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[DOD] [17/18] [CPC and Review Session ] by [Dr. Shah]

[No PowerPoint slide release] [title of slide]
[Dr. Shah] Ok good afternoon students. How are you guys? Theres a lot smaller
crowd. What is it? Do you have a test? On Monday? Thats still far away. Today
basically um, btw, Im sorry I ran from clinic. Im in clinic all day Wednesday. I
couldnt leave my patient bleeding after a biopsy. I sutured him up and then I came
here. What Im doing today, Im just doing a review and cases. I did not post this b/c
this is designed to be interactive. I have the answers and all of the info in this
presentation. That is why its not posted. Many times I use similar cases every year
so I may not post this. So please take your notes. The presentation is just pictures.
The information is in the interaction. Theres not much text coming from the
presentation. At least for right now, this is designed to be interactive. Im doing
cases that will tie together the things Ive been over. Itll get you thinking in the
format that will be in the examination. It will be August 15
th
. The format of the exam
is not definitive yet. Would you prefer all multiple choice or short answer as well? I
think I know the answer to that. All multiple choices. Im just being very blunt and
honest but normally I dont prefer multiple choice, b/c it does not test knowledge.
Im not going to pop out one day and say A. lymphoma, B. Mucoseal. You got to know
these word and terms. I have done free response in the past but you guys are luck
b/c Im taking a trip to the Bahamas for the week and I may not have time to grade
them. You can thank my husband for that. I will definitively let you know, but it will
probably be 75 multiple-choice questions. Very case and figure based. Lots of
pictures, radiographs. I had a couple questions on the last lecture. It was definitely a
lot of information. The things you dont need to know to write a prescription. You
dont need to know the dosage, the number of times/ day; you need to know the
classes, the names of the medications. Which ones are anti-fungal, which ones are
the steroids we use, which ones are anti-viral drugs. Thats mainly what you need to
know. In some cases I put a name in parenthesis. That might be the trade name/
brand name. I hope Im very clear on when I mean you need to know the drugs. You
dont need to know the dosage and the amount but you need to know the names,
usages, trade/ brand names. Other than that. Oh one more thing. On Friday, youll
notice in your schedule there was a lecture scheduled from 3-5. Online oral cancer
time. I know youre going to be so disappointed but were actually cancelling that.
You can use that time to study Im sure. What it is, theres an online oral cancer
course that weve developed that normally the 3
rd
year students take in the oral
path course. We want to move it to the second year, but its not ready for that. The
paperwork wasnt done in time. Youll be taking it in next year. We had given that
time so you could take the course, but now Friday 3-5 is cancelled so you can use
that time to study. I knew you wouldnt be too upset. Ok. Before I do the cases are
there any other final questions? I hope you have enjoyed the oral path section. You
had an oralfacial pain section. Any other questions? You know you can always email
me.

Lets do these cases guys. Again, Im going to be really evolving you. Maybe
you dont know me as well yet. If no one volunteers, then I pick on you. Im not doing
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it to embarrassed anyone. Just trying to gauge what the class knows. Heres the first
case. We have a 54 year old that presents for a routine check up. Her medical history
shes diabetic type II, the medication shes taking is Glucotrol. Oral exam. The dentist
notes lesions on the lateral border on the tongue. The patient is unaware but notes
that the tongue feels weird sometimes. This is the picture of the lesion. Who would
like to volunteer to describe what they see. Give me the differential diagnosis and
give me the next step. Someone should volunteer. If no one volunteers, the person
who looks away the most gets called. Thats a good question. Can you wipe it off? No.
Ill penalize you for asking a question. Describe what you see here. There is
something to see. IF you cant, its all along here. Ok. Leukoplakia is a good clinical
descriptive term. Flat white areas that dont wipe off. I might call it an erythroplakia.
Theres some areas here as well. The tongue looks red here as well. You can go w/
both if they are true red areas. Its diffuse and ill defined. Give me an idea of some
possible diagnosis and what you would do next. Well you dont have too much
longer to get a lot more guys. The test will creep up on you soon. Thats a good thing
to do. No, it feels a little rough surface but not indurated or hard. The patient doesnt
know but for a while. Progressively getting larger for a couple months year. How
about you? The patient feels a little tingling or sensation sometimes but it doesnt
really hurt. Slightly rough surface/ raised. Its not exophitic lesion or nodule but its
definitely a little raised and rough surface. How about you? Strange behaviors such
as what? That sounds interesting. Ok. Thats actually a very good point. Definitely
look on the other side and see if there is something similar. If you see something on
the other side, you feel more benign about it. It might be the patients anatomy or
some habit. When youre talking about strange habits, you might be talking about
sharp or broken teeth and they might be biting their tongue. Thats all negative. The
patient doesnt bite their tongue. None of the teeth are really sharp. Whats a
differential diagnosis guys. What could this be? If you recall either Dr. Kerr or myself
we would have said that any leukoplakia that didnt wipe off theres a standard
diagnosis of three things. What are most leukoplakias? What do they end up being?
Hyperkeratosis. Hyperkeratosis is at the top of the differential diagnosis. Then what.
What else are we worried about? Whats the next possibility? Epithelial dysplasia. A
pre-cancer. The worse case scenario is squamous cell carcinoma. We are in a high-
risk site (ventral lateral tongue). Anytime you have a red/ white lesion in this area,
you cant directly prove that its traumatic, you have to have SCC and dysplasia in
the diagnosis. What do we do next? This is where we talk about the biopsy
technique lecture. What kind do we do? Remember your four choices. What are your
choices? Incisional, excisional. Punch is not a type of biopsy. It can be incisional or
excisional depending on the size of the lesion and the size of the pump. So those are
the four choices: brush, mucosal smear, and incisional, excisional biopsy. Which one
of the four should we do here? These are the types of questions you will get on the
exam. Youll get a picture, itll ask for a clinical diagnosis, type of biopsy, treatment.
