Oral Pathology And Oral

Medicine1

OSCE Station 1.1

A 58-year-old trucker came to the oral medicine clinic with

complaint of a swelling on the left side of the face. He remembers
that the swelling was as small as a peanut four years ago and has
been slowly increasing in size since the last three years. He gives
no history of discomfort, pain, discharge or fever associated with
the swelling. The reason he seeks advice is because of facial
asymmetry, appearance and he is worried about the fact that he is
a chronic smoker for the last 30 years.

Specimen: Incisional biopsy

QUESTIONS

1. What is the histopathological diagnosis based on features

noted in Figures 1.1A and B?

2. What is the histogenesis of the tumor?

3. What is the role of smoking in development of this lesion?

What is the treatment and prognosis?

OSCE Station 1.2

:
 A 40-year-old Indian man came to a dental clinic with a complaint
of mobile teeth. On clinical examination you also notice a
nonscrapable white patch on the right commissure measuring
about 2 cm × 1 cm. He gives a history of smoking approximately
ten cigarettes a day for the last 10–15 years. He is keen on
quitting his habit and also seeks advice.

QUESTIONS

1. Name three nonscrapable white lesions presenting in the oral

cavity.

2. What type of biopsy is indicated for this case?

3. What is the clinical term used for diagnosis of this lesion?

What is the histopathological diagnosis?

4. Mention three microscopic features noted on the given slide

(Figure 1.2B).

5. Name one commercially available product that can help in

quitting his habit.

OSCE Station 1.3

A 45-year-old man came to the oral medicine clinic with a

complaint of slow growing mass in the left mandible measuring 3
cm × 3 cm. He mentions that he was told by a dentist about an
impacted lower left third molar 2 years ago, but he ignored
removing it as it was never painful. Now he suspects it to be the
cause of the trouble. Radiographs showed a large multilocular
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 radiolucency associated with unerupted 38.

Specimen: Incisional biopsy

QUESTIONS

1. Name three lesions associated with impacted teeth. Why are

impacted/unerupted teeth recommended for removal?

2. Identify the pathology based on the photomicrograph and

label the marked structure.

3. Name four histopathological types of this lesion.

4. Which is the most common odontogenic tumor?

OSCE Station 1.4

George is a 19-year-old health science foundation student, very

active sportsman with keen interest in badminton. He gets an
opportunity to train with student teams from the European Union
in Denmark. For visa formalities he is asked to get his routine
health check up done where his dental check-up showed 3 cm ×2
cm radiolucency associated with his impacted 48.

The inscional biopsy report was dentigerous cyst and

recommended surgical treatment. He is worried and fears he
won't be able to make it for the training camp which is four weeks
away.
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 QUESTIONS

1. What is a dentigerous cyst? What is the treatment?

2. Do you think George will be able to attend the training camp?

Why?

3. Is the picture given consistent with the histopathological

diagnosis? Justify mentioning two points. Label the marked
structures.

OSCE Station 1.5

A 17-year-old girl was brought to the oral medicine clinic with

complaint of a swelling on the lower lip (1 cm × 1 cm) since last
three weeks. She has a history of trauma to the region a month
ago.

Specimen: Excisional biopsy from lower lip.

QUESTIONS

1. What is the rationale behind doing an excisional biopsy?

2. What is the histopathological diagnosis?

3. What is the pathogenesis of the lesion?

4. What is the treatment and prognosis?

OSCE Station 1.6

:
 Mr Lee (ID No: K012345) a 44-year-old businessman visited your
dental clinic with chief complaint of a growth in the mouth since
last five months. He is a known case of diabetes and hypertension
under medication and smokes 3–5 cigarettes a day for the last 20
years.

An asymptomatic, non-tender, pedunculated soft tissue growth

measuring 1 cm × 1 cm was seen on the right buccal mucosa of
normal color, texture and soft in consistency. Excisional biopsy
done and submitted for histopathology.

