Patient
Clinical Case Presentation
Building Blocks of Life
Amino Acid Metabolism
Template for CCP
•Chief Complaint (CC)
•History of Chief Complaint (HCC)
•Medications (M)
•Social History (SH)
•Family History (FH)
•Dental History (DH)
•Medical History (MH)
•Review of Systems (RS)
•Diagnosis -Risk Assessment (DRA)
•Differential Diagnosis (DD)
•Treatment (Tx)
•Prognosis (PR)
Objective of Clinical Case
Presentations
• Integrate basic science and clinical concepts
• Teach critical thinking
• Active learning
• Help improve student performance on Board Part II
Proposed Format of These
Presentations
• A case from admission clinic/made up
• Patient examination format
• Student participation
• Cases to be included in exam
• Cases kept on web-site/DVD
Test at the end of this presentation!
Patient
• 35 year old male
• Chief Complaint (CC)
• Bad breath
• History of Chief Complaint (HCC)
• Bad breath - was told by the neighbor and noticed the behavior of co-workers for the past 5 years
• Medications
• No medication
• Social History (SH)
• Smoking 15 cigarette/day, for 15 years, daily 2 cups of coffee; likes spicy food
• Family History (FH)
• Father suffers of chronic bronchitis, mother has insulin independent diabetes mellitus, 2 children, age 7 and 3.
• Dental History (DH)
• Last dental work 2 years ago. Diagnosed with Fissured
Tongue ( Lingua Plicata , or Scrotal Tongue). Poor oral hygiene
•Medical History (MH)
• Exercises regularly. No known allergies. High blood pressure, calcium channel blocker (Nifedipine)
• Review of Systems (RS)
•
Cardiovascular
– Blood Pressure, 145/90. Pulse 70.
•
Respiratory
– Rate 16/min. Breathing through his mouth.
Due to a septum deviation, caused by a car accident that broke his nose and jaw.
• Nervous – Calm demeanor, balanced person. No history of depression or other disorder. No pain or numbness in any major cranial or spinal nerve.
• Endocrine and renal – WNL
•
Gastrointestinal – Hyperacidity, treated with Tagamet
• Skin and mucosa – Color and texture of skin and mucosa
WNL. No persistent lesions or moles
•
Osteoarticular
– Fracture of the jaw 5 years ago due to a car accident. The left body of the mandible was fractured along with the right subcondylar area. Treated surgically.
Diagnosis and Risk Assessment
Are any of the condition in the medical and social history connected to halitosis?
1. Fracture of the jaw?
2. Fracture of the nasal septum?
3. Mouth breathing?
4. Cardiovascular (HBP)?
5. GI problems (gastric hyperacidity)?
6. Diet?
7. Smoking, coffee?
8. Fissured tongue?
9. Oral hygiene?
Steps in Malodor Formation
Proteolysis:
Proteins Amino acids
Aminolysis:
Amino acids Odoriferous volatile and tissue harming products
Oral Pathogens Causing Halitosis
•
Fusobacterium nucleatum
•
Veionella alcalescens
•
Porphyromonas gingivalis
•
Prevotella intermedia
•
Prevotella loeschii
•
Treponema denticola
•
Klebsiella pneumoniae
Gram Negative Anaerobes are trapped
Bacterial Growth
Bacterial enzymes
Inflammation Protein Substrate
Salivary and tissue proteins
Enzymatic degradation
Tissue Permeability
Collagen breakdown
Delayed Wound Healing
Volatile
Sulphur
Compounds affects
Amino Acids
Cys-Cys, Cys, Met,
Ser, Trp, Orn
Bacterial metabolism
Volatile sulfur and other objectionable compounds
H
2
S, CH
3
SH, (CH
3
)
2
S, indole, skatole
Protein Substrate
CH
3
SH
Methionine
Serine thiocysteine
H
2
S
Cystine
Homocysteine
H
2
S
Cystathionine
NH
3 a
-ketobutyrate
Cysteine
H
2
S pyruvate
NH
3
Homoserine
Tryptophan propionate
Indole, Skatole acetic acid
The Mechanism of Malodor Formation
Components of Bad Breath
“The Oral Bouquet”
• Hydrogen sulfide (H
2
S)
• Methyl mercaptan (CH
3
SH)
•
Dimethyl sulfide and Dimethyl disulfide
•
Indole, Skatole, Cadaverine, Putrescine
• Volatile fatty acids
• Amines
The source of the odor?
Saliva supernatant
Saliva sediment
Saliva super + sediment
No odor
Odor
Strong odor
What conditions or factors favor halitosis?
Discuss it with your partner first
.
• Poor oral hygiene
•
Periodontitis
• Oral infections/ulcerations
•
Oral cancer
• Mouth breathing
•
Xerostomia
• Retronasal drip
• Retentive tongue: Fissured tongue, Geographic tongue,
Median rhomboid glossitis, Black hairy tongue
• Food impaction/Faulty restorations
•
Diet, smoking, coffee
Diagnosis of Halitosis
•
Organoleptic
•
Halimeter
•
Microbiological
•
Gas Chromatography/Flame
Photometric Detection
•
Gas Chromatography/Mass
Spectrometry
Differential Diagnosis
•
Oral causes (90-95%)
•
Gastrointestinal system
Dietary
•
Respiratory system
•
Metabolic
Trimethylaminuria (TMAU)
Diabetes
Uremia
Treatment and Prognosis
Etiologic and symptomatic treatment
• Maintenance of Proper Oral Hygiene
• Elimination of Inflammation and periodontal treatment (if necessary)
•Treat nasal septum deviation, adenoids, mouth breathing, xerostomia
• Change dietary habits
• Removal of faulty restoration
• Tongue brushing or scraping, flossing
• Mouthwashes containing zinc chloride
Prognosis
• Excellent
Evaluation of Treatment
Efficacy
•
Organoleptic measurement
•
Halimeter
•
Microbiological assays
•
Cysteine challenge
Answer the following
• What amino acids are the source of the odor?
• What is the pathogenesis of halitosis?
• What five major factors maintain halitosis?
• What are the differential diagnoses of halitosis?
• What are the five main steps to treat/avoid halitosis?
Bad breath is better than no breath at all
L.Z.G. Touyz