Things like that. Thats why we are going through the exercise here. Well be doing
incisional. Where should we biopsy this? Do you guys remember the rules? The
worst looking area. Whats the worst looking area? I would personally go right here
since theres a little bit of red color here. If I saw an ulcer, I would go around the
ulcer. I wouldnt go straight in it but Id go around the ulcer. What if this is pure
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white then where do you go? Not borders. No. The roughest area. Right. Remember I
talked about rough vs. smooth so as dysplasias progress, the surface becomes
pebbly and rough and granular. If you have a plain white lesion, you want to go for
the rougher areas then the smoother areas. If you have a mixed red and white lesion
you want to go for the red areas. Remember you can do multiple biopsies. This
lesion is big enough. Its pretty diffuse. I can go one here, over here, wherever else I
want to. You have to decide just before I answer your question. I think Dr. Kerr
would have talked about. Lets say youre completely clueless. I have no idea where I
should biopsy this. Can you think of something that can help you decide? Some
techniques he talked about that can help you decide? Yea. Thats an idea too. You can
feel and take a firmer area. Im talking about, yea go ahead. There you go. The
velscope and the T blue. He talked about that right? If you have no idea and even if
you have an idea and we use these things, you can use that toluidine blue which
correlates well for dysplasia or the velscope, the loss of fluorescence. The green light
and look for the black areas. Is this all familiar to you? You can use those things to
guide where to do biopsy as well. The velscope and the loss of fluorescence and the
T blue. We should do a biopsy. Thats the next step. This is a differential diagnosis
that we talked about. Hyperkeratosis, epithelial dysplasia and squamous cell
carcinoma. This is what you should be thinking when you see that lesion. And in this
order. Ok. Differential diagnosis means that the realest possibility is at the top of the
list and the least likely is at the bottom of the list. This is just based on frequency. 4:5
white lesions are hyperkeratosis. Considering the fact that we are on a higher risk
site and not the buccal mucosa, these become more possible dysplasia and
squamous cell carcinoma. Incisional biopsy was done and this is what we see under
the microscope. You have these islands of epithelial cells going into the connective
tissue and coming from the surface epithelium. This is a high power view. This is
called a keratin pearl. Then you have these pleomorphic cells with large dark nuclei
in the connective tissue. What do you think this is? Squamous cell carcinoma. Where
you get infiltration in the epithelium into the connective tissue. Dysplasia is confined
to the epithelium and there is no break in the basement membrane. These has gone
through and islands are invading into the connective tissue. This is a keratin pearl,
which only squamous cells do. So you know this is a squamous cell carcinoma. This
was indeed a squamous cell carcinoma. What do you think will happen to this
patient in terms of management? What happens next? Ok but anything before that?
Yea, I mean. We need to deal w/ this lesion. We still need to deal w/ this lesion.
What would you do w/ this diagnosis after you give it to the patient before the
surgeon digs in and cuts. There is something else you have to do. Do you remember
the staging? It needs to be staged. Does anyone know bout the TNM staging system.
Did Dr. Kerr talk about that? T for tumor size, N for node involvement, M for
metastasis. Stages 1-4. I think he traditionally talks about these things guys. He did
briefly? Ok. Anytime time a patient is diagnosed with a SCC they have to be staged
w/ the TNM staging system. It ultimately does T tumor size, N node involvement,
and M distant mets, you break that into stage 1-4. That determines the prognosis,
the 5-year survival rate, and the type of treatment the patient will get. If they have
stage 1 or stage 2, then surgery w/ margin is all you need. IF you go to stage 3 you
throw radiation in. Stage 4 if you have distant mets you might put chemo in. The
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staging is really important in terms of prognosis and treatment. The patient will get
staged. How are we going to stage the patient? We need more imaging. You can
palpate for lymph nodes but also many times you cant see the deep lymph nodes.
Imaging, CT Scans, MRIs. They will show you lymph nodes involved. The patient will
get a complete workout and staged before the treatment begins. Most cases of SCC is
surgery w/ margins. Ok. Ill go to the next case. Case 2? Yes. Ok. So I just have to say,
that this isnt a written in stone rule. It depends on the patients medical status. It
also depends on where the tumor is. If you have an oral pharyngeal cancer that they
cant get to they might use radiation. This is not a hard and fast rule. Im not an
oncologist. Generally speaking, the stages 1 and 2 are usually surgical and when you
get higher stages you add radiation. Chemo is rarely used for oral cancers. Its used
very rarely for stage 4s. Case 2. Are there any more questions on Case 1 before I go
to the next thing?

Case 2 is a 67 female patient that presents to dental clinic for new dentures.
Her medical history: hypertension and is a smoker. Shes taking Norvasc, which is a
medication for hypertension. She reports she has soreness and burning pain on the
top of her mouth. When you hear soreness and burning pain you should think of 3
things really. What are the things you should think of? Candidiasis. The various
forms of Candidiasis. What else? Not quite. Ulcers can be sore but burning doesnt go
w/ that really. What else? Ok. Ummm. Not quite. What else? Ok. Dry mouth can lead
to burning sensation, thrombo infection and lycanoid lesions. Lycanplanous,
lycanoid mucositis patients will say they have soreness and burning of their cheeks
or where ever their lesions are. This is what you should be thinking of just based on
their history. The way that you should approach this is, you look at the history and
you start thinking bout things that occur in that area. Then you look at the picture
and see whats most consistent. Thats how you come up with your differential
diagnosis list and your favored diagnosis. So. Dry mouth causes burning b/c you lose
that layer of lubrication that coats the oral mucosa. Alright. So, what do we have
here. Who would like to go for this one? This is the easier ones so you might want to
raise your hand now. Ok. Also known as? What else can you call this? Ok. What type
of candidiasis. Erythematous (chronic atrophic candidiasis). Trophic means red and
chronic meaning the patient has had it for a while. Chronic atrophic candidiasis,
dentrostomitis, erythemtis candidiasis. These are interchangeable terms. Could this
be anything else? You think of anything else this could be? Besides a dentrostomitis
or a candidiasis? Anyone? Not quite. What Im going w/this is, is if it was a new
denture. What if I told you they had a new denture and then they came to see you 3-
4 days later like this? Can you think of anything else? Hypersensitivity or allergic
reaction. Maybe to the denture acrylic. That would certainly have to be right after a
new denture was delivered. If a patient told you theyve had a denture for years, I
dont think its very realistic to put that in. Although, I there are cases where
patients have had it from the beginning. Some sort of hypersensitivity or allergic
reaction and never got it treated and kept wearing the denture. Thats a remote
possibility. What should we do next? What should we do next? Ok. Lets say were
unsure so we should do a mucosal smear right? Mucosal smear. Candidiasis is an
indication for a mucosal smear. Whats the other one? Herpes. So those are good
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things to do. A smear was done. These are the fungal hyphae. These are the clump of
epithelial cells so it was definitely positive for candidiasis. What now? What do we
do for treatment? Whats next. Lets be a little more specific. Give me some names.