QUESTIONS

1. Please fill out the biopsy request form for this case.

2. Which solution will you use to fix the specimen?

BIOPSY REQUEST FORM

Name: Age: Gender:

ID No: Date of Biopsy: For lab use only:
Referred by:

CLINICAL DESCRIPTION

Soft tissue lesion

Color Morphology
White Flat

Red Raised

Pink Ulcer
:
 Others__________________ Others___________________

Radiographic
Tooth Number ________
Changes________________
Hard tissue lesion
Lucent Opaque

Mixed Radiograph submitted ? Yes/ No

Tooth Number ________ Radiographic Changes________________

TYPE OF SPECIMEN SUBMITTED

Biopsy Cytology Immunofluorescence

PAP Stain
Incisional Perilesional
(Dysplasia/Carcinoma)
Excisional PAS Stain (Infectious) Clinically normal
HPV

RELEVANT HISTORY (Include habit history)

_______________________________________________________
_________________
_______________________________________________________
_________________
_______________________________________________________
_________________

DIFFERENTIAL DIAGNOSIS (Minimum two)

_______________________________________________________
_________________
_______________________________________________________
_________________
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 OSCE Station 1.7

Following is the conversation between a dentist and his patient:

Dentist: “Hello! Mr Harry, how are you?”

Harry: “I am fine doctor. Just that I have noticed a small red and
white area on my cheek that feels kind of weird and is there for
the last 5 weeks”.

Dentist: “Well that looks big and abnormal. Do you still chew
those tobacco products?”

Harry: “Yes I do, but I have reduced the number to 4 times a day.
I keep them right next to the red area to relieve the pain
sometimes”.

Dentist: “Well Harry we need to take a piece of tissue from there

to find out what's happening.”

Photomicrograph of Biopsy specimen

QUESTIONS

1. What type of biopsy has been done here?

2. What has happened microscopically?

3. How will you motivate Harry to quit his habit?

4. Describe the role of tobacco in the development of this

lesion.
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 OSCE Station 1.8

Please read the following biopsy report and answer the questions
below:

BIOPSY REPORT

Patient Details

Name: Ms. Katie Age: 28 Years Gender: Female

ID No:305-07-5112 OP. No.:3127/10 Biopsy No.:59/12
Referred by: Dr Lim Date of Date of
(OMFS) Biopsy:06/12/12 Reporting:14/12/12

Clinical Details

Patient complains of swelling in the lower right retromolar region

since the last 5 years, history of previous excision with no known
histopathology report. Associated mild intermittent pain
aggravated on eating. On oral examination a 2 cm×2 cm solitary
swelling with normal color and consistency seen.

Biopsy Details

Incision biopsy.

Histopathology

H and E stained superficial and deep sections show multiple soft

tissue bits composed of overlying hyperplastic stratified
squamous epithelium and connective tissue showing
nonencapsulated tumor tissue composed of multicystic areas.
Cystic spaces are lined by large number of mucus cells with
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 basaloid or cuboidal intermediate cells and fewer epidermoid
cells. Some solid areas show sheets of clear cells, focal areas of
chronic inflammatory cells, areas of hyalinization and numerous
dilated blood capillaries.

Tumor tissue shows mucicarmine positive staining for sialomucin.

QUESTIONS

1. What is your histopathologic diagnosis based on the

description?

2. What is mucicarmine stain? Why is it used?

3. What is the treatment and prognosis for this lesion?

OSCE Station 1.9

A 25-year-old pregnant woman in second trimester came to

dental clinic with chief complaint of painful swelling on the gums.
The swelling appears ulcerated, boggy and inflamed. Oral hygiene
was poor. She requests you to prescribe medication for pain relief
before deciding on the treatment options.

QUESTIONS

1. Mention three differential diagnoses.

2. What is the probable pathogenesis for the lesion?

:
 3. Can the patient be prescribed an analgesic? Justify your
answer.

4. What is your approach to manage this case?

OSCE Station 1.10

WM Tilakratne

A 30-year-old female patient presented to periodontology clinic

for routine periodontal check-up. This is the radiograph taken for
the assessment of alveolar bone loss.

QUESTIONS

1. Identify the radiograph.

2. Describe the radiological findings.

3. Mention three differential diagnoses.

4. What additional information/investigations you may require in

order to arrive at the definitive diagnosis?

OSCE Station 1.11

WM Tilakratne

Following are extracted tooth specimens that were taken from

three different patients.
:
 QUESTIONS

1. Identify the anomaly with specimens (Figs 1.10A to C).

2. What are the etiological factors responsible for above

anomalies?

3. List two clinical implications each for these three anomalies.

OSCE Station 1.12

WM Tilakratne

A 50-year-old male presented to oral medicine clinic with burning

sensation and leathery feeling of oral mucosa. He gives a history
of betel nut with tobacco quid chewing since the last ten years.

QUESTIONS

1. What is the most likely diagnosis that can be arrived at with

the provided clinical information, clinical picture and
histopathological features?

