Relationship between Social Anxiety Disorder and Halitosis

Transcription

1 International Journal of Clinical Preventive Dentistry Volume 7, Number 1, March 2011 Relationship between Social Anxiety Disorder and Halitosis Takashi Zaitsu 1, Masayuki Ueno 1, Kayoko Shinada 1, Clive Wright 2, Yoko Kawaguchi 1 1 Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan, 2 Centre for Oral Health Strategy, New South Wales, Australia Objective: The objective of this study was to investigate the nature of social anxiety disorder in halitosis patients. Methods: The 472 halitosis patients were divided into genuine halitosis and pseudohalitosis groups based upon an organoleptic test. The Japanese version of the Liebowitz Social Anxiety Scale (LSAS), was used to evaluate the clinical impact of social anxiety disorder in the patients. Results: More than half of subjects had a score of 30 or more on the LSAS, indicating a high risk of social anxiety disorder; and more than 20% of subjects had a score of 60 or more on the LSAS, indicating a high risk of generalized social anxiety disorder. Pseudohalitosis patients had significantly higher performance scores compared to genuine halitosis patients. However, there was no significant difference in social interaction scores between those with genuine halitosis and pseudohalitosis. Conclusion: Halitosis patients have a high risk of social anxiety disorder, especially pseudohalitosis patients. Our results suggest that the LSAS could be a valuable screening tool for assessing social anxiety in halitosis patients. Keywords: genuine halitosis, pseudohalitosis, social anxiety disorder, the Liebowitz Social Anxiety Scale Introduction Social anxiety disorder has attracted considerable recent attention (1,2). The Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) of the American Psychiatric Association, currently defines social anxiety disorder as a persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others (3). In the United States of America, social anxiety disorder is a psychological disease with a prevalence ranking third highest after depression and alcohol dependence (4). Social anxiety disorder tends to precede depression and alcoholic dependence, and one-third of social anxiety disorder patients have Corresponding author Takashi Zaitsu zaitsu.ohp@tmd.ac.jp Received January, 5, 2011, Revised February, 11, 2011, Accepted February, 13, 2011 concomitant psychological disorders such as depression or alcohol dependence (5). Moreover, the risk of suicide increases when social anxiety disorder is amalgamated with other psychological diseases (6). Excessive anxiety in social situations causes considerable distress and impairs functional ability in daily lives (7). To evaluate social anxiety disorder, the Liebowitz Social Anxiety Scale (LSAS) is often used (8). the LSAS is recognized by the International Consensus Group on Depression and Anxiety as the gold standard for evaluating the clinical impact of social anxiety disorder in an individual (9). The LSAS has been translated into many languages besides English (10,11), and its reliability and validity are confirmed. The Japanese version of the LSAS also shows high reliability and verified validity (12). Recently, an increasing number of people who believe they have a major bad breath problem consult a medical institution in Japan. The survey on "Worry Concerning the Teeth and Mouth" by the Japanese Ministry of Health (13) indicated that 25

2 International Journal of Clinical Preventive Dentistry bad breath is ranked 4th among major concerns. Increasingly, medical institutions are establishing special oral malodor departments for outpatients. Most of these patients have biologically verified oral malodor which is defined as genuine halitosis (14-17). However, a small group of patients persistently insist that they have bad breath, despite the lack of objective biological signs of oral malodor being detected by either volatile sulfide measurement or by an organoleptic test. These cases are defined as pseudohalitosis or halitophobia (18). Some patients present with such severe problems communicating with others that their perceived halitosis induces social difficulties and maladaptive behaviors in their daily lives. Moreover, pseudohalitosis patients may feel psychological uneasiness in public. A tendency for strong depression and anxiety has been shown in these patients (19,20). The hypothesis proposed in this study is that the tendency for social anxiety disorder will be stronger in pseudohalitosis or halitophobia patients than in genuine halitosis patients, because their worries about bad breath may be closely related to social situations and performance. Information on the psychological dimension of social anxiety disorder in halitosis patients might also be useful for diagnosis and treatment of oral malodor. However, there have been no reports on the relationship between social anxiety disorder and oral malodor in patients presenting with halitosis. Thus, the aim of this study was to use the LSAS to investigate the degree of social anxiety disorder in halitosis patients attending a special oral malodor clinic. Material and Methods Subjects Five-hundred and eleven patients who visited or were referred to the Fresh Breath Clinic at the Dental Hospital of Tokyo Medical and Dental University, between March 2008 and October 2009, were invited to join the study and had the nature and details of the research explained to them. Eighteen patients who declined to participate in the study and 21 patients with incomplete data were excluded from this study. In total, 472 patients (152 males and 320 females, mean age: 48.0±14.5 years, age range years) signed the informed consent form and entered the study. The study protocol was approved by the Tokyo Medical and Dental University Ethics Committee. Methods A self-administered questionnaire was completed by all subjects at the initial visit. Following completion of the questionnaire, oral malodor was assessed and clinical examinations were performed. All clinical examiners and oral malodor assessors were trained and calibrated in diagnostic and assessments standards. 