Coctrimicoltrosis. A patient can suck on these laugengous (spelling?). What is it? I
wouldnt really recommend the disc in a patient who wear dentures since they have
to wear it all day and they cant wear their denture over it. Nystatin rinse I would
use or an ointment in the denture base. Nystatin comes in different forms. Tablet,
ointment, rinse, cream. All of these other things. You can do a nystatin ointment in
the denture base and do it 3 times a day. You can have the Pt take out the denture
and do a nystatin rinse. It wont help if they are doing the rinse w/ the denture in.
You can also do the coctrimicoltrosis but again the patient cant be wearing the
denture b/c you want the contact anti-fungal to contact the area to contact in
question. I personally would be doing the nystatin ointment denture in the base b/c
I know it will cover the right area. Then you would do a follow up with a patient to
make sure it was resolved. What would you do long term for management w/ a
patient like this? Exactly. Keep your dentures at night. If they are poor or ill-fitting,
fabrication of new dentures. Thats the longer-term management of this. Denture
stomitis, erythemtis candidiasis, and we talked about the treatment. Ok, so any
questions on that case? Is it pretty clear? Moving on to the next case.

Middle aged male patient that presents to the oral medicine clinic
complaining of recurrent painful oral ulcers. He denies a medical history and no
medications. He says he gets sores like these every couple of months. Before I
progress to the picture, whats a key word in this history here? There are two
important words that point you in the right direction. Recurrent is an important
word. Recurrent and painful. Actually, even this last phrase. Gets sores like these
every could months. What should you be thinking. What things are recurrent?
Herpes or apthus ulcers. Right? So, take a good look at this. Im trying to make it a bit
brighter. Who would like to describe this and come up with a differential. This side
has been active while this side has been quiet. Who would like to volunteer and
come up with a diagnosis? Are you volunteering or stretching? Ok go for it? Ok, why
do you say that? Describe it briefly and tell me why you said that. On the soft tissue.
You mean, movable non-keratinized. Based on the location, movable non-
keratinized, its got a yellow white, fibrin coating. One thing you left out thats classic
for apthus ulcers is the red hallow and the shape around it (nice round oval shape).
The fact that its on movable mucosa, its got the yellow white coating, its got a red
halo, its round to oval in shape. All of these things points to an apthus ulcer. In this
particular case. Dont just zoom in on one thing. Look at everything. Is there
something else this could be? Look at the entire picture and think about some other
possibility. Yea. Possibly, a traumatic ulcer since you have some stuff going on over
here right? Maybe there is a traumatic component to this. It has a round regular
shape. And the patient tells you an important question to ask. Whats one thing also,
that will help you from the history help distinguish this from a traumatic ulcer.
Whats another important question, I would ask my patient. There you go. Thats the
correct answer. Recurrent apthus ulcer patients dont get it in the same spot every
time. I would want to know where it is. Is the recurrent ulcer always in the same
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area? That would be a result of trauma. If it was recurrent in movable mucosa, I
would point to apthus. Does that make sense? At any rate, what should we do next?
Differential diagnosis? Apthus ulcer. Potentially traumatic and I just put herpetic
here since its a differential for an ulcer in the oral cancer. Realistically its not a
herpetic ulcer since its on movable not fixed and its not a tiny group of ulcers like
most herpetic are. What do we do next? Whats a possibility to do next? You feel
pretty good that its an apthus ulcer. Whats next? Your patient wants you to do
something. I wouldnt use a rinse for one ulcer. You can do a topical steroid
ointment. Right? Theres another ointment called canilogin orabased (I didnt cover
but thats a possibility). Or, in many cases, if this was the only ulcer they had, I may
reassure the patient if they are health w/ no medical issue, I would reassure them
that it would heal in a week. Idk if I showed you the picture or not, but there are OTC
products you can use but you get a worse reaction. I may have shown you a case
where a patient put something on it and it got worse. I think they developed an EM
on it. Sometimes its better to tell your patient, look this is what it is and its going to
heal in a couple days. You can recommend some OTC anesthetics, OraBase,
Kanocover, things like that. If its really painful (multiple ulcers) you can give a
steroid ulcer or rinse. One other question to ask you all. If this patient tells you ya I
get sores like these all the time, is there any other workup or anything that we
should do? The answer is yes. Can you tell me what else you do for this patient?
Every person that gets a diagnosis for apthus ulcers needs a work up to try and find
a cause. You should remember that list with the slide of all the potential systemic
diseases associated with recurrent apthus ulcers. Does anybody know any of them?
Gluten sensitivity, celiac bashets, what else? Neutropenia. Right? Ok. HIV is another
one. The GI disease is Crohns and ulcerative colitis. For any patient that shows up in
our clinic with apthus ulcers we try to find the cause. We ask about GI issues, we ask
about gluten sensitivity, this and that. We always order CBC Blood work to look for
neutropenia or Vitamin deficiencies since they can be a cause of recurrent apthus
ulcers. We do a full workup. In some cases youll find an underlying cause. If you find
an underlying cause and treat it, the patient will be doing much better and have less
episodes. In the majority of cases you dont find an underlying systemic cause.
Theres also a familial or genetic component to apthus ulcers. You need to at least do
the workout to rule out other systemic cause. Recurrent apthus ulcers, treatment no
treatment recommended, topical steroids, rule out underlying systemic causes
which I just went over, immune deficiency, Crohns, ulcerative colitis, nutritional
deficiencies, sprue, and gluten sensitivity. You really do need to know this list of
diseases that are associated w/ recurrent apthus ulcers. Sprue is like gluten
sensitivity. Very similar. I dont know what the fine difference is. I think its a more
regional type of disease. Any questions on that case? The recurrent apthus ulcer
case?