2. List three histopathological features present in the

photomicrograph that may have contributed to arrive at the
above diagnosis.

3. What is the etiology of this disease?

4. Briefly mention the significance of close follow-up of this

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 patient.

OSCE Station 1.13

WM Tilakratne

A 30-year-old male was seen in the oral surgery clinic who

presented with a large bony hard swelling of the right body of the
mandible present since the last few weeks.

QUESTIONS

1. What is your diagnosis? (Credit given for accuracy)

2. List three histopathological features in support of your

diagnosis.

3. What clinical features would you expect to see in this patient?

4. Outline the management of this patient.

5. Comment on the prognosis.

OSCE Station 1.14

WM Tilakratne

A 40-year-old male patient presented to oral surgery clinic with

enlargement of bilateral parotid gland and swelling of both lips.
The patient also complained of difficulty in breathing.
:
 Specimen: Labial biopsy

QUESTIONS

1. State the histopathological features you observed in the

photomicrograph.

2. What other clinical features you would expect in this patient?

3. What are the investigations that should be carried out in this

patient to arrive at the definite diagnosis?

4. Mention two syndromes associated with this disease.

5. List the main features of one syndrome you mentioned in

Question no. 4.

OSCE Station 1.15

A 30-year-old engineer complained of dryness and soreness of

the mouth since a few months. He has also observed a small
swelling in the floor of the mouth at every meal time. He finds it
difficult to swallow food and has to sip in a lot of water. These
days the swelling is increasingly becoming painful and
uncomfortable.

QUESTION

Please demonstrate how you would go about doing the

examination of this patient.
:
 OSCE Station 1.16

A soft tissue pedunculated growth was seen in the denture

bearing area of the palate in a 54-year-old postmenopausal
female. The growth was asymptomatic, but caused discomfort to
the patient during insertion of the denture and hence forced her
to discontinue the denture use since few weeks.

QUESTIONS

1. Identify the lesion.

2. Outline the management for the lesion.

3. Name two other denture-related lesions.

OSCE Station 1.17

Diffuse greyish pigmentation is seen bilaterally in the buccal

mucosa of a 40-year-old female.

QUESTIONS

1. Name at least four systemic causes of intraoral pigmentation.

2. List two groups of drugs that cause pigmentation of oral

mucosa.

3. Give examples of two syndromes associated with cafe-au-lait

:
 pigmentation.

OSCE Station 1.18

Mr Dan, a 67 years old male, is a controlled hypertensive and

diabetic since the last 25 years. He has been on prolonged topical
steroid use in his oral cavity for few months.

QUESTIONS

1. Name the most common oral lesion which may result after
prolonged use of this drug.

2. As a dentist, what systemic manifestations should you worry

about?

3. Name two autoimmune diseases causing oral ulcers which

can be treated using this drug in the picture.

OSCE Station 1.19

The following are four different cases of white lesions in the oral
cavity.

Fig. 1.17A: A 16-year-old school girl complains of roughness of

the buccal mucosa on both sides and has a habit of clenching her
teeth when she plays chess

Fig. 1.17B: A 16-year-old school girl complains of roughness of

the buccal mucosa on both sides and has a habit of clenching her
:
 teeth when she plays chess

Fig. 1.17c: Mrs Zeenath, 53 years of age, is on

immunosuppressant drugs since few months following organ
transplant. Her physician noticed this lesion on her palate during
a routine examination. She is however unaware of its presence

Fig. 1.17d: A 45-year-old bus driver noticed a white area in his

mouth since a few weeks; he says it is not causing him any pain.
He is a chain smoker

QUESTIONS

1. State the reasons for white appearance of the oral mucosa.

2. Give the most probable diagnosis for each of these lesions

based on the history provided (Figs 1.17A to D).
3. Identify the scrapable lesions from the figures (Figs 1.17A to
D).

OSCE Station 1.20

Rosnah Binti Zain

On clinical examination of a 56-year-old man, you notice that the

tooth 28 was carious with crown fracture and 8 mm ulcer on the
left posterior retromolar area extending to posterior sulcus.
Patient confirmed the presence of the ulcer for more than two
weeks and also gave history of smoking for more than 20 years.
:
 QUESTIONS

1. Your differential diagnosis was traumatic ulcer, recurrent

aphthous ulcer and a malignant ulcer. What are the important
clinical features that can distinguish each of these
diagnoses?

2. 1. Identify two relevant facts from patient's history and

suggest provisional diagnosis of a malignant ulcer.

