relationship between halitosis and psychologic status
TRANSCRIPT
Relationship between halitosis and psychologic statusNao Suzuki, DDS, PhD, Masahiro Yoneda, DDS, PhD, Toru Naito, DDS, PhD,Tomoyuki Iwamoto, DDS, and Takao Hirofuji, DDS, PhD, Fukuoka, JapanSECTION OF GENERAL DENTISTRY, DEPARTMENT OF GENERAL DENTISTRY, FUKUOKA DENTALCOLLEGE
Objective. To examine the psychosomatic aspects of patients complaining of halitosis.Study design. Breath malodor in 165 patients was measured using an organoleptic test (OLT), sulfide monitoring, andgas chromatography. Clinical evaluation included oral examination, OLT, and volatile sulfur compound measurement.The psychologic condition of patients was assessed using the Cornell Medical Index (CMI).Results. Every item in the CMI questionnaire was negatively correlated with the OLT scores. Nine of 21 subjects(42.9%) diagnosed with pseudohalitosis and approximately 20% of subjects diagnosed with genuine halitosis wereconsidered to be provisionally neurotic. Subjects with pseudohalitosis reported significantly higher physical scores, butnot mental scores, than those with genuine halitosis. Subjects with physiologic halitosis showed significantly highersymptoms of depression than those with oral pathologic halitosis.Conclusion. The psychologic condition of patients complaining of halitosis was associated with the actual degree of
malodor and the clinical characteristics. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:542-7)Halitosis is a common problem in humans. Oral mal-odor is primarily associated with the condition of theoral cavity, including the oral hygiene level and peri-odontal condition,1-3 and is mainly the result of themicrobial metabolism of amino acids in local debris.4
Many of the major compounds that contribute to oralmalodor are volatile sulfur compounds (VSCs) such ashydrogen sulfide and methyl mercaptan.5,6 Addition-ally, methylamine, dimethylamine, propionic acid, bu-tyric acid, indole, scatole, and cadaverine have beenreported to cause oral malodor.7,8 To evaluate the levelof oral malodor in patients complaining of halitosis,VSC levels have typically been measured, along withan organoleptic test (OLT).9
To diagnose halitosis, a simple classification withcorresponding treatment needs has been developed,10,11
which includes the categories of genuine halitosis,pseudohalitosis, and halitophobia. Genuine halitosis issubclassified as physiologic or pathologic halitosis, andpathologic halitosis is subclassified as oral or nonoralpathologic halitosis. The treatment of physiologic ha-litosis primarily involves dental and oral care, oralhygiene instruction, and counseling. Oral pathologic
Supported by Grants-in-Aid for Scientific Research (C)18592296 and(C)16592071, a Grant-in-Aid for Young Scientists (B)19791645,Grants-in-Aid for Frontier Research from the Ministry of Education,Culture, Sports, Science and Technology of Japan, and as a researchproject of the 8020 Promotion Foundation.Received for publication Nov 14, 2007; returned for revision Feb 14,2008; accepted for publication Mar 10, 2008.1079-2104/$ - see front matter© 2008 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2008.03.009542
halitosis is caused largely by periodontal disease,12 andits treatment requires periodontal treatment in additionto dental and oral care, oral hygiene instruction, andcounseling. Additionally, dental treatment may be nec-essary to correct faulty restorations that could contrib-ute to poor oral health.11 If there is no oral malodor, butthe patient believes that he or she has oral malodor, thediagnosis is pseudohalitosis. Subjects with pseudohali-tosis need to be counseled, with education and expla-nations of examination results, that the intensity of theirmalodor is not beyond socially acceptable levels. Be-cause they generally accept the counseling and respondfavorably to the explanation of examination data, fur-ther professional instruction, education, and reassur-ance, they are different from patients with halitophobia.Halitophobia is characterized by a patient’s persistentbelief that he or she has halitosis despite reassurance,treatment, and counseling. Subjects with nonoral patho-logic halitosis and halitophobia should be referred tomedical specialists.