Case 4 is a 24-year-old male dental student who presents to the oral
medicine clinic with a bump on the lower lip. No medications, no other significant
exraoral or intraoral findings. What should you be thinking even before I show you
the picture. What are the common oral lesions that could present as a bump on the
lower lip. There are two that should come to mind. Fibroma and mucoseal. How do
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you tell the difference between them clinically? By palpating them. The fibroma is
firm and the mucoseal is softer and compressible. Right? Ok. Sometimes you cant
tell the difference w/o biopsy. Some mucoseals can develop fibrosis and keratosis
around them too. Anyways. This is what it looks like. This actually felt a bit fluctuant
or soft or compressible. Which of the ones do you think? Yea. We talk about the
differential diagnosis before you feel it. This could also be a fibroma. Very rarely at
the bottom of the list, you can get minor salivary gland tumors. You have a lot of
minor salivary glands on your lower lip. They are pretty on the lower lip. Its kind of
in there, in the differential diagnosis. Mucoseal on the top, fibroma, minor salivary
gland tumor (at the bottom less likely). What kind of treatment do we do? Whats
the next step? Excisional, not incisional. Here is the excisional biopsy. Remember a
mucoseal is not a true cyst. Its a space filled w/ mucus which often washes out
during processing. You have a compressed connective tissue wall here. Granulation
tissue, and CT tissue. These are some salivary glands and this is the surface
epithelium. Always tell your patient that there is a chance of recurrence of mucoseal.
What caused the mucoseal to begin w/? Severing of the duct. How? What kind of
trauma? Usually when you bite yourself. You tend to see it in younger patients.
Youd be surprised that one of the common times of mucoseal formation is when?
Think about this one. When would a kid be more likely to bite themselves. After
dental work, after local anesthesia. The kids are like oh this feels so cool and
theyre biting their lip. Thats a time when many mucoseals do form in pediatric
patients. It doesnt have to be. Any body can get a mucoseal. I have to tell you, that
several dental students have gotten, b/c when youre stressed out, you might bite
your lip or something and cause a mucoseal. This dental student told me he was
really stressed out. He said it was some other class. That was a mucoseal. Any
questions on that case? Ok. Thats a good question. Would somebody else like to
answer that? Do you think that this could ever go away on its own? Not really. What
can happen and what does happen, or what most patients do is that they stick a
safety pin in this and they sort of pop it. The salvia and mucus comes out and
deflates, but it almost always comes back. The truth is, is that ruptured duct is in
there. Once saliva is produced, its going to come out. When the soft tissue heals on
top, its going to enclose the saliva. W/ that being said, there are always exceptions
to the rule. There are small mucoseals on your palate (superficial) that can rupture
on their own and not reoccur. In 99% mucoseals need to be removed. You do need
to treat it. Ill tell you one thing. This is a smaller mucoseal. Ive seen much bigger
mucoseals. Some patients my tell you they vary in size, depending on if its meal
time and if they salivate more and more salivate is produced. The mucoseal may
inflate and deflate. It doesnt have to, but it may change in size. Its a good clue if the
patient tells you that it changes in size regularly. You should be thinking of
mucoseal. Every time you do this excision, you have to warn your patient that there
is a chance for recurrence. When you remove this, if you rupture the mucoseal you
lose the margins of it. Theres a higher chance for recurrence. Also, we tell people
that when you remove the mucoseal, you should pluck out the surrounding salivary
glands as well to try to get the ruptured duct w/ the mucoseal. You dont want to dig
in there too much or youll create another mucoseal or create another problem. Its
not always the easiest to treat a mucoseal. Once you know how to do it, you do blunt
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dissection and incision here and you use your forceps to separate the fascia and take
it out as a hold. Any other questions about the mucoseal? It progressively gets
bigger. Its not going to transform into a malignancy. The lip wont be destroyed or
anything like that. We want to tell our patients ideally, that they should get it
removed. Nothing terrible will happen if you dont remove it though. Keep in mind,
how do you know its a mucoseal for sure unless you take it out and look at it under
a microscope. What if it was a minor salivary gland tumor and you said oh its a
mucoseal and leave it alone. Its your liability. It might often, does not have to, but
yes, when you eat the aroma causes more salivary secretion and when more saliva is
secreted, obviously more is going to leak out of the broken duct. Does that make
sense? Lets move on to the next case.

Case 5 is a 59 year old woman that presented to the oral medicine clinic w/ a
chief complaint of dry mouth w/ burning discomfort She claims that this problem
has been present for 3 months. Medical history: severe seasonal allergies. Shes
taking Benadryl and Sudafed. On examination, her mouth is definitely dry. Shes got
some changes to her tongue. So let me show you the pictures. We have a picture
here, we another one here. Ok. So who can describe what we see in these two
pictures. How about you? Deep papillated tongue. Does that have a term? Yea.
Fissured tongue. It is a little fissured but Im looking for something else. Whats the
term for a painful deep papillated red tongue. There is a term for it. Glossitis right?
What else do you notice in this picture? There is a mild angular cheilitis. You can see
it better in this picture. This patient has mild angular cheilitis and glositis with a
little bit of fissuring as one of the students mentioned. What can be going on? Whats
a possible differential diagnosis and next step. This actually eludes to the lecture on
salivary gland pathology. Theres some stuff you should be thinking about here
right? Such as what? What could be going on w/ this patient? All the way in the back.
Sjogrens syndrome. Do you think this patients demographic is correct for the
syndrome? What kind of people usually get it? Males or females? Is it younger or
older? Older. Is it white or black? Ok. Its usually older white females that get the
disease but anybody can get it, dont get me wrong. Anyone can get the syndrome.
By far, females are more likely to develop the syndrome. Thats definitely something
you should be thinking. Drug related xerostomea. And shes taking two medications.
