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Probability diagnosis

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  • Dietary habits

  • Poor oral hygiene

  • Oro-dental disease (esp. gingivitis, discharging abscess)

  • Dry mouth (e.g. on waking)

  • Smoking/alcohol

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Serious disorders not to be missed

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Malignancy

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  • lung, oropharynx, larynx, stomach, nose, leukaemia

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Pulmonary tuberculosis

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Quinsy

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Lung abscess

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Blood dyscrasias/leukaemia

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Uraemia

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Hepatic failure

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Pitfalls (often missed)

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Nasal and sinus infection

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Tonsillitis

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Mouth breathing

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Systemic infection

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Appendicitis

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Bronchiectasis

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GORD/Hiatus hernia

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Rarities:

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  • pharyngeal and oesophageal diverticula

  • Sjögren syndrome

  • scurvy

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Masquerades checklist

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Depression

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Diabetes (acetone)

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Drugs (e.g. antidepressants, isosorbide)

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Is the patient trying to tell me something?

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Possible manifestation of psychogenic disorder (e.g. depression).

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Key history

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  • General health

  • Respiratory history

  • Gastrointestinal history including dry mouth and reflux

  • Dental history

  • Drug history including OTC preparations, alcohol and smoking

  • Dietary history: ask about onions, garlic, peppers, curries, spicy salami and similar meats, strong cheeses and water intake

  • Psychosocial history

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Key examination

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  • Orodental inspection, also oropharynx, nose and sinuses

  • Respiratory system

  • Abdominal examination

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Key investigations

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  • FBE

  • ESR/CRP

  • Urine analysis

  • Blood sugar

  • Kidney function tests

  • Liver function tests

  • X-ray of sinuses

  • Consider CT scan sinuses

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Diagnostic tips

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  • If cause is unknown refer to a dental surgeon; consider an ENT opinion.

  • Bacterial putrefaction of dental and food debris plus inflammation of the gums are largely responsible for oral malodour.

  • Smoking, alcohol and a dry mouth all aggravate the problem.

  • One survey indicated that 87% had an oral cause, 8% ENT and 5% an unidentified cause.

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