Quartz 4

16. Allergies and Immune mediated disease_integrated

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Oral Burning Sensation Case Study1

DISCUSSION CASE

Case Description and Patient History

Patient Profile and Chief Complaint2

A 58-year-old female presents with a burning sensation in the oral cavity that has persisted for two months.

Medical and Social History

  • Medical History: Significant for hypertension and diabetes. The patient's diabetic status is relevant for treatment planning due to the risk of oral candidiasis when using steroids.
  • Medications: Currently managed with hydrochlorothiazide (for hypertension) and metformin (for diabetes).
  • Smoking History: Ex-smoker with a 30-year history (one pack per day); quit 10 years ago.
  • Alcohol Consumption: None.
  • Dental History: Last professional dental visit was 12 months ago.

Clinical Activity and Differential Diagnosis

Clinical Assessment Tasks12

  1. Identify the pathosis and describe the clinical features.
  2. Determine the differential diagnosis.
  3. Identify the relevant clinical investigations required.
  4. Establish the definitive diagnosis.
  5. Outline the management plan for this patient.

1. Idnetify the pathosis and describe the clinical features

  • Has plaque like lesion on 46 could be leukoplakia ⇒ do blood tests
    • An obvious white lesion is present around a molar.
    • This specific plaque-like lesion may or may not be part of the same process as the reticular lesions.
  • Reticular erythmatous lesions
    • Subtle reticular lesions are visible on the maxillary gingiva and bilaterally on the buccal mucosa.
    • The lesions appear bilateral and more or less symmetric.
  • ==Frictional Hyperkeratosis: Some areas on the buccal mucosa are attributed to frictional hyperkeratosis from occlusal trauma.==
  • ==Symptoms: The patient reports a burning sensation.==

3. Diagnostics

  • she has diabetes so do Hba1c
    • HBA1C is required to check diabetes control, which impacts the risk of developing candidiasis during treatment.
  • Biopsies
    • take multiple biopsies
    • Multiple biopsies are necessary because there are different types of lesions (reticular vs. plaque-like).
    • Recommended sites: The plaque-like lesion and one or two reticular sites.
    • ==Biopsy is essential to check for dysplasia (e.g., keratosis with moderate dysplasia).==

Differential Diagnosis

  • ==Lichen Planus: The primary consideration due to the bilateral, symmetric reticular lesions.==
  • ==Leukoplakia: Specifically considered for the plaque-like lesion, which may exist as a separate entity.==
  • ==Proliferative Verrucous Leukoplakia (PVL): A possibility when white lesions show dysplasia or transform; it can initially mimic lichen planus.==
  • ==Malignant Transformation: Lichen planus has a quoted malignant transformation risk of approximately 1%.==

Clinical Monitoring

  • Use of clinical photography to track changes over time.
  • Close follow-up (no more than three months between examinations) is required, especially if dysplasia is present.
  • The highest risk of transformation is within the first five years.

Management and Treatment

  • ==Symptom Control: The goal is to manage burning and ulceration while using the minimum amount of medication necessary.==
  • ==Topical Steroids:==
    • Used to control symptoms, but use should be minimized if dysplasia is present.
    • ==Dexamethasone mouthwash: Effective but carries a higher risk of oral candidiasis.==
    • ==Targeted approach: Using a medicinal spray or targeting specific symptomatic sites is preferred over a general mouthwash to limit exposure to non-affected areas.==
  • ==Alternative/Initial Therapy: Starting with “D-flab” (Diflam) to avoid steroids initially if there is no ulceration.==
  • ==Systemic vs. Topical: Topical is preferred over systemic immunomodulating drugs to minimize side effects.==
  • ==The “Inflammation Balance”: Treating ulcerated lichen planus is a “fine balance.” While inflammation can be a defense mechanism against dysplasia, chronic inflammation and tissue damage also increase malignancy risks.==

: Original PDF page 1: 16. Allergies and Immune mediated disease case 2, p.1 : Original PDF page 2: 16. Allergies and Immune mediated disease case 2, p.2

Footnotes

  1. Original PDF page 1 ↩ ↩2

  2. Original PDF page 2 ↩ ↩2

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