What types of medications are these guys. What do you know about them? What
types of drugs are those? Anti-histamines right? Which are designed to reduce
secretion. So you can see how dry mouth can be a side effect of those. If youre
thinking about the syndrome, what else can we check or think about. What else
would you ask if you thought somebody had it? Dry eye. Do you have a dry eye
issue? The pt tells you yes, then maybe she does have it. If the patient tells you no,
then she probably doesnt have it. For any rate, for the syndrome, whats the
workup? Whats the workup if she said her eye was dry too? Who knows what you
do for the syndrome? Yea, theres a couple more things. Thats part of it. Blood work.
Honestly its a difficult diagnosis. These autoimmune disease require multiple types
of criteria. SSA/SSB is one of them. Who knows some other criteria for they
syndrome. Theres a test for eye dryness. What are some other ways of diagnosing it.
A patient w/ the syndrome has bilateral parotid gland enlargement. Labial salivary
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gland biopsy. You block out some glands from the lower lip and look at it. I dont
favor that b/c even inflammation of the lip can look the same under the microscope.
Thats something you can do as well. What about imaging? Is there any type of test
or X ray you can do to help w/ the syndrome? Theres something called a sialogram
too. Its where you inject a dye into the duct and take a look. That can help w/ the
diagnosis of the syndrome. You do a lot of these different tests. It helps w/ the
diagnosis. If the patient has another autoimmune disease you know they are at a
higher risk for another autoimmune disease. These are all things you look at. So far
in this case, we have some cause for dry mouth of burning. It could be the syndrome,
it can be drug related. Is there anything else that can cause these symptoms?
Anything else? Candidiasis which ties in w/ the dry mouth right? Obviously if the
mouth is drier, the balance is off and they are more prone to developing candidiasis.
In general, whats another cause of glositis. What else can cause a painful red
tongue? Not dry mouth but something else that Im looking for. Vitamin B and iron
delicacies. It can cause an glositis and angular chelitis. We have to ask a bunch of
questions and do some test to come up w/ the answer in this case. This is a nice case
to tie together various things that can happen. In reality, the truth is that when you
see patients in the oral medicine clinic, it isnt always straightforward. Theres a
bunch of things you have to work through and piece together. This is our different
diagnosis in this case. Medication related xerostomea, Sjogrens syndrome, glositis,
secondary to iron/ vitamin B deficiency anemia, angular chelitis, and erythematous
candidiasis. You all see how these are all in the differential diagnosis. How are we
going to work though all of this? Here I show you that the two medications, some of
their major adverse effects s xerostema. Benadryl also causes xerophthalmia. What
does this word mean? Dry eye. Now you maybe misled into thinking now that you
xerostema and xeropthalmia that you didnt know if they were side effects of the
medication youd think they had Sjogrens syndrome. The diagnostic process, taking
a history, knowing the medications and their side effects. Lab tests if we are
expecting Sjogrens syndrome, shell tell you her eye is also dry. Blood tests for
SSA/SSB labial salivary gland biopsy. If I think she has a glositis that is due to a
vitamin deficiency I would order a CBC. If you want to rule out fungal infections, you
can do a mucosal smear and microscopic exam. The diagnosis in this case, was
medication related xerostema. It was the medications that really dried out her
mouth. She did not have Sjogrens syndrome once the workup was done. She had a
secondary candidiasis. Due to the dry mouth she had a fungal infection. A smear was
done and it was positive for a fungal hyphae. We noticed that when she stopped
taking the Sudafed and Benadryl, she had increased salivary flow. The more salivary
flow she had and using the anti-fungal, the burning and soreness was gone. Thats
what was going on in this case. The medications and then the secondary candidiasis.
Yes sir. Thats a good question. Its a bit of complicated question. It really depends
on how confident I am based on this history I gather. For example in this case, she
said her symptoms got a lot worse now that her allergies have gotten worse and this
and that. I probably would see if she can cut down before I did all of this other stuff. I
would see if lowering the medications or using other types of meds can improve the
symptoms. Then again, you know, if I think she has candidiasis, most anti-fungal are
harmless so I would go ahead and prescribe that too. As far as the blood and
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Sjogrens syndrome work, I wouldnt do that until I ruled out the medications.
Unless I felt really, she had the enlarged glands and she said her eyes were dry and a
bunch of other things. Sjogrens is a pretty rare diagnosis. I would rule out other
things that are more likely than going into something more invasive such as a labial
salivary gland biopsy or ordering SSA/SSB. Did I answer your question? It can. You
know it definitely in this case, it can. Asking about dry eye isnt really going to
distinguish b/w. In that case Id want to know how long had she had a dry eye
problem. Has she noticed its been getting worse since shes been increasing her
dosage when she has allergies. You try to find a correlation and that would help you
make the distinction. Youre right. The anti-histamines can make your eyes dry as
well. Yes. No. It has to go through the patients physician. We can make a
recommendation. We can ask a patient to discus it and I can even get on the phone
and say look this patient has really severe dry mouth and burning and fungal
infections, can we try to change the medications. Ive written letters to physicians.
We can do that kind of stuff. We cant tell the patient to just do it. We cant change
any of those prescriptions. So. Anything else? Again, thats a good question. Every
patient is different. They all come w/ different circumstances. Different ages.
Different thresholds of what cause a fungal infection dry mouth or not. The older
you get the less salivary flow you have. The patients age can be a factor. That is a
good question, but every patient is different and acts differently.

Im going to go to the next case now. The next case is a 70-year-old woman
that presented to the oral medicine clinic complaining of painful oral ulcers. The
ulcers began about 6 months prior to her presentation in the clinic. The started in
the back of her mouth and have progressed to include her buccal mucosa tongue
and lips. He has high b.p. She takes Propranolol (B-blocker b.p. med). Allergy: NKDA
(no known drug allergies). There are a couple pictures here. This is one. This is two.
Ok. Take note of the gingiva in this picture. This is three. This a fourth picture. And
then if Im wondering if I go to the next one if its an answer or not. Were good.
