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Oral Pathology:  Soft Tissue Case #21

 

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Patient: Adult woman.

Chief Complaint: The patient reports a sore mouth of eight to nine months duration. The discomfort consistently involves the gingiva and buccal mucosa. The discomfort has varied in intensity, but has never resolved. Blisters have been observed on the buccal mucosa. The discomfort is worse when the patient drinks fruit juice, rinses with peroxide and Listerine, and when her mouth is dry. The patient's physician prescribed Decadron and Kenalog in Orabase. Both of these medications resulted in some improvement, but not total resolution of the discomfort. The patient reports soreness of the left eye five months ago. This was treated with an unknown ointment, resulting in improvement.

Medical History: The patient reports hypertension treated with Ser-Ap-Es and occasional arthritis in the left shoulder treated with aspirin. The patient previously used Minipress for hypertension, but this medication caused xerostomia and a sore throat. The patient has had a cholecystectomy (gallbladder removed) because of gallstones, and varicose veins stripped.

Dental History: The patient has had numerous teeth extracted due to caries. Her last dental visit was approximately one year ago for adjustment of partial dentures. The patient has used maxillary and mandibular partial dentures for ten years. She does not wear her partial dentures at night. She has difficulty wearing her partial dentures because they irritate her gingiva. She has difficulty brushing her teeth because of her gingival discomfort.

Summary of Visuals: Examination of the visuals reveals ulcerations of the buccal mucosa bilaterally, gingival erythema and ulceration, plaque, calculus, and periodontitis.

Clinical Findings: Ulcerations are present on the buccal mucosa, attached gingiva and attached alveolar mucosa. The ulcerations are mildly compressible, tender, and fixed to surface mucosa and underlying structures. A Nikolsky's sign is present. Cervical lymphadenopathy and skin lesions are not present.

Clinical Images
labial gingiva close-up of labial gingiva
Labial Gingiva Close-up of Labial Gingiva
maxillary anterior lingual gingiva close-up of maxillary anterior lingual gingiva
Maxillary Anterior Lingual Gingiva Close-up of Maxillary Anterior Lingual Gingiva
mandibular lingual gingiva mandibular lingual gingiva
Mandibular Lingual Gingiva Mandibular Lingual Gingiva
right buccal mucosa with ulceration left buccal mucosa with ulceration
Right Buccal Mucosa with Ulceration Left Buccal Mucosa with Ulceration

 

There are no radiographs available for this case.

There are no lab reports available for this case.

There are no charts available for this case.

Summary:
This is a chronic, persistent, vesicular-ulcerated-erythematous disease which involves multiple areas of oral mucosa.

Lesions to Exclude from the Differential Diagnosis:
Hereditary Epidermolysis Bullosa
  ~Almost all cases begin at birth or early childhood
  ~Skin lesions are consistently present
Viral infections
  ~Acute onset and resolution
Mycotic infections
  ~Candidosis (candidiasis) is not composed primarily of ulcers.
Idiopathic Diseases
  ~Aphthous ulcers, Erythema Multiforme,
*Abrupt onset and heal spontaneously
  ~Contact stomatitis and medication-induced mucositis
*No history of exposure to agents or medications that typically these
  ~Epithelial Dysplasia, Carcinoma-in-situ, and Squamous Cell Carcinoma
*Main feature is erythroplakia/leukoplakia rather than multiple painful ulcers
*Do not produce Nikolsky sign.
Autoimmune Diseases
  ~Bullous Pemphigoid
*Consistently has skin lesions

Lesions to Include in the Differential Diagnosis:
Lichen Planus
Pemphigus
Mucous Membrane Pemphigoid
  ~History of eye soreness is suggestive, but not diagnostic of mucous membrane pemphigoid
Lupus Erythematosus
  ~Less likely because usually has skin lesions.

Management:
Definitive diagnosis must be obtained because of the difference in treatment, referral, and prognosis of the diseases in the differential diagnosis.
Explain to the patient the nature of the diseases in the differential diagnosis and the need for a definitive diagnosis.

Referral of this patient to an oral surgeon or oral pathologist is recommended for incisional biopsy and other laboratory tests, such as direct immunofluorescence studies.

Pemphigus and mucous membrane pemphigoid require more aggressive therapy.

Final Diagnosis:
Mucous Membrane Pemphigoid