalence in patients with periodontitis varies widely (37%-81.7%), showing methodological heterogeneity. No previous meta-analysis has quantified pooled prevalence using objective volatile sulfur compound (VSC) measures. Methods: Following the PRISMA 2020 guidelines, we systematically searched PubMed, Cochrane, Wiley, and Google Scholar (2000-2025). Observational studies reporting objectively measured halitosis (gas chromatography/sulfide monitors) in patients with periodontitis were included. The risk of bias was assessed using Hoy's tool. Random-effects meta-analysis was performed, with qualitative synthesis to explore heterogeneity sources.Results: Nine studies (n=529 patients) were analyzed. The pooled prevalence of halitosis was 62.0% (95% CI: 46.6–75.4%), but with substantial heterogeneity (I² = 85.77%, τ²=0.53, p<0.001). Qualitative synthesis identified several important heterogeneity sources: first, Periodontitis diagnostic criteria (2018 AAP/EFP classification vs. PD thresholds); second, the VSC measurement methods (gas chromatography vs. sulfide monitors); third, VSC diagnostic thresholds (80–140 ppb); fourth, Tongue coating assessment inconsistency (WTCI used in 4/9 studies)Conclusion: Approximately two-thirds of patients with periodontitis exhibit objectively confirmed halitosis. High heterogeneity prevents a definitive prevalence estimate, highlighting the need for standardized diagnostic protocols.Key words: Halitosis, Oral malodor, Periodontitis, Periodontal diseases, Volatile sulfur compounds.To cite this article: Amin S E, Homayouni S, Zahid M R, Azizi F, Yosofy M A, Amini S M. Prevalence of halitosis in Patients with periodontitis: a systematic review and meta-analysis. Ghalib Medical Journal. [Internet]. September 22, 2025. [taking date]; 2(2): 13-29: https://doi.org/10.58342/ghalibMj.V.2.I.2.2This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 International License 13335444500IntroductionHalitosis is an unpleasant or offensive breath odor that occurs in the oral cavity in nearly 80–90% of cases PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbHpvbWFuPC9BdXRob3I+PFllYXI+MjAyMTwvWWVhcj48
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ADDIN EN.CITE.DATA [1-4]. Halitosis primarily arises when gram-negative anaerobic bacteria break down substrates in the oral cavity, producing volatile sulfur compounds (VSCs) as byproducts like hydrogen sulfide (H₂S) and methyl mercaptan (CH₃SH)and CH3SCH3 ADDIN EN.CITE <EndNote><Cite><Author>Bollen</Author><Year>2012</Year><RecNum>1084</RecNum><DisplayText>[5, 6]</DisplayText><record><rec-number>1084</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1750300181">1084</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bollen, Curd ML</author><author>Beikler, Thomas</author></authors></contributors><titles><title>Halitosis: the multidisciplinary approach</title><secondary-title>International journal of oral science</secondary-title></titles><periodical><full-title>International journal of oral science</full-title></periodical><pages>55-63</pages><volume>4</volume><number>2</number><dates><year>2012</year></dates><isbn>2049-3169</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1038/ijos.2012.39 </electronic-resource-num></record></Cite><Cite><Author>Szalai</Author><Year>2023</Year><RecNum>1075</RecNum><record><rec-number>1075</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1749641178">1075</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Szalai, Eszter</author><author>Tajti, Peter</author><author>Szabo, Bence</author><author>Koi, Tamas</author><author>Hegyi, Peter</author><author>Czumbel, Laszlo Mark</author><author>Varga, Gabor</author><author>Keremi, Beata</author></authors></contributors><titles><title>Organoleptic and halitometric assessments do not correlate well in intra-oral halitosis: a systematic review and meta-analysis</title><secondary-title>Journal of Evidence-Based Dental Practice</secondary-title></titles><periodical><full-title>Journal of Evidence-Based Dental Practice</full-title></periodical><pages>101862</pages><volume>23</volume><number>3</number><dates><year>2023</year></dates><isbn>1532-3382</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1016/j.jebdp.2023.101862</electronic-resource-num></record></Cite></EndNote>[5, 6]. There are three assessment methods for halitosis diagnosis; i) organoleptic scoring (OLS) , a subjective approach that involves sensory evaluation which is done by a trained examiner; ii) gas chromatography (e.g., OralChroma), an objective approach that measures and differentiates between VSCs and iii) electrochemical sensor (e.g., Halimeter), an objective approach that measures total sulfur levels without differentiating between VSCs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Bcm1zdHJvbmc8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFy
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ADDIN EN.CITE.DATA [6, 7]. Halitosis prevalence affects 22-50% of the general population globally PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Tb2FyZXM8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [4, 9, 10]. On the other hand, periodontitis is a chronic inflammatory disease characterized by the irreversible destruction of tooth-supporting tissues, especially the alveolar bone and periodontal ligaments. Periodontitis is most commonly assessed through periodontal probing to measure pocket depth (PD), with varied cutoff ranges of 3 to 6mm, and clinical attachment loss (CAL), with varied cutoff ranges of 2 to 6mm ADDIN EN.CITE <EndNote><Cite><Author>Savage</Author><Year>2009</Year><RecNum>1086</RecNum><DisplayText>[11]</DisplayText><record><rec-number>1086</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1750310495">1086</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Savage, Amir</author><author>Eaton, Kenneth A</author><author>Moles, David R</author><author>Needleman, Ian</author></authors></contributors><titles><title>A systematic review of definitions of periodontitis and methods that have been used to identify this disease</title><secondary-title>Journal of clinical periodontology</secondary-title></titles><periodical><full-title>Journal of Clinical Periodontology</full-title></periodical><pages>458-467</pages><volume>36</volume><number>6</number><dates><year>2009</year></dates><isbn>0303-6979</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1111/j.1600-051X.2009.01408.x</electronic-resource-num></record></Cite></EndNote>[11]. The burden of periodontitis is substantial, affecting an estimated 20-50% of people worldwide and 59.9% in Portugal, with nearly half exhibiting moderate or severe forms PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDIzPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbHpvbWFuPC9BdXRob3I+PFllYXI+MjAyMTwvWWVhcj48
