Clinical Case PresentationClinical Case Presentation

Building Blocks of Life

Amino Acid Metabolism

Building Blocks of Life

Amino Acid Metabolism

Template for CCPTemplate 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)

•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

Objective of Clinical Case Presentations

• Integrate basic science and clinical concepts • Teach critical thinking• Active learning• Help improve student performance on Board Part II

• Integrate basic science and clinical concepts • Teach critical thinking• Active learning• Help improve student performance on Board Part II

Proposed Format of These Presentations

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

• 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!

PatientPatient• 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 AssessmentAre any of the condition in the medical and social

history connected to halitosis?

Diagnosis and Risk AssessmentAre 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?

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?

Proteolysis: Proteins

Steps in Malodor Formation

Amino acids

Odoriferous volatile and tissue harming products

Aminolysis: Amino acids

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

Protein SubstrateSalivary and tissue proteins

Bacterial enzymes

Amino AcidsCys-Cys, Cys, Met,

Ser, Trp, Orn

Enzymatic degradation

Volatile sulfur and otherobjectionable compoundsH2S, CH3SH, (CH3)2S, indole, skatole

Bacterial metabolism

Tissue Permeability Collagen breakdown Delayed Wound Healing

VolatileSulphur Compounds affects

Inflammation

Protein Substrate

The Mechanism of Malodor Formation

Methionine

Homocysteine

-ketobutyrate

CH3SH

Cystathionine

H2S

NH3

Homoserine

Serine

Cysteine

CystineH2S

thiocysteine

H2SNH3

pyruvate

acetic acid

propionateTryptophan

Indole, Skatole

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

The source of the odor?

Saliva supernatant No odor

OdorStrong odor

Saliva sediment

Saliva super + sediment

What conditions or factors favor halitosis? Discuss it with your partner first.

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

• 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

• Excellent• Excellent

Treatment and PrognosisTreatment and Prognosis

PrognosisPrognosis

Etiologic and symptomatic treatmentEtiologic 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

• 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

Evaluation of Treatment Efficacy

• Organoleptic measurement

• Halimeter

• Microbiological assays

• Cysteine challenge

Answer the followingAnswer 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?

• 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 YouThank You