but also by stimulating the gingival melanocytes to produce melanin, therefore causing a gingival melanosis.
Q2 The diagnosis of this lesion is based mainly on:
1 Intra‐oral examination
2 History
3 Culture
4 Biopsy
5 Allergic tests
Answers:
1 Intra‐oral examination shows the brown covering of the dorsum of tongue.
2 History of drug/smoking or drinking habits allows clinicians to identify the possible risk factors of hairy tongue.
3 No
4 No
5 No
Comments: Although cultures and biopsies show the presence of various chromogenic bacteria and Candida species within the elongated filiform papillae in hairy tongue lesions, these techniques are not widely used for diagnosis as they are expensive, time consuming and their results do not seem to alter the clinical course of this disease.
Q3 What symptom is/or are commonly associated with brown hairy tongue?
1 Pruritus
2 Metallic taste
3 Belching
4 Fatigue
5 Nausea
Answers:
1 No
2 Metallic taste is a common complaint of patients with hairy tongue as it is induced by the alteration of gustatory papillae (proliferation or delayed apoptosis) as a result of the excessive smoking, drinking, or use of strong mouthwashes.
3 No
4 No
5 No
Comments: The excessive tongue coating sometimes causes a local irritation on the palate that provokes nausea, belching, or even pruritus, especially in anxious patients.
4 Malodor
Malodor, also known as halitosis, is unpleasant bad breath that causes severe patient concern and a negative effect on the patient's life. Halitosis is caused by the release of various volatile gases, either during food breakdown from various bacteria that are normal inhabitants in the patient's mouth, or during expiration of odorous substances which are moved via circulation from the periphery. Halitosis can easily be detected by other people (real) or not (fake). The majority of causes of real halitosis come from disorders inside the mouth (>85%) and the remaining are from nose, sinuses, throat, lungs, stomach, pancreas, and liver. Fake halitosis (halitophobia) is common in patients with severe anxiety, depression, or obsessive compulsive disorder. The basic step in halitosis treatment is the recognition and treatment of its underlying cause (Figure 4.0a and b).
The more common causes of halitosis are listed in Table 4.
Figure 4.0a Halitosis from a patient with advanced oro‐nasal carcinoma.
Figure 4.0b Halitosis from a patient with a neglected mouth.
Table 4 Common and important conditions associated with malodor
| Malodor |
| Physical causesFood or fluid ingredientsOnions/garlicFoodstuffs/additivesSpiceAlcoholFood or fluid lackStarvation or dehydrationHabitsSmokingHeavy drinkingLocal causesRelated with the mouthCariesAcute ulcerative gingivitisPericoronitisChronic periodontitisChronic dental abscessOsteonecrosismyelitisMedicated osteonecrosis (due to bisphosphonates, denosumab, bevacizumab)Dry socketNomaOroantral fistulaSinusitisUlcerations, i.e. pemphigus vulgaris (PV)SialdenitisNeoplasmsRelated with pharynx/esophagusTonsillitisEsophangeal infectionrefluxpouchNeoplasmsSystemic causes Diseases fromliverHepatic failureKidneyRenal failureLungsInfectionsBronchiectasisNeoplasmsGutGastric regurgitationCNSTemporal lobe epilepsyTemporal lobe tumorsDelusionsMetabolismTrimethylaminuriaDrugsAssociated with xerostomiaAntihistaminesDiureticsNarcoticsAntidepressantsDecongestantsAntihypertensiveAntipsychotics |
Case 4.1
CO: A 43‐year‐old woman presented with halitosis and severe pain in the area of a recent extraction.
HPC: The pain started immediately after a difficult extraction of a severely decayed second lower molar, becoming even more intense over the following three days and radiating toward the ipsilateral upper molars and ear. One day later, a bad rotten smell coming from her mouth was noted and remained unchanged at her last dental examination.
PMH: Her medical history did not reveal any serious diseases or drug uptake, and her dental history recorded only occasional visits to her GDP for dental pain relief. Smoking (>25 cigarettes daily) was reported.
OE: Oral mucosa did not show any oral lesions apart from erythematous and tender gingivae around the socket of the extracted molar. The socket was empty of clot and showed a partially exposed alveolar bone which was covered with debris and saliva (Figure 4.1). Pain was coming from the socket and was exacerbated with probing. No evidence of a dental abscess, facial swelling or cervical lympho‐adenopathy was noticed, except that a bad, rotten smell was arising from the socket. Her mouth and dentition was neglected and many decayed teeth and roots due to her poor oral hygiene were recorded.
Q1 What is the cause of her bad breath?
1 Tooth avulsion
2 Intra‐alveolar carcinoma
3 Dry socket
4 Metastatic tumors
5 Osteonecrosis induced by drugs
Answers:
1 No