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ADDIN EN.CITE.DATA [1, 4, 12, 13]. In periodontitis the gram-negative anaerobic bacteria mentioned earlier, especially P. gingivalis and T. forsythia, which reside in periodontal pockets, metabolize sulfur-containing amino acids to produce the VSCs, contributing to halitosis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZW1vbjwvQXV0aG9yPjxZZWFyPjIwMjM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [16, 17], there is a debate on the prevalence of halitosis in patients with periodontitis in clinical settings. We can see that the reported prevalence varies significantly across studies: high (81.7%) ADDIN EN.CITE <EndNote><Cite><Author>Alzoman</Author><Year>2021</Year><RecNum>342</RecNum><DisplayText>[1]</DisplayText><record><rec-number>342</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1738996544">342</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Alzoman, Hamad</author></authors></contributors><titles><title>The association between periodontal diseases and halitosis among Saudi patients</title><secondary-title>The Saudi Dental Journal</secondary-title></titles><periodical><full-title>The Saudi Dental Journal</full-title></periodical><pages>34-38</pages><volume>33</volume><number>1</number><dates><year>2021</year></dates><isbn>1013-9052</isbn><urls><related-urls><url>https://pmc.ncbi.nlm.nih.gov/articles/PMC7801244/pdf/main.pdf</url></related-urls></urls><electronic-resource-num>https://doi.org/10.1016/j.sdentj.2020.02.005</electronic-resource-num></record></Cite></EndNote>[1], moderate (61.9%) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BeW8tWXVzdWY8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA [1, 6, 9, 18-20]. No existing meta-analysis quantifies the pooled prevalence of halitosis objectively in patients with periodontitis using halitometers (e.g., gas chromatographs).Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence of objectively measured halitosis among patients diagnosed with periodontitis and to explore the sources of heterogeneity across the available studies.Methods We conducted the current systematic review in accordance with the PRISMA 2020 statement ADDIN EN.CITE <EndNote><Cite><Author>Page</Author><Year>2021</Year><RecNum>1043</RecNum><DisplayText>[21]</DisplayText><record><rec-number>1043</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1746151615">1043</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Page, Matthew J</author><author>McKenzie, Joanne E</author><author>Bossuyt, Patrick M</author><author>Boutron, Isabelle</author><author>Hoffmann, Tammy C</author><author>Mulrow, Cynthia D</author><author>Shamseer, Larissa</author><author>Tetzlaff, Jennifer M</author><author>Akl, Elie A</author><author>Brennan, Sue E</author></authors></contributors><titles><title>The PRISMA 2020 statement: an updated guideline for reporting systematic reviews</title><secondary-title>bmj</secondary-title></titles><periodical><full-title>bmj</full-title></periodical><volume>372</volume><dates><year>2021</year></dates><isbn>1756-1833</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1136/bmj.n71 </electronic-resource-num></record></Cite></EndNote>[21] . We didn’t register the protocol for this study, but the full protocol can be observed throughout this article.Search strategy We searched PubMed, Wiley Online Library, Cochrane Library, and Google Scholar on 26 January 2025 for peer-reviewed articles on halitosis among patients with periodontal diseases. We operationalized different combinations of each keyword by integrating the methodology from 2 systematic reviews on halitosis and periodontal diseases PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZW1vbjwvQXV0aG9yPjxZZWFyPjIwMjM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [14, 22]. The full details of the search strategy are written in the table 1.Our initial search identified 111 articles in PubMed, 5 in Cochrane Library, 65 in Wiley Library, and 196 in Google Scholar which were imported into EndNote reference management software. Of these 377 articles, 54 were identified as duplicates, leaving 323 for the screening and eligibility stages, as in figure 1 (PRISMA Flow Diagram).Inclusion/exclusionWe applied a series of inclusion and exclusion criteria. Articles were included if they were; i) published in a peer-reviewed journal; ii) written in English; iii) published in 2000 onwards, because there was only one study prior to the time as we found in databases that we searched and the study didn’t control extraoral causes of halitosis ADDIN EN.CITE <EndNote><Cite><Author>Bossy</Author><Year>1994</Year><RecNum>478</RecNum><DisplayText>[23]</DisplayText><record><rec-number>478</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1738996544">478</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bossy, A</author><author>Kulkorni, GV</author><author>Rosenberg, M</author><author>McCulloch, CAG</author></authors></contributors><titles><title>Relationship of oral malodor too periodontitis: evidence of independence in discrete subpopulation</title><secondary-title>Journal of Periodontol</secondary-title></titles><periodical><full-title>Journal of Periodontol</full-title></periodical><pages>37-46</pages><volume>65</volume><dates><year>1994</year></dates><urls></urls><electronic-resource-num> https://doi.org/10.1902/jop.1994.65.1.37</electronic-resource-num></record></Cite></EndNote>[23]; iv) Observational studies that reported prevalence of halitosis in patients with periodontitis by using validated diagnostic techniques for periodontitis, measuring PPD and CAL with a periodontal probe ADDIN EN.CITE <EndNote><Cite><Author>Heitz‐Mayfield</Author><Year>2024</Year><RecNum>1046</RecNum><DisplayText>[24]</DisplayText><record><rec-number>1046</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1746153552">1046</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Heitz‐Mayfield, Lisa JA</author></authors></contributors><titles><title>Conventional diagnostic criteria for periodontal diseases (plaque‐induced gingivitis and periodontitis)</title><secondary-title>Periodontology 2000</secondary-title></titles><periodical><full-title>Periodontology 2000</full-title></periodical><pages>10-19</pages><volume>95</volume><number>1</number><dates><year>2024</year></dates><isbn>0906-6713</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1111/prd.12579</electronic-resource-num></record></Cite></EndNote>[24]. and v) Studies that used validated diagnostic techniques to assess halitosis objectively either by gas chromatography or sulfide monitoring ADDIN EN.CITE <EndNote><Cite><Author>Van den Broek</Author><Year>2007</Year><RecNum>1042</RecNum><DisplayText>[25]</DisplayText><record><rec-number>1042</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1746150925">1042</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Van den Broek, Annemiek MWT</author><author>Feenstra, Louw</author><author>de Baat, Cees</author></authors></contributors><titles><title>A review of the current literature on aetiology and measurement methods of halitosis</title><secondary-title>Journal of dentistry</secondary-title></titles><periodical><full-title>Journal of dentistry</full-title></periodical><pages>627-635</pages><volume>35</volume><number>8</number><dates><year>2007</year></dates><isbn>0300-5712</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1016/j.jdent.2007.04.009 </electronic-resource-num></record></Cite></EndNote>[25] or follow threshold values for detecting VSC according to the manufacturer’s instructions that is equivalent to the cognitive threshold (OLT ≥ 2 meaning clearly noticeable odor or worse) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbE1hZGhpPC9BdXRob3I+PFllYXI+MjAyMTwvWWVhcj48
