Quartz 4

8. OPMDs_integrated

4 min read

Clinical Discussion Case: Oral Lesion (OPMDs Integrated)

Patient presentation

A 62-year-old female presents with a lesion on the buccal mucosa.

  • Clinical appearance (initial): Mainly a red (erythematous) lesion, quite well-defined, with subtle white specks within the red area. Solitary at initial presentation.
  • Onset: First noticed 3–4 months prior to the clinical visit.
  • Symptoms: Mostly asymptomatic; occasional irritation at the site triggered by spicy or acidic foods (history of mild irritation specifically with spicy foods).

Medical & social history

  • Medical: Hypercholesterolaemia; depression. (High cholesterol and depression)
  • Social: Non-smoker; does not consume alcohol. (Non-smoker and does not consume alcohol)

Referral context / case description

The patient was originally referred for “gingivitis,” but the clinical presentation was a “fiery red,” solitary gingival lesion that did not align with standard plaque-induced gingivitis.

Key concern early on

A solitary, well-defined erythematous lesion should be treated with higher suspicion than typical lichen planus, even if histology suggests lichenoid inflammation.

Disease course / progression

At ~12 months

New lesions began to appear in other areas, including the front of the mouth.

At ~2 years

A significant change occurred within a three-month window:

  • White plaques appeared
  • Loss of interdental papilla/bone
    This was described as a “major alarm bell” for malignancy.

Major alarm bell

Rapid change + new white plaques + interdental papilla/bone loss → high concern for malignancy.

Clinical features & pathosis (identify the pathosis)

  • Clinical description: Well-defined, predominantly red area on the gingiva.
  • Histopathological features (initial biopsy):
    • Liquefactive degeneration of the basal cell layer
    • Lymphocytic infiltrate in the lamina propria
    • These features are characteristic of lichenoid inflammation
  • Desquamative gingivitis: Clinical descriptive term for these inflammatory gingival lesions, often seen in lichen planus or pemphigoid.

Differential diagnosis

  • Trauma: Considered but unlikely given the presentation.
  • Inflammatory conditions: Lichen planus (most common inflammatory condition to rule out)
  • Desquamative gingivitis: Clinical presentation category for inflammatory gingival lesions
  • Lupus (systemic/discoid): Considered due to autoimmune nature; lupus usually presents with multiple lesions
  • Erythroplakia: Highest risk of malignancy; early-stage erythroplakia can histologically resemble lichen planus

Clinical investigations

Biopsy

  • Initial biopsy: Necessary to establish a baseline. Even if uniform, biopsy is required to check for dysplasia. Notes indicated a single biopsy can be performed because the lesion looked pretty much the same.
  • Repeat biopsy: In chronic cases, repeat if the lesion changes, or at least every 18–24 months even if stable.
  • Techniques:
    • H&E staining: Standard for histopathology
    • Direct immunofluorescence (DIF): If autoimmune condition (e.g., lupus or pemphigoid) suspected

Biopsy cadence (chronic lesions)

Repeat biopsy with change or routinely every 18–24 months even if stable.

Hematinics

  • Tests: B12 and folate
  • Rationale: Deficiencies can be associated with dysplastic changes in oral mucosa, even in non-ulcerated lesions. Notes mentioned this in the context of an ulcerated leukoplakia, but still applicable even if not ulcerated.

Fasting glucose

Standard part of systemic workup for chronic oral inflammatory conditions.

Full blood count

Required to rule out systemic involvement or underlying blood dyscrasias.

Diagnosis (working → final)

  • Initial pathological diagnosis: Lichen planus (based on histology) due to liquefactive degeneration of basal cell layer.
  • Clinical refinement: Because lesion was solitary (not bilateral/symmetric), the more accurate initial diagnosis was Oral Lichenoid Lesion (lichen planus should be symmetric and bilateral).
  • Final diagnosis (2 years): Squamous Cell Carcinoma (SCC)
  • Retrospective diagnosis: Initial red lesion was likely erythroplakia that progressed to SCC.

Management

Follow-up / surveillance

  • Close surveillance mandatory.
  • Reviewed every 3 months with photographic documentation to track subtle changes.
  • If it develops into bilateral symmetric lesions, then it turns into lichen planus.
  • Clinicians must not “just trust the pathologist report”—if solitary and red, treat with higher suspicion than typical lichen planus.

Surgical intervention (once SCC confirmed)

  • Underwent partial maxillectomy
  • Required 1 cm surgical margin
  • Resulted in loss of teeth and bone

If lesions spread / multiple lesions develop

  • Then it needs a biopsy
  • In this case it turned into an OSCC
  • Field cancerization: Developed a second primary SCC three years after the first.
  • Recurrence vs second primary: New lesion in a different area (even within five years) → second primary tumor, not recurrence.
  • Management of multiple lesions: If one area undergoes malignant transformation, all other lichenoid/erythematous areas must be biopsied, as they are all at risk.

Field cancerization implication

One malignant transformation → biopsy all other lichenoid/erythematous areas (ongoing risk across the field).

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