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 leukoplakia
4 Lichen planus
5 Geographic tongue
Answers:
1 Acute pseudomembranous candidiasis, or thrush, also develops white lesions on the dorsum of the tongue which are easily scraped off, but cause a tingling or burning sensation and leaving erythematous areas underneath.
2 No
3 No
4 No
5 No
Comments: Other white lesions on the dorsum of the tongue are persistent as in lichen planus and hairy leukoplakia, or transient as in geographic tongue. However all the above lesions are not associated with halitosis and have different symptomatology and clinical features. The black hairy tongue lesion differs in the color and the length of the filiform papillae, as the patient's tongue coat is whitish and not black, while the length of the filiform papillae is normal.
Q3 Which other conditions are associated with similar furry tongue lesions?
1 Scarlet fever
2 Cold
3 Sjogren syndrome
4 Chronic pneumonia
5 Hyperplastic candidiasis
Answers:
1 Scarlet fever is an acute infection from Streptococcus A bacterium and characterized by white coating on the tongue, gradually changing into a strawberry‐like appearance due to the inflammation of taste papillae and associated with sore throat, fever, swollen glands as well as a generalized sandpaper skin rash.
2 Cold is an acute viral infection of the upper respiratory system that is characterized by sore throat, runny nose, white furry tongue and accompanied with cough, fever, muscle aches and general fatigue as well.
3 No
4 No
5 No
Comments: Sjogren syndrome, chronic pneumonia, and hyperplastic candidiasis are often associated with furry tongue but with different etiology clinical picture or and duration.
Case 4.10
CO: A 58‐year‐old woman presented for an evaluation of some pain from her upper teeth and bad breath.
HPC: The pain was located at the upper molars area and characterized as a constant, dull ache without exacerbations from various cold or hot stimuli. It appeared gradually after a severe cold infection three weeks ago and became associated with a partial loss of smell and taste, as well as bad breath. This was more obvious in the mornings, slightly improved with teeth and mouth cleaning, but remained unchanged with eating.
PMH: She was an overweight lady with no serious medical problems apart from a few episodes of hay fever in spring which were controlled with antihistamine sprays. She was not under any drugs and only a few paracetamol tablets were taken for a flu infection three weeks ago. She had never been a smoker, drinker, or consumer of spicy foods.
OE: The oral examination revealed oral mucosa and dentition in good condition. Despite her heavy restorations (crowns and fillings) her teeth responded well to pulp vitality tests. A slight tenderness around her molars together with stuffy nose, nasal drip secretions and slight cervical lymphadenopathy were seen. A rotten‐like bad breath was detected during the examination. Laboratory investigations revealed hematological and biochemical tests within normal values but sinus X‐rays revealed opacification of the lower third part of both maxillary sinuses (Figure 4.10). The nasal septum and the rest of the visualized sinuses and teeth were normal. A similar episode of pain was reported one year ago and gone with wide broad antibiotics.
Q1 What is the cause of her bad breath?
1 Cystic fibrosis
2 Fungal sinusitis
3 Foreign bodies in maxillary sinuses
4 Sinus malignancies
5 Chronic sinusitis
Answers:
1 No
2 No
3 No
4 No
5 Chronic sinusitis is the cause. Chronic sinusitis is characterized by a chronic infection of the sinuses causing an increased production of mucus with bad odor, which drains down the back of the throat. There, the odor of the infected mucus is intermingled with the exhaled air and causes malodor.
Comments: Halitosis is also detected in deep fungal infections (mainly from Aspergillus or Mucor species) and various sinus malignancies, but these affect a certain group of patients (with immunodeficiencies or with uncontrolled
