Tutorial Cases Flashcards
case example
A 56-year-old male presents to the GDP for a routine dental visit. Durinng the visit, he is made aware of “white lesions on the right and left cheeks”. He was not aware of them, as never had any symptoms associated withh them.
His teeth are intact and well restored with no amalgam fillings. Some teeth were missed. He is not a drinker but a smoker (10 cigarettes per day) and otherwise healthy. He was not taking any medications, but just vitamin D, vitamin B12 and folate.
Description of oral lesion:
Wickham’s striae (white striae) across right and left buccal mucosa (bilateral) which cannot be scraped off.
Erythmatous mucosa underneath which is non-ulcerative.
What is your differential diagnosis?
- reticular lichen planus
- candidal infection
- smoker-related keratosis
- squamous cell carcinoma
- lichenoid tissue reaction
- vesiculobullous disease
- graft vs host disease (GVHD)
case example
A 56-year-old male presents to the GDP for a routine dental visit. Durinng the visit, he is made aware of “white lesions on the right and left cheeks”. He was not aware of them, as never had any symptoms associated withh them.
His teeth are intact and well restored with no amalgam fillings. Some teeth were missed. He is not a drinker but a smoker (10 cigarettes per day) and otherwise healthy. He was not taking any medications, but just vitamin D, vitamin B12 and folate.
Description of oral lesion:
Wickham’s striae (white striae) across right and left buccal mucosa (bilateral) which cannot be scraped off.
Erythmatous mucosa underneath which is non-ulcerative.
What is the most likely aetiology/pathogenesis of these lesions?
It is a immunologically mediated process where CD4 and CD8 T-Cells attack basal keratinocytes.
case example
A 56-year-old male presents to the GDP for a routine dental visit. Durinng the visit, he is made aware of “white lesions on the right and left cheeks”. He was not aware of them, as never had any symptoms associated withh them.
His teeth are intact and well restored with no amalgam fillings. Some teeth were missed. He is not a drinker but a smoker (10 cigarettes per day) and otherwise healthy. He was not taking any medications, but just vitamin D, vitamin B12 and folate.
Description of oral lesion:
Wickham’s striae (white striae) across right and left buccal mucosa (bilateral) which cannot be scraped off.
Erythmatous mucosa underneath which is non-ulcerative.
Based on the patient’s medical and dental history, can these lesions be associated to any specific factors?
Smoker
case example
A 56-year-old male presents to the GDP for a routine dental visit. Durinng the visit, he is made aware of “white lesions on the right and left cheeks”. He was not aware of them, as never had any symptoms associated withh them.
His teeth are intact and well restored with no amalgam fillings. Some teeth were missed. He is not a drinker but a smoker (10 cigarettes per day) and otherwise healthy. He was not taking any medications, but just vitamin D, vitamin B12 and folate.
Description of oral lesion:
Wickham’s striae (white striae) across right and left buccal mucosa (bilateral) which cannot be scraped off.
Erythmatous mucosa underneath which is non-ulcerative.
How would you manage the patient (inc. any investigations) as a general dentist inn a primary care setting?
Clinical photographs
Thorough history
Remove any causes:
* medicines
* amalgam restorations
Recommend topical OTC remedies:
* chlorhexidine mouthwash 0.2%
* benzdamine mouthwash 0.15%
Avoid SLS-containing toothpaste, instead use:
* Sensodyne Pronamel
* Kingfisher
For persistent lesions: Topical steroids
* Beclomethasone MDI 50mcg/puff, 1-2 puffs, twice daily
* Bethamethasone rinse 500mcg/10ml, 4 times daily
SDCEP doses
case example
A 56-year-old male presents to the GDP for a routine dental visit. Durinng the visit, he is made aware of “white lesions on the right and left cheeks”. He was not aware of them, as never had any symptoms associated withh them.
His teeth are intact and well restored with no amalgam fillings. Some teeth were missed. He is not a drinker but a smoker (10 cigarettes per day) and otherwise healthy. He was not taking any medications, but just vitamin D, vitamin B12 and folate.
Description of oral lesion:
Wickham’s striae (white striae) across right and left buccal mucosa (bilateral) which cannot be scraped off.
Erythmatous mucosa underneath which is non-ulcerative.
What type of management (including investigations) this patient may receive in secondary care/dental hospital (oral med specialist/consutlant) once referred by you?
Punch tissue biopsy (baseline)
Call back patient for review and monitoring. Inform patient what to look out for (changes).
As patient is asymptomatic, no prescription of meds is needed.
Ensure good oral hygiene.
case example
A 56-year-old male presents to the GDP for a routine dental visit. Durinng the visit, he is made aware of “white lesions on the right and left cheeks”. He was not aware of them, as never had any symptoms associated withh them.
His teeth are intact and well restored with no amalgam fillings. Some teeth were missed. He is not a drinker but a smoker (10 cigarettes per day) and otherwise healthy. He was not taking any medications, but just vitamin D, vitamin B12 and folate.
Description of oral lesion:
Wickham’s striae (white striae) across right and left buccal mucosa (bilateral) which cannot be scraped off.
