The Case of Pterygium

A 37-year-old male came through the screening clinic for routine dental care. During the head and neck exam, the student noticed a flap of tissue extending over the patient's cornea and asked me to come take a look.

37-year-old patient with pterygium

The man couldn't really tell how long this problem had been present. He did say that recently he had noticed a dark spot in his vision. I told him that this flap of tissue extending over his cornea is called a pterygium and requires him to see an ophthalmologist, especially since it's already interfering with vision.

Pterygium:

Since I'm not an ophthalmologist, I might not be the best person to comment on this topic, but I'll cover the basics.

Pterygium is a benign growth of the conjunctival epithelium that extends onto the cornea. It is commonly seen in people chronically exposed to sunlight, dust or other irritants. It can result in itching, tearing, foreign body sensations and vision problems. Variable forms of surgery are performed to manage this condition. 

The Case of Multiple Leukoplakias

A 65-year-old female was seen in the surgery clinic for multiple white lesions on the oral mucosa. The lesions were asymptomatic and had been present for a while. The patient's regular dentist had noticed these lesions, but had initially considered them an irritation reaction to the patient's denture. When the lesions grew larger, he became a little concerned and referred the patient to the oral surgery clinic. 

Leukoplakia on the mandibular alveolar ridge
(Apologies for the quality of the pictures, the surgery resident was practicing with my camera, I didn't notice how bad the pictures were until I returned to my room)

Subtle lesions on buccal and palatal mucosa

Palatal leukoplakia

Extra-oral exam was unremarkable. Intra-oral exam revealed leukoplakias on the lower left alveolar ridge and the palatal mucosa. Subtle lesions were noticed on the right and left buccal mucosa as well. This presentation is most consistent with proliferative verrucous leukoplakia. I recommended biopsies of the most prominent lesions. Their diagnosis ranged between epithelial atypia and mild epithelial dyplasia. The patient was kept on strict 3-6 month follow-ups. New lesions and previous lesions undergoing changes in shape, size and texture were biopsied. We still see her periodically in clinic. 

Proliferative Verrucous Leukoplakia:

Proliferative verrucous leukoplakia (PVL) is a condition characterized by development of multiple leukoplakias in the oral cavity. The lesions may be subtle at first but they gradually evolve into more prominent plaques over a period of time. These leukoplakias have the ability to transform into verrucous carcinoma or squamous cell carcinoma. 

Unfortunately, we cannot treat this condition. Complete excision is also not a viable option because usually the entire mucosa is involved and because of the high rate of recurrence. The only thing we can do is monitor for changes. For that, it is recommended that patients with PVL are seen are regular 3-6 month intervals. Any changes in the lesions is documented and lesions showing changes in shape, size and texture are biopsied immediately. If the biopsy result grades a lesion between epithelial atypia and mild epithelial dysplasia, then the lesion will continue to be monitored. If the lesion is graded between moderate epithelial dysplasia and carcinoma in situ, it is mandatory to perform complete excision of that lesion. 

The patient will require monitoring for the rest of his life. For patient's that don't return for their periodic follow-ups, rates of transformation is high. 

The Case of a White Lesion

A 48-year-old female presented with a white lesion on her lower labial mucosa noted during her follow-up exam in the implant clinic. The lesion was asymptomatic and the patient was unaware of it presence. The hygienist evaluating this patient recorded the dimensions as 40 X 40 mm. She also documented in her noted that the lesion appeared to be "well defined". (Hygienists take wonderfully thorough notes!). There was no significant medical or social history.

Leukoplakia in a 48-year-old female

The lesion was diagnosed as leukoplakia and an excisional biopsy was recommended. The biopsy result read mild epithelial dysplasia. The patient was kept under close observation because almost a third of these tend to return. 

Leukoplakia:

The traditional definition of leukoplakia lumps up all unclassifiable white lesions with no identifiable etiology. I was taught that leukoplakias are white lesions with a crisp margin, i.e margins that you can trace out using a pen. The rationale behind this odd thought is that it is humanly impossible to irritate the same number of mucosal cells each time. You will irritate some cells at first, a little more the next time, and a little less next time after that. This will result in a gradient, from the normal skin to a little white, more white, less white and normal skin and "not a crisply defined margin". A crisply defined margin forms when the cells constituting that margin are dysplastic.

