Quartz 4

5. Injuries_integrated

4 min read

Case Discussion Of Oral Pathosis

Patient Presentation and History1

A 73-year-old female presented with a painful lesion of six weeks duration affecting the right lateral surface of her tongue. Her medical history is significant for the following conditions:

  • Osteoarthritis
  • Hypertension
  • Hypercholesterolemia

Relevant Dental and Oncological History

The patient has a complex oral history, including:

  • 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).
  • Post-Treatment Complications:
    • Xerostomia (Dry Mouth): Lack of lubrication makes the mucosa more susceptible to friction and traumatic ulceration.
    • Altered Sensation/Nerve Damage: Reduced sensation means the patient may not feel trauma occurring.
    • Scarring: Surgical scarring has reduced the elasticity and blood supply of the tissue.
  • The patient is a non-smoker and non-drinker.

Clinical Case Description

Lesion

Lesion: 1 cm "punched out" ulcer with raised, white margins; no significant keratosis.

Case Description And Patient History

Comparison of Diagnostic Approaches

  • Low-Risk Patient: Remove trauma source and wait two weeks to observe healing before biopsy.
  • High-Risk Patient (Oncology History): Perform an incisional biopsy on the first visit to rule out malignancy immediately due to high recurrence risk.

Biopsy Techniques

  • Incisional Scalpel Biopsy: Preferred to obtain a representative sample.
  • Punch Biopsy: Common tool, though preferences vary.
  • Representative Sampling: Critical to avoid a "false sense of security" (false negative) from non-representative sites.

Identify the pathosis and describe the clinical features.

Marks

3 marks for location 3 marks for description

  • Location
    • Left lateral tongue
  • Ulcer
    • NOT RED, therefore no inflammation thus its a chronic ulcer

Is it a primary or recurrent lesion?

The patient had OSCC, so when would we call it a secondary primary lesion?

  • AFTER 5 years

What is the differential diagnosis?

Differential diagnosis

Differential Diagnosis: Recurrent SCC (primary concern as it is within 5 years of original), Chronic Traumatic Ulcer (due to xerostomia/sensory deficit), or Secondary Fungal Infection.

  • Recurrent OSCC
  • Traumatic Ulcer
    • its very close tooth
    • shes particularly sensitive because
      • radiotherapy: low salivary flow
      • susceptible to trauma

What are the relevant clinical investigations?

Investigations

Investigations: Immediate incisional biopsy (required for high-risk patients), Hematinics (Iron, Folate, B12), FBC, and Fasting Glucose (to rule out Diabetes).

Biopsy

  • When should biopsy be undertaken
  • she has super sus symptoms and has lots of points to OSCC so take biopsy right away

Blood tests

Hematinic blood tests

  • iron, b12, folate etc

Full blood counts

Diabetes

  • Don’t necessarily have to do HbA1c
  • for an unknown diabetic the best test would be Fasting Glucose

What is the diagnosis?

  • Biopsy was taken and came back as traumatic ulcer

How would you manage this patient?

Initial management

Management: Initial treatment involved smoothing sharp teeth and Chlorhexidine. Healing was extremely slow due to hypovascularity.

Benign traumatic ulcer

do all the obvious like check occlusion and interferences

Meds

  • Chlorhexidine (highest concentration)

Recall

  • longer recall period because the biopsy gave a diagnosis, so 6 weeks
    • because we aren’t expecting healing to be quick

Theoretical

  • 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:
      • could the pathology be wrong
        • Yes
      • Therefore biopsy should be repeated
      • When biopsy was retaken
        • A secondary candida infection was found

Secondary diagnosis + outcome

Secondary Diagnosis: After 3 months of minimal improvement, a repeat biopsy identified a secondary candidal infection.

Outcome: The ulcer took 12 months to fully epithelialize.

Antifungal tablet

Pharmacology

Pharmacology: Miconazole Oral Gel was used. Nystatin was avoided due to high sugar/caries risk; Amphotericin B was avoided as lozenges won't dissolve in a dry mouth.

  • Amphotericin isn’t a good candidate because p/t has a dry mouth
  • Nystatin drops are bad because they are sugary and can promote caries
  • Miconazole oral gel is a good alternative
    • For 6 weeks 4 times a day
    • Tell GP about miconazole due to interactions with drugs

Footnotes

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

Graph View