These are your pictures. Who would like to go for this one? I want to see if anyone
else volunteers. Someone different guys. Havent you? Are you a new volunteer? Ok
go ahead. Pemphigus. So first tell me what are you seeing in these pictures. How do
you describe all of this stuff. What are you seeing? How did you get to pemphigus?
You just remember what? Ok. Pealing is good. Erythema, bleeding. What is that
word for the sign that points towards pemphigus or pemphigoid? Nikolsky when
you rub the tissue it kinds of peals off. There was a positive Nikolsky sign. Whats
the term for this though? Desquamative gingivitis. Thats the clinical term for this
presentation. When you have red pealing gingiva. And then, this in and of itself along
w/ other ulcers and peeling should lead to a differential diagnosis. You got one of
them. There are four things that you should think of. I wont leave you alone until
you come up w/ at least one more. Pemphigus is the least common. There are two
other things that are more common. Pemphigoid is one. Erosive lichen planus and
that sort of ties w/ pemphigus at the bottom. Whats the fourth thing? Erythema
multiforme can present as a disquamative gingivitis. All of these pictures. If I gave
you no other history and I just showed you these pictures, you could use all four of
these diagnosis. The thing w/ erythema multiforme whats the most important
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clinical feature of EM that distinguishes it from these 3 other disease? The blood
crusted lips but thats not it. Target lesions. What about the length of time the
patient has had it. Erythema multiforme tends to be acute. All of this happened in
one week. You can tell from the history I gave you that the lady had been suffering
for 6 months and the ulcers are getting worse. That rules out EM but you can have
patients that have recurrent EM. They wont heal in b/w outbreaks. EM is sort of out
here. In this particular case if youre thinking about erosive lichen planus, you dont
see any striations on any of these lesions. You may not but it doesnt 100% rule it
out. Since I dont see any, I would put it on the side. Since its chronic I would put
erythema multiforme on the side. Really focus on pemphigus and pemphigoid on
this patient. What is the next step? What do we do next? Where? Where are we
going to biopsy? Perilesional. Around the effected area. I might just go somewhere
around here on the gingiva. Not straight into the lesion. Maybe a border of it. Maybe
right here .You can even go on the lip over here. I would prefer to go on gingiva
rather than lip. Definitely a perilesional incisional biopsy. What else should we do to
rule out pemphigus and pemphigoid. Well Nikolskys sign we do it, and it sloughs
yes. Im talking about another definitive test. Whats a standard test?
Immunofluorescence. Realistically you should do two biopsies although people will
do one and split the tissue in half. You shouldnt do that. You should do two
perilesional and send one for routine microscopy and one for immunofluorescence.
So, the differential diagnosis. Pemphigoid is a lot more common than pemphigus. Its
10 times more common. I put these two at the top. Lichen planus and EM are here.
EM is at the bottom b/c this is more of a chronic process than an acute process.
Lichen planus, even its the most common cause of disquamative gingivitis in this
particular case, based on the fact that I didnt see straie anywhere, I decided to put
this third. The differential is a bit fluid based on what you see. This was the order
that I liked for this presentation. Than an incisional biopsy was done and here you
see peeling of the epithelium separation from the connective tissue but the basal
cells are still attached. Which one do we favor? Do you favor pemphigus or
pemphigoid. I heard half and half. Lets see if we can clear it up w/ the
immunofluorescence. This is described as a chicken wire effect. This is CT.
Pemphigus vulgaris right? Where is the attack in it? Whats attacking what?
Autoantibodies are attacking? What? Desmoglands 1/3 which are proteins in
desmosomes that hold epithelial cells together. The epithelium is just falling apart.
Remember the basal cells are still attached since the hemidesmosomes dont have
the desmoglands 1/3. If you think about this, it makes sense. Really try to think
about why things happen and whats going on here. That was pemphigus vulgaris.
What is going to be the treatment for this? What happens next? Thats a favorite
answer. Refer. Refer to who for what? Hopefully you refer to me. What would I then
do? High dose steroids. You cant keep a patient on it for long b/c of Cushings
syndrome and all the negative side effects. You then try to wean them off and go
towards other suppressant meds. Such as micophenalate. Theres some other
treatments I talked about (IVIG). Remember I talked about rituximab and these new
monoclonal antibody treatments. There are a couple things going on for pemphigus
and autoimmune diseases in general. Refer patient to specialist, high dose steroids,
IVIG steroids meds. Its important that we regularly their lab values their
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desmogland 1/3 antibody titers so we know whats going on inside rather than just
looking at clinical manifestations. I mean monitor their blood count, their glucose
level. Any of these medications are doing something to the CBC and the metabolic
panel. You need to keep up w/ the blood work. Routinely check for and ask about
extraoral involvement. You all should know that pemphigoid and pemphigus can
have extraoral manifestations. You can get vesicles and blisters anywhere on the
skin, the eye, or in the genital mucosa. There can be many other sites involved. You
routinely have to ask the patient. When they develop these you send them to the
dermatologist that can deal w/ extraoral manifestations. That was pemphigus
vulgaris. Any questions on that case? Yea whats your question? Did you just raise
your hand? Lichen planus is the most likely diagnosis for disquamative gingivitis. Its
the most common cause. Then I would say pemphigoid and then pemphigus are a tie
at the bottom. But I changed it in this case since I didnt see striae anywhere.
Generally in lichen planus you see the white striae but you can have erosive where
its so red and ulcerated that you dont even see it. Based on frequency and
likelihood, yes it should be at the top. Any other questions about this case? Ok. It
would for systemic steroids. It does. Thats for sure. But still, if the patient does still
develop any extraoral lesions while youre treating them, you have to involve other
specialist for skin lesions. They have some other things that they are doing.
Certainly any systemic med is going to have effects outside just the oral cavity. Ok.
Im going to move on to the next case.

Case 7 is a 43-year-old male patient that presents w/ painful ulcers on the
rough of the mouth. He denies any medical history. He is a smoker and is worried
about oral cancer. Again, what you should be thinking here. Ulcers in the mouth. I
should think about 3 types of ulcers. Which are? Apthus, herpetic, and traumatic.
This is what you should be thinking instantly. Then you look at the picture. And you
see something here. Who wants to go for this one? Go for it. Nicotinic stomatitis.