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ADDIN EN.CITE.DATA [25-27]. studies were excluded if they were: i) not controlled for extraoral causes of halitosis ADDIN EN.CITE <EndNote><Cite><Author>Monfort Codinach</Author><Year>2014</Year><RecNum>1047</RecNum><DisplayText>[12]</DisplayText><record><rec-number>1047</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1746154635">1047</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Monfort Codinach, Mariona</author><author>Chimenos Küstner, Eduardo</author><author>Alburquerque, Rui</author><author>López López, José</author></authors></contributors><titles><title>Update of intra and extra oral causes of halitosis: A systematic review</title><secondary-title>Oral Health and Dental Management, 2014, vol. 13, num. 4, p. 975-981</secondary-title></titles><periodical><full-title>Oral Health and Dental Management, 2014, vol. 13, num. 4, p. 975-981</full-title></periodical><dates><year>2014</year></dates><isbn>2247-2452</isbn><urls></urls><electronic-resource-num>https://hdl.handle.net/2445/67556</electronic-resource-num></record></Cite></EndNote>[12]. and ii) Case reports, editorials, reviews, commentaries, and non-peer-reviewed sources. Of the 323 records screened, we excluded 289 because they didn’t report prevalence of halitosis among patients with periodontal diseases and 9 were not in English, leaving 25 articles for retrieval. We were unable to find the full text for 2 articles, resulting in 23 articles for eligibility. At eligibility, after reviewing the full text, we excluded another 5 articles, which were identified to be reviews. We also further excluded 3 articles because they didn’t use validated diagnostic techniques to assess halitosis objectively. In addition, we excluded 3 studies, which were self-reported halitosis, one more study that had no prevalence data, and one study in which participants were selected based on the outcome. This left 9 articles for final review.Data Extraction ProcessWe independently extracted data on studies, including author, year, and country into Microsoft Excel. Additional data were extracted to evaluate the prevalence of halitosis in patients with periodontitis including design, diagnostic criteria of periodontitis and halitosis, sample sizes, mean age, VSC thresholds, TC scores, and prevalence data. Finally, for the quality assessment of the included studies, we used the risk of bias (ROB) developed by D. Hoy et al ADDIN EN.CITE <EndNote><Cite><Author>Hoy</Author><Year>2012</Year><RecNum>1054</RecNum><DisplayText>[28]</DisplayText><record><rec-number>1054</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1746430748">1054</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hoy, Damian</author><author>Brooks, Peter</author><author>Woolf, Anthony</author><author>Blyth, Fiona</author><author>March, Lyn</author><author>Bain, Chris</author><author>Baker, Peter</author><author>Smith, Emma</author><author>Buchbinder, Rachelle</author></authors></contributors><titles><title>Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement</title><secondary-title>Journal of clinical epidemiology</secondary-title></titles><periodical><full-title>Journal of clinical epidemiology</full-title></periodical><pages>934-939</pages><volume>65</volume><number>9</number><dates><year>2012</year></dates><isbn>0895-4356</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1016/j.jclinepi.2011.11.014</electronic-resource-num></record></Cite></EndNote>[28], and evaluated ten methodological domains. Each domain was scored as "Yes" (low risk) or "No" (high risk). Studies were categorized into three risk levels based on total "No" responses: Low (0–3), Moderate (4–6), or High (7–10). Two reviewers performed ROB assessment independently, and they agreed after a discussion with a third person. AnalysisWe performed a meta-analysis to estimate the pooled prevalence of halitosis in the 9 studies, using the random-effects model in Meta-Essentials (MEs) with Microsoft Excel 2021, under the assumption of heterogeneity in reported prevalence rates ADDIN EN.CITE <EndNote><Cite><Author>Suurmond</Author><Year>2017</Year><RecNum>1060</RecNum><DisplayText>[29, 30]</DisplayText><record><rec-number>1060</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1747708197">1060</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Suurmond, Robert</author><author>van Rhee, Henk</author><author>Hak, Tony</author></authors></contributors><titles><title>Introduction, comparison, and validation of Meta‐Essentials: a free and simple tool for meta‐analysis</title><secondary-title>Research synthesis methods</secondary-title></titles><periodical><full-title>Research synthesis methods</full-title></periodical><pages>537-553</pages><volume>8</volume><number>4</number><dates><year>2017</year></dates><isbn>1759-2879</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1002/jrsm.1260</electronic-resource-num></record></Cite><Cite><Author>van Rhee</Author><Year>2018</Year><RecNum>1087</RecNum><record><rec-number>1087</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1750490439">1087</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van Rhee, Henk</author><author>Suurmond, Robert</author><author>Hak, Tony</author></authors></contributors><titles><title>User manual for Meta-Essentials: Workbooks for meta-analyses (Version 1.3)</title></titles><dates><year>2018</year></dates><urls></urls><electronic-resource-num>https://doi.org/10.2139/ssrn.3241355</electronic-resource-num></record></Cite></EndNote>[29, 30]. We entered all 9 studies with their number of observations, the logit-transformed prevalence proportion(pp) as effect size (Formula; =LN(pp/(1 - pp))) and the number of observed halitosis cases (k) within the total sample of periodontal patients (n) as standard error (Formula; =SQRT(1/k + 1/(n - k))) in the input sheet of MEs ADDIN EN.CITE <EndNote><Cite><Author>Suurmond</Author><Year>2017</Year><RecNum>1060</RecNum><DisplayText>[29, 