Clinical Case Presentation

1. Clinical Case Presentation Building Blocks of Life Amino Acid Metabolism

2. 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 -RiskAssessment (DRA) • Differential Diagnosis (DD) • Treatment (Tx) • Prognosis (PR)

3. Objective of Clinical Case Presentations Integrate basic science and clinical concepts Teach critical thinking Active learning Help improve student performance on Board Part II

4. 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

5. Test at the end of this presentation!

6. 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

7. 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)

8. 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.

9. Diagnosis and Risk AssessmentAre any of the condition in the medical and social history connected to halitosis? • Fracture of the jaw? • Fracture of the nasal septum? • Mouth breathing? • Cardiovascular (HBP)? • GI problems (gastric hyperacidity)? • Diet? • Smoking, coffee? • Fissured tongue? • Oral hygiene?

10. Amino acids Odoriferous volatile and tissue harming products Steps in Malodor Formation Proteolysis: Proteins Aminolysis: Amino acids

11. Oral Pathogens Causing Halitosis • Fusobacterium nucleatum • Veionella alcalescens • Porphyromonas gingivalis • Prevotella intermedia • Prevotella loeschii • Treponema denticola • Klebsiella pneumoniae

12. Bacterial Growth Bacterial enzymes Inflammation Protein Substrate Salivary and tissue proteins Enzymatic degradation Tissue Permeability Collagen breakdown Delayed Wound Healing Amino Acids Cys-Cys, Cys, Met, Ser, Trp, Orn Bacterial metabolism Volatile Sulphur Compounds affects Volatile sulfur and other objectionable compounds H2S, CH3SH, (CH3)2S, indole, skatole Gram Negative Anaerobes are trapped

13. Protein Substrate CH3SH Methionine Serine thiocysteine Cystine H2S Homocysteine H2S NH3 Cystathionine a-ketobutyrate Cysteine Homoserine NH3 H2S Tryptophan pyruvate propionate Indole, Skatole acetic acid The Mechanism of Malodor Formation

14. Components of Bad Breath“The Oral Bouquet” • Hydrogen sulfide (H2S) • Methyl mercaptan (CH3SH) • Dimethyl sulfide and Dimethyl disulfide • Indole, Skatole, Cadaverine, Putrescine • Volatile fatty acids • Amines

15. The source of the odor? Saliva supernatant No odor Saliva sediment Odor Strong odor Saliva super + sediment

16. 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

17. Diagnosis of Halitosis • Organoleptic • Halimeter • Microbiological • Gas Chromatography/Flame Photometric Detection • Gas Chromatography/Mass Spectrometry

18. Differential Diagnosis • Oral causes (90-95%) • Gastrointestinal system • Dietary • Respiratory system • Metabolic • Trimethylaminuria (TMAU) • Diabetes • Uremia

19. 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

20. Evaluation of Treatment Efficacy • Organoleptic measurement • Halimeter • Microbiological assays • Cysteine challenge

21. 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?

22. Bad breath is better than no breath at all L.Z.G. Touyz Thank You