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Clinical Case PresentationClinical Case Presentation
Building Blocks of Life
Amino Acid Metabolism
Building Blocks of Life
Amino Acid Metabolism
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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)
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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
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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
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Test at the end of this presentation!
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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
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• 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)
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• 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.
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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?
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Proteolysis: Proteins
Steps in Malodor Formation
Amino acids
Odoriferous volatile and tissue harming products
Aminolysis: Amino acids
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Oral Pathogens Causing Halitosis
• Fusobacterium nucleatum
• Veionella alcalescens
• Porphyromonas gingivalis
• Prevotella intermedia
• Prevotella loeschii
• Treponema denticola
• Klebsiella pneumoniae
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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
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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
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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
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The source of the odor?
Saliva supernatant No odor
OdorStrong odor
Saliva sediment
Saliva super + sediment
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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
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Diagnosis of Halitosis
• Organoleptic• Halimeter• Microbiological• Gas Chromatography/Flame
Photometric Detection• Gas Chromatography/Mass
Spectrometry
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Differential Diagnosis
• Oral causes (90-95%)• Gastrointestinal system
Dietary
• Respiratory system• Metabolic
Trimethylaminuria (TMAU) Diabetes Uremia
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• 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
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Evaluation of Treatment Efficacy
• Organoleptic measurement
• Halimeter
• Microbiological assays
• Cysteine challenge
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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?
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Bad breath is better than no breath at all
L.Z.G. Touyz
Thank YouThank You