Erythmatous mucosa underneath which is non-ulcerative.
What may potentially happen to the patient in the future?
The risk for malignancy is ~1%.
Tobacco use increases the risk of carcinoma by 2.
case example
A 61-year-old female reports a 1-year history of “white and red/yellow patch just on the right ventral side of the tongue”. She complains of a constant mild-to-moderate soreness in the entire mouth which has improved over the past 2 months with a mouthwash given bby her GP, but she does not recall the name. Her teeth are intact and well restored with multiple amalgam fillings. She has been suffering from rheumatoid arthritis treated with tocilizumab for the last 4 months, and hypertension treated with olmesartan/hydrochlorothiazide. She is otherwise healthy.
Description of oral lesion:
A white-red lesion on the right ventral side of the tongue about 2 cm in length and 1 cm in width. The centre/base of the flat lesion is white/yellow in colour. The marginns are defined and erythmatous.
What is your differential diagnosis?
- Lichenoid tissue reaction (amalgam-related)
- Lichenoid drug reaction (ACE inhibitor, gold, beta-blocker)
- Erosive lichen planus
- Traumatic ulcer (surrounding white lesion)
- Oral squamous cell carcinoma (location is high-risk site, ulcerated/erosive)
case example
A 61-year-old female reports a 1-year history of “white and red/yellow patch just on the right ventral side of the tongue”. She complains of a constant mild-to-moderate soreness in the entire mouth which has improved over the past 2 months with a mouthwash given bby her GP, but she does not recall the name. Her teeth are intact and well restored with multiple amalgam fillings. She has been suffering from rheumatoid arthritis treated with tocilizumab for the last 4 months, and hypertension treated with olmesartan/hydrochlorothiazide. She is otherwise healthy.
Description of oral lesion:
A white-red lesion on the right ventral side of the tongue about 2 cm in length and 1 cm in width. The centre/base of the flat lesion is white/yellow in colour. The marginns are defined and erythmatous.
How would you manage the patient (inc. any investigations) as a general dentist in a primary care setting?
Clinical photographs
Allergy patch test (inc. dental materials hypersensitivity)
Replace amalgam and explain the risks of doing so to the patient:
* high vol. aspiration and rubber dam
* might not solve issue
Benefits… reduces the risk of malignancy
Urgent referral to secondary care
Recommend topical OTC remedies:
* chlorhexidine mouthwash 0.2%
* benzdamine mouthwash 0.15%
Avoid SLS-containing toothpaste, instead use:
* Sensodyne Pronamel
* Kingfisher
For persistent lesions: Topical steroids
* Beclomethasone MDI 50mcg/puff, 1-2 puffs, twice daily
* Bethamethasone rinse 500mcg/10ml, 4 times daily
case example
A 61-year-old female reports a 1-year history of “white and red/yellow patch just on the right ventral side of the tongue”. She complains of a constant mild-to-moderate soreness in the entire mouth which has improved over the past 2 months with a mouthwash given by her GP, but she does not recall the name. Her teeth are intact and well restored with multiple amalgam fillings. She has been suffering from rheumatoid arthritis treated with tocilizumab for the last 4 months, and hypertension treated with olmesartan/hydrochlorothiazide. She is otherwise healthy.
Description of oral lesion:
A white-red lesion on the right ventral side of the tongue about 2 cm in length and 1 cm in width. The centre/base of the flat lesion is white/yellow in colour. The marginns are defined and erythmatous.
What type of management (inc. any investigations) this patient may receive in secondary care/dental hospital (oral med specialist/consultant) once referred by you?
Biopsy of:
1. ulcerative lesion
2. white lesion
Clobetasol (higher strength topical “skin” steroid cream)
Topical tacrolimus (ointment or mouthwash)
Hydroxychloroquine
Systemic immunomodulators:
* azathioprine
* mycophenolate motefil
case example
A 49-year-old female reports a long-standing history of “white and red/yellow patch just on the tongue and left cheek”. She complains of a constant severe burning pain, which failed to respond to the use of corticosteroid mouthwash, annd oral drynaess. She has been suffering from asthma, depression, type 2 diabetes mellitus, and for which she has been taking metformin, insuline, budesonide/formoterol inhaler, atorvastatin, escitalopram, and reported that she received a allogenic stem cell transplant for a haematologic malignancy last year.
Description of oral lesion:
Thickened white lesions and ulcers with underlying erythema on left buccal mucosa and retromolar pad/triangle (alveolar ridge). Lesions are irregular in shape.
Depapillated, smooth and shiny tongue.
What is your differential diagnosis?
- Erosive Lichen Planus
- Graft vs Host Disease (GvHD)
case example
A 49-year-old female reports a long-standing history of “white and red/yellow patch just on the tongue and left cheek”. She complains of a constant severe burning pain, which failed to respond to the use of corticosteroid mouthwash, annd oral drynaess. She has been suffering from asthma, depression, type 2 diabetes mellitus, and for which she has been taking metformin, insuline, budesonide/formoterol inhaler, atorvastatin, escitalopram, and reported that she received a allogenic stem cell transplant for a haematologic malignancy last year.