1) Questions related to oral malodor The following five questions were asked: 1) When are you aware that you have bad breath? ; 2) What do you see as the problem in your having bad breath? ; 3) "Is there anything you do to decrease your bad breath?"; 4) "Do you have any worries about your job, family, or friends now? ; 5) "Do you have any family members or friends whom you can talk with about your concerns about bad breath?". 2) Liebowitz Social Anxiety Scale (LSAS) The LSAS contains 24 situational questions (13 performance and 11 social interaction items), to which subjects respond on a 4-point scale for both the fear/anxiety and avoidance sections (Table 1) (21-23). The scale range of anxiety is from 0 to 3 (0=none, 1=mild, 2=moderate, 3=severe) and avoidance is from 0 to 3 (0=never, 1=occasionally, 2=often, 3=usually). Combined item scores are calculated by adding fear and avoid- Table Situational questions of the Liebowitz Social Anxiety Scale Telephoning in public (p) Participating in small groups (p) 3. Eating in public places (p) 4. Drinking with others in public places (p) 5. Talking to people in authority (s) 6. Acting, performing, or giving a talk in front of an audience (p) 7. Going to a party (s) 8. Working while being observed (p) 9. Writing while being observed (p) 10. Calling someone you don't know very well (s) 1 Talking with people you don't know very well (s) 1 Meeting strangers (s) 13. Urinating in a public bathroom (p) 14. Entering a room when others are already seated (p) 15. Being the center of attention (s) 16. Speaking up at a meeting (p) 17. Taking a written test (p) 18. Expressing appropriate disagreement or disapproval to people you don't know very well (s) 19. Looking at people you don't know very well in the eyes (s) 20. Giving a report to a group (p) 2 Trying to pick up someone (p) 2 Returning goods to a store where returns are normally accepted (s) 23. Giving an average party (s) 24. Resisting a high-pressure salesperson (s) From Liebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry 1987;22: s: social interaction: 5,7,10-12,15,18,19,22-24, p: performance: 1-4,6,8,913,14,16,17,20,2 26 Vol. 7, No. 1, March 2011

3 Takashi Zaitsu, et al:social Anxiety Disorder and Halitosis ance scores for each item (0-6). Moreover, the LSAS is divided into subscales such as fear of performance (0-39), avoidance of performance (0-39), total performance (0-78), fear of social interaction (0-33), avoidance of social interaction (0-33) and total social interaction (0-66). Total fear and total avoidance scores are both 0-72, and thus, the total LSAS score falls between The Japanese version of the LSAS was used in this study (12). The accepted cutoff value of the LSAS for diagnosis of social anxiety disorder is 30, and for generalized social anxiety disorder is 60 (24,25). Generalized social anxiety disorder is a particularly virulent form of social anxiety disorder in which anxiety is experienced in most social situations. Individuals with general social anxiety disorder suffer greater life impairment than those with non-generalized social anxiety (26,27). We defined subjects with a total LSAS of 30 and higher as consistent with social anxiety disorder, and a LSAS of 60 and higher as consistent with generalized social anxiety disorder, according to previous research (24,25). 3) Oral malodor assessment Patients were advised not to have food or drink, and to refrain from their usual oral hygiene practice on the morning of the oral malodor assessment. They were also instructed to stop eating strong-smelling foods for at least 48 hours before the oral malodor assessment, stop using strong-scented perfumes for 24 hours, and stop smoking or drinking alcohol for 12 hours prior to the assessment, to exclude confounding odors. Measurements were conducted between 9 and 11 O clock in the morning because morning breath odor has been used as a standard mouth breath for oral malodor (28). The Organoleptic Test (OT) was conducted as the oral malodor measuring method after subjects had closed their mouth for 3 minutes while breathing through their nose (29,30). The OT was performed by trained dentists, who were calibrated with the T&T Olfactometer (Daiichi Yakuhin Sangyo Co., Tokyo, Japan), an odor solution kit for examining the olfactory sense. Two judges, rated the malodor on a 0-5 scale where a score of 0 indicated absence of odor, a 1 indicated barely appreciable odor, a 2 indicated slight malodor, a 3 indicated moderate malodor, a 4 indicated strong malodor; and a 5 indicated severe malodor (31-33). If the judges gave different scores, the mean score was used as the representative score for the subject. 