Clinically, some patients complaining of halitosishave actual malodor, whereas others have almost nomalodor. It has been suggested that halitosis is a symp-tom related to both somatic and emotional status andthat psychologic disorders are strongly associated withthe condition in some patients.13,14 Not only patientswith pseudohalitosis, but also those with genuine hali-tosis may have an accompanying psychologic condi-tion.11 A questionnaire is of benefit to evaluate thepsychologic condition of halitosis patients.15,16 We in-vestigated the relationships among the actual degree ofmalodor, the clinical classification, and the psychologic
condition of patients complaining of halitosis using the
OOOOEVolume 106, Number 4 Suzuki et al. 543
Cornell Medical Index (CMI) health questionnaire.17
The questionnaire was created to collect a large body ofpertinent medical and psychiatric data with minimaltime expenditure.
SUBJECTS AND METHODSStudy population
The study population comprised 165 subjects (64male and 101 female, aged 10-78 years with a mean ageof 47.5 � 14.7 years) complaining of halitosis andpresenting to the Oral Malodor Clinic of the FukuokaDental College Medical and Dental Hospital from June2005 to September 2006. All of the subjects who par-ticipated understood the nature of the research projectand provided informed consent. None had taken anti-biotics within 3 months before entering the study. Be-fore the appointment for malodor assessment, eachsubject was asked to refrain from eating, drinking,chewing, smoking, brushing, or rinsing the mouth for atleast 5 h.
Malodor assessmentThe severity of oral malodor in each individual was
determined using an OLT, portable sulfide monitoring(MS-Halimeter E; Interscan Corporation, Chatsworth,CA), and gas chromatography (model GC14B; Shi-madzu Works, Kyoto, Japan). For the OLT, patientswere instructed to exhale through the mouth with mod-erate force into a Teflon sampling bag (GL Science,Tokyo, Japan) for 2-3 s to prevent the dilution of mouthodor with lung and room air. This procedure was re-peated until approximately 1 L of breath sample wasobtained. Two or 3 evaluators estimated the odor at adistance of approximately 10 cm from the samplingbag. The OLT scores were estimated on a scale of 0 to5 (0, absence of odor; 1, questionable odor; 2, slightmalodor; 3, moderate malodor; 4, strong malodor; 5,severe malodor),10 and the mean scores given by thedifferent judges were used. The percentage of agree-ment in diagnosing the presence of genuine malodor(�2 OLT score) among the 3 evaluators always ex-ceeded 75.0% (� � 0.50). The total VSC levels (ppb)were measured using the MS-Halimeter E. Patientswere asked to breathe through the nose, with the mouthclosed, for 30 s. A disposable straw attached to theMS-Halimeter E was then placed onto the center of thetongue and the maximum VSC values in the mouthwere determined. For gas chromatography measure-ments, subjects were asked to remain quiet with theirmouths closed for 30 s, after which mouth air (10 mL)was aspirated using a gas-tight syringe. Subsequently,samples were injected into the gas chromatograph col-umn at 70°C. A glass column was packed with 25%
�,� 9-oxydipropionitrile on a 60-80 mesh ChromosorbW AW-DMCS-ST device (Shimadzu Works) fittedwith a flame photometric detector. The concentration ofeach VSC (ng/10 mL mouth air) was determined basedon a standard of hydrogen sulfide and methyl mercap-tan gas prepared with a permeater (PD-1B; GL Sci-ence).
Clinical examinationsThe oral health of each patient was examined, in-
cluding the number of teeth, number of teeth, numberof caries, periodontal pocket depth (PPD), tongue coat-ing, and volume of stimulated salivary flow. The PPD)was measured at 6 points around each tooth in allsubjects. The total area and thickness of the tonguecoating were determined by clinical inspection. Thetongue coating was scored based on conventional cri-teria,18 with a simple modification (0, no tongue coat-ing; 1, thin tongue coating covering less than one-thirdof the tongue dorsum; 2, thick tongue coating coveringapproximately one-third of the tongue dorsum or thintongue coating covering one-third to two-thirds of thetongue dorsum; 3, thick tongue coating covering one-third to two-thirds of the tongue dorsum or thin tonguecoating covering more than two-thirds of the tonguedorsum; 4, thick tongue coating more than two-thirds ofthe tongue dorsum). The volume of stimulated salivaryflow was measured using the chewing gum test. Thepatient was asked to pool saliva in the oral cavity andspit into a vessel every minute throughout the entirecollection period (5 min). Data about the presence ofsystemic illness was determined using the question-naire.
