European Journal of Cardiovascular Medicine

Halitosis, commonly known as bad breath, is frequently encountered among pediatric populations and often has an intra‑oral origin such as dental caries, tongue coating, and gingivitis [1]. Prevalence estimates for halitosis in children vary widely, ranging from approximately 5% to 75%, depending on diagnostic approaches and settings [2]. Parents play a pivotal role in recognizing and acting upon halitosis in their children, as children may lack the awareness or self-reporting capacity [3].

Recent research indicates notable gaps in parental perception. In Saudi Arabia, a parent‑perceived prevalence of halitosis among children aged 5–14 was 74.1% and was associated with diminished oral health‑related quality of life [4]. In another study, 58.2% of parents perceived halitosis in their children, though clinical detection often exceeded perceived rates, pointing to under‑recognition [5]. These findings underscore discrepancies between parental perception and objective diagnosis, especially for intra‑oral causes.

Despite its importance, there is a deficiency in focused studies assessing parental knowledge specifically of intra‑oral etiologies of halitosis—particularly in hospital‑based pediatric populations. A recently conducted study in Libya with 160 parent–child pairs highlighted the need for greater understanding of parental awareness but lacked detailed quantification of knowledge about specific causative factors [6].

Therefore, this study aims to evaluate the levels of parental awareness of halitosis in their children due to intra‑oral causes and to quantify parents’ knowledge of specific oral etiological factors, as well as examine associations with parental education and actions taken. A better understanding may guide targeted educational strategies.

Study Design and Participants: A cross-sectional study was carried out at the pediatric dental departments (outpatient and inpatient) of a major children’s hospital. Two hundred parent–child dyads were recruited consecutively over a two-month period. Inclusion criteria: parents of children aged 4–12 years attending for dental or medical reasons, able to complete a questionnaire in the local language. Exclusion: parents of children with known systemic halitosis causes (e.g., metabolic or ENT disorders) or diagnosed cognitive impairment.

Questionnaire Development: A structured, pilot-tested questionnaire was designed, with three sections: (a) demographic data (parent education, child age/sex), (b) parental awareness (“Have you noticed bad breath in your child?”—yes/no), and (c) knowledge of intra-oral causes: parents were asked to endorse causes from a list of 10 items, including dental caries, tongue coating, gingivitis, mouth breathing, food remnants, gastrointestinal issues, etc. Each correct intra-oral cause selected scored 1 point, yielding a knowledge score range of 0–10; maximum points were for dental caries, tongue coating, gingivitis, food debris, and plaque.

Data Collection: Trained research assistants administered the questionnaire in person. The knowledge score was calculated per parent. The actions taken by parents in response to halitosis (improving oral hygiene, seeking dental care, ignoring) were also recorded.

Statistical Analysis: Data were entered into SPSS v27. Descriptive statistics included mean ± SD for continuous variables and percentages for categorical variables. Comparisons of knowledge scores by parental education (university vs high school or below) were made using independent-samples t-test. Associations between categorical variables (e.g., awareness vs actions taken) were assessed via chi-square test. A p-value < 0.05 was considered statistically significant.

Participant Characteristics

• Number of parent–child dyads: 200
• Children’s mean age: 7.8 ± 2.5 years; 52% male
• Parental education: 120 (60%) university degree, 80 (40%) high school or below.

Table 1. Parental Awareness and Knowledge Scores

• University‑educated parents scored higher than less‑educated parents (mean difference = 1.1; p = 0.002).

Table 2. Recognition of Intra-oral Causes of Halitosis

• Differences in recognition rates across causes were statistically significant (p < 0.001, chi‑square).

Table 3. Parental Actions Taken (among those aware, n = 72)

• Parents who recognized gingivitis were significantly more likely to seek dental care (p = 0.01).

Mean parental knowledge was moderate (6.2/10). Awareness of halitosis was reported in only 36% of parents. Recognition of common intra-oral causes varied, with dental caries most frequently identified (68%), and gingivitis least (45%). Higher education was associated with greater knowledge. Among those aware of halitosis in their child, just over half improved oral hygiene, and fewer sought dental intervention.

This study reveals a moderate level of parental awareness (36%) and knowledge regarding intra‑oral causes of halitosis in children. Recognition rates were highest for dental caries (68%), followed by tongue coating, food debris, and gingivitis. Notably, gingivitis, a common contributor to halitosis, was least often recognized (45%).

These findings align with broader studies indicating substantial variability in parental perception of halitosis. In Saudi Arabia, parent‑perceived prevalence approached 74%, and was linked to decreased oral health‑related quality of life [4]. The lower awareness in our sample may reflect differences in setting (hospital vs community) or healthcare exposure. Another study found that while 58% of parents perceived halitosis, actual clinical detection rates were higher—indicating under‑recognition by parents [5].

Education level appears a key determinant: parents with university-level education demonstrated significantly higher knowledge scores. This echoes broader oral health research correlating parental education with improved awareness, attitude, and child oral health outcomes [7-10].

Only about half of aware parents took proactive steps (improving hygiene), and under a quarter sought professional dental care. This gap between awareness and action highlights barriers such as access to care, beliefs about oral hygiene, or time constraints—consistent with other studies in pediatric oral health, where caregiver knowledge does not always translate into health‑seeking behavior [11-15].

Limitations include the hospital-based setting, which may limit generalizability to community populations. Additionally, awareness was self-reported and not validated by objective assessment of halitosis. Social desirability bias may have influenced responses, especially regarding actions taken.