2. Which palpatory finding will support the above

provisional diagnosis?

3. Justify.

OSCE Station 1.21

Rosnah Binti Zain

A 23-year-old male factory worker presented at your clinic with

multiple ulcerations in the oral cavity for the past six months. He
had no history of chewing tobacco/betel quid and is a non-
smoker.

QUESTIONS

1. Your differential diagnoses are recurrent aphthous

ulcerations, pemphigus vulgaris and recurrent intraoral
herpes simplex virus (HSV) infection. Write one key feature
that differentiates the clinical characteristics that you will be
looking for in each of these diagnoses.
:
 2. If the diagnosis is recurrent aphthous ulcers, one of the
systemic conditions which may give rise to similar
ulcerations, is Behcet's syndrome. What are the additional
clinical characteristics for this syndrome?

OSCE Station 1.22

Rosnah Binti Zain

A 45-year-old man reported with multiple painful ulcerations

since a few days. He had a history of fever preceding the ulcers.

QUESTIONS

1. Based on the above picture, give two differential diagnoses.

2. What is your definitive diagnosis for this case and give

reason?

OSCE Station 1.23

Rosnah Binti Zain

A 21-year-old girl visits your clinic. While doing a general

examination; you notice pallor and spoon-shaped nails
(koilonychia).

QUESTIONS
:
 1. What does this finding indicate with regards to the patient's
medical history?

2. While conducting the oral examination, you notice the patient

having atrophied dorsum of tongue. How is the atrophied
tongue related to the findings in Question 1 above?

3. You referred the patient to oral medicine specialist who did a

full blood investigation. What additional blood investigation
should be requested in view of the atrophied tongue?

Answers

OSCE STATION 1.1

1. Pleomorphic adenoma is the histopathologic diagnosis based

on the following features identified:

1. Encapsulation with area showing normal parotid tissue

and tumor tissue.

2. Numerous ducts like structures with eosinophilic

coagulum and stromal hyalinization.

2. Pleomorphic adenoma develops from pluripotent stem cells.

3. Smoking is not the etiology of this lesion. The treatment

advised is surgical excision with preservation of the facial
nerve. The prognosis of the lesion is fair to good.
:
 OSCE STATION 1.2

1. Leukoplakia, Hyperplastic candidiasis, Lichen planus.

2. Excision biopsy is indicated as the lesion is within 2 cm × cm.

3. Leukoplakia. Histopathologic diagnosis is Epithelial Dysplasia

(Moderate grade).

4. Basilar hyperplasia, nuclear hyperchromatism, loss of

stratification and mitotic figures. All features involve lower
and middle one third of the epithelium.

5. Commercially available nicotine patches can act as smoking

substitute in order to help quit the habit.

OSCE STATION 1.3

1. Dentigerous Cyst, Adenomatoid Odontogenic Tumor (AOT),

Odontogenic Keratocyst. Impacted teeth are recommended
for removal because they can give rise to cyst, odontogenic
tumor, associated infection or malocclusion.

2. Ameloblastoma (plexiform type). Labelled tissue is stellate

reticulum like tissue.

3. Follicular, Granular, Basal cell and Desmoplastic.

4. Odontomes are described as the most common odontogenic

tumors.

OSCE STATION 1.4

:
 1. Dentigerous cyst is a developmental odontogenic cyst which
is commonly associated with impacted teeth and develops
from reduced enamel epithelium. The treatment is
enucleation of the cyst as the size is small.

2. Yes, George will be able to attend the training camp as the

surgical wound will reepithelialize in seven days. However,
the bone formation can take many weeks.

3. Yes the histopathological picture shows a 2–4 cell layered

cystic lining epithelium which resembles reduced enamel
epithelium with a fibrocollagenous cyst wall features which
are consistent with dentigerous cyst. The marked structures
are – cyst lumen (arrow 1) and lining epithelium (arrow 2).

OSCE STATION 1.5

1. Since the lesion is small in size and the history is suggestive

of a benign lesion, surgical excision is the treatment. The
complete specimen removed is sent for histopathologic
confirmation thus termed excisional biopsy.

2. Mucocele (Extravasation Phenomenon)

3. Trauma to the region causes the severance of the salivary

duct which leads to the pooling of saliva in the connective
tissue and dilation of ducts. The pooled saliva is perceived as
a foreign substance by the body and thus the inflammatory
response surrounding the mucin pooling. This also leads to
inflammation of the gland with subsequent acinar
degeneration.
:
 4. Treatment is surgical excision with removal of the associated
gland and duct. Prognosis is good.

