Quartz 4

9. Epithelial Pathosis II_integrated

4 min read

Clinical Discussion Case

Patient Profile and History1

  • Patient: 58-year-old female
  • Medical History: Hypertension
  • Social History: Non-smoker; social alcohol consumption
  • Dental History: Wears a removable partial denture
  • Chief Complaint: Troublesome gingival lesion in the 21 region
  • Previous Diagnosis: 2-year history of oral lichen planus

Identify the pathosis and describe the clinical features.

  • Red and white patches on gingiva
    • Transcript notes: Red and white lesions, including a white patch with a "sakila white" appearance.
    • Areas are described as red and pink compared to the surrounding tissue.
  • ulcer
    • The ulcerated area is located on the gingiva (predominantly maxillary).
  • Swelling within the lesions (Note: Lichen planus is typically flat, so swelling is a significant clinical finding).
  • ==Clinical History Details:==
    • The patient has a two-year history of biopsy-proven lichen planus.
    • She experiences periodic soreness that usually settles within a few days with corticosteroids.
    • The current area has been sore for six weeks and is not responding to topical steroid ointment (betamethasone).
    • The soreness is interfering with the patient's ability to wear her denture.

What is the differential diagnosis?

  • SCC
    • A primary concern due to the non-healing nature of the ulcer and the known (small) risk of malignancy associated with lichen planus.
  • Lichenoid drug reaction
    • due to medications for hypertension
    • The patient takes antihypertensive medication, which can be associated with these reactions.
  • Lichen Planus
    • The patient has a known history; however, the lack of response to steroids in this specific area is a concern.
  • Traumatic ulcer
    • Denture Trauma: Irritation from an ill-fitting denture causing gingival swelling and ulceration.
  • ==Erythroleukoplakia: Considered if the lesion is isolated and inflammatory causes are ruled out.==
  • ==Desquamative Gingivitis: Discussed as a descriptive clinical term rather than a final diagnosis; it encompasses conditions like Lichen planus, Linear IgA disease, or other autoimmune/inflammatory diseases.==
  • ==Pyogenic Granuloma: Mentioned as a possibility for the clinical appearance.==
  • ==Secondary Infection: Specifically candidal infection (secondary to steroid use or denture wear).==

What are the relevant clinical investigations?

Make sure to look at the denture

that its seating well and not irritating the gingiva

  • Ask the paitent how she manages the lichen planus:
    • she uses topical corticosteroids and bethamethasone ointment to settle flare ups
      • her flareups settle within a few days and she stops the ointment, but this area she has been treating it daily for 6 weeks

Treatment of Traumatic vs Inflammatory Ulcers

  • You shouldn’t treat traumatic ulcers with topical corticosteroids, but you can treat inflammtory ones with them

Blood Tests

  • ==Hematomics: Full blood count.==

Glucose tolerance

  • we don’t know if the patient is diabetic
  • Fasting Glucose: To check for underlying systemic issues like diabetes.

Dentures

  • adjustment or asking patient to stop earing them
  • ==Clinical Examination: Check if the denture is well-fitting.==
  • ==Adjustment: Adjust the denture to see if the lesion resolves once the source of irritation is removed.==

Biopsy

  • she is at 1% risk of malignancy due to having OLP
  • We are worried about swelling because lichen planus is flat so there shouldn’t be any swelling
  • ==Timing: Can be performed on the first visit if there is high clinical suspicion of malignancy, or after a two-week trial of conservative management (denture adjustment/antiseptics).==
  • ==Procedure: Multiple biopsies can be performed if other areas are also not responding to treatment, though the primary focus is the non-healing ulcerated area.==

Histology

  • Nuclear pleomorphism
    • Variation in the shape and size of epithelial cells and nuclei.
  • Lymphocytic infiltrate
    • Hyperchromatism: Dark-staining lymphocytic infiltrate (seen as small blue dots).
  • Mitotic figures
    • Presence of abnormal mitotic figures (nuclear material arranged in lines).
  • The histology is classic for a sqaumous cell carcinoma
  • ==Invasion: Epithelial cells invading the underlying connective tissue; small islands of keratin-producing cells seen within the tissue.==
  • ==Differentiation: Presence of “keratin pearls” or well-formed keratin indicates a well-differentiated malignancy.==

What is the diagnosis?

  • Early Squamous cell carcinoma that has developed
  • Developed within a pre-existing area of lichen planus.

How would you manage this patient?

  • should still make the patient wait 2 weeks without hte dneture, as those two weeks wont make a difference , but two months will
  • ==Conservative Trial (Initial Phase):==
    • Adjust the denture and instruct the patient to leave the denture out.
    • Prescribe antiseptic mouthwash (e.g., Chlorhexidine) instead of steroids if trauma is suspected.
    • ==Review in two weeks: This is the critical window; if the lesion does not improve, a biopsy is mandatory.==
  • ==Communication:==
    • Be honest but careful. Inform the patient that while the denture might be the cause, lichen planus carries a small risk of mouth cancer, and a biopsy is necessary if it doesn't heal.
  • ==Referral:==
    • Once a biopsy confirms SCC, refer the patient to a specialist head and neck surgeon.
    • The patient will then be managed through a multidisciplinary team (MDT) process.

Footnotes

  1. Original PDF page 1: 9. epithelial Pathosis II, p.1 ↩

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