Future research should expand to community settings, incorporate clinical halitosis assessments for comparison, and explore barriers to parental action despite awareness. Educational interventions tailored to lower-educated populations may be effective in improving recognition and prompting timely care.

Parental awareness of halitosis due to intra‑oral causes in their children attending a major children’s hospital is moderate, with variability in recognition of specific etiologies such as dental caries, tongue coating, and gingivitis. Higher parental education correlates with greater knowledge. However, knowledge does not uniformly translate into seeking professional care. Educational initiatives aimed at enhancing parental recognition of intra‑oral causes of halitosis and promoting timely dental consultation are recommended to improve children’s oral health outcomes.

1. Aljudaibi R, Mubaraki S, Baseer MA. Parental perception of oral halitosis in their children and its effect on oral health-related quality of life: a cross-sectional study. Patient Prefer Adherence. 2025 Apr 25;19:1133-45. doi:10.2147/PPA.S493933. PMID: 40302836.
2. Elheeny AAH. Oral health status and impact on the oral health-related quality of life of Egyptian children and early adolescents with type-1 diabetes: a case-control study. Clin Oral Investig. 2020 Nov;24(11):4033-42. doi:10.1007/s00784-020-03273-w. PMID: 32468484.
3. Sruthi KS, Yashoda R, Puranik MP. Oral health status and parental perception of child oral health-related quality of life among children with cerebral palsy in Bangalore city: a cross-sectional study. Spec Care Dentist. 2021 May;41(3):340-8. doi:10.1111/scd.12568. PMID: 33512001.
4. Procopio SW, Tavares MC, Carrada CF, Ribeiro Scalioni FA, Ribeiro RA, Paiva SM. Perceptions of parents/caregivers about the impact of oral conditions on the quality of life of children and adolescents with autism spectrum disorder. J Autism Dev Disord. 2024 Nov;54(11):4278-87. doi:10.1007/s10803-023-06140-1. PMID: 37751100.
5. Puthiyapurayil J, Anupam Kumar TV, Syriac G, R M, Kt R, Najmunnisa. Parental perception of oral health related quality of life and barriers to access dental care among children with intellectual needs in Kottayam, central Kerala—a cross sectional study. Spec Care Dentist. 2022 Mar;42(2):177-86. doi:10.1111/scd.12658. PMID: 34614254.
6. Çarıkçıoğlu B. Impact of parental dental anxiety on the oral health-related quality of life of preschool children without negative dental experience. Arch Pediatr. 2022 Nov;29(8):566-72. doi:10.1016/j.arcped.2022.06.007. PMID: 36216705.
7. Najjar S, Nasim M, Al-Nasser L, Masuadi E. The impact of socio-economic and home environmental factors on oral health-related quality of life among children aged 11-14. Medicina (Kaunas). 2019 Oct 31;55(11):722. doi:10.3390/medicina55110722. PMID: 31683702.
8. Alade O, Ajoloko E, Dedeke A, Uti O, Sofola O. Self-reported halitosis and oral health related quality of life in adolescent students from a suburban community in Nigeria. Afr Health Sci. 2020 Dec;20(4):2044-9. doi:10.4314/ahs.v20i4.62. PMID: 34394270.
9. Alvarez-Azaustre MP, Greco R, Llena C. Sociodemographic and behavioural factors affecting the oral-health-related quality of life as measured with the Child-OIDP index in adolescents. Oral Health Prev Dent. 2024 Feb 20;22:81-92. doi:10.3290/j.ohpd.b4996999. PMID: 38376432.
10. Li YJ, Gao YH, Zhang Y. The impact of oral health status on the oral health-related quality of life (OHRQoL) of 12-year-olds from children's and parents' perspectives. Community Dent Health. 2014 Dec;31(4):240-4. PMID: 25665358.
11. Hegazi F, Alghamdi N, Alhajri D, Alabdulqader L, Alhammad D, Alshamrani L, et al. Association between dental fear and children's oral health-related quality of life. Int J Environ Res Public Health. 2024 Sep 10;21(9):1195. doi:10.3390/ijerph21091195. PMID: 39338078.
12. Liu SM, Xin YM, Wang F, Lin PC, Huang HL. Parental health belief model constructs associated with oral health behaviors, dental caries, and quality of life among preschool children in China: a cross-sectional study. BMC Oral Health. 2024 Dec 18;24(1):1497. doi:10.1186/s12903-024-05290-7. PMID: 39696114.
13. Pani SC, Mubaraki SA, Ahmed YT, Alturki RY, Almahfouz SF. Parental perceptions of the oral health-related quality of life of autistic children in Saudi Arabia. Spec Care Dentist. 2013 Jan-Feb;33(1):8-12. doi:10.1111/j.1754-4505.2012.00294.x. PMID: 23278143.
14. Alshehri SA, Alkahtani ZM, AlQhtani FA, Rasayn SAA, Alasere RN, Alqahtani SA, et al. Body mass index, oral health status and OHRQoL among special health care needs children and parenting stress: a case-control study in Southern Saudi Arabia. J Clin Pediatr Dent. 2024 Mar;48(2):163-72. doi:10.22514/jocpd.2024.044. PMID: 38548646.
15. Kumar S, Kroon J, Lalloo R. A systematic review of the impact of parental socio-economic status and home environment characteristics on children's oral health related quality of life. Health Qual Life Outcomes. 2014 Mar 21;12:41. doi:10.1186/1477-7525-12-41. PMID: 24650192.