OSCE STATION 1.6

1. BIOPSY REQUEST FORM

PATIENT DETAILS

Name: Mr. Lee Age: 44 years Gender: Male

ID No: K012345 Date of Biopsy: For lab use only:
Referred by: your name

CLINICAL DESCRIPTION

Soft tissue lesion

Color Morphology
White Flat

Red Raised

Pink Ulcer

Others: Normal Others-: Pedunculated Growth

Tooth Number ________ Radiographic Changes________________

Hard tissue lesion
Lucent Opaque

Mixed Radiograph submitted ? Yes/ No

Tooth Number ________ Radiographic Changes________________

:
 TYPE OF SPECIMEN SUBMITTED

Biopsy Cytology Immunofluorescence

PAP Stain
Incisional Perilesional
(Dysplasia/Carcinoma)
Excisional PAS Stain (Infectious) Clinically normal
HPV

RELEVANT HISTORY (Include habit history)

Chief complaint of a growth in the mouth since the last 5 months.

Oral examination: An asymptomatic, non-tender, pedunculated
soft tissue growth measuring 1 cm x 1 cm seen on the left buccal
mucosa of normal color, texture and soft in consistency.

Known case of diabetes and hypertension under medication and

smokes 3–5 cigarettes a day for the last 20 years.26

DIFFERENTIAL DIAGNOSIS (Minimum 02)

Fibroma.

Neurofibroma.

2. In the case 10% formalin is used as the standard fixative for

routine histopathology specimens.

OSCE STATION 1.7

1. Incisional biopsy

2. At the microscopic level the epithelium shows a break in the

basement membrane with tumor invading the connective
:
 tissue in whorls and islands. The tumor is composed of
squamous epithelial cells showing atypia, moderate amount
of keratin.

3. Based on the history and clinical examination, the lesion in

question is associated with tobacco habit and the patient can
be motivated to quit the habit by the following:

1. Explain the role of tobacco in development of precancer and

cancer of the oral tissues.

2. Showing photographs and health promotion

pamphlets/videos.

3. Explaining the impact of the various treatment procedures

he/she would have to undergo if cancer sets in.

4. Suggest alternatives to tobacco such as use of nicotine

patches to help in quitting.

4. Tobacco has been described by the WHO as a potent

carcinogen which has the potential to cause DNA damage
which could become irreparable. The association of tobacco
having a dose dependent cumulative effect on the DNA has
been proven. This DNA damage can transform a normal cell
into a tumor cell which proliferates and also has a defective
apoptosis mechanism. These changes lead to the
development of squamous cell carcinoma when it affects the
squamous cells of the oral mucosa.

OSCE STATION 1.8

1. Low grade mucoepidermoid carcinoma (MEC).

:
 2. Mucicarmine is a special stain used for the identification of
mucin producing mucus cells.

3. The treatment for low grade MEC is surgical resection. The

prognosis of this lesion is good compared to the other
grades.

OSCE STATION 1.9

1. Pyogenic granuloma, peripheral ossifying fibroma, peripheral

giant cell granuloma.

2. Poor oral hygiene and hormonal changes associated with

pregnancy increase the reaction of oral tissue to minor
irritation or trauma caused by dental plaque or calculus
leading to the formation of the reactive lesion in this case.

3. As she is in second trimester, she can be prescribed

paracetamol 250 mg safely.

4. Symptomatic treatments for pain with follow up. Elective

treatment can be postponed for post delivery.

OSCE STATION 1.10

1. Intraoral periapical view of lower anterior region.

2. Multiple radiolucent lesions in relation to periapical area of

lower central and lateral incisors. Some lesions are well
defined but all are noncorticated. There is an ill-defined
radiolucency at the periapical area of the lower right canine.
:
 Interradicular alveolar bone loss is also present.

3. Multiple periapical granulomas, early cysts or periapical

abcesses or periapical cemental dysplasia.

4. In order to exclude the common lesions of the first category,

teeth should be nonvital. Therefore, history should be
explored to find out any cause leading to nonvital teeth such
as trauma, previous orthodontic treatment, etc. Vitality test
should be performed. If the teeth are vital, the most likely
diagnosis is periapical cemental dysplasia and previous
radiographs if any available should be reviewed in an attempt
to identify early lesions. Follow up radiographs are
recommended in six months to one year intervals to observe
the radiographic changes ranging from radiolucent to mixed
radiodense and finally to radio-opaque lesions.

