HPC: The pain started after the surgical removal of a carcinoma from his palate six months ago and worsened from the end of the third week of chemo‐radiotherapy. Together with his pain, bad breath like rotten fruit was detected, remaining unchanged during the course of his treatment.
PMH: He was an old man with cachexia due to his recent treatment for an extensive oral carcinoma, while his hypertension and respiratory failure was controlled with drugs and ceasing smoking.
OE: His examination revealed a large indurate ulcer with raised margins on the skin above the right corner of his mouth (Figure 4.8). The ulcer was deep and extended to the adjacent alveolar mucosa and hard palate, and infiltrated facial skin close to his right nostril. Some superficial ulcerations covered most of his oral mucosa (mucositis grade III) together with xerostomia, halitosis, and difficulties in consuming food and drinks.
Q1 Which is/are the possible cause/s of the patient's halitosis?
1 Resistant carcinoma
2 Mucositis
3 Xerostomia
4 Malnutrition
5 Mouth breathing
Answers:
1 His extensive oral cancer and local necrosis–sepsis allow a number of anaerobic bacteria to grow and produce strong volatile gases which are easily detected by the patient and his close relatives.
2 Mucositis causes difficulties in brushing his remaining teeth, and allows the accretion of halitosis‐induced pathogenic bacteria.
3 Xerostomia occurs with halitosis in various ways. Oral dryness assists the growth of various pathogenic halitosis bacteria, by reducing the mechanical washing–cleaning action of saliva or eliminating various antimicrobial components (enzymes, immunoglobulins). Xerostomia was seen and induced by the damage of the salivary glands (minor and major) with radiotherapy and boosted with the reduced fluid consumption due to patient's mucositis‐induced dysphagia.
4 The malnutrition of this patient, due to his eating and swallowing problems from mucositis, causes his liver to break down the lipids and proteins for energy and release of ketones into the blood. When these substances reach the lungs, they are exhaled into the air, producing breath smelling of rotten fruit.
5 No
Comments: Mouth breathing causes a temporary oral dryness and halitosis that easily go with fluid and food consumption and teeth brushing.
Q2 What are the other causes of cachexia apart from oral cancer?
1 Acquired immunodeficiency syndrome
2 Diabetes mellitus
3 Anorexia nervosa
4 Kwashiorkor
5 Hyperthyroidism
Answers:
1 Patients with full‐blown AIDS are often characterized by loss of weight, muscle atrophy, fatigue, weakness, and loss of appetite (typical characteristics of cachexia).
2 No
3 No
4 No
5 No
Comments: Diseases such as uncontrolled diabetes mellitus and hyperthyroidism are characterized by weight loss due to increased metabolism of fat and muscles. Anorexia nervosa is a typical example of marasmus; a condition characterized by energy deficiency due to severe malnutrition, while in Kwashiorkor, the malnutrition involves only protein intake.
Q3 Which pathogens are isolated in oral mucositis lesions?
1 Candida spp.
2 Pseudomonas aeruginosa
3 Herpes simplex
4 Mycobacterium ulcerans
5 Treponema pallidum
Answers:
1 Radio‐chemotherapy disrupts the epithelial barrier and alters the host immunity allowing the entrance and growth of Candida species such as albicans, glabrata, krusei, and tropicalis in mucositis lesions.
2 Pseudomonas aeruginosa and Escherichia coli are among the Gram‐negative bacteria which grow in increased numbers in oral mucositis lesions.
3 Alterations in a patient's immunity allow the growth of fungi and viruses like Candida and Herpes species in oral mucositis.
4 No
5 No
Comments: Mycobacterium ulcerans is a slowly growing mycobacterium infecting the skin and subcutaneous tissues but not oral mucosa causing non‐ulcerated nodules/plaques and ulcerated lesions. Treponema pallidum is responsible for ulcerations in syphilis and not in mucositis.
Case 4.9
CO: A 62‐year‐old woman was presented for evaluation of her bad breath.
HPC: Her bad breath was first noticed by her husband four days ago, and was more intense in the mornings and slightly improved during eating or brushing her teeth. Her halitosis appeared at the same time with a febrile viral infection of her mouth and throat.
GMH: Diabetes and mild hypertension were her main medical problems and were under control with drugs and daily exercise. Smoking was stopped after an episode of pneumonia last year.
OE: A whitish yellow asymptomatic thick coating was found, on the dorsum of her tongue, which was partially removed with scraping (Figure 4.9) and associated with sore throat, stuffy nose, mild fever (<38 C) and cervical lymphadenitis. Her oral hygiene was inadequate and the patient wore partial ill‐fitted dentures. Malodor was noted during examination.
Q1 Which is the main origin of her bad breath?
1 Furry or coated tongue
2 Stuffy nose
3 Mouth breathing
4 Fever‐induced dehydration
5 Bad prostheses
Answers:
1 Bad breath was caused mainly by degradation of food debris and necrotic epithelial cells from various anaerobic bacteria that located on the dorsum of the tongue (white coat), found in large quantities in upper respiratory viral infections.
2 No
3 No
4 No
5 No
Comments: The oral dehydration facilitates the growth of a number of bacteria, including those responsible for bad breath. However, in this patient, the dehydration was not severe, as the mouth breathing and fever were neither intense nor high. Her poor OH and bad prosthesis caused constant malador, which was not restricted to the period of her febrile illness.
Q2 Which other diseases have similar clinical features with this condition?
1 Acute pseudomembranous candidiasis
2 Black hairy tongue
3 Hairy