30]</DisplayText><record><rec-number>1060</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1747708197">1060</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Suurmond, Robert</author><author>van Rhee, Henk</author><author>Hak, Tony</author></authors></contributors><titles><title>Introduction, comparison, and validation of Meta‐Essentials: a free and simple tool for meta‐analysis</title><secondary-title>Research synthesis methods</secondary-title></titles><periodical><full-title>Research synthesis methods</full-title></periodical><pages>537-553</pages><volume>8</volume><number>4</number><dates><year>2017</year></dates><isbn>1759-2879</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1002/jrsm.1260</electronic-resource-num></record></Cite><Cite><Author>van Rhee</Author><Year>2018</Year><RecNum>1087</RecNum><record><rec-number>1087</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1750490439">1087</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van Rhee, Henk</author><author>Suurmond, Robert</author><author>Hak, Tony</author></authors></contributors><titles><title>User manual for Meta-Essentials: Workbooks for meta-analyses (Version 1.3)</title></titles><dates><year>2018</year></dates><urls></urls><electronic-resource-num>https://doi.org/10.2139/ssrn.3241355</electronic-resource-num></record></Cite></EndNote>[29, 30]. To test the overall effect whether the pooled prevalence differed from 50% (i.e., H₀: logit-transformed effect size = 0), we used the two-tailed p-value. Heterogeneity via Cochran’s Q and I², the forest plot and potential publication bias (Egger’s linear regression test and funnel plot) were automatically measured by MEs ADDIN EN.CITE <EndNote><Cite><Author>Suurmond</Author><Year>2017</Year><RecNum>1060</RecNum><DisplayText>[29, 30]</DisplayText><record><rec-number>1060</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1747708197">1060</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Suurmond, Robert</author><author>van Rhee, Henk</author><author>Hak, Tony</author></authors></contributors><titles><title>Introduction, comparison, and validation of Meta‐Essentials: a free and simple tool for meta‐analysis</title><secondary-title>Research synthesis methods</secondary-title></titles><periodical><full-title>Research synthesis methods</full-title></periodical><pages>537-553</pages><volume>8</volume><number>4</number><dates><year>2017</year></dates><isbn>1759-2879</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1002/jrsm.1260</electronic-resource-num></record></Cite><Cite><Author>van Rhee</Author><Year>2018</Year><RecNum>1087</RecNum><record><rec-number>1087</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1750490439">1087</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van Rhee, Henk</author><author>Suurmond, Robert</author><author>Hak, Tony</author></authors></contributors><titles><title>User manual for Meta-Essentials: Workbooks for meta-analyses (Version 1.3)</title></titles><dates><year>2018</year></dates><urls></urls><electronic-resource-num>https://doi.org/10.2139/ssrn.3241355</electronic-resource-num></record></Cite></EndNote>[29, 30].Due to substantial heterogeneity from variability in diagnostic criteria for periodontitis/halitosis and differences in VSC thresholds/measurement tools, we supplemented quantitative findings with qualitative synthesis to contextualize heterogeneity sources, thus interpret the results with caution.Table SEQ Table \* ARABIC 1. Full details of the search strategy used to identify studies on halitosis in patients with periodontal disease. Databases (PubMed, Cochrane, Wiley, Google Scholar), search terms, and results are shown. Note that we used an advanced Google Scholar search with the exact phrase in the title of the article and spaces between Boolean Operators and keywords are removed (because spaces are interpreted as AND being a Boolean Operator)DatabasesSearch strategyResultPubMed(("Epidemiological Studies"[Title/Abstract] OR "Cross-sectional Studies"[Title/Abstract] OR "Cross-sectional study"[Title/Abstract] OR "Studies, Cross-sectional"[Title/Abstract] OR "Prevalence Studies"[Title/Abstract] OR "Prevalence Study"[Title/Abstract] OR "Studies, Prevalence"[Title/Abstract] OR "Study, Prevalence"[Title/Abstract] OR "Cohort Study"[Title/Abstract] OR "Cohort Studies"[Title/Abstract] OR "Studies, Cohort"[Title/Abstract] OR "Study, Cohort"[Title/Abstract] OR "Longitudinal Study"[Title/Abstract] OR "Longitudinal Studies"[Title/Abstract] OR "Studies, Longitudinal"[Title/Abstract] OR "Study,Longitudinal"[Title/Abstract] OR "Incidence Study"[Title/Abstract] OR "Studies, Incidence"[Title/Abstract] OR "Study, Incidence"[Title/Abstract] OR "Follow up Studies"[Title/Abstract] OR "Follow-up Study"[Title/Abstract] OR "Prevalence"[Title/Abstract] OR "Incidence"[Title/Abstract] OR "Surveys"[Title/Abstract] OR "Questionnaires"[Title/Abstract]) AND ("periodontal disease(s)"[Title/Abstract] OR "periodontitis"[Title/Abstract] OR "gingivitis"[Title/Abstract] OR "Periodontal Disease"[Title/Abstract] OR "Disease, Periodontal"[Title/Abstract] OR "Diseases, Periodontal"[Title/Abstract] OR "Periodontal Diseases"[Title/Abstract])) AND (Halitosis: "halitosis"[Title/Abstract] OR "bad-breath"[Title/Abstract] OR "oral malodour"[Title/Abstract] OR "Oral Malodor"[Title/Abstract] OR "Foetor Ex Ore"[Title/Abstract] OR "Bad Breath"[Title/Abstract])111Cochrane Library (5 article)And Wiley Library (65 article) “halitosis” OR “bad-breath” OR “oral malodour” OR "Oral Malodor" OR "Foetor Ex Ore" OR "Bad Breath" in Title Abstract Keyword AND “periodontal disease(s)” OR “periodontitis” OR “gingivitis” in Title Abstract Keyword AND “Epidemiological Studies” OR “Cross-sectional Studies” OR “Cross-sectional study” OR “Studies, Cross-sectional” OR “Prevalence Studies” OR “Prevalence Study” OR “Studies, Prevalence” OR “Study, Prevalence” OR “Cohort Study” OR “Cohort Studies” OR “Studies, Cohort” OR “Study, Cohort” OR “Longitudinal Study” OR “Longitudinal Studies” OR “Studies, Longitudinal” OR “Study, Longitudinal” OR “Incidence Study” OR “Studies, Incidence” OR “Study, Incidence” OR “Follow up Studies” OR “Follow-up Study” OR “Prevalence” OR “Incidence” OR “Surveys” OR “Questionnaires” in Title Abstract 70Google scholar“halitosis”OR“bad-breath”OR“oral malodour”OR"Oral Malodor"OR"Foetor Ex Ore" OR "Bad Breath" “periodontal disease(s)” OR “periodontitis” OR “gingivitis” OR “Periodontal Disease”OR“Disease, Periodontal”OR“Diseases, Periodontal”OR“Periodontal Diseases”196Figure 1. PRISMA flow diagram. The figure visualizes study selection process: 377 records identified, 323 screened after duplicate removal, 9 studies included in the meta-analysis. -935355107886500-1138555153860500Table SEQ Table \* ARABIC 2. Data extraction table derived from Microsoft Excel 2021. studies characteristics like author, year, country, sample size, diagnostic tools for halitosis (Halimeter/gas chromatography), and prevalence rates are extracted.