OSCE STATION 1.11

1. Specimen 1.10A: Hypercementosis

Specimen 1.10B: Dilaceration

Specimen 1.10C: Concrescence

2. Etiological factors

1. Hypercementosis: Common causes: Occlusal trauma,

inflammation in and around roots, isolated unopposed
teeth. Rare causes: Paget's disease of bone, acromegaly,
thyroid goiter, rheumatic fever.

2. Dilaceration: Most cases are attributed to trauma to the

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 primary predecessor in the form of intrusive or avulsive
injury. It can rarely happen as a secondary event such as
presence of odontomes, supernumerary, cyst or a tumor
in relation to the developing tooth. However, occasional
cases can be idiopathic.

3. Concrescence: Space restrictions during development,

divergent roots, local trauma, excessive occlusal force or
local infection after development are the suggested
causes.

3. 1. Hypercementosis: Extraction of teeth with

hypercementosis leads to fracture of roots which need
surgical exposure for removal. Orthodontic movement of
teeth with hypercementosis may create difficulties
depending on the severity of the problem.

2. Dilaceration: Clinical implications depend on the severity

of dilaceration. The dilacerated teeth with delayed
eruption may need to be surgically exposed and
orthodontically moved into correct position. Orthodontic
movement is not indicated and not possible in severe
cases. Endodontic treatment in these teeth should be
performed with caution in order to prevent root
perforation.28

3. Concrescence: Extraction of these teeth leads to

fracture of roots or fracture of the maxillary tuberosity.
Oro-antral fenestration is another common complication
when trying to extract these teeth.

OSCE STATION 1.12

:
 1. Oral submucous fibrosis (OSMF).

2. Atrophic stratified squamous epithelium, Juxtaepithelial

hyalinization, extensive fibrosis of the corium and
replacement of muscle by fibrous tissue.

3. Arecoline present in arecanut via multiple pathways cause

imbalance between collagen formation and degradation
leading to accumulation of collagen.

4. As this is an oral potentially malignant disorder, regular follow

up is mandatory in order to identify early changes of the
condition leading to malignancy. Because of the poor
visibility of the oral mucosa due to restricted mouth opening
diagnosis of subsequent cancer may be delayed as the
patient is not in a position to see the early lesion. Therefore,
frequent professional examination is mandatory.

OSCE STATION 1.13

1. Ameloblastoma; Unicystic luminal type.

2. Cystic lesion lined by odontogenic epithelium comprised of

elongate basal cells mimicking the appearance of
ameloblasts, basal cells are hyperchromatic and show
reverse polarity, surface cells of the epithelium are
vacuolated and similar to stellate reticulum cells.

3. Slow growing painless swelling, no inflammatory changes on

the surface mucosa, anesthesia or paresthesia of the lower
lip, buccolingual expansion, drifting and mobility of adjacent
teeth.
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 4. Treatment of ameloblastoma varies depending on the type.
Solid multicystic type and unicystic mural type need more
radical treatment such as removal of the affected segment of
the mandible in most cases. Luminal type of unicystic
ameloblastoma needs more conservative treatment such as
enucleation and proper curettage of the surface bone.
However, enucleation as a treatment modality for any type of
ameloblastoma is questionable according to current
literature. Regular follow up is mandatory after surgical
treatment.

5. Prognosis of unicystic ameloblastoma, especially luminal

type is much better than solid multicystic type. Although, the
recurrence rate varies according to the type of treatment, it
may be up to 30%. Majority of the recurrences appear during
first 5 years after surgery.

OSCE STATION 1.14

1. Numerous granulomas comprised of epithelioid

macrophages without any evidence of central caseous
necrosis. Lymphocytic aggregates are also present in
between granulomas.

2. Clinical features depend on the involvement of different parts

of the body. However, the common features such as fatigue,
malaise, arthralgia, chest pain and weight loss are seen in
most patients. Some patients may not develop obvious
symptoms for many years. Tender erythematous nodules
referred to as erythema nodosum is a common skin
manifestation. Ocular symptoms are also present in some
patients. Xerostomia and xerophthalmia may also be
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 present.29

3. Radiological investigations especially chest X-rays, elevated

serum calcium levels, Kveim test, negative findings for
culture and special stains for organisms, elevated serum
angiotensin'converting enzyme levels and increased ESR.
Sarcoidosis is the most likely diagnosis.

