The Complaint of Oral Malodour: Psychopathological and Personality Profiles

Halitosis, a condition which may affect up to 30% of the population [1] , is used to describe any disagreeable odour of the breath [2] . However, despite patient complaints of halitosis, actual halitosis is often not found during sensory and instrumental examination [3] . If the complaint of a halitosis that does not exist is improved by counselling and simple oral hygiene measures, this condition has been defined as pseudo-halitosis; if the complaint persists, halitosis has been defined as halitophobia [4] . Pryse-Phillips [5] introduced the term ‘olfactory reference syndrome’ (ORS) to describe a syndrome in which patients claim to actually perceive a malodour that others cannot detect. ORS has not been included in the DSM-IV [6] as a separate category, but several anxiety or somatic disorders, i.e. obsessive-compulsive disorder and body dysmorphic disorder (BDD), have sufficient overlap with the symptomatology of ORS [7] . In the present study, we investigated the relationship between the degree of malodour, both objective and subjective, and the psychopathological and personality profile of patients who had been examined at the Division of Periodontology at the Dental School of the University of Turin, Italy, between February and December 2004. The study population included 66 consecutive subjects (n = 33, 50% women, and n = 33, 50% men) with a complaint of oral malodour. Subjects were excluded if they had non-oral aetiologies of halitosis, an organic disease that could cause halitosis, an upper or lower total prosthesis and if they were pregnant or breast-feeding. The subject’s oral malodour was evaluated by the measurement of volatile sulphur compound levels inside the mouth using a portable gas chromatograph (Oral Chroma). Subjects were requested to score their self-perception of oral malodour using a 10-cm visual analogue scale (VAS). The Revised Symptom Checklist 90 (SCL90-R) [8] , a 90-item self-report questionnaire, was given to assess psychopathology. We investigated the presence of a psychiatric disorder using the Structured Clinical Interview for DSM-IV [9] . In order to evaluate a subject’s personality profile, the Minnesota Multiphasic Personality Inventory (MMPI-2) [10] was used [11] . Statistical analyses were performed using the software Statistical Package for the Social Sciences, version 17 (SPSS Inc., 2008). The overall sample was divided into 3 groups. The first group (n = 15; n = 8, 53% women, and n = 7, 47% men) included patients with a complaint of halitosis but no appreciable or slight oral malodour (subjective halitosis). The second one (n = 42; n = 19, 45% women, and n = 23, 55% men) included subjects with a complaint of halitosis and clearly noticeable or strong oral malodour (objective halitosis). From those groups, subjects who fulfilled DSM-IV criteria for a psychiatric disorder were excluded and subsequently included in a third group (psychiatric patients, all showing clearCDS cutoff scores for clinical settings (two-stage screening) were derived by considering the cutoff score which provided maximum sensitivity with 6 75% specificity and then rounding to the nearest multiple of 5. The recommended CDS cutoff scores for research settings (single-stage screening) were derived by considering the score which produced the maximal Youden index and then rounding this score to the nearest multiple of 5. For major depression, the CDS has a very high area under the curve of 0.96. For screening in clinical (two-stage) settings, where the diagnosis can subsequently be confirmed clinically, we initially derived a CDS cutoff score of 6 90 for major depression, which provided 97% sensitivity and 79% specificity. For estimating the prevalence of depression in research settings, where overall diagnostic accuracy rather than just sensitivity is important, we derived a CDS cutoff of 6 95 for major depression, which gives 97% sensitivity and 85% specificity. We noted that moving from a CDS cutoff score of 6 90 to 6 95 produced no drop in sensitivity but a 6% gain in specificity (the cutoff of 6 90 was initially derived from the rounding up of 6 89). For the 25-item CDS, we therefore recommend a cutoff score of 6 95 for major depression for both singleand two-stage screening settings. This cutoff provides 97% sensitivity and 85% specificity. As the CDS was designed for cardiac patients, further validation in other medical populations with a high incidence of comorbid depression is warranted. This study demonstrates the utility of the CDS for diagnosing major depression. We have produced CDS cutoff scores for major depression that can be used effectively in routine clinical diagnosis as well as in future epidemiological and clinical studies.