Clinical classification of halitosisThreshold levels of genuine halitosis were defined as
�2 OLT score, �100 ppm by the MS-Halimeter E,�1.5 ng/10 mL mouth air of hydrogen sulfide, and�0.5 ng/10 mL mouth air of methyl mercaptan.11,19
The OLT score was given priority over the VSC levelsfor the evaluation of malodor. After counseling usingliterature support, education, and explanation of exam-ination results based on classification according to cor-responding treatment needs,10 halitosis was classifiedinto 3 categories: genuine halitosis, including physio-logic halitosis, oral pathologic halitosis, and extraoralpathologic halitosis; pseudohalitosis; and halitophobia.Patients having malodor (’2 OLT score) and at least 1untreated PPD greater than 5 mm were classified ashaving oral pathologic halitosis. However, patients thathad malodor (�2 OLT score) when neither a specificdisease nor pathologic condition that could cause hali-tosis was found were classified as having physiologichalitosis. When malodor originated primarily from sys-
temic illness rather than oral health conditions, the
OOOOE544 Suzuki et al. October 2008
patients were classified as having extraoral pathologichalitosis. When obvious malodor was not perceived byothers (�2 OLT score) and the patient’s complaint wasimproved by counseling, education, and explanation ofexamination results, he or she was classified as havingpseudohalitosis. Without relation to the halitosis level,when unusual perseverance and imagination were ob-served after counseling treatment, the diagnosis washalitophobia.
QuestionnaireThe subjects’ psychologic conditions were evaluated
using the Japanese CMI health questionnaire.20 Thisquestionnaire contains simply worded questions thatcover a broad range of somatic and emotional statuses;all questions, totaling 211 for male and 213 for femalesubjects, are answered “yes” or “no.” For the evaluationof somatic symptoms and habits, the CMI questionnaireasks about the condition of the eyes and ears (A), upperrespiratory system (B), cardiovascular system (C), di-gestive tract (D), musculoskeletal system (E), skin (F),nervous system (G), genitourinary systems (H), fatiga-bility (I), frequency of illness (J), miscellaneous dis-eases (K), and habits (L). For the evaluation of emo-tional status, questions concerning inadequacy (M),depression (N), anxiety (O), sensitivity (P), anger (Q),and tension (R) are included. According to the study byKanehisa et al.,20 the neurotic tendency of patients wasdivided into 4 classes (1-4) based on the total number of“yes” responses to items C, I, and J and the totalnumber of “yes” responses to questions about theiremotional status (M-R). Class 1 was diagnosed as nor-mal and class 4 was diagnosed as neurotic. Classes 2and 3 are boundary states between normal and neurotic.Class 2 has a higher likelihood of being normal, result-ing in a provisional diagnosis as normal; class 3 has alesser likelihood of being normal, resulting in a provi-sional diagnosis as neurotic.
Statistical analysisThe raw data from the questionnaires were entered
into a computer database. Continuous variables arepresented as means with standard deviations, and cat-egoric data are presented as numbers and percentages.To determine the differences among groups, analysis ofvariance (ANOVA) and the chi-squared test were usedwhen appropriate. Scheffé post hoc test was used todetermine the differences among physiologic halitosis,oral pathologic halitosis, and pseudohalitosis. To deter-mine the correlations between variables, we used the2-tailed Spearman rank order correlation coefficient.All tests were conducted at the 5% significance level.
The SPSS statistical software package was used for allanalyses (SPSS release 11.0J; SPSS Japan, Tokyo, Ja-pan).
RESULTSClinical classification of halitosis patients
In the clinical classifications of halitosis, the propor-tion of physiologic halitosis was highest (54.5%), fol-lowed by oral pathologic halitosis (30.3%) andpseudohalitosis (12.7%). Chronic sinus infection andrecurrent tonsillitis were attributed etiologically to 2patients (1.2%) with extraoral pathologic halitosis. Twopatients, a man aged 27 years and a woman aged 48years, were classified as having halitophobia (1.2%);although they had no or only slight malodor, they stillstrongly believed that they had strong bad breath, evenafter they had received counseling treatment. Table Ishows the malodor levels and clinical parameters inthe patients with physiologic, oral pathologic, andpseudohalitosis. High malodor levels measured byOLT, sulfide monitoring, and gas chromatography wereshown in patients with oral pathologic halitosis, fol-lowed by those with physiologic halitosis and thosewith pseudohalitosis. About 25% of the patients withgenuine halitosis, including both physiologic and oralpathologic halitosis, had a tongue coating score of �3,in contrast to only 4.8% of the patients with pseudohali-tosis (chi-squared test: P � .045). The patients withoral pathologic halitosis showed high averages of PPDcompared with the subjects with physiologic halitosis(Scheffé test: P � .001) and pseudohalitosis (p �0.001). The findings suggest that the cause of physio-logic halitosis is mainly related to tongue debris and thecause of oral pathologic halitosis is mainly related totongue debris and periodontal disease.