Description of oral lesion:
Thickened white lesions and ulcers with underlying erythema on left buccal mucosa and retromolar pad/triangle (alveolar ridge). Lesions are irregular in shape.
Depapillated, smooth and shiny tongue.
What is the most likely aetiology of these oral lesions?
Patient received allogenic stem cell transplant.
case example
A 49-year-old female reports a long-standing history of “white and red/yellow patch just on the tongue and left cheek”. She complains of a constant severe burning pain, which failed to respond to the use of corticosteroid mouthwash, annd oral drynaess. She has been suffering from asthma, depression, type 2 diabetes mellitus, and for which she has been taking metformin, insuline, budesonide/formoterol inhaler, atorvastatin, escitalopram, and reported that she received a allogenic stem cell transplant for a haematologic malignancy last year.
Description of oral lesion:
Thickened white lesions and ulcers with underlying erythema on left buccal mucosa and retromolar pad/triangle (alveolar ridge). Lesions are irregular in shape.
Depapillated, smooth and shiny tongue.
How would you manage the patiennt (inc. any investigations) as a general dentist in a primary care setting?
Clinical photographs.
Thorough history.
High-risk caries. Prevention:
* high fluoride toothpaste (SLS-free)
* saliva-enhancer
* fluoride varnish (although may stick to ulcer)
Remove any causes:
* medicines
* amalgam restorations
Recommend topical OTC remedies:
* chlorhexidine mouthwash 0.2%
* benzdamine mouthwash 0.15%
Avoid SLS-containing toothpaste, instead use:
* Sensodyne Pronamel
* Kingfisher
For persistent lesions: Topical steroids
* Beclomethasone MDI 50mcg/puff, 1-2 puffs, twice daily
* Bethamethasone rinse 500mcg/10ml, 4 times daily
case example
A 49-year-old female reports a long-standing history of “white and red/yellow patch just on the tongue and left cheek”. She complains of a constant severe burning pain, which failed to respond to the use of corticosteroid mouthwash, annd oral drynaess. She has been suffering from asthma, depression, type 2 diabetes mellitus, and for which she has been taking metformin, insuline, budesonide/formoterol inhaler, atorvastatin, escitalopram, and reported that she received a allogenic stem cell transplant for a haematologic malignancy last year.
Description of oral lesion:
Thickened white lesions and ulcers with underlying erythema on left buccal mucosa and retromolar pad/triangle (alveolar ridge). Lesions are irregular in shape.
Depapillated, smooth and shiny tongue.
What type of management (inc. any investigations) this patient may receive in secondary care/dental hospital (oral med specialist/consultant) once reffered by you?
Thyroid Function Test
Blood test (haematinics)
Biopsy
Clobetasol (higher strength topical “skin” steroid cream)
Topical tacrolimus (ointment or mouthwash)
Hydroxychloroquine
Systemic immunomodulators:
* azathioprine
* mycophenolate motefil
case example
A 30-year-old female attended your practice complaining of recurrent oral ulcerations for many years. These are usually very painful and may occur in different/multiple oral sites. She can have more than one at any time. Oral lesiosn may take up to 2 weeks to heal with some ulcer-free periods. The patient denies the use of new medicines, foods, oral hygiene products, and is unable to state whether other family members have had similar oral lesions. She has previously used mouth rinse anaesthetics and fluconazole, with no benefit. Her past medical history includes GERD treated with lansoprazole, and anxiety managed with meditation and yoga.
Description of oral lesions:
4 round lesiosn on dorsum of tongue on right side. One is ~8mm in diameter. Two are ~5mm in diameter, both located near bborder of tongue (right side). One (the smallest) is ~2mm in diameter, at border of tongue. All lesions have flat red margins with a grey base.
A round lesion ~10mm in diameter at upper left buccal frenum/buccal mucosa. Has flat red margins with grey base (looks rough).
Based on the patient’s medical and dental history, can these lesions be associated to any systemic diseases?
GERD (lansoprazole) - iron-deficiency
Anxiety - stress
case example
A 30-year-old female attended your practice complaining of recurrent oral ulcerations for many years. These are usually very painful and may occur in different/multiple oral sites. She can have more than one at any time. Oral lesiosn may take up to 2 weeks to heal with some ulcer-free periods. The patient denies the use of new medicines, foods, oral hygiene products, and is unable to state whether other family members have had similar oral lesions. She has previously used mouth rinse anaesthetics and fluconazole, with no benefit. Her past medical history includes GERD treated with lansoprazole, and anxiety managed with meditation and yoga.
Description of oral lesions:
4 round lesiosn on dorsum of tongue on right side. One is ~8mm in diameter. Two are ~5mm in diameter, both located near bborder of tongue (right side). One (the smallest) is ~2mm in diameter, at border of tongue. All lesions have flat red margins with a grey base.
A round lesion ~10mm in diameter at upper left buccal frenum/buccal mucosa. Has flat red margins with grey base (looks rough).
What is your differential diagnosis?
- minor aphthous ulcer
- major aphthous ulcer
- herpetiform ulcer