Thats a good thought, this patient is a smoker, we are on the palate, but these arent
red spots. They are pinpoint ulcers ok? Some of them have fused together into
lesions. Im sorry what? Herpetic. Ok. Is this the right area for herpetic ulcers? Fixed
keratinized right? Intraoral. Most locations are the palate and the gingiva. You have
multiple tiny red, punctate ulcers on the hard palate. You should think of herpetic.
Multiple like a group we call it a crop of ulcers. Lets say youre unsure. Youre just
not convinced. Someone is looking at me like theyre skeptical. If youre unsure what
can you do? What type of biopsy? Remember on any exam I give, biopsy isnt good
enough. What kind and where. What type of biopsy? What can we do to diagnose
this as herpes? A mucosal smear. Im going to make one comment though. Mucosal
smears work much better earlier on. If this has been around for a while you might
get a false negative. The smears work best when you see the fluid filled blisters or
freshly ruptured. After a while you dont see the tzanck cells youre looking for
under the microscope. Tzanck cells. So you do a mucosal smear. This is what the
smear looked like. This is a tzanck cell. Multi-nucleated. We now diagnose that this
patient has intraoral herpes. The patient says ill gross but now what do we do? Do
you think we should prescribe Valtrex right now? Im sorry what? Carry on. Anyone
else? Whats that? Ok. I guess where Im going w/ this, at this point its probably too
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late for these lesions. You just have to reassure and let it heal. What you do is ask the
patient and see if there is a correlation w/ anything. Dental work. Trauma,
injections, dental work can bring this on. The stress can trigger this. If a patient gets
a herpes outbreak every time you do dental work you may suggest a prophylactic
regimen of Valtrex where they take 2g at the time of the appointment and 2g 12
hours later. So 4 tabs and 4 tabs. Definitely for future outbreaks. What else can you
recommend to a patient who gets recurrent herpetic lesions. What are some other
things besides Valtrex use regularly? Remember, you tell them these things work
best when they feel the tingling and before they have the outbreak. What are some
other things you can suggest? Lysine supplements since it effects the viral
replication ratio. Zinc promotes epithelial turnover when they have lesions but it
wont protect an outbreak. Essentially looking for a trigger, minimizing the trigger.
Some patients get herpes labialis due to cold or wind (protection might help). Ice
may also help since it slows down the viral replication. Prophylactic Valtrex and
lysine supplements. These are things I recommend. You have to let your patient
know that at this point its just going to come and go but for future out breaks. If a
patient gets constant recurrent herpetic lesions, you can do herpes antibody titer to
help w/ the diagnosis. You can find that in the blood as well, HSV1/2 antibody titers.
There you are, mucosal smear. Intraoral herpetic ulcers and we talked about
treatment. Any questions before I go to the next case.

The next case is a 51-year-old female patient that presents a dental office
stating the inside of my right cheek is sore and very sensitive to hot or spicy foods.
The patients has blood pressure and hypercholesterolemia. Takes Atenolol and
Lipitor. The social history is smokes a half pack a day. Theres some key medical
history in this clinical history. Sensitive to hot or spicy foods. What else? What else is
important in this history? Whats that? The patients grievance is with their right
check but you cant tell if its unilateral or not. Anything else? Ok. Where I was going
w/ this is the medication list is important here. Theres a blood pressure and
cholesterol medication. Especially Lipitor. Keep this in your head as we go through
the case and youll see what were talking about. This is a clinical picture. Who wants
to go for this? I want a completely new volunteer. Volunteer or I will pick on you.
First describe what you see here. You always want to be able to describe things
before you jump into a diagnosis. Which are called what? There is a term for those
white lines. Wickham striae. There are definitely radiating white lines and there are
some red areas too. Do you see some erythema in the background. Whats the
differential diagnosis. Could this be anything else? The answer is yes. It could be
something else. Can you think of anything else in lieu of the patients medical history
it could be thats similar to lycan planus. Its called lichenoid reaction or lichenoid
mucositis. Related to b.p. and cholesterol meds (esp. Lipitoir). The can also be
caused by amalgam or cinnamon sensitivity. Keep in mind lichen planus is an actual
autoimmune disease process that can effect the skin as well or vaginal mucosa.
Lichenoid mucositis is a confined local reaction in the mouth due to certain
medications. They carry different prognosis. If you have to pick b/w lichenoid
mucositis and lichen planus I would pick lichenoid mucositis since planus is
autoimmune and can occur on your skin and it can increase your chance for oral
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cancer. Plus w/ lichenoid mucositis if you can find your cause, you can eliminate
that and cure yourself. It doesnt always work out though. But many times you can.
Whats the next step? The same student. Im going to pester you one last time. What
do we do next to make our diagnosis. Incisional biopsy. Where are we going to do
this? Tell me the area you would go in. Would you go for a red area or an ulcer? Not
in this case. Anyone else have another idea? When youre trying to diagnose
something lichenoid you go for the straie. The red is inflammation in the
background. Its not going to help w/ the diagnosis in anyway. If youre trying to
rule out if its cancerous you might go for the red area. If youre unsure go for the
white/ red area both. The real thing to do is to go for a white straie. Lichenoid
mucositis that are drug related have a strong red component to them and are
symptomatic. I have soreness or burning when I eat something spicy or acidic. This
is a biopsy. It was indeed lichenoid mucositis. You have degeneration of the basal
cells. You have a mixed infiltrate. You remember when I talked about planus there
was a band of lymphocytes. The cells are all scattered. If you look at them, they are
plasma cells and lymphocytes. They go around blood vessels. You can see some
inflammatory cells deep around the vessels. This is very characteristics of a
lichenoid mucositis or drug reaction and not planus where you have that band of
lymphocytes. It was indeed lichenoid mucositis and most likely drug related. What
would be the treatment for this patient. What should we do to treat this patient?