-61722073977500ResultsStudy descriptiveAmong the included studies, four were conducted in Asia (3, 4, 31, 32), three in Europe (2, 11, 14), one in South America (9), and one in South Africa (5). Altogether, 529 participants diagnosed with periodontitis were enrolled across these studies. Halitosis was evaluated using a halimeter in six studies (2, 5, 9, 11, 14, 31), and gas chromatography was employed in three studies (3, 4, 32).Quantitative synthesis to estimate the pooled prevalence rate -3175150177500In the meta-analysis, we found 62% (95% CI: 46.6%–75.4 %), as the pooled prevalence of halitosis among patients with periodontitis when halitosis was measured objectively by halitometers. The twotailed pvalue of the overall effect test was 0.072, which was greater than 0.05, indicating that the pooled estimate did not reach statistical significance (i.e., we cannot reject the null hypothesis that the true prevalence is 50%). We also observed substantial heterogeneity I² = 85.77%, Cochran’s Q= 56.21, (p < 0.001), and between-study variance was τ ² = 0.53, as shown in the figure 2. For publication bias, Egger’s regression revealed a non-significant intercept (p = 0.928), suggesting no evidence of bias as shown in the figure 3 and Funnel plot visualization showed no asymmetry as seen in the figure 4. 711201776730Figure 2. (Forest plot): meta-analysis 62% (95CI: 46.6%-75.4%)-I2=85.77%, Cochran’s Q = 56.21.17945102159000Figure 3. Egger's regression shown non-significant intercept (p=0.928p=0.928), indicates no bias.162560013779500Figure 4. Funnel plot visualization shown symmetric distribution of studies that suggests no bias.Qualitative synthesis to explore the sources of heterogeneityDiagnostic criteria for periodontal patients and its severityWe found significant heterogeneity in the definition criteria used by studies for periodontitis, namely the 2018 AAP/EFP classification ADDIN EN.CITE <EndNote><Cite><Author>Jokstad</Author><Year>2019</Year><RecNum>1064</RecNum><DisplayText>[31]</DisplayText><record><rec-number>1064</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1748060544">1064</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jokstad, Asbjorn</author></authors></contributors><titles><title>The 2018 AAP/EFP classification of periodontal diseases, a focus on “risks” as a faux ami and language gone on holiday</title><secondary-title>Clinical and Experimental Dental Research</secondary-title></titles><periodical><full-title>Clinical and Experimental Dental Research</full-title></periodical><pages>449</pages><volume>5</volume><number>5</number><dates><year>2019</year></dates><urls></urls><electronic-resource-num>https://doi.org/10.1002/cre2.257</electronic-resource-num></record></Cite></EndNote>[31], PD ≥4, PD≥5, CAL of ≥5 mm, and 2017 World Workshop ADDIN EN.CITE <EndNote><Cite><Author>Papapanou</Author><Year>2018</Year><RecNum>1065</RecNum><DisplayText>[32]</DisplayText><record><rec-number>1065</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1748060681">1065</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Papapanou, Panos N</author><author>Sanz, Mariano</author><author>Buduneli, Nurcan</author><author>Dietrich, Thomas</author><author>Feres, Magda</author><author>Fine, Daniel H</author><author>Flemmig, Thomas F</author><author>Garcia, Raul</author><author>Giannobile, William V</author><author>Graziani, Filippo</author></authors></contributors><titles><title>Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions</title><secondary-title>Journal of periodontology</secondary-title></titles><periodical><full-title>Journal of Periodontology</full-title></periodical><pages>S173-S182</pages><volume>89</volume><dates><year>2018</year></dates><isbn>0022-3492</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1002/JPER.17-0721</electronic-resource-num></record></Cite></EndNote>[32] that resulted in different kinds of classification of exposure severity and even most of the studies didn’t classify the severity of the exposure (table 3). This affected the reported prevalence of halitosis to be different. Generally, we found that with low PD thresholds (>3–4) mm, low prevalence rates reported PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jemlkb3JvPC9BdXRob3I+PFllYXI+MjAyMzwvWWVhcj48
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ADDIN EN.CITE.DATA [1, 3, 8, 13, 34], with the exception of one study, it was considered a potential outlier, isolated in the table PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDIzPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA [2]. Table SEQ Table \* ARABIC 3. studies stratified by exposure severity and compared with outcome prevalence. Higher periodontitis severity (PD ≥5mm) correlates with higher halitosis prevalence (e.g., 75–82%), except one outlier (PD ≥6mm: 42.9%).Study namesSample sizeExposure Severityexposure classificationsPrevalence rates of halitosisC Izidoro et al 202351PD>3mmNot defined37.30%C Izidoro et al 202172PD>3mmNot defined44.40%H Kurata et al 200816PD≥4mmNot defined43.80%L. G Soares et al 2015112PD≥5mmchronic periodontitis75%A Apatzidou et al 201328PD≥5mmChronic periodontitis 82%O A Ayo-Yusuf et al 201142PD≥5mmNot defined61.90%Bolepalli et al 2015120CAL≥5mmNot defined75%H Alzoman 202160PD>3mmChronic periodontitis81.7%Potential Outlier StudyStudy namesSample sizeExposure Severityexposure classificationsOutcome prevalenceY H Lee et al 202328PD≥6mmNot defined42.9%Assessment devices for halitosisWe found that halitosis assessment was performed using various of instruments (Table 4). 6 of 9 studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jemlkb3JvPC9BdXRob3I+PFllYXI+MjAyMzwvWWVhcj48
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ADDIN EN.CITE.DATA [1, 2, 33] used different Gas chromatographs. Maybe the variation in devices, their specificity and sensitivity contributed to the heterogeneity in the prevalence rates.Table SEQ Table \* ARABIC 4. studies were stratified by instrument type and compared by outcome proportions.Study namesSample sizeMethodPrevalence ratesC Izidoro et al 202351Halimeter0.373C Izidoro et al 202172Halimeter0.444L. G Soares et al 2015112Halimeter0.75A Apatzidou et al 201328Halimeter0.82Bolepalli et al 2015120Halimeter0.75O A Ayo-Yusuf et al 201142Halimeter0.619H Alzoman 202160GC (OralChroma-Kyoto)0.817Y H Lee et al 202328GC (TwinBreasor II)0.429H Kurata et al 200816GC (G2800)0.438VSC threshold values for the diagnosis of halitosisWe found that different threshold criteria of VSCs were defined for halitosis diagnosis, as shown in table 5. In studies that used Halimter, 3 out them PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jemlkb3JvPC9BdXRob3I+PFllYXI+MjAyMTwvWWVhcj48
