Final Exam Flashcards by Chelsie Wharton

Clinical Description

Multiple white plaques that are mildly corrugated on the anterior floor of the mouth. The plaques have well-demarcated margins that are separated by deep fissures with focal areas of erythema

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Differential Diagnosis

Leukoplakia

Squamous cell carcinoma

Proliferative verrucous Leukoplakia

Candidiasis (hyperplastic)

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Confirmatory Test

Excisional Biopsy

Histopathological examination of every part of tissue

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Management

Tobacco cessation

Low grade dysplasia: Frequent follow-up

High grade dysplasia: assess margins and wider excision if margins transected with frequent follow-up

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Clinical Description

Multiple areas of curd-like white plaques on the anterior labial mucosa with coalesced areas.

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Differential Diagnosis

Pseudomembranous Candidiasis (Thrush)

Leukoplakia

Verrucous Carcinoma

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Confirmatory Test

Clinical findings (oral mucosa in susceptible individual for thrush)

Cytosmear stained with KOH to identify hyphae and spores

Swabs on sabourauds agar medium to grow white, curd-like colonies

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Management

Manage drug-induced xerostomia

Better control of diabetes

Nystatin oral rinse

Clotrimazole oral troches

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Clinical Description

White plaque on lower buccal mucosa/vestibule that has well-demarcated borders. The plaque is adjacent to a tooth with a cavity. There are areas that appear lifted or peeling (pseudomembrane)

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Differential Diagnosis

Chemical burn

Tobacco pouch keratosis

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Confirmatory test

Diagnosed clinically (acute onset, pseudomembrane, pain) and history of aspirin in that location

No biopsy required

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Management

Do not remove pseudomembrane

Treat tooth

Viscous xylocaine mouth rinse to alleviate pain/burning of chemical burn

Lesions heal spontaneously over 7-10 days with reepithelization

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Clinical Description

White lesion enclosing mild erythema on the lower left posterior buccal mucosa adjacent to a metal crown. Lesion exhibits fine radiating white striae

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Differential Diagnosis

Lichenoid contact metal reaction

Lichen planus

Lupus erythematosus

Drug-induced lichenoid mucositis

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Confirmatory test

Clinical presentation (localized nature of lesion, adjacent to metal restoration)

Skin sensitivity patch test by rheumatologist/dermatologist if patient desires

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Management

Asymptomatic do not need treatment

Mild soreness due to superimposed candidiasis (antifungal medications) or excessive inflammatory response (topical steroid)

Replace crown if desired

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Clinical Description

White plaque on the right lateral tongue with multiple coalescing areas varying in size. Granular corrugated surface with indistinct margins

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Differential Diagnosis

Hairy Leukoplakia

Leukoplakia

Tongue chewing (morsicatio)

Cinnamon reaction

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Confirmatory Test

RT-PCR for HIV RNA (viral load)

CD4 T-lymphocyte counts (less than 200 cells/ul of blood)

Lesion biopsy (koilocytes in spinous layer, demonstration of Epstein Barr virus in koilocytes)

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Management

Benign condition requires no treatment

Clinical indicator of low CD4 T-lymphocyte count (less than 200 cells/ul of blood) - transition point of HIV to AIDS

Indicator to initiate highly active antiretroviral therapy

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Clinical Description

Irregular red patch with intermittent white areas on the left posterior soft palate

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Differential Diagnosis

Erythroplakia (speckled leukoplakia)

Candidiasis

Thermal Burn

Autoimmune mucositis

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Confirmatory Test

Excisional Biopsy

Histopathological examination of tissue

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Management

Tobacco cessation

90% high-grade dysplasia or invasive carcinoma

Wide excision with assessment of margins for high-grade dysplasia or carcinoma (wider excision is margins are involved)

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Clinical Description

Generalized erythema of denture bearing area on the maxilla. Focal areas on alveolar ridge show light frictional keratosis

Differential Diagnosis

**_Chronic Atrophic Candidiasis_** (denture sore mouth)

Confirmatory Test

Clinical findings (most cases with poor denture hygiene) Cytosmear stained with KOH to identify hyphae and spores Swabs on Sabourauds agar medium to grow white, curd-like colonies

