5. Injuries_integrated

Case Discussion Of Oral Pathosis

Patient presentation

Snapshot

• Patient: 73-year-old female
• Chief complaint: Painful, non-healing tongue lesion/ulcer for 6 weeks
• Risk context: Non-smoker, non-drinker; considered “high risk” due to medical history
• Key background: Previous oral cancer at the same site (treated 2 years ago)

History of presenting complaint

• Painful, non-healing lesion/ulcer of six weeks duration
• Site: right lateral surface of tongue
• The patient does not smoke and does not drink alcohol, and is considered "high risk" due to her medical history.

Medical history

• Osteoarthritis
• Hypertension
• Hypercholesterolemia

==Current Status: Presents with a non-healing lesion/ulcer in the mouth.==

Relevant dental & oncological history

Prior malignancy and treatment

==* Previous Malignancy: History of oral cancer at the same site as the current lesion.

• Treatment History: Completed cancer treatment two years prior, which included:
  • Surgery: Resulted in altered anatomy and scarring.
  • Radiation Therapy: Leads to long-term side effects such as xerostomia (dry mouth) and reduced blood supply to the tissues.
  • Chemotherapy: Contributes to the overall complexity of the case.==

Additional relevant oral history

• Biopsy-proven Oral Lichen Planus (OLP).
• Squamous Cell Carcinoma (SCC) of the right lateral tongue, treated with surgery and chemo-radiation therapy (treatment completed two years ago).
• The patient is a non-smoker and non-drinker.

Clinical examination / lesion description

Current lesion characteristics

==* Location: The lesion is located at the site of the previous surgery, in close proximity to a tooth.

• Type: Ulcerated lesion (not a lump).
• Size: Approximately 1 cm in diameter.
• Appearance:
  • The lesion looks “punched out.”
  • Margins are raised and appear white (indication of a chronic process).
  • No evidence of keratosis.
  • The surrounding anatomy is disfigured due to previous surgical intervention.==

Local factors affecting symptoms/healing

Why this site is vulnerable

==* Sensory Changes: The patient has altered sensation in the area (paresthesia/anesthesia) due to previous surgery, meaning she may not feel trauma occurring at the site.

• Tissue Quality: The area has significant scarring and poor blood supply (hypovascularity) due to radiation, making the mucosa more susceptible to breakdown and slower to heal.==

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Question: Identify the pathosis and describe the clinical features.

Marks

3 marks for location
3 marks for description

Identification

• Pathosis: Chronic ulcerated lesion
• ==Margins: Well-defined but with raised, white margins==

Clinical features

• Location: Left lateral tongue
• Ulcer characteristics:
  • NOT RED, therefore no inflammation, indicating it is a chronic ulcer
  • Associated with dry mouth (lack of lubrication causes mucosa to rub against teeth)
  • The dorsal surface of the tongue may appear disfigured or "crazy" due to previous surgical reconstruction

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Question: Is it a primary or recurrent lesion?

Definitions used in this case

• Second Primary: A new lesion appearing at the site after a 5-year disease-free interval (AFTER 5 years)
• Recurrence: lesion appearing at the same site within 5 years of treatment

==Current Classification: This is the primary concern because the lesion is at the same site as the previous cancer. Since this patient is only 2 years post-treatment, it would be classified as a recurrence (defined as a lesion appearing at the same site within 5 years of treatment).==

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Question: What is the differential diagnosis?

Differential diagnosis (ranked/priority implied by notes)

• Recurrent OSCC (Squamous Cell Carcinoma): Must be the #1 differential given the history.
• Traumatic Ulcer (Chronic): Likely due to the combination of dry mouth, altered sensation, and scarring
  • Its very close tooth (the tissue rubs against the adjacent tooth)
  • Shes particularly sensitive because
    • radiotherapy: low salivary flow (dry mouth)
    • susceptible to trauma (altered sensation)
• ==Secondary Candidal Infection: A secondary infection of a pre-existing benign ulcer.==

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Question: What are the relevant clinical investigations?

Clinical assessment

• Check for sharp teeth, rough fillings, or calculus that could be causing trauma.

Biopsy

Biopsy timing in a high-risk patient

• When should biopsy be undertaken: ==Unlike a standard case where you might wait 2 weeks for a traumatic ulcer to heal, a biopsy should be performed immediately (first visit) because the patient is high-risk for recurrence.== She has super sus symptoms and has lots of points to OSCC so take biopsy right away.

• Type: Incisional biopsy (scalp biopsy).
• Repeat biopsy: If the lesion does not respond to treatment as expected, a repeat biopsy is necessary to rule out a "false negative" (non-representative sample) or to check for secondary changes.

Blood tests

Hematinic blood tests

• Iron, B12, folate, etc. Check levels to rule out nutritional deficiencies that prevent healing.

Full blood counts

• Should be performed as a routine investigation for non-healing ulcers.

Diabetes screening

• Fasting Glucose: Recommended as a minimum to rule out undiagnosed diabetes in a patient with a non-healing lesion. For an unknown diabetic the best test would be Fasting Glucose.
• HbA1c: Don’t necessarily have to do HbA1c. Can be used for diagnosis but may have Medicare billing restrictions for general dentists; fasting glucose is often more accessible.

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Question: What is the diagnosis?

Results / working diagnosis from notes

• Biopsy was taken and came back as traumatic ulcer
• ==Subsequent finding: Secondary candidal infection (identified when the ulcer failed to heal after initial management)==

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Question: How would you manage this patient?

Benign traumatic ulcer

Remove contributing trauma + support healing

do all the obvious like check occlusion and interferences—smooth down any sharp tooth surfaces, remove calculus, and ensure no rough fillings are irritating the site

• ==Hygiene: Use Chlorhexidine (e.g., Curasept) to keep the area clean==

Meds

• Chlorhexidine (highest concentration) to keep the area clean
• ==Antifungals: Required once a secondary infection is suspected==

Recall / follow-up

• ==Initial follow-up: 2 weeks==
• longer recall period because the biopsy gave a diagnosis , so 6 weeks
  • In post-radiation patients, healing is extremely slow due to poor blood supply
  • because we aren’t expecting healing to be quick
• ==Total healing time: It took 12 months for the ulcer to fully epithelialize==

If not improving (theoretical course in notes)

• patient comes in after 6 weeks and is not better even after medications
  • a rebiopsy is not recommended because it will just make a better wound!
• Tell the patient to continue with the prescribed treatment and recall again in 6 weeks
  • it got a bit better , so its a sign to kep doing it
• In the end this was done for 3 months, at the end of the 3 month period the ulcer wasn’t getting worse or better
  • At this point the diagnosis should be questioned ex: if a benign ulcer does not reduce by at least 50% within 3 months despite compliance, you must question if the biopsy was representative or if there is a secondary factor (like infection or undiagnosed diabetes)
    • could the pathology be wrong
      • Yes
    • Therefor biopsy should be repeated
    • When biopsy was retaken
      • A secondary candida infection was found

Antifungal tablet (agent selection considerations)

• Amphotericin isn’t a good candidate because p/t has a dry mouth (lozenges are difficult for patients with severe dry mouth as they cannot dissolve the tablet). Theoretically, a compounding pharmacy could create a custom gel version of Amphotericin, though it is expensive
• Nystatin drops are bad because they are sugary and can promote caries —avoided in this case due to high sugar content and the patient's high caries risk from xerostomia
• Miconazole oral gel is a good alternative
  • For 6 weeks 4 times a day
  • Tell GP about miconazole due to interactions with drugs (e.g., Statins, Warfarin). If the patient is on a Statin, consult the GP to monitor or temporarily suspend the medication