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ADDIN EN.CITE.DATA [3, 13, 34] defined high VSC cut-off values (110-140 ppb). In the mentioned studies VSC threshold values (80-140) had a neglected impact in the heterogeneity of prevalence rates in context of severe periodontitis (PD≥5mm), and also in studies that gas chromatograph was used, even with different type of scales for measuring VSCs, at cognitive thresholds the defined thresholds had the same impact as Halimeter was used on prevalence rates in context of periodontal status. For example, in a study in Saudi Arabia prevalence rate was high (81.7) ADDIN EN.CITE <EndNote><Cite><Author>Alzoman</Author><Year>2021</Year><RecNum>342</RecNum><DisplayText>[1]</DisplayText><record><rec-number>342</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1738996544">342</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Alzoman, Hamad</author></authors></contributors><titles><title>The association between periodontal diseases and halitosis among Saudi patients</title><secondary-title>The Saudi Dental Journal</secondary-title></titles><periodical><full-title>The Saudi Dental Journal</full-title></periodical><pages>34-38</pages><volume>33</volume><number>1</number><dates><year>2021</year></dates><isbn>1013-9052</isbn><urls><related-urls><url>https://pmc.ncbi.nlm.nih.gov/articles/PMC7801244/pdf/main.pdf</url></related-urls></urls><electronic-resource-num>https://doi.org/10.1016/j.sdentj.2020.02.005</electronic-resource-num></record></Cite></EndNote>[1] in context of severe periodontitis. These findings suggest that the different VSC cut-off values defined the included studies did not moderate the prevalence proportion in the context of periodontal status, with an exception of one study PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDIzPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA [2]. Table SEQ Table \* ARABIC 5. Halitosis defined by different VSC cutoff values (80–140 ppb). No clear threshold effect on prevalence in severe periodontitis.Assessment of tongue coating (TC)We found significant heterogeneity in the assessment method of TC, as seen in the table 6. Four studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jemlkb3JvPC9BdXRob3I+PFllYXI+MjAyMzwvWWVhcj48
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ADDIN EN.CITE.DATA [4, 8, 13, 34] used the Winkel Tongue Coating Index (WTCI) ADDIN EN.CITE <EndNote><Cite><Author>Winkel</Author><Year>2003</Year><RecNum>1068</RecNum><DisplayText>[35]</DisplayText><record><rec-number>1068</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1749625547">1068</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Winkel, EG</author><author>Roldan, Silvia</author><author>Van Winkelhoff, Arie Jan</author><author>Herrera, David</author><author>Sanz, Mariano</author></authors></contributors><titles><title>Clinical effects of a new mouthrinse containing chlorhexidine, cetylpyridinium chloride and zinc‐lactate on oral halitosis: A dual‐center, double‐blind placebo‐controlled study</title><secondary-title>Journal of clinical periodontology</secondary-title></titles><periodical><full-title>Journal of Clinical Periodontology</full-title></periodical><pages>300-306</pages><volume>30</volume><number>4</number><dates><year>2003</year></dates><isbn>0303-6979</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1034/j.1600-051X.2003.00342.x</electronic-resource-num></record></Cite></EndNote>[35]. Three studies didn’t assess TC PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jemlkb3JvPC9BdXRob3I+PFllYXI+MjAyMTwvWWVhcj48
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ADDIN EN.CITE.DATA [3], and the other assessed the distribution area of coating ADDIN EN.CITE <EndNote><Cite><Author>Kurata</Author><Year>2008</Year><RecNum>1034</RecNum><DisplayText>[33]</DisplayText><record><rec-number>1034</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1740294025">1034</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kurata, H.</author><author>Awano, S.</author><author>Yoshida, A.</author><author>Ansai, T.</author><author>Takehara, T.</author></authors></contributors><auth-address>Division of Community Oral Health Science, Department of Health Promotion, Kyushu Dental College, 2-6-1 Manazuru, Kokurakitaku, Kitakyushu 803-8580, Japan.</auth-address><titles><title>Volatile sulphide compound levels in mouth air with plaque-related periodontal disease are associated with a change in the proportion of periodontopathic bacteria in saliva</title><secondary-title>J Breath Res</secondary-title></titles><periodical><full-title>J Breath Res</full-title></periodical><pages>017006</pages><volume>2</volume><number>1</number><edition>20080307</edition><dates><year>2008</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1752-7155 (Print)
1752-7155</isbn><accession-num>21386150</accession-num><urls></urls><electronic-resource-num>https://doi.org/10.1088/1752-7155/2/1/017006</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[33]. Most studies that used WTCI as a TC assessment reported that TC consistently contributed to halitosis prevalence through VSC production in patients with periodontitis.Table SEQ Table \* ARABIC 6. TC consistently contributed to halitosis prevalence through VSC production in patients with periodontitis.Authors yearmethods for TCSmean scores (±SD)significance of TCS on VSC productionProportion of halitosis exposure severityC Izidoro et al 2023WTCI3 (±2)correlated significantly with VSC production0.373PD>3mmL. G Soares et al 2015WTCI7±1.58strong relationship 0.750PD≥5mmA Apatzidou et al 2013WTCI3.2±2.1no significance, but slightly elevated 0.820PD≥5mmBolepalli et al 2015WTCI8.22±.2.7very strong positive correlation between TCS and VSC levels0.75CAL of ≥5 and CAL of 1–4 mmO A Ayo-Yusuf et al 2011presence of Coating31% TC -presenceassociated with an increased likelihood0.619PD≥5mmH Kurata et al 2008distribution area1.65±0.5increase in the tongue coating influenced the VSCs level0.438PD≥4mmC Izidoro et al 2021not measured--0.444PD>3mmH Alzoman 2021not measured--0.817PD>3mmY H Lee et al 2023not measured--0.429PD≥6mmRisk of bias assessment We assessed the quality of the included studies via the Hoy 2012 tool (Table 7). We found a low-risk profile in the overall result of the assessment. However, weaknesses existed in the representation domain (D1), sampling (D2) and random selection domain (D3) across all included studies. Two studies had moderate risk of bias.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDIzPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA [2, 4]. The quality of the included studies may have a small contribution to the heterogeneity in prevalence rates. 