Quartz 4

6. Injuries

3 min read

Case Discussion Of Oral Lesion

Patient Presentation and History1

A 52-year-old male presented with a 6-week history of a painful oral lesion. The patient has been self-treating the area with Kenalog, which has yielded no clinical response.

Medical and Social History

Clinical Case Description

  • Medical Conditions: Diabetes, hypertension, and hypercholesterolemia.
  • Social History:
    • Long-term smoker (30 years), currently smoking 15 cigarettes per day.
    • Alcohol consumption averages two drinks per day.
  • Dental Status: The patient is edentulous; his current dentures are 5 years old.

Case Description And Patient History

Identify the pathosis and describe the clinical features.

Chronic ulcer features vs Acute ulcer

Chronic has scaring:

What is the differential diagnosis?

  • traumatic ulceration
  • Oral Squamous cell carcinoma
  • Leukoplakia
    • could be an ulcerated leukoplakia but its a bit of a stretch
  • Tuberculosis
  • Fungal infection

Since OSCC is a differential

  • then the differentials for OSCC are fair game too!
  • ex. TB, fungal infect

What are the relevant clinical investigations?

Blood tests

Full blood count

Hematinic

Ulcerated Lesions

ALWAYS DO HEMATINICS FOR ULCERS

  • B12, FOLATE , IRON BY DEFAULT FOR ULCERS

HbA1c

  • Diabetic so they may have an ulcer so they’re not

Biopsy

  • Should be done after other less invasive tests

Misc

  • since he wears a denture ask him if he wears it at night
    • this was actually the case with this patient and he wears it at night

What is the diagnosis?

  • the diagnosis is a chronic traumatic ulcer

How would you manage this patient?

Meds and rinses

  • Chlorhexidine (highest concentration)
    • antibacterial
    • 2x a day everyday until next appointment
  • Difflam
    • usage: PRN for pain control

Chlorhexidine gel vs mouthrinse

  • The patient will end up poking their wound with their finger, could be dirty and will irritate the wound

On the continuation of kenalog

  • it will interfere with healing
  • thus it must be stopped

Cause of continuation of ulcer

Part of the reason the ulcer is lasting so long is because he keeps hitting it with kenalog

Dentures

  • Instruct the patient to only wear the denture if they have to
    • this is because they have a wound that is trying to heal!

Recall interval

  • 2 weeks is the recommended recall

theoretical

  • the patient comes back after 2 weeks and the ulcer is slowly getting better but not healed
  • A BIOPSY IS NOT NEEDED
    • a chronic ulcer won’t be healed in two weeks, as long as the ulcer is getting better tell the patient to carry on with the same protocol:
      • chlorhexidine twice a day, difflam etc
    • bring him back in a 2-3 week interval
  • Took two months for lesion to result

Footnotes

  1. Original PDF page 1: Injuries Case 2, p.1 ↩

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