4. Heerfordt's syndrome (Uveo-parotid fever) and Lofgren's

syndrome.

5. Heerfordt's syndrome: Facial paralysis, anterior uveitis,

parotid enlargement and fever.

Lofgren's syndrome: Bilateral hilar lymphadenopathy, erythema

nodosum and arthralgia.

OSCE STATION 1.15

The symptoms of the patient point towards a problem in the

submandibular region. An intermittent swelling in the floor of
the mouth at meal time is most commonly suggestive of a
submandibular salivary gland duct swelling. Following are the
steps towards examination of the patient:

Greet and introduce yourself to the patient politely.

Seat the patient comfortably upright on the dental chair.

Explain the procedure and take permission.

Stand behind the patient, tilt the patient's head towards the
side to be examined. Cup your fingers around the mandible
:
 and palpate the submandibular region for the swelling.

To confirm the intraoral extent of the swelling, palpate the

floor of the mouth with gloved fingers. The extent of the
swelling both intraorally and extraorally can be confirmed by
bi-manual palpation. This technique also helps distinguishe
between a submandibular gland, sublingual glands and
submandibular lymph node.

Salivary flow can be examined intraorally by milking the gland

and observing the salivary flow from the orifice. Saliva can be
expressed from the submandibular gland by compressing the
gland with bimanual palpation and by pressing towards the
orifice.

OSCE STATION 1.16

1. Epulis/epulis fissuratum

2. Excisional biopsy of the lesion should be done keeping the

size of lesion in mind. Denture hygiene instructions are given
to the patient. Fabrication of new dentures has to be done.

3. Denture related lesions: Denture stomatitis, Traumatic ulcer.

OSCE STATION 1.17

1. Systemic causes of intra-oral pigmentation:

Cushing's syndrome
:
 Hyperthyroidism

Primary biliary cirrhosis

Vitamin B12 deficiency

Peutz-Jeghers syndrome

HIV/AIDS associated melanosis.

2. Drugs causing pigmentation of oral mucosa:

Antimalarial

Phenothiazines

Oral contraceptives

Cytotoxic drugs

Antimicrobials like Minocycline.

3. Syndromes associated with cafe-au-lait pigmentation:

Neurofibromatosis

McCune –Albright syndrome

Noonan syndrome

LEOPARD syndrome

OSCE STATION 1.18

1. Oral candidiasis.
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 2. Systemic manifestations of raise in blood pressure and
increased blood sugar levels may be expected.

3. Pemphigus, pemphigoid.

OSCE STATION 1.19

1. The reason for white appearance of oral mucosa:

Hyperkeratosis

Acanthosis (abnormal but benign thickening of stratum

spinosum).

Accumulation of fluid- intra and extracellular.

Necrosis.

Pseudomembrane- e.g. Oral thrush

2. Diagnosis of the lesions:

Figure 1.17A: Chronic cheek biting

Figure 1.17B: Chemical burn
Figure 1.17C: Oral thrush
Figure 1.17D: Oral lichen planus

3. The scrapable lesions are chemical burn and oral thrush.

OSCE STATION 1.20

1. In order for this lesion to be a traumatic ulcer, there must be a

cause and effect relationship where in the history of this
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 patient it was described as a crown fracture with 28, thus the
possibility of a traumatic ulcer. The characteristic
presentation of an aphthous ulcer is usually an ovoid or
round, yellowish or white centred, with a red halo. However, a
major aphthous ulcer may present with raised borders as in
this picture. A malignant ulcer would also have the
characteristics of a raised border which is evident in this
picture.

2. 1. Firstly, the patient had a history of smoking for 20 years.

Smoking is a known risk factor for oral cancer. Secondly,
the ulcer has not healed for over 2 weeks.

2. The clinician can palpate the ulcer border and a firm

indurated ulcer border will support the provisional
diagnosis of a malignant ulcer.

3. Firstly, traumatic ulcer must be ruled out. This is done by

eliminating the cause which may be a rough tooth edge of the
carious tooth 26. There are many ways to eliminate the cause
namely, doing a restoration and/or smoothening the sharp
cusp, or tooth extraction if the tooth is broken. A provisional
diagnosis of a malignant ulcer can be made after a review of
2 weeks if the ulcer showed no signs of healing.

OSCE STATION 1.21

1. Recurrent aphthous ulcers usually present as shallow ulcers

with whitish-yellow ovoid centers with a red halo. They
usually are present on non-keratinized mucosa and are
recurrent in nature.
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 Pemphigus vulgaris usually presents as superficial
erosions and ulcerations of the oral mucosa. Vesicles
precede the lesions. Skin lesions may develop after the
oral lesions.