4) Clinical examinations The clinical oral examination included an assessment of the number of teeth present and decayed teeth, periodontal pocket depth (PPD), plaque index and volume of resting saliva. Standardized clinical criteria were based on the W.H.O. format (34). The PPD status was examined for all teeth using a dental mirror and a periodontal probe. The deepest periodontal pocket depth of each tooth was recorded. The mean value of PPD of all teeth was calculated. Oral hygiene was evaluated using the Silness-Löe plaque index, with scores from 0 to 3: where a score of 0 indicated no plaque, a score of 1 indicated a film of plaque adhering to the free gingival margin and adjacent area of the tooth. It was conducted on the six index teeth. Missing teeth were not substituted. Each of the four surfaces of the teeth (buccal, lingual, mesial and distal) was given a score. The plaque could be seen by using the probe on the tooth surface. A score of 2 indicated a moderate accumulation of soft deposits within the gingival pocket, or the tooth and gingival margin which could be seen with the naked eye, and a score of 3 indicated an abundance of soft matter within the gingival pocket or on the tooth and gingival margin. The mean value of all surfaces of the teeth was used as the plaque index score (35). The resting saliva was collected shortly after the oral malodor assessment by subjects spitting into a cup the saliva pooled during the collection period (5 minutes). The resting salivary flow rate was calculated as amount per minute. 5) Diagnosis of oral malodor Subjects were diagnosed according to the international classification of halitosis (Table 2) (14,16). Subjects who were scored two or more by the OT were diagnosed as genuine halitosis. Subjects, who were scored less than two by the OT and whose symptoms were reduced after explanation of the examination data and counseling, were defined as pseudohalitosis. Subjects who were scored less than two by the OT, but did not believe that their breath was normal after explanation of the examination data and counseling were defined as halitophobia (17). 3. Statistical analysis The Student t-test was used to investigate the mean differences of age, number of natural teeth present, number of decayed teeth, PPD, plaque index, and volume of salivary flow. The Chi-squared test was used to investigate the bivariate associations of gender, oral malodor status, the 5 questions about oral malodor, and the two LSAS groups. ANCOVA was performed, with the LSAS and its subscales as dependent variables and oral malodor status as the independent variable. Adjustments were made for oral health status, which differed significantly with classification of halitosis (i.e., number of decayed teeth, PPD and plaque index), and for demographic information (gender and age). All tests were conducted at the 5% significance level. The SPSS statistical software package was used for all analyses IJCPD 27

4 International Journal of Clinical Preventive Dentistry Table Classification of halitosis Classification I. Genuine halitosis Physiologic halitosis Pathologic halitosis 1) Oral 2) Extraoral II. Pseudohalitosis III. Halitophobia Description Obvious malodor with intensity beyond a socially acceptable level is perceived Malodor arises through putrefactive processes within the oral cavity. Neither specific disease nor pathologic condition that could cause halitosis is found. Origin is mainly the dorsoposterior region of the tongue. Temporary halitosis, due to dietary factors (e.g., garlic), should be excluded. Halitosis caused by disease, a pathologic condition or malfunction of oral tissues. Halitosis derived from tongue coating, modified by a pathologic condition (e.g., periodontal disease, xerostomia), is included in this subdivision. Malodor originates from nasal, paranasal and/or laryngeal regions. Malodor originates from pulmonary tract or upper digestive tract. Malodor originates from disorders anywhere in the body whereby the odor is blood borne and emitted via the lungs (e.g., diabetes mellitus, hepatic cirrhosis, uremia, internal bleeding). Obvious malodor is not perceived by others, although the patient stubbornlycomplains of its existence. Condition is improved by counseling (using literature support, education and explanation of examination results) and simple oral hygiene measures. After treatment for genuine halitosis or pseudohalitosis, the patient persists in believing that he/she has halitosis. No physical or social evidence exisits to suggest that halitosis is present. From Yaegaki K, Coil JM. Examination, classification, and treatment of halitosis; clinical perspectives. J Can Dent Assoc 2000;66(5):257-6 Table 3. Clinical characteristics of subjects by oral malodor status Genuine halitosis Pseudohalitosis Mean SD Mean SD p-value* Teeth present Decayed teeth PPD (mm) Plaque Index Salivary flow rate (ml/min) *T-test. (SPSS 17.0J; SPSS Japan, Tokyo, Japan). Results Demographic and clinical characteristics Of the total sample presenting during the course of the study, 343 people (77%) were classified as genuine halitosis, 129 people (27.3%) as pseudohalitosis, and there were no halitophobia patients. There was no significant distributional difference of female between genuine halitosis (67.1%) and pseudohalitosis (69.8%) subjects. However, the mean age was significantly higher in genuine halitosis subjects (49.6±14.4) compared with the pseudohalitosis group (43.7±14.1, p). As shown in Table 3, genuine halitosis subjects had a significantly higher mean number of decayed