2286040386000Table SEQ Table \* ARABIC 7. Risk of bias assessment of nine studies conducted using the Hoy 2012 tool. The table shows Low overall bias riskDiscussion Our systematic review highlights some important findings on the prevalence halitosis in patients with periodontitis. First of all, in our analysis, we calculated pooled effect sizes as 62% (95% CI: 46.6–75.4%), this finding suggests a positive association between periodontitis and halitosis as other studies support this PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OaW5pPC9BdXRob3I+PFllYXI+MjAyNDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [16, 17], but the generalizability of the estimate is limited due to the high heterogeneity (I² = 85.77%) found in the studies, which is not unexpected in view of the heterogeneity associated with diagnostic criteria for periodontitis, VSCs measurement devices, and TC involvement. However, a meta-analysis of such studies might still be useful in providing an idea of the overall prevalence and in estimation of the burden of halitosis in periodontal patients in clinical settings. Second, we found that halitosis was more prevalent in high-stage periodontitis than lower stages which is supported by several other studies PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Tb2FyZXM8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [3, 8, 13, 34]. This finding aligns with the understanding that a high severity of periodontitis, characterized by deeper periodontal pockets and greater microbial activities, leads to a high amount of VSC production that can be detected objectively PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FaGl6ZWxlPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48
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ADDIN EN.CITE.DATA [9, 36, 37]. Third, the variation in devices, their specificity and sensitivity contributed to the heterogeneity in prevalence rates; using gas chromatography-based devices preferred and defined as the gold standard by some studies for its high specificity and sensitivity in detecting the main VSCs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5ZYWVnYWtpPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA [9, 20, 38], although in a systematic review concluded that none of the halitometers demonstrated a clear advantage over the others ADDIN EN.CITE <EndNote><Cite><Author>Szalai</Author><Year>2023</Year><RecNum>1075</RecNum><DisplayText>[6]</DisplayText><record><rec-number>1075</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1749641178">1075</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Szalai, Eszter</author><author>Tajti, Peter</author><author>Szabo, Bence</author><author>Koi, Tamas</author><author>Hegyi, Peter</author><author>Czumbel, Laszlo Mark</author><author>Varga, Gabor</author><author>Keremi, Beata</author></authors></contributors><titles><title>Organoleptic and halitometric assessments do not correlate well in intra-oral halitosis: a systematic review and meta-analysis</title><secondary-title>Journal of Evidence-Based Dental Practice</secondary-title></titles><periodical><full-title>Journal of Evidence-Based Dental Practice</full-title></periodical><pages>101862</pages><volume>23</volume><number>3</number><dates><year>2023</year></dates><isbn>1532-3382</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1016/j.jebdp.2023.101862</electronic-resource-num></record></Cite></EndNote>[6] thus, Standardization of measurement tools and developing better halitometers is critical to minimize heterogeneity in prevalence rates. Fourth, the different threshold criteria of VSCs that were used for halitometers, did not moderate the prevalence proportion in the context of periodontal status. This finding aligns with knowledge-based article defined by Halimeter® company that a range of 80-140 is considered normal cutoff ranges for halitosis diagnosis ADDIN EN.CITE <EndNote><Cite><Author>Corporation</Author><Year>2012</Year><RecNum>1073</RecNum><DisplayText>[27]</DisplayText><record><rec-number>1073</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1749638579">1073</key></foreign-keys><ref-type name="Electronic Article">43</ref-type><contributors><authors><author>Interscan Corporation</author></authors></contributors><titles><title>Interpreting Halimeter readings</title></titles><dates><year>2012</year></dates><pub-location>Chatsworth (CA)</pub-location><publisher>Interscan Corporation</publisher><urls><related-urls><url>https://www.halimeter.com/interpreting-halimeter-readings/</url></related-urls></urls></record></Cite></EndNote>[27] also, aligns with gas chromatograph manufacturers that halitosis is diagnosed, if levels of H2S or CH3SH pass 112 ppb and 26 ppb ADDIN EN.CITE <EndNote><Cite><Author>Vandekerckhove</Author><Year>2009</Year><RecNum>1079</RecNum><DisplayText>[19]</DisplayText><record><rec-number>1079</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1749828689">1079</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vandekerckhove, Betty</author><author>Van den Velde, Sandra</author><author>De Smit, Menke</author><author>Dadamio, Jesica</author><author>Teughels, Wim</author><author>Van Tornout, Marie</author><author>Quirynen, Marc</author></authors></contributors><titles><title>Clinical reliability of non‐organoleptic oral malodour measurements</title><secondary-title>Journal of clinical periodontology</secondary-title></titles><periodical><full-title>Journal of Clinical Periodontology</full-title></periodical><pages>964-969</pages><volume>36</volume><number>11</number><dates><year>2009</year></dates><isbn>0303-6979</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1111/j.1600-051X.2009.01473.x</electronic-resource-num></record></Cite></EndNote>[19]. Therefore, the findings suggest that this didn’t contribute to the heterogeneity of reported prevalence rates across studies, but generally its maybe better to have standard threshold values of VSCs for diagnosis of halitosis. Fifth, heterogeneity in TC assessment methods identified in this review (Table 6), ranges from the use of the WTCI PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jemlkb3JvPC9BdXRob3I+PFllYXI+MjAyMzwvWWVhcj48
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ADDIN EN.CITE.DATA [1, 2, 10] that poses another challenge for synthesizing a pooled prevalence of halitosis in people with periodontitis. Crucially, studies using the standardized WTCI consistently identified TC as a significant factor associated with halitosis via VSC production PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jemlkb3JvPC9BdXRob3I+PFllYXI+MjAyMzwvWWVhcj48
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Jemlkb3JvPC9BdXRob3I+PFllYXI+MjAyMzwvWWVhcj48