Management

Teach patient hygiene Brush/rinse denture Soak denture in Nystatin rinse solution overnight (for 7-10 nights) Nystatin oral suspension (100,000 units/ml, DISP 240 ml: use 10 ml to rinse 5 times daily)

Clinical Description

Large erythematous mass extending from the alveolar ridge to the lingual area with involvement in the vestibule and left posterior floor of the mouth

Differential Diagnosis

**_Squamous cell carcinoma_** Histoplasmosis

Confirmatory test

Incisional biopsy Histopathological examination of tissue

Management

Depends on stage Determine the stage Wide surgical excision and/or radiation therapy Neck node dissection Chemotherapy

Clinical Description

Multiple areas of depapillation on the dorsal tongue extending to the lateral surface. Red areas partially surrounded by a yellow-white line

Differential Diagnosis

**_Migratory Glossitis_** (Geographic tongue) Migratory stomatitis Anemia (iron deficiency, megaloblastic vitamin B12 deficiency)

Confirmatory Test

Clinical presentation for migratory glossitis (lesions heal spontaneously and reappear in another area, Sometimes associated with fissured tongue) Migratory - other areas affected

Management

No treatment necessary Rarely symptomatic cases have superimposed candida infection Clotrimazole oral torches 10 mg, DISP 50, dissolve one in mouth 5X/day for 10 days

Clinical Description

Palatal soft tissue nodule that appears pushed against the palate. Areas of red and white that likely arise from the palatal gingiva around the maxillary right premolar/molar area

Differential Diagnosis

**_Pyogenic Granuloma_** Peripheral Giant Cell Granuloma Neurofibroma

Confirmatory Test

Evaluate to determine origin Fairly rapid growth, current history of pregnancy all favor a working clinical diagnosis of pyogenic granuloma Biopsy: Surgical removal scheduled 2 weeks after delivery

Management

Biopsy: Surgical removal scheduled 2 weeks after baby delivery Through removal of local factors 15% recurrence

Clinical Description

Solitary dome-shaped, exophytic, popular sessile nodule on the right dorsum of the tongue. It is presented in the submucosa and non-ulcerated with no change in color

Differential Diagnosis

**_Granular Cell Tumor_** Fibroma Schwannoma Neurofibroma

Confirmatory Test

Biopsy (size \<1 cm in size excisional biopsy can be done) Deeper extent of lesion harder to predict Histopathological exam of biopsied tissue

Management

Even incisional biopsy is curative No Recurrence has been reported

Clinical Description

Exophytic sessile nodule on the right commissure that is less than 5 mm. It has a smooth dome-shaped surface that is pink to pale pink in color

Differential Diagnosis

**_Fibroma_** Neurofibroma Schwannoma Lipoma

Confirmatory Test

Excisional Biopsy Histopathological examination

Management

Excisional Biopsy No recurrence

Clinical Description

Smooth dome-shaped sessile exophytic nodule on the right posterior palate.

Differential Diagnosis

**_Pleomorphic Adenoma_** Malignant salivary gland tumor (mucoepidermoid carcinoma, Polymorphous adenocarcinoma)

Confirmatory Test

Excisional Biopsy Histopathological examination of excised tissue

management

Excisional biopsy is curative Long-term followup

Clinical Description

Smooth pink dome-shaped sessile exophytic nodule on the anterior left mandibular ridge

Differential Diagnosis

**_Peripheral ossifying fibroma_** Pyogenic granuloma Peripheral giant cell granuloma Peripheral odontogenic tumor

Confirmatory Test

Excisional Biopsy Histopathological examination of excised tissue

Management

Excisional Biopsy At this size, may require removal of teeth in the vicinity of the lesion 15% rate of recurrence

Clinical Description

Smooth dome-shaped yellow-red submucosal sessile nodule in the area of the left pharyngeal tonsils

Differential Diagnosis

**_Oral Lymphoepithelial Cyst_** Tonsillar Stone

Confirmatory Test

Excisional Biopsy Histopathological examination of excised tissue

Management

Excisional Biopsy is curative Low recurrence potential

Clinical Description

Gray submucosal macule in the area of the edentulous ridge at a healing extraction site