OLT scores and psychological statusWe obtained the following OLT estimates for the
halitosis levels of the 165 subjects: score 0, 2 (1.2%);score 1, 23 (13.9%); score 2, 55 (33.3%); score 3, 65(39.4%), score 4, 20 (12.1%), and score 5, 0 (0.0%).The relationship between OLT scores and CMI scoreswas examined using Spearman rank correlation (TableII). Every class of neurotic tendency (CMI class), so-matic symptoms and habits (A–L), and emotionalsymptoms (M–R) showed negative correlations withthe OLT scores, although the correlation coefficientswere weak. The score for the question regarding ten-sion (R) had a significant negative correlation with theOLT score (Spearman correlation coefficient r ��0.236; P � .003).
Clinical classifications and psychological statusTable III shows the distribution of CMI classes for
the subjects with physiologic halitosis, oral pathologic
tosis at
OOOOEVolume 106, Number 4 Suzuki et al. 545
halitosis, and pseudohalitosis. No subjects were classi-fied into class 4 (neurotic). Nine of 21 subjects withpseudohalitosis (42.9%) were considered to be class 3(provisionally diagnosed as neurotic). In contrast,20.0% of subjects with physiologic halitosis and 18.0%of subjects with oral pathologic halitosis were classifiedas class 3. Significant differences were detected amongthe 3 groups (chi-squared test: P � .032). Among thesubscales of the CMI, the subjects with pseudohalitosisdemonstrated significantly higher somatic symptoms,including the sum of “yes” responses to C, I, and J,compared with the subjects with physiologic halitosis(Scheffé test: P � .043) and oral pathologic halitosis (P� .032; Table IV). Among C, I, and J, the scores foritem I (fatigability) were significantly higher for the
Table I. Malodor levels and clinical parameters in theand pseudohalitosis
Genuine h
Physiologichalitosis (n � 90)
Age (years) 45.1 � 15.6*Gender (female/male) 57 (63.3)/33 (36.7)OLT score (0, 1/2–5) 0 (0.0)/90 (100.0)Halimeter value (ppb) 244.6 � 159.8*‡H2S (ng/10 mL mouth air) 4.62 � 3.21‡CH3SH (ng/10 mL mouth air) 3.00 � 2.68*‡Number of teeth 26.7 � 4.29Number of caries 0.32 � 1.29Tongue coating score (0-2/3-4) 67 (74.5)/23 (25.5)PPD (mm) 2.40 � 0.48*Stimulated salivary flow (mL/5 min) 6.79 � 10.27
Data are expressed as the number (%) or the mean � SD. P valuesOLT, Organoleptic test; H2S, hydrogen sulfide; CH3SH; methyl mer*Significant difference between physiologic halitosis and oral patho†Significant difference between oral pathologic halitosis and pseudo‡Significant difference between physiologic halitosis and pseudohali
Table II. Correlation between the CMI and OLTscores
r* (P value)
CMI (overall) �0.104 (.188)A–L (global somatic symptoms and habits) �0.056 (.482)C, I, J (representative somatic symptoms) �0.105 (.184)M–R (global emotional symptoms) �0.108 (.173)M (inadequacy) �0.051 (.522)N (depression) �0.083 (.293)O (anxiety) �0.086 (.279)P (sensitivity) �0.082 (.303)Q (anger) �0.058 (.468)R (tension) �0.236 (.003)
CMI, Cornell Medical Index; OLT, organoleptic test.*Spearman correlation coefficient.
pseudohalitosis patients that for those with oral patho-
logic halitosis (Scheffé test: P � .005). A slight differ-ence was also observed in the emotional symptoms(M-R) among the 3 groups (ANOVA: P � .066).Among every item of M through R, the averages of“yes” responses were higher in the subjects withpseudohalitosis than in the subjects with oral pathologichalitosis; however, no significant difference was de-tected between the 2 groups. The subjects with physi-ologic halitosis showed significantly higher symptomsof depression (N; Scheffé test: P � .048) comparedwith subjects with oral pathologic halitosis.
