The Case of the Yellow Thing in the Eye

A student of mine was curious about the round, yellowish bulge in his patient's eyes.

Pinguela

That small, yellowish bulge on the medial side of the cornea is called a pinguecula. The bulge forms due to the thickening of the conjunctival epithelium. This is a result of constant irritation, usually through excessive exposure to sunlight or dust. The process usually requires no treatment. 

The Case of Leukoplakia

A 39-year-old female was seen in the dental hygiene clinic for a routine cleaning appointment. During the initial exam, the student noticed this white lesion on her posterior buccal gingiva. The patient had first noticed the lesion several months ago. As far as she could tell, there had been no recent changes in size or appearance. 

Intra-oral exam revealed a well-demarcated white lesion on the gingiva below the mandibular canines and premolars. The lesion was approximately 15 x 10 mm in size. The lesion was a little non-homogenized in appearance.

39-year-old female with leukoplakia

Based on the appearance, this lesion was diagnosed as leukoplakia. A biopsy of the lesion was recommended. The periodontist performed an incisional biopsy. The pathologist felt that the tissue appeared pre-neoplastic under the microscope. The case was signed out as mild epithelial dysplasia. The patient was scheduled for regular follow-ups to monitor changes in size, texture and appearance. If any of these was detected, a re-biopsy was strongly recommended.

For a detailed discussion on leukoplakia, please see post, The Case of a White Lesion.

Oral Dysplasia:

Dysplasia is usually a difficult concept to grasp for clinicians. The best way to describe dysplasia is as "pre-cancer". It is a phase that the epithelial cells go through before invading the underlying connective tissue. According the extent of epithelial involvement, dysplasia is classified as mild, moderate and severe.

It is important to keep in mind that the criteria according to which oral dysplasia is classified is very different than the rest of the body. Oral dysplasia tends to be a lot more subtle. General pathologists are more familiar with cervical dysplasia and try to enforce a similar criteria for oral dysplasia, this usually results is misdiagnosis and delayed intervention. 

The Case of a Foreign Body Tattoo

This 12-year-old boy was undergoing an initial evaluation at the orthodontics department when a grey-colored spot was noted above his left lateral incisor. Since there were no amalgams on his teeth, or had ever been, the orthodontist was curious about what it was.

I asked the mother if the patient had a history of trauma in the region. There had been an a bicycle accident when the boy was 6. He had lost his left central and lateral incisors as the result of it. She remembered that small spot being there for several years but couldn't recall exactly when it had appeared.

12-year-old boy with foreign body tattoo

This was called a foreign body tattoo. The most likely conclusion is that some kind of foreign material got incorporated at the site at the time of the accident. However, a pencil injury (graphite tattoo) or some other incident cannot be completely ruled out. No treatment is usually required for this condition unless the patient has esthetic concerns. In those cases, a simple surgical excision is sufficient. 

The Case of a Gum Boil

A 46-year-old female came to the dental clinic for routine dental care. Her teeth were in a pretty bad state. She also complained about a "pimple" in her mouth that gets bigger with time, bursts and then gets bigger again. 

Intra-oral examination revealed a 3 x 3 mm papules above the right maxillary lateral incisor. The lateral incisor was extensively carious. A radiograph was taken to confirm presence of periapical inflammatory disease at the site. A prominent radiolucency was noted above the tooth. 

46-year-old female with a parulis

The diagnosis of parulis was made. The patient preferred to undergo extraction for the lateral incisor.  Histopathology of the tissue acquired during the extraction confirmed periapical inflammatory disease. The lesion had healed by the time the patient returned for her denture appointment. 

Parulis:

Parulis, also known as gum boil is a sinus tract that opens into the oral cavity. The sinus tract originates the apex of the infected tooth, passes through the bone and opens at an intra-oral site. It is usually reddish-yellow in color. Although gingiva is the most common site of involvement, other sites like the palate, the buccal and lingual vestibules may also be involved. The increase in size is due to the accumulation of pus inside the lesion. Once the pus is released, the lesion returns to its original size. Radiographs are useful in establishing diagnosis. The affected tooth is either extracted or root canal treated. 

The Case of an Ear Tag

I met my 8-month-old niece over the weekend and she happened to have a tiny ear tag, also known as an accessory tragus on her right ear. I asked her mum if it was okay for me to take a picture of this developmental anomaly, and she let me take a couple of pictures. 

Accessory tragus in an 8-month-old

Accessory tragus is a congenital anomaly that appears as a skin covered nodule on the external ear. It doesn't really require treatment but some people prefer to surgically remove it for cosmetic reasons. 

The Case of a Smokeless Tobacco-associated White Lesion

A 46-year-old male was seen at the general practice clinic for routine dental care. The resident noticed a white lesion in the anterior lower vestibule. Although there was a history of smokeless tobacco placement at this site, the patient had quit at least 12 months ago.

The white lesion appeared to be more than just a surface change. It was firm on palpation with approximate dimensions of 10 x 4 mm. Gingival recession adjacent to the site of placement was also noted. 

White lesion at the site of smokeless tobacco placement

The persistence of this lesion despite cessation of habit was a little concerning (smokeless tobacco keratosis disappears within two weeks of changing placement site), so a biopsy was recommended. The histopathology report described the epithelial changes as atypical and the underlying connective tissue as scar tissue.  Since the pathologist's comment on the epithelial changes did not rule out a premalignant process, the patient was told to return for regular follow-ups.

In my opinion, the changes seen in this case were more suggestive of a reactive etiology. Repeated placement had probably resulted in the formation of scar tissue at this site. 