Leukoplakias need to undergo biopsies to establish their histologic grade. Smaller ones can undergo excisional biopsies while the larger ones can be incisionally biopsied. Biopsies resulting in a diagnosis of epithelial atypia or mild epithelial dysplasia should be kept under close observation. Recurrent lesions or changes in shape, size or texture of residual lesions should be promptly biopsied and treated accordingly.

For lesions graded as moderate to severe epithelial dysplasia, or carcinoma in situ, surgical excision of the involved tissue is recommended. These patients are also kept under close observation to monitor for recurrent lesions.

There have been numerous attempts to find non-invasive cures/treatments of leukoplakia, as of now, very little evidence supports their use. 

The Case of "Brown-Brown Thing"

My 3-year-old nephew pointed out something on my 64-year-old mother's hand the other day, and asked her what that brown-brown thing was. I asked my mother if he had located an age-spot (lentigines). She told that she didn't think so because this one felt slightly elevated, kind of "stuck on". Unfortunately, her lesion was about 2 X 2 mm in size and kind of hard to photograph, but I do have another really nice picture of this process.

Seborrheic keratosis

The lesion on my mother's hand was seborrheic keratosis, a benign proliferation of skin cells that is common in individuals over the age of 40. It presents as a brown, slightly raised and well defined plaque with an irregular surface. The appearance is described as either "stuck on" or as "wax drippings". Face, trunk, arms and legs are commonly affected. Usually more than one lesion is present. 

Removal by cryotherapy or surgery can be performed for esthetic purposes. 

In rare instances, an internal malignancy can lead to formation of numerous lesions of itchy seborrheic keratosis. This is known as the Leser-Trelat sign.  

The Case of White Striations

I was asked a review some glass slides for a case last week. The patient was a 48-year-old woman who had reported to the oral surgery clinic with a complaint of painful bilateral lesions on the buccal mucosa. The lesions had been present for over 3 years. They were especially painful when the patient tried to consume something acidic or spicy. The history was waxing and waning of the lesions was not provided. 

A metal crown, placed several years ago was present adjacent to one of the lesions. The patient was hypertensive and diabetic. She was currently taking medications for both these diseases.

48-year-old woman with erosive lichen planus. The white striae can be identified at the margins of the ulcers.
Courtesy: Dr. Sidra-tul-Muntaha

The lesions were biopsied by the surgeon and submitted for histopathologic examination. The general pathologist signed this process out as chronic mucositis. The surgeon then asked me to review the slides. She told me that the striations were so prominent that it could only be lichen planus or a lichenoid reaction.

And she was right. The history, the clinical picture and the histopathologic presentation all favored a lichenoid process. Since this presentation was bilateral, lichen planus was the most appropriate diagnosis.

Lichen Planus:

Lichen planus is an autoimmune process characterized by presence of white striae. It has two major forms, reticular and erosive. Reticular lichen planus is asymptomatic and usually discovered during routine oral exams. It appears as symmetrical and bilateral, white lace-like pattern on the patient's buccal mucosa. Occasionally other sites may also be involved. It does have the ability to evolve into the more painful, erosive form. Erosive lichen planus in painful because of mucosal atrophy and ulcer formation. This type of lichen planus is associated with desquamative gingivitis.

Like all autoimmune processes, lichen planus waxes and wanes over a period of time. A flare is noted every few weeks to months.

No management is required for the reticular type.

For erosive lichen planus, potent topical steroids should be applied 4-6 times a day to control the flare. Once the lesions heal up, the patient can stop drug application until the next flare.

It is important to keep in mind that steroid application inside the mouth may lead to candidiasis. In such instances, the steroid will no longer heal the lesions and the symptoms would continue. Following confirmation of a candida infection by culture or cytology, a course of appropriate anti fungal therapy is recommended. I prefer using Clotrimazole troches for this purpose. Fifty tablets are dissolved slowly in mouth over a course of 10 days. Once the candida infection in under control, steroid application can begin again.