Recurrent intraoral HSV infection usually appears as

multiple small ulcers on keratinized mucosa, for example
the hard palate or gingiva. There is usually a prodromal
symptom of burning sensation prior to the appearance of
the lesions.

2. Behcet's Syndrome is a rare syndrome which also presents

with recurrent genital ulcerations, eye lesions, skin and other
systems involvement including the joints.

OSCE STATION 1.22

1. Differential diagnosis:

Erythema multiforme, which may be preceded by a fever

from a herpes simplex virus (HSV) infection.

Herpes zoster virus infection which is usually also

preceded by a fever from a HSV infection.

2. The definitive diagnosis is the herpes zoster virus infection

because there are superficial irregular ulcerations of the oral
mucosa and skin along one branch of the trigeminal nerve
which in this case is the maxillary branch.

OSCE STATION 1.23

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 1. The koilonychia is indicative of anemia, which has been
present for a long time.

2. Anemia may cause atrophy of the tongue papillae.

3. Atrophied tongue may also be related to deficiencies of iron,

folic acid and vitamin B12. Thus, serum iron, folic acid and
vitamin B12 levels should be requested in addition to the full
blood investigation.

History Taking and Examination

A 55-year-old man came to your practice complaining of

soreness in the mouth. You are the attending dentist and you
must make a diagnosis and institute treatment.

Exercise: Conduct a patient-dentist consultation

ANSWER

Basic components of patient-dentist consultation are:

1. Initial encounter

2. Conducting interview

3. Responding to the patient

4. Negotiate treatment plan

5. Closure of interview

INITIAL ENCOUNTER
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 First impression is always the best impression and will lay the
foundation for the future dentist patient relationship. Patient
during the initial moments will decide if he/she will be comfortable
with the consulting dentist or not.

Greet and introduce yourself to the patient politely and then

obtain patient's name. When welcoming the patient, make
eye contact and shake hands.

Using a formal title to address the patient (e.g., Mr James, Ms

Mary) is always best. For children or adolescents, avoid
surnames unless you have permission from the patient or
family. If you are unsure how to pronounce the patient's
name, don't be afraid to ask.

Set the patient at ease and develop rapport.

CONDUCTING INTERVIEW

As the patient explains the chief complaint and the history of the
present illness, you can question the patient using the following
examples:

Ask the patient the purpose of the dental visit by using

statements like “How can I help you…… “What problems
bring you to the dental office today?”

If patient has number of concerns, ask to prioritize them.

Encourage the patient to tell the story in chronological

manner from the start.

Use open ended questions to gather to more information like

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 Describe the pain……

Use direct or closed ended questions as follow up to open

ended like “Does the pain spread to other areas……

Avoid asking leading questions. Always ask one question at a

time otherwise the patient will be confused. Give adequate
time to the patient to think before answering the questions.

Listen to the patient attentively, allowing to complete the

statement without interruption. During the interview, you can
repeat or rephrase the statements said by patient. This tells
the patient that you are listening and understanding what
he/she is telling.

Keep the interview organized and use transition statements

when proceeding to another topic. These transitional
statements prepare the patient of what is coming next.

For example, “I think I've got a pretty good idea of your main
problem and how they developed. Now I would like to ask you
some questions about your past health”.

Learn about the patient and his/her family during the course
of interview (social and family history).

Create opportunities to the patient to ask questions during

and after the consultation.

RESPONDING TO THE PATIENT

Pay attention to patient's verbal and nonverbal cues (body

language, speech and facial expressions).
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 Express empathy to patient's concerns, which will help to
develop trust between the patient and the dentist.

Do not be judgemental.

Be aware of your nonverbal cues. Your body language should

be such that you are paying close attention to the patient's
statement.

NEGOTIATING TREATMENT PLAN

After history taking, examination and testing; explain to the

patient in the language they can understand (avoid jargon)
what do you think the problem is and what will be the next
steps.

Make sure that the patient understands the information

provided.

Explore and discuss all available treatment options.

Collaborate with the patient to decide upon a mutually

acceptable treatment plan.

CLOSURE OF INTERVIEW

At the end of interview:

Summarize the encounter to establish that both you and the

patient understand the problem and agree upon the
treatment plan.
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 Answer patient's questions and provide additional
information.

Set up a follow up appointment.

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