Translation, Transcultural Adaptation and Validation of the Halitosis Associated Life-Quality Test for Use in Brazilian Adolescents

Aline Carrascosa Agostinho, Karina Guedes de Sousa, Camila Nobre de Freitas, Tais de Souza Barbosa


Objective: To perform the transcultural adaptation to Brazil and validation of the Halitosis Associated Life-quality Test (HALT) for use in adolescents. Material and Methods:Students aged 12 to 15 years, of both sexes, with healthy permanent dentition, attending public schools in Piracicaba, Brazil, were selected for this study. The HALT was translated, backtranslated, reviewed by an expert committee and submitted to a pre-test. In the first phase (n = 13), 15% of the sample did not understand items 2, 12 and 15; therefore, these items were reformulated and resubmitted to 13 adolescents. The version with a sociocultural adaptation was self-applied by 56 adolescents (64% females, 13.4 ± 1.0 years), of whom 25 participated in the test-retest. The presence of visible biofilm, gingival bleeding, calculus and tongue coating, was evaluated. Self-perception of halitosis after exhalation/breathing was assessed by a single question. Results:The HALT score ranged from 0 to 62 points (mean = 10.1±13.4) and the floor effect was 5.4%. Internal consistency was excellent (Cronbach's alpha = 0.92) and reproducibility was moderate (Intraclass Correlation Coefficient = 0.59). Individuals with “excessive” tongue coating had a higher HALT score than those with mild and/or moderate coating (p<0.001). Multiple linear regression analysis indicated that only the male sex was related to a higher HALT score (p<0.05). Conclusion:The Brazilian Portuguese version of the HALT was easily understood by adolescents. Those with greater tongue coating accumulation reported more frequently the presence of halitosis, which was only associated to male sex.


Validation Studies; Surveys and Questionnaires; Quality of Life

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Rosenberg M, Kozlovsky A, Gelernter I, Cherniak O, Gabbay J, Baht R, et al. Self-estimation of oral malodor. J Dent Res 1995; 74(9):1577-82.

van den Broek AM, Feenstra L, de Baat C. A review of the current literature on aetiology and measurement methods of halitosis. J Dent 2007; 35(8):627-35.

Aimetti M, Perotto S, Castiglione A, Ercoli E, Romano F. Prevalence estimation of halitosis and its association with oral health-related parameters in an adult population of a city in North Italy. J Clin Periodontol 2015; 42(12):1105-14.

Silva MF, Leite FRM, Ferreira LB, Pola NM, Scannapieco FA, Demarco FF, et al. Estimated prevalence of halitosis: A systematic review and meta-regression analysis. Clin Oral Investig 2018; 22(1):47-55.

Kizhner V, Xu D, Krespi YP. A new tool measuring oral malodor quality of life. Eur Arch Otorhinolaryngol 2011; 268(8):1227-32.

Lu HX, Tang C, Chen X, Wong MC, Ye W. Characteristics of patients complaining of halitosis and factors associated with halitosis. Oral Dis 2014; 20(8):787-95.

Winkel EG, Roldán S, Van Winkelhoff AJ, Herrera D, Sanz M. Clinical effects of a new mouthrinse containing chlorhexidine, cetylpyridinium chloride and zinc-lactate on oral halitosis. A dual-center, double-blind placebo-controlled study. J Clin Periodontol 2003; 30(4):300-6.

Lopes RG, de Santi ME, Franco BE, Deana AM, Prates RA, França CM, et al. Photodynamic therapy as novel treatment for halitosis in adolescents: A case series study. J Lasers Med Sci 2014; 5(3):146-52.

Patil PS, Pujar P, Poornima S, Subbareddy VV. Prevalence of oral malodour and its relationship with oral parameters in Indian children aged 7-15 years. Eur Arch Paediatr Dent 2014; 15(4):251-8.

Villa A, Zollanvari A, Alterovitz G, Cagetti MG, Strohmenger L, Abati S. Prevalence of halitosis in children considering oral hygiene, gender and age. Int J Dent Hyg 2014; 12(3):208-12.

Rosenberg M. Bad breath, diagnosis and treatment. Univ Tor Dent J 1990; 3(2):7-11.

Bornstein MM, Kislig K, Hoti BB, Seemann R, Lussi A. Prevalence of halitosis in the population of the city of Bern, Switzerland: a study comparing self-reported and clinical data. Eur J Oral Sci 2009; 117(3):261-7.

Bollen CM, Beikler T. Halitosis: The multidisciplinary approach. Int J Oral Sci 2012; 4(2):55-63.

Rosenberg M, Kulkarni GV, Bosy A, McCulloch CA. Reproducibility and sensitivity of oral malodor measurements with a portable sulphide monitor. J Dent Res 1991; 70(11):1436-40.

Colussi PR, Hugo FN, Muniz FW, Rösing CK. Oral health-related quality of life and associated factors in Brazilian adolescents. Braz Dent J 2017; 28(1):113-20.

Pham TA. Comparison between self-estimated and clinical oral malodor. Acta Odontol Scand 2013; 71(1):263-70.

Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: Literature review and proposed guidelines. J Clin Epidemiol 1993; 46(12):1417-32.

Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000; 25(24):3186-91.

Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Coordenação Nacional de Saúde Bucal. SB Brasil 2010: Pesquisa Nacional de Saúde Bucal. Projeto técnico. Brasília: Ministério da Saúde; 2012. Available at: [Accessed on October 15, 2018]

Bonanato K, Pordeus IA, Moura-Leite FR, Ramos-Jorge ML, Vale MP, Paiva SM. Oral disease and social class in a random sample of five-year-old preschool children in a Brazilian city. Oral Health Prev Dent 2010; 8(2):125-32.

World Health Organization. Oral Health Surveys: Basic Methods. Geneva: World Health Organization; 1997.

Rosenberg M, McCulloch CA. Measurement of oral malodor: Current methods and future prospects. J Periodontol 1992; 63(9):776-82.

Bland JM, Altman DG. Cronbach's alpha. BMJ 1997; 314(7080):572.

Kramer MS, Feinstein AR. Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther 1981; 29(1):111-23.

Dudzik A, Chomyszyn-Gajewska M, Łazarz-Bartyzel K. An Evaluation of halitosis using oral chroma™ data manager, organoleptic scores and patients' subjective opinions. J Int Oral Health 2015; 7(3):6-11.

Barbosa TS, Steiner-Oliveira C, Gavião MBD. Translation and Brazilian adaptation of the Parental-Caregiver Perceptions Questionnaire (P-CPQ). Saúde Soc 2010; 19(3):698-708.

Ferreira L, Neves NA, Campana MB, Tavares MCGCF. AAOS/IWH guide: Suggestions for cross-cultural scale adaptation. Aval Psicol 2014;13(3):457-61.

Romano F, Pigella E, Guzzi N, Aimetti M. Patients' self-assessment of oral malodour and its relationship with organoleptic scores and oral conditions. Int J Dent Hyg 2010; 8(1):41-6.

Amir E, Shimonov R, Rosenberg M. Halitosis in children. J Pediatr 1999; 134(3):338-43.

Amou T, Hinode D, Yoshioka M, Grenier D. Relationship between halitosis and periodontal disease - associated oral bacteria in tongue coatings. Int J Dent Hyg 2014; 12(2):145-51.

Jamali Z, Aminabadi NA, Samiei M, Sighari Deljavan A, Shokravi M, Shirazi S. Impact of chlorhexidine pretreatment followed by probiotic streptococcus salivarius strain k12 on halitosis in children: A randomised controlled clinical trial. Oral Health Prev Dent 2016; 14(4):305-13.