Note:

This patient is particularly interesting because she had a metal crown adjacent to one of the lesion, and she was using both antihypertensive and hypoglycemic drugs. All three factors have been linked to lichenoid reactions. In this case, these processes were easy to rule out because this woman's presentation was symmetric and bilateral. Lichenoid reactions are "always" asymmetric or unilateral.

A special thanks to Dr. Sidra-tul-Muntaha for sharing this case.

The Case of a Black Spot on the Lips

A student in the screening clinic had documented the lesion seen in the picture as a mole. 

Melanotic macule in a 40-year-old male

The brown spot seen on this 40-year-old man's lip is called a melanotic macule. 

Melanotic Macule:

Melanotic macule is a focal discoloration of the oral mucosa. It is believed to be a result of an increased expression of melanin (the pigment that gives color to our skins). The color varies from brown to black. The cause for development of melanotic macules is not known. 

Treatment is usually not required. If a patient wishes to remove it for cosmetic reasons, conservative excision is sufficient. 

It is important that pigmented lesions on the maxillary gingiva and palate are kept under close observation or excised and submitted for histopathologic examination. This is because of the high incidence of oral melanoma at these sites. 

The Case of Lump on Tongue

A very sweet 70 something year-old woman came through the clinic. She was extremely concerned that she has oral cancer. She stuck out her tongue and showed me the small bump on mid dorsal.

70-year-old female with a fibroma

She was unable to confirm a history of trauma in the area but did add that her memory had not been reliable recently. 

The bump was firm on palpation. Following the oral exam, I put two things in my differential. The first one was a fibroma, because that's what this bump looked and felt like. The other one was granular cell tumor, because dorsal tongue is a frequent site of occurrence and I really wanted a good clinical picture for that tumor.

I assured the patient that I would be extremely shocked if this ended up being cancer and recommended an excisional biopsy. The biopsy results confirmed the diagnosis of a fibroma. 

Fibroma:

Fibromas are extremely common, benign tumors commonly found in the oral cavity. They are believed to be an exaggerated response to trauma. The traumatic event leads to excess deposition of collagen fibers in the area resulting in a small bump or lump. 

Conservative excision is the preferred form of treatment.

The Case of "Suspected" Plasma Cell Gingivitis

A resident in the general practice told me that she had a patient in her chair whose gingiva looked identical to the picture of plasma cell gingivitis in Dr. Allen's book*. The patient was 23-year-old intellectually disable woman. Her parents told us that her gums are usually this red. They schedule cleanings under sedation every six months because she refuses to brush. They couldn't recall if it gets better after the cleaning appointment.

23-year-old diabetic female with plaque deposition and gingivitis

(I apologize for the quality of the picture, the girl was wonderful during the exam but would not let us use retractors)

The patient had a complex medical history with all sorts of problems including heart disease and diabetes.

Based on the medical history and the clinical picture, this condition was diagnosed as diabetic gingivitis. (Plasma cell gingivitis is an entirely different process, and hopefully will be discussed in the future).


Diabetic gingivitis is not a unique entity, it is just a more severe presentation of "regular" gingivitis seen in diabetic people. It is believed that insufficient glucose control leads to increased bacterial growth and decreased resistance to infection. Patients with diabetes need to be more vigilant about their hygiene routines. Brushing twice a day, flossing daily and professional cleanings every six months are mandatory for this purpose. 


Unfortunately, this young woman was not capable of maintaining such a thorough cleaning regimen but she had minimal dental caries and her periodontal health was not significantly bad. The every 6 month cleaning regimen appeared to be working well for her. This is why it was extremely difficult for me to understand why her regular dentist had recommended complete extractions for this 23-year-old. I asked the parents if she was in pain, they said no. I asked them if she had trouble eating, they said no. "Then why?" was my final question. Their answer was because she didn't brush. 


I spent the next half an hour with her mother and father explaining to them why, in my opinion, full extractions on someone who already has a very difficult life is not a good idea. I don't know if I had managed to convince them and honestly, I am too afraid to ask.

* Oral and Maxillofacial Pathology - Neville, Damm, Allen and Bouqout