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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
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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.
2.
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9.
Fracture of the jaw?
Fracture of the nasal septum?
Mouth breathing?
Cardiovascular (HBP)?
GI problems (gastric hyperacidity)?
Diet?
Smoking, coffee?
Fissured tongue?
Oral hygiene?
Steps in Malodor Formation
Proteolysis:
Proteins
Aminolysis:
Amino acids
Amino acids
Odoriferous
volatile and tissue
harming products
Oral Pathogens Causing Halitosis
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Fusobacterium nucleatum
Veionella alcalescens
Porphyromonas gingivalis
Prevotella intermedia
Prevotella loeschii
Treponema denticola
Klebsiella pneumoniae
Gram Negative Anaerobes are trapped
Bacterial Growth
Inflammation
Bacterial
enzymes
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
Volatile sulfur and other
objectionable compounds
H2S, CH3SH, (CH3)2S, indole, skatole
Bacterial
metabolism
Protein Substrate
Methionine
CH3SH
Serine
thiocysteine
Cystine
H2S
Homocysteine
H2S
NH3
Cystathionine
a-ketobutyrate
Cysteine
NH3
Homoserine
H2S
pyruvate
acetic acid
Tryptophan
propionate
Indole, Skatole
The Mechanism of Malodor Formation
Components of Bad Breath
“The Oral Bouquet”
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Hydrogen sulfide (H2S)
Methyl mercaptan (CH3SH)
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.
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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
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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
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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
Thank You