Topical steroids right? clobetasol ointment or clobetasol ointment. Theres also
other things. Please note that we discussed in this class are the most commonly used
that work well but note there are other ones. If its diffuse I would prefer the
clobetasol ointment. If its more localized I would go w/ clobetasol ointment. Any
questions on that case. You have to know the difference b/w lichenoid mucositis and
planus. Clinically you cannot not for sure until you do a biopsy. Just b/c they are
taking a million med and Lipitor, it doesnt mean its lichenoid mucositis. You still
have to do a biopsy. You have to make the distinction. It effects the prognosis. Its
autoimmune and it does slightly increase the risk for oral cancer. If you something
lichenoid you should be asking your patient do you have any skin rashes or any skin
lesions. For females Im straight up do you have any vaginal mucosal lesions or
burning or pain there. Its so often misdiagnosed as a yeast infection. Ok. Any
questions? Ok. Id like to think that you guys are really piecing this together rather
than youre terrified and you feel overwhelmed. I hope this process is helping you
guys tie it together and think the right way and the way youre approaching the
subject. Its not just memorizing useless random facts. My purpose is to ensure that
you guys are competent enough that when you see patients that have these diseases
you know what to do. Can you recognize something and help your patient do right?
Thats how Im approaching this material.

Case 9 presents with a chief complaint of a large annoying bump on my
upper gums. The patients denies pain and says the bump is slow growing. No
medical history or meds. What should you be thinking right away? What are the
common oral lesions that occur on the gingiva? Before you even look at the gingiva?
Who knows what these common lesions are? Who knows? Ok. So the three P lesions.
Pyogenic granuloma, Peripheral ossifying fibroma, and peripheral giant cell
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granuloma. 90% of all gingival lesions are one of these 3 reactive gingival lesions.
This is what you should be thinking about. The truth is you can clinically look at it
and put those 3 in, in order but you cant be sure what it is w/o taking it out and
looking at it under the microscope. Do you see the big bump on the gums. Ill ask you
out of the 3 P lesions, think about the names, which do you think is the most likely
diagnosis about the 3. Does anyone remember anything about the pyogenic
granuloma? It bleeds easily, its spongy and red usually. Its associated w/ pregnant
patients. You dont have to be pregnant to get it though. The other two lesions,
peripheral ossifying fibroma (forms bone and calcifications) meaning it will be very
hard, firm, and fibrous. The third, peripheral giant cell granuloma is a bluish-
purplish in b/w lesion. Which one would you favor? Its not red and spongy right?
Like it would bleed easily? Not really. I wouldnt go w/ a pyogenic granuloma. Does
it look fibrous and might be hard if you feel it? Yes. Does it look bluish purplish and
it might be middle consistency? No. I would put $1,000 on peripheral ossifying
fibroma if I was at the casino. Thats what you would think but you have to do an
excisional biopsy. You have to take it out and look at it under the microscope. Heres
the differential. I just put this as the standard 3 Ps differential. Pyogenic granuloma
is the most common. But in looking at this case, I would put POF before pyogenic
granuloma since it doesnt look red as if it would bleed. Theres always standard
differential diagnosis and then theres some that are particular to your case. Yes sir.
For the peripheral giant cell granuloma. Generally yes, but it doesnt have to be. Im
trying to give you guide lines but not all giant cell is blue/ purple. But thats what
you look for. If you look at this w/ certain angulation I guess, but not quite. If you
look at the overall picture its really very fibrous, pale, white, and it feels firm
hard. What type of biopsy do we have to do for this? Brush, mucosal smear,
incisional, excisional. Excisional. You have to take out the whole thing no matter
how big it is. Many of them are pedunculated and the stem is a lot smaller than the
top of it. Its actually a lot easier than it looks to remove this. This is your differential.
This is what it looks like. This is a fibrous background. This is bone formation and
calcifications. Therefore it definitely is diagnosed as a peripheral ossifying fibroma.
Its also important for these 3 P lesions to not only remove the lesion but it was
caused by plaque and calculus deposits in the pocket of the teeth. To prevent
recurrence you want to teach them good OHI and really floss in the area. At the time
you remove the lesion you should perform scaling and root planning of both
involved teeth. W/o fail youll pull out calculus. If you dont do that and you remove
all of this the patient comes back and its like you never did anything at all. It was a
part of your imagination. You really need to remove the underlying cause with these
lesions. Always tell your patient that there is a chance for recurrence. Any question
on the 3P lesion? We have our last case coming up? You guys look really dead man.

Before you totally collapse lets get through the 10
th
case. A female pt
presents w/ a growth on the lower lip. It has been present for a while but it is
gradually increasing in size. Medical history: hyperthyroidism and arthritis. What
are some potential growths on the lower lip? What is it? I didnt hear. Fibroma,
whats another one? Mucoseal. Its actually 1/3
rd
possibility that we havent focused
on. If I dont show you a picture you should think of something else you can find on
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the lower lip. I also want to say in many cases, viral lesions. Warts. When I talked
about common oral lesions, whats the most common site for HPV lesions? Do you
remember? Its the soft palate and the oral pharyngeal area. HPV likes the tonsillar
crypts. The lower lip can also have it. If you find a rough surface or finger like
projections on the lower lip, you should think about the HPV viral lesion or wart.
This is what the lesion looks like. Who wants to describe this and give me a
differential on what they would do next? Its the grand finale. Im going to pick on
the gentleman in the corner there. Are you w/ us? What do you think here? Looks
like a bump. Ok sounds good. Whats your differential diagnosis? Lets go there.
What is the next thing you would do w/ this? Do you want to phone a friend? Im
just trying to involve you sir. I would palpate this next. Lets say it felt firm. Now
what? Excisional biopsy is the way to go. What are we favoring here? Fibroma is
what were favoring here. It feels kind of firm but it rules out mucoseal. You should
be thinking of a fibroma. You should do an excisional biopsy. Does it look sessile or
penduculated. You would do an excisional biopsy. We went over the differential
diagnosis. Its a little beyond the scope of this course but there really are some other
soft tissue tumors that this could be. By far the most common is fibroma and
mucoseal. This is what the biopsy shows. Dense connective tissue and hyperplastic
epithelium and keratin formation. Very dense CT. This was a fibroma. Alright guys, it
has been a pleasure. Ill keep you posted about the exam. Let me know if you have
any questions. No class on Friday.