teeth, higher mean plaque index score and deeper mean PPD compared with pseudohalitosis subjects. There were no significant differences in number of teeth present, or in flow rate of resting saliva between the two groups. Questions related to oral malodor Table 4 presents the responses to questions related to oral malodor between genuine halitosis and pseudohalitosis subjects. The proportion of people who answered the question When are you aware that you have bad breath? with When pointed out by others was significantly higher in the genuine halitosis group compared to pseudohalitosis subjects. On the other hand, the number of subjects answering When tense or nervous or In crowded vehicles or small spaces was at significantly higher rates in the pseudohalitosis group. For the question What do you see as the problem in your having bad breath?, the per- 28 Vol. 7, No. 1, March 2011

5 Takashi Zaitsu, et al:social Anxiety Disorder and Halitosis Table 4. Oral malodor related worries and problems by oral malodor status Genuine halitosis Pseudohalitosis Number % Number % p-value* When are you aware that you have bad breath? (multiple answers) When pointed out by others While talking with others When tense or nervous In crowded vehicles or small spaces When looking at person s action or behavior Always Other What do you see as the problem in your having bad breath? (multiple answers) Nothing in particular Cannot talk with people Cannot act with people People avoid me Cannot be active and become negative about everything Cannot concentrate Cannot make close friends Other 3. Is there anything you do to decrease your bad breath? (multiple answers) Nothing in particular Brush my teeth many times Use mouth-rinsing solution/ chewing gum/ mouth drops Decrease the frequency of meals or snacks Cover my mouth while talking with people Try to find out the cause of bad breath by visiting many hospitals and undergoing examinations Other 4. Do you have anyworries about your job, family or friends now? (yes) 5. Do you have any family members or friends whom you can talk with about your concerns about bad breath? (yes) *Chi-squared test. centages of subjects who answered Cannot be active and become negative about everything, Cannot concentrate or Cannot make close friends were significantly higher in pseudohalitosis subjects compared with genuine halitosis subjects. The percentages of subjects who answered the question Is there anything you do to decrease your bad breath? with Brush teeth many times and Try to find out the cause of bad breath by visiting many hospitals and undergoing examinations were higher in the pseudohalitosis group. The rates of subjects who answered yes to the question Do you have any worries about your job, family, or friends now? were significantly higher in the pseudohalitosis group, while percentages of those who answered yes to the question Do you have any family members or friends whom you can talk with about your concerns about bad breath? were significantly lower in the pseudohalitosis group. 3. LSAS The proportion of the subjects who had LSAS scores of 30 and higher was 50.1% in the genuine halitosis subjects, 59.7% in the pseudohalitosis subjects and 58% in the total subjects. The proportion of the subjects who had LSAS scores of 60 and higher was 19.5% in the genuine halitosis subjects, 27.9% in the pseudohalitosis subjects and 28% in the total subjects. There were no significant difference in LSAS scores between genuine halitosis subjects and pseudohalitosis subjects at either LSAS IJCPD 29

6 International Journal of Clinical Preventive Dentistry Table 5. Mean subscale scores of the LSAS by ANCOVA Genuine halitosis Pseudohalitosis Mean SE Mean SE p-value Total score (0-144) Total anxiety (0-72) Total avoidance (0-72) Total social situations (0-66) Total performance (0-78) Anxiety of social situations (0-33) Avoidance of social situations (0-33) Anxiety of performance (0-39) Avoidance of performance (0-39) level. The mean scores of the LSAS and its subscales, computed with the ANCOVA adjusting for gender, age, decayed teeth, PPD and plaque index (the oral health status which had significant differences with classification of halitosis) are shown in Table 5. Pseudohalitosis subjects tended to have higher total LSAS scores (44; S.E=4) compared with genuine halitosis subjects (37.2; S.E=5), although there was no statistically significant difference. The total performance score and anxiety of performance score were significantly higher in pseudohalitosis subjects compared with genuine halitosis subjects. The scores for total social interaction, anxiety of social interaction and avoidance of social interaction showed no significance differences between the genuine halitosis and pseudohalitosis groups. Further, the total anxiety score and total avoidance score showed no significant differences between the groups. Discussion Before social anxiety disorder had received a lot of international attention, anthropophobia was reported initially in Japan. However, the diagnostic norm of anthropophobia had not been clearly defined, and had been thought to be a symptom peculiar to the Japanese. Recently, many common features have been reported between anthropophobia and social anxiety disorder, but detailed scrutiny of the relationship has not yet been conducted. The definition of social phobia (social anxiety disorder) is standardized by the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association