DISCUSSIONThe CMI health questionnaire has been used previ-
ously to evaluate the psychologic condition of patientscomplaining of halitosis or the outcome of oral malodortreatment.16,21 We used this questionnaire to examinethe relationship between the subjective symptoms ofpatients complaining of halitosis and halitosis levels,estimated based on the OLT, and the clinical classifi-cations. Our results demonstrated that patients with alower degree of halitosis, as estimated by the OLT, hadstronger psychologic profiles, for both somatic andemotional symptoms, although the correlation coeffi-cients were weak (Table II). Not only patients withpseudohalitosis, but also those with genuine halitosismay have an accompanying psychologic condition.22
Therefore, strong significant differences may have notbeen detected among the patients with halitosis.Iwakura et al.23 reported that the majority of patientswith primary complaints of halitosis at a dental clinic
ts with physiologic halitosis, oral pathologic halitosis,
(n � 140)
Pseudohalitosis(n � 21) P value
Oral pathologichalitosis (n � 50)
53.8 � 10.4*† 44.8 � 15.6† .00224 (48.0)/26 (52.0) 17 (81.0)/4 (19.0) .0260 (0.0)/100 (100.0) 21 (100.0)/0 (0.0) �.001355.3 � 272.5*† 72.4 � 27.3†‡ �.0016.07 � 4.24† 0.74 � 0.48†‡ �.0014.33 � 3.19*† 0.36 � 0.28†‡ �.00124.5 � 5.65 27.2 � 3.06 .0190.76 � 1.81 0.58 � 1.12 .238
38 (76.0)/12 (24.0) 20 (95.2)/1 (4.8) .0452.88 � 0.75*† 2.27 � 0.64† �.0016.51 � 3.19 5.72 � 2.38 .857
ANOVA or chi-squared test, as appropriate.PPD, probing pocket depth.litosis at P � .05 (Scheffé test).s at P � .05 (Scheffé test).P � .05 (Scheffé test).
patien
alitosis
are bycaptan;logic hahalitosi
did not actually have halitosis, but suffered from an
logic ha
OOOOE546 Suzuki et al. October 2008
imaginary halitosis because of presumptions based onothers’ attitudes. They discussed that some of thesepeople represented cases analogous to those of olfac-tory reference syndrome (ORS). Olfactory referencesyndrome has been suggested to fall within the spec-trum of social anxiety disorder24 and can be defined asa psychiatric disorder that is characterized by persistentpreoccupation with body odor, including halitosis, ac-companied by significant depression and/or avoidanceof social situations. The majority of the patients firstvisited our oral malodor clinic, and some of them hadvisited physicians and/or otolaryngologists, rather thanpsychiatrists, before visiting our clinic. We need toconsider the possibility of ORS when a patient with alow degree of halitosis is unaware of or does not wantto admit his or her possible psychogenic problems.
The analysis of the relationship between the clinicalclassification of halitosis and psychologic status indi-cated that subjects with pseudohalitosis had a greatertendency toward neurosis than subjects with physio-logic halitosis or oral pathologic halitosis (Table III).Among the subscales, the scores for fatigability (I)
Table III. Neurotic tendency classified using CMI am
CMI classPhysiologic halitosis
(n � 90 (%))
1 (normal) 41 (45.6)2 (provisionally normal) 31 (34.4)3 (provisionally neurotic) 18 (20.0)
CMI, Cornell Medical Index.*Chi-squared test.