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ADDIN EN.CITE.DATA [4, 8, 34]. This methodological variation may oppose the true contribution of TC to overall halitosis prevalence estimates in patients with periodontitis and explain the heterogeneity observed in reported prevalence rates across studies. Standardization of TC assessment, particularly using validated indices like the WTCI, is therefore essential for obtaining accurate and reliable estimates of halitosis prevalence in this population.Our review has important limitations. First, the generalizability of the overall prevalence estimate is limited due to high heterogeneity. To address this limitation, we conducted a qualitative synthesis of the data, thus permitting comparisons across studies and identifying the sources of heterogeneity. Second, the absence of a pre-registered protocol of this study. To address this limitation, we followed and presented the protocol transparently in this article. Third, we didn’t include Scopus and Web of science databases in our search strategy and we may have missed some studies. To address this limitation, we extensively used gray literature by using Google Scholar to find more studies and publication bias test was not significant according to our publication bias analysis. Fourth, we didn’t dig into the methods that halitosis was assessed by halitometers that may give us insights on the heterogeneity of outcomes that are within studies, but there are many different devices with different sensitivity, specificity, reliability issues and even constantly evolving that they can further complicate the process PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TemFsYWk8L0F1dGhvcj48WWVhcj4yMDIzPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA [6, 16]. While they confirmed periodontitis-halitosis links, our 62% pool estimate quantifies the clinical burden of halitosis in periodontal patients, providing insight to support its management by healthcare professionals. Third, because there was high heterogeneity among studies, we have a detailed qualitative synthesis. This approach helped us systematically define the main sources of heterogeneity (e.g., diagnostic criteria for periodontitis). It gave us much richer insights than a simple pooled estimate. RecommendationsOur systematic review points to several promising directions for future research. First, future studies should use a standardized diagnostic criterion like the 2018 AAP/EFP classification ADDIN EN.CITE <EndNote><Cite><Author>Jokstad</Author><Year>2019</Year><RecNum>1064</RecNum><DisplayText>[31]</DisplayText><record><rec-number>1064</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1748060544">1064</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jokstad, Asbjorn</author></authors></contributors><titles><title>The 2018 AAP/EFP classification of periodontal diseases, a focus on “risks” as a faux ami and language gone on holiday</title><secondary-title>Clinical and Experimental Dental Research</secondary-title></titles><periodical><full-title>Clinical and Experimental Dental Research</full-title></periodical><pages>449</pages><volume>5</volume><number>5</number><dates><year>2019</year></dates><urls></urls><electronic-resource-num>https://doi.org/10.1002/cre2.257</electronic-resource-num></record></Cite></EndNote>[31] for periodontitis severity to reduce heterogeneity. Second, for researching in the field it’s better to use gas chromatography as supported by several studies when we assess halitosis objectively PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5ZYWVnYWtpPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48
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ADDIN EN.CITE.DATA [1, 2, 6, 9, 33] although, no device showed superiority over the others ADDIN EN.CITE <EndNote><Cite><Author>Szalai</Author><Year>2023</Year><RecNum>1075</RecNum><DisplayText>[6]</DisplayText><record><rec-number>1075</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1749641178">1075</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Szalai, Eszter</author><author>Tajti, Peter</author><author>Szabo, Bence</author><author>Koi, Tamas</author><author>Hegyi, Peter</author><author>Czumbel, Laszlo Mark</author><author>Varga, Gabor</author><author>Keremi, Beata</author></authors></contributors><titles><title>Organoleptic and halitometric assessments do not correlate well in intra-oral halitosis: a systematic review and meta-analysis</title><secondary-title>Journal of Evidence-Based Dental Practice</secondary-title></titles><periodical><full-title>Journal of Evidence-Based Dental Practice</full-title></periodical><pages>101862</pages><volume>23</volume><number>3</number><dates><year>2023</year></dates><isbn>1532-3382</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1016/j.jebdp.2023.101862</electronic-resource-num></record></Cite></EndNote>[6]. Third, studies should identify optimal VSC thresholds for halitosis diagnosis. Fourth, future studies should isolate tongue coating’s contribution in VSC production. Fifth, use a standardized tongue coating assessment like WTCI ADDIN EN.CITE <EndNote><Cite><Author>Winkel</Author><Year>2003</Year><RecNum>1068</RecNum><DisplayText>[35]</DisplayText><record><rec-number>1068</rec-number><foreign-keys><key app="EN" db-id="xdx9t29fj9tttyes9r9xd0x05vxpsxe9ese9" timestamp="1749625547">1068</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Winkel, EG</author><author>Roldan, Silvia</author><author>Van Winkelhoff, Arie Jan</author><author>Herrera, David</author><author>Sanz, Mariano</author></authors></contributors><titles><title>Clinical effects of a new mouthrinse containing chlorhexidine, cetylpyridinium chloride and zinc‐lactate on oral halitosis: A dual‐center, double‐blind placebo‐controlled study</title><secondary-title>Journal of clinical periodontology</secondary-title></titles><periodical><full-title>Journal of Clinical Periodontology</full-title></periodical><pages>300-306</pages><volume>30</volume><number>4</number><dates><year>2003</year></dates><isbn>0303-6979</isbn><urls></urls><electronic-resource-num>https://doi.org/10.1034/j.1600-051X.2003.00342.x</electronic-resource-num></record></Cite></EndNote>[35] in studies to clarify its role in halitosis prevalence. Finally, researchers must pre-register their protocol for a systematic review and include Scopus/Web of Science in the search strategy to minimize selection biasConclusionBased on the evidence shown above, approximately two-thirds of patients with periodontitis were found to have confirmed halitosis following assessment with VSC measuring devices. High heterogeneity and tongue coating involvement prevented a definitive prevalence estimate, highlighting the need for standardized diagnostic protocols.AcknowledgementsThe authors thank Serous Saberi, the librarian, for facilitating our access to the literature needed for this study, and Ali Kalantary for providing related resources.Funding The funding of this research was covered by the Scientific Research Center of Ghalib University, Herat, Afghanistan. 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