and the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) of the W.H.O., and is used internationally. Therefore it is possible to investigate uneasiness and fear in a social situation by using the standard of the social anxiety disorder. The LSAS, which evaluates social anxiety disorder, has been used to examine the relation of social anxiety disorder to diseases such as alcohol dependency or strabismus. However, the LSAS had not been previously applied to halitosis patients. Therefore, we investigated the relationship between halitosis and social anxiety disorder assessed by the LSAS. This research revealed that pseudohalitosis patients had fewer dental caries, better periodontal status and better oral hygiene compared to genuine halitosis patients. This is because pseudohalitosis patients tend to concentrate on brushing teeth to prevent oral malodor. Therefore, the oral hygiene status of pseudohalitosis patients is better than that of genuine halitosis patients, which consequently leads to better caries and periodontal status of the pseudohalitosis subjects. In their responses to general questions related to their perception of oral malodor, pseudohalitosis patients tend to be more worried about oral malodor and identify more problems caused by oral malodor than genuine halitosis patients, in spite of their better oral condition. In addition, pseudohalitosis patients were more likely to persistently question their mouth breath, and consult several clinics in order to ensure a correct diagnosis. Pseudohalitosis patients were less likely to have family members or friends to consult about oral malodor concerns, and were more likely to have worries about their relationships with family or friends. These findings indicated that anxiety about social communication in pseudohalitosis patients is very strong. Our results indicate that a high proportion of halitosis patients have features consistent with a social anxiety disorder. More than half of the patients in this study were considered to have social anxiety disorder, and more than 20% to have generalized social anxiety disorder. Generalized social anxiety disorder typically involves a persistent, intense, and chronic fear of being judged by others and of potentially being embarrassed or humiliated by ones own actions. Pseudohalitosis patients had higher LSAS scores compared with genuine halitosis patients, especially among sub-scale performance scores. This finding 30 Vol. 7, No. 1, March 2011

7 Takashi Zaitsu, et al:social Anxiety Disorder and Halitosis is a similar to previous reports that pseudohalitosis patients tend to have depression and anxiety (19,20). Performance items are related to the concept of acquaintance, while the social interaction items are related to sociability of communications with an unknown person or stranger. This study indicated that pseudohalitosis patients felt social anxiety in situations where friends or colleagues were around them. The responses to the performance items of the LSAS show that pseudohalitosis patients feel especially anxious in situations where they have to present themselves ( Speaking up at a meeting ) or when they dine out ( Eating in public places ). Pseudohalitosis patients also feel anxiety when Talking to people in authority or Going to a party in the social interaction items. Generally, in our oral malodor department, the medical interview is conducted first and then an oral malodor measurement is taken. Based upon the oral malodor measurement, the oral malodor patient is defined as having oral malodor (genuine halitosis) or not having oral malodor (pseudohalitosis or halotophobia) (15,16). Genuine halitosis is largely related to the subject s oral condition, such as tongue coating, periodontal disease, and so on. Once the cause of oral malodor is identified appropriate treatment and hygiene instructions are given. Patients who do not have oral malodor need not only the usual treatment but also need to be counseled. Although some halitosis patients may have social anxiety disorder, screening or treatment for social anxiety disorder has never been conducted. This study suggests that the LSAS is an effective screening tool for assessing social anxiety disorder in halitosis patients. Scores on the performance item of the LSAS, especially the items related to meals and conversation, were significantly higher in pseudohalitosis patients than genuine halitosis patients. Based on these results, it should be possible to develop modified questionnaires for the differential diagnosis of different types of patients with halitosis. Moreover, it is important for clinicians to understand and manage social anxiety disorder, when there is clear evidence that a patient s anxiety about oral malodor may be strongly related to an underlying social anxiety disorder. Therefore, dental professionals should be aware of the general concept of cognitive-behavioral therapy (36,37) and medical treatment (38-41) of social anxiety disorder, in order to appropriately manage halitosis patients with social anxiety disorder. Conclusion This study suggests, that it is necessary not only to carry out the usual regimens of clinical treatment for oral malodor, but also for the clinician to conduct an LSAS exam to screen for social anxiety disorder. A careful and sensitive psychological approach is needed to assist halitosis patients with social anxiety disorder. 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