Table IV. Comparison of the average scores (mean �physiologic, oral pathologic, and pseudohalitosis
Physiologic hali(n � 90)
Somatic statusA-L (global somatic symptoms) 17.9 � 10.4C, I, J (representative somatic symptoms) 2.63 � 2.86*
Emotional statusM-R (global emotional symptoms) 6.98 � 6.44M (inadequacy) 2.26 � 2.35N (depression) 0.28 � 0.58‡O (anxiety) 0.93 � 1.13P (sensitivity) 1.17 � 1.34Q (anger) 1.37 � 1.93R (tension) 0.95 � 1.21
P values by ANOVA.CMI, Cornell Medical Index.*Significant difference between physiologic halitosis and pseudohali†Significant difference between oral pathologic halitosis and pseudo‡Significant difference between physiologic halitosis and oral patho
regarding somatic status were significantly higher for
the pseudohalitosis patients. Additionally, 24% of thesubjects with pseudohalitosis answered “yes” to thequestion of “Do or did you have a psychiatric patient inyour family?” (question no. 171, in item O [anxiety]).This is a significant difference compared with the sub-jects with genuine halitosis (chi-squared test: P �.001). A history of maternal mental illness is consideredto be one of the environmental factors that bears on themental health of children.25 Such a question may behelpful in encouraging further subclassification of sub-jects with pseudohalitosis based on mental status.
The bad-breath history of the patients was obtained bydirect interviews. The percentages of subjects who hadidentified their own oral malodor were 21.1% of thosewith physiologic halitosis, 18.0% of those with oral patho-logic halitosis, and 42.9% of those with pseudohalitosis(data not shown). Although halitosis is not a self-obvioussymptom,26 many subjects with pseudohalitosis have theolfactory delusion that they emit a foul smell from themouth. Eli et al.27 investigated the correlation betweenpsychopathologic traits and oral malodor self-perception.Depression, hostility, paranoid ideation, and personal sen-
hysiologic, oral pathologic, and pseudohalitosispathologic halitosis(n � 50 (%))
Pseudohalitosis(n � 21 (%))
Pvalue*
31 (62.0) 9 (42.9) .03210 (20.0) 3 (14.3)9 (18.0) 9 (42.9)
for “yes” responses in the CMI questionnaire among
Oral pathologic halitosis(n � 50)
Pseudohalitosis(n � 21)
Pvalue*
18.2 � 9.2 22.9 � 12.6 0.1342.42 � 2.09† 4.33 � 3.66*† 0.023
4.92 � 6.30 8.61 � 7.82 0.0661.42 � 2.22 2.33 � 2.59 0.1010.06 � 0.23‡ 0.23 � 0.70 0.0470.76 � 1.36 1.42 � 1.71 0.1430.84 � 1.44 1.57 � 1.77 0.1321.14 � 1.76 1.95 � 2.06 0.2620.70 � 1.07 1.09 � 1.22 0.331
P � .05 (Scheffé test).s at P � .05 (Scheffé test).litosis at P � .05 (Scheffé test).
ong pOral
SD)
tosis
tosis athalitosi
sitivity have been reported to show positive associations
OOOOEVolume 106, Number 4 Suzuki et al. 547
with self-perception of oral malodor. We must also becareful not to overlook patients who have obvious mal-odor and also exhibit high neurotic tendencies. The pa-tients that had physiologic halitosis showed significantlygreater symptoms of depression (N) than did those thathad oral pathologic halitosis, and although the differencewas not statistically significant their symptoms were alsohigher than those with pseudohalitosis (Table IV). Theorigin of physiologic halitosis is primarily tongue debrisand poor oral hygiene.11,28 Depression may promote alack of motivation and lead to poor oral hygiene. Further-more, although the patients with oral pathologic halitosisshowed the lowest scores in every item on the CMIquestionnaire, indicating that many of them may havenormal mental status, no significant difference was ob-served in the subscale of items for emotional symptomsbetween oral pathologic halitosis and pseudohalitosis.Self-estimation of oral malodor is difficult,29 and manysubjects may feel some sort of emotional disorder, regard-less of the actual degree of halitosis. Some of the patientsclassified with genuine halitosis may have become de-pressed and suffered emotional injury over a long periodbefore visiting the clinic. A true cure in patients complain-ing of halitosis is produced by a reduction in malodor andthe refinement of their mental health status. The CMIquestionnaire may be a helpful tool for the primary de-tection of the patients complaining of halitosis with anunhealthy mental condition and the evaluation of recoveryfrom an unhealthy mental condition.
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Nao Suzuki, DDS, PhDSection of General DentistryDepartment of General DentistryFukuoka Dental College2-15-1, Tamura, Sawara-kuFukuoka 814-0193Japan
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