Differential Diagnosis

**_Amalgam Tattoo_** Drug-induced pigmentation Melanotic macule

Confirmatory Test

X-ray (may or may not show radiopaque material) Excisional biopsy (lesion is small and readily accessible) Send biopsied tissue for histopathological exam

Management

Nothing needs to be done for amalgam tattoo once confirmed Inform patient, explain inert nature of the material Follow-up to complete healing of biopsy site

Clinical Description

Generalized brown/black macular homogenous pigmentation on the attached gingiva of the maxilla and mandible

Differential Diagnosis

**_Physiological/Ethnic Pigmentation_** Intentional Social Tattooing Drug-induced pigmentation Melanoma

Confirmatory Test

No compelling reason to test (biopsy)

Management

Reexamine at each follow-up visit | (there should be no significant change)

Clinical Description

Diffuse macular gray/black variable density pigmentation of the palatal mucosa. Mucosa is smooth and uninterrupted

Differential Diagnosis

**_Drug-induced Pigmentation_** Ethnic/physiologic pigmentation Addison disease Melanoma

Confirmatory Test

Due to patient use of Imatinib mesylate for leukemia no further testing is necessary Clinical Features (lack of mass or ulceration) and lack of other history (hypotension/Salt craving) others are excluded

Management

No specific management required for pigmentation Patient counselled that the pigmentation is due to the medication Will fade over months following cessation of medication

Clinical Description

left lower lip brown-black solitary well-defined smooth macule

Differential Diagnosis

**_Melanotic Macule_** Drug-induced pigmentation Melanocytic Nevus Melanoma

Confirmatory Test

Unless patient is concerned or wants to have lesion removed for esthetic purpose, no biopsy is required

Management

If the patient concerned or desires removal, an excisional biopsy may be performed In the absence of above, do nothing other than reexamine at follow-up visits

Clinical Description

Large area of variable ill-defined pigmentation changes from black, brown to tan that is affecting the maxillary attached gingiva from the incisors to the molar region

Differential Diagnosis

**_Melanoma_**

Confirmatory Test

Immediate Biopsy and histopathological examination

Management

Immediate referral to an oncologist Surgical resection with 1.5 cm margins, neck nodes dissection for occult metastasis. Oral tumors present with early distant metastasis 5 year survival rate 15% with median survival of 25 months Nodal involvement reduces survival to 18 months

Clinical Description

Diffuse Erythematous areas on the marginal and attached gingiva of the maxilla and mandible. Fine white striae at some margins of red areas. Edema and swelling are not prominent.

Differential Diagnosis

**_Erosive Lichen Planus_** Pemphigus vulgaris Cicatricial (mucous membrane) Pemphigoid

Confirmatory Test

Incisional biopsy (lichenoid mucositis: saw-tooth rete ridges) Direct immunofluorescence study (shaggy band of fibrinogen at basement membrane)

Management

Strong topical corticosteroids Fluocinonide (gel) Clobetasol (gel)

Clinical Description

Erythematous gingiva with several areas of ulceration with fibrin on the maxillary anterior attached gingiva. At least one intact fluid-filled blister on the right anterior with no significant local factors or gingival swelling throughout

Differential Diagnosis

**_Mucous membrane (cicatricial) Pemphigoid_** Erosive lichen planus Pemphigus vulgaris

Confirmatory Test

Biopsy unaffected perilesional tissue Half specimen in routine formalin (H&E stain) and half into Michel's solution for DIF (to show immunoreactants)

Management

Tetracycline and niacinamide Dapsone Topical Steroids Systemic steroids if there is ocular disease

Clinical Description

Solitary well-circumscribed round superficial ulcer less than 1 cm in diameter with an erythema halo in the maxillary right vestibule

Differential diagnosis

**_Aphthous Ulcer Minor_** Herpetic ulcer Behcet's Syndrome Traumatic Ulcer

Confirmatory Test

Clinical presentation including previous episodes, self-healding are all highly diagnostic for aphthous ulceration Biopsy is not indicated because histopathology is non-specific

Management

Self-healing For prodromal symptoms, you can prescribe topical strong cortical steroids: Fluocinonide gel, Clobetasol gel

