What Would You Do?

The following photographs and clinical descriptions are actual case submissions to the University of Pittsburgh Department of Oral and Maxillofacial Pathology. In each case, ask yourself what diagnoses are you considering? How would you manage this patient?

Case I

A female patient in her mid-50s presents to your practice for a new patient exam. You notice a 4x5mm round, dark brown or black pigmented lesion of the left buccal mucosa above the level of the occlusal plane. When asked, the patient is unaware of its presence. The patient is fair-skinned and has an unremarkable medical history. No other lesions or irregularities are seen in the mouth and she has good oral hygiene despite numerous crowns and restorations that were placed when she was younger.

Case II

A 64 year old female patient you have treated for many years is in for a cleaning and recall examination. You notice decreased salivary flow and the patient complains of dry mouth.

She was recently diagnosed with vitamin B12 deficiency and is now taking oral supplements for vitamins B2, B6, B12, and D3. She also is treated by a physician for multiple sclerosis, left heart failure, and porphyria.

Case III

A 54 year old female patient presents to your practice seeking a second opinion. This patient saw her PCP several months ago who noticed several white patches in her mouth and prescribed nystatin with a diagnosis of oral thrush. The patient sees her physician regularly, takes no medications, and her medical history is non-contributory.

You observe striated white and red lesions on both buccal mucosa, the labial vestibules, dorsum of tongue, and entire hard palate. Ulcerations are noted sporadically on these tissues among the striations, and the attached gingiva shows areas of ulceration. The patient’s entire mouth is painful. Eating and even talking are difficult for her, and her oral hygiene has deteriorated. She denies lesions in her genitourinary tissues, but has noticed plaque-like lesions on her scalp and abdomen.

Answers

Case I

Amalgam tattoo, likely created during preparation and placement of her crowns on teeth #14 and 15. Differential diagnosis should include blue nevus, melanotic macule, and possibly oral melanoma, however the proximity to previous dental restorations suggests implanted metallic debris. Small debris may or may not be visible on a radiograph. No treatment is required, but the lesion should be documented and monitored over time.

Case II

Erythema Migrans (geographic tongue). While the patient’s vitamin deficiency is notable, the appearance is pathognomonic for geographic tongue. To verify, the lesion should be followed over a short period and would be expected to change in size, shape, or number. The xerostomia and tingling sensation of the lips and tongue make it prudent to suggest a swab culture for candidiasis, and an antifungal suspension would be appropriate. Reassure the patient that this is a common and harmless condition that will wax and wane periodically. Avoiding acidic and spicy foods will help if flair ups are uncomfortable.

Case III

This is an example of erosive lichen planus, determined histologically after incisional biopsy of numerous sites. Biopsy is indicated, and your differential may include chronic candidiasis, proliferative verrucous leukoplakia, and verrucous carcinoma. The diseases associated with desquamative gingivitis may also be considered, but the lace-like, white striae make this less likely. Oral corticosteroid ointments and gels can be helpful to manage painful flair-ups, but the extensive presentation seen in these photographs is better managed with systemic steroids. Referral to PCP or rheumatologist would also be appropriate to investigate systemic conditions. The patient should be monitored on a regular basis and any change in texture of the lesions should be carefully scrutinized for new biopsy as there is a slight risk for malignant transformation.

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