Clinical Description

Multiple superficial ulcers in the hard palate gingiva with some coalesced and an erythematous bed. Areas of gingival recession and necrosis

Differential Diagnosis

**_Recurrent Intraoral Herpes Simplex_** Intraoral Herpes Zoster (shingles) Primary herpetic gingivostomatitis Herpangina

Confirmatory Test

Clinical presentation is diagnostic Lesions resolve within 7-10 days No other tests are necessary

Management

Often mild and unnoticed Self resolving (no treatment) Precaution for spread by contact since contagious Xylocaine mouthwash prior to mealtime Popsicles for irritation

Clinical Description

Irregular, deep ulcer with raised margins on the left lateral tongue that is surrounded by erythema and swelling

Differential Diagnosis

**_Traumatic Ulcer_** Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) Squamous Cell Carcinoma Tuberculosis Deep fungal infections

Confirmatory Test

Incisional Biopsy with histological exam including special stain (GMS: fungus, acid-fast: TB) MUST BE DONE due to the high-risk area and especially if it has been present for a long period of time Clinical characteristic, likely trauma may have been preexisting asymptomatic condition (such as carcinoma/TB/histoplasmosis)

Management

Incisional Biopsy curative resulting in healing Zilactin gel over lesion to reduce friction TOpical steroids not recommended because they suppress healing

Clinical Description

Multiple papillary/warty pink coalescing lesions on the right buccal mucosa that vary in size

Differential Diagnosis

**_Condyloma Acuminatum (venereal warts)_** Verruca vulgaris Squamous papilloma

Confirmatory Test

Test for HIV infection (ELISA screening, Western Blot) Biopsy one or two lesions (koilocytes, in-situ PCR staining for HPV 6, 11, 16, 18)

Management

Scalpel excision or cryotherapy Avoid laser/electrocautery due to aerosolization of virus Highly contagious, new lesions develop by direct contact or inoculation (recurrence \>30%)

Clinical Description

Multiple papillary wart-like growths on the right vermillion commissure. These papillary growths vary in size from 1-2 mm and in their phase of growth

Differential Diagnosis

**_Verruca Vulgaris_** Squamous papilloma Multifocal epithelial hyperplasia Condyloma acuminatum

Confirmatory Test

Clinical is characteristic Single lesion may be biopsied for histopathological confirmation (papillary surface architecture, epithelial hyperplasia with alternating hyperpara and hyperortho keratosis, Koilocytes)

Management

Skin lesions: Topical salicylic acid, cryotherapy, intralesional bleomycin Intraoral Lesions: Surgical excision, laser ablation, cryotherapy

Clinical Description

Single mucus-filled vesicle on the lower left lip. Incidental findings: skin of left chin nevus

Differential Diagnosis

**_Mucus extravasation phenomenon (mucocele)_** Salivary gland tumor

Confirmatory Test

Clinical presentation is diagnostic but an excisional biopsy is required for management Histopathological exam of tissue confirms diagnosis and excludes tumor

Management

Excisional biopsy including deep wedge to remove the involved minor mucus gland lobules to mitigate recurrence

Clinical Description

Left anterior floor of the mouth solitary submucosal nodule that is pale pink to yellow near the Wharton's duct

Differential Diagnosis

**_Sialolith_** Oral lymphoepithelial cyst Lipoma Salivary gland tumor

Confirmatory Test

Palpation (bi-manual palpation will reveal firm mass) Occlusal x-ray (shows an oval-shaped radiopaque mass) Biopsy - excisional (results in removal of hard mass)

Management

Excisional biopsy if pain persists upon removal of stone - chronic sialadenitis of left submandibular gland is suspected - gland may require removal

Clinical Description

Irregular lobulated deep-seated swelling on the right retromolar to pterygomandibular area. Extent is not defined. Surface telangiectasia.

Differential Diagnosis

**_Mucoepidermoid Carcinoma_** Until proven otherwise

Confirmatory Test

CT exam for extent of lesion and possible bone involvement Incisional biopsy and histopathological exam of tissue

Management

Surgical excision with wide margins Bone involvement requires segmental resection Intermediate/high-grade tumors require neck dissection for lymph node involvement High-grade may be treated with proton beam therapy