It is extremely rare to develop oral squamous cell carcinoma with Swedish and some American types of smokeless tobacco. But since the risk is there, the American Dental Association maintains smokeless tobacco in its list of oral carcinogens. 

It is also important to understand that the composition of smokeless tobacco is highly variable throughout the world. In places like Sweden, scientific studies have affirmed the safety of smokeless tobacco. It is now recommended as a smoking-cessation aid in these parts. However, in places like Pakistan, the story is very different. Majority of cancers in the northern part of the country are a result of smokeless tobacco (Niswar) use. 

The Case of "Suspected Squamous Cell Carcinoma"

I got called down to the emergency clinic to take a look at "cancer". The patient was a 57-year-old male with mass on his posterior mandibular gingiva. It had been present for a "while". There was a recent history of rapid enlargement. No pain was associated with the lesion prior to the ulceration. 

The patient appeared to be in good health otherwise. There was no history of tobacco usage.

The student taking care of the patient had put squamous cell carcinoma as the provisional diagnosis. 

Intra-oral examination revealed an ulcerated mass approximately 30 x 12 mm in size on the right mandibular gingiva. 

Plasmablastic lymphoma in a 57-year-old HIV positive male

I agreed with the student, the mass did look scary. The patient was sent for a biopsy to the surgery clinics the same day. They performed an incisional biopsy. 

The specimen exhibited features consistent with lymphoma. The case was discussed with the hematopathology people who rendered the final diagnosis of plasmablastic lymphoma (a type of non-Hodgkin's lymphoma) following immunohistochemical studies. That put the patient's HIV status into question (plasmablastic lymphoma is usually seen in patients with HIV). The patient was referred to an oncologist who ordered HIV tests, he tested positive!

He was put on chemotherapy and that's the last information I have on him.

Lymphoma:

Lymphoma is a malignancy that arises from lymphocytes. It is classified into two major types, Hodgkin's lymphoma and non-Hodgkin's lymphoma. Both types are seen over a wide age range. Hodgkin's lymphoma predominantly involved the lymph nodes. Non-Hodgkin's lymphoma most commonly involves extra-nodal structures, it rarely ever involves lymph nodes. 

The prognosis varies with the type of lymphoma. Treatment options include chemotherapy and rarely radiotherapy.

The Case of Red Bumps

An 87-year-old male came through the screening clinic with some "red bumps" on his forehead. They had been present for a while, he had some more on his arms and maybe some on his back. Some were tiny red dots while the others were bigger and more elevated. The lesions were completely asymptomatic. The patient had consulted a doctor at some point, he had been told that these were nothing to worry about. 

The patient was on medication for hypertension and heart disease.

This presentation is consistent with cherry angiomas.

Cherry angioma in an 87-year-old

Cherry angiomas are benign proliferations of vascular channels that are commonly seen in individuals in their forth and fifth decades of life. Occasionally, lesions may be seen in younger people. The reason for their occurrence unknown. 

The size of the lesions can be highly variable. Initially, cherry angiomas are flat. Over time, the lesions increase in thickness and become dome-shaped. 

Removal is only warranted for esthetic reasons. Surgical removal, cryotherapy or electrosurgery are some of the options available. 

The Case of Sore Tongue and Cracked Lip Corners

Angular cheilitis in a 65-year-old female

I saw a 65-year-old female the other day with a complaint of soreness in mouth. The soreness had been present for 2 years and it was especially difficult for her to consume spicy and acidic foods. Tongue and corners of the lips were particularly more painful. The patient had seen several doctors, had been prescribed topical steroids, antivirals and antibiotics. The topical steroids seemed to help initially but then the pain started getting worse. 

The patient was on medication for diabetes and hypertension. She was also taking antibiotics for her urinary tract infection quite frequently. 

Extra-oral exam revealed redness at the corners of the mouth. Papillary atrophy was noted on the tongue. Because of pain at lip commissures, the patient was unable to open mouth completely for intra-oral photographs.

The candida culture was positive. The patient was given a course of antifungals, Clotrimazole troches in this case. She was told to dissolve the tablet slowly in mouth and ensure that she licks the corners of the lips (to heal angular cheilitis). Fifty troches were to be used over 10 days.

Vytone, which is blend of iodquinol and corticosteroid can be prescribed separately to treat angular cheilitis. This product can only be used externally.

The patient was also told that diabetes and frequent use of antibiotics have predisposed her to candidiasis. The organism will reappear  at some point and we will just have to retreat it (topical antifungals do not have systemic effects and repetitive usage is not harmful).

Three days later the patient called to say that she was pain-free. She did return for follow-up 10 days later, the redness at the corner of the lips was healed and the papilla on the tongue was regenerating. 

For a detailed discussion on candidiasis, please see The Case of Central Papillary Atrophy.

The Case of Two Pathologies - Part 2

A 32-year old female was seen at the clinic for aphthous ulcers (See The Case of Two Pathologies - Part 1). During the intra-oral exam, a strange pattern was noted on her tongue. 

The tongue appeared to have red areas surrounded by a thin and delicate white margin. The patient had noticed this pattern on her tongue on occasion, but was not concerned. There were no symptoms associated with this process.

This condition is referred to as erythema migrans (geographic tongue). No management is needed in asymptomatic cases.

Erythema migrans (Geographic Tongue):

Erythema migrans is believed to be an autoimmune process. The exact etiology for this condition is  unknown. It is characterized by appearance of well-demarcated red spot surrounded by a white outline. The lesions heal over a period of time and usually appear at a different location (they tend to migrate). The duration of the lesions is highly variable. For some people the healing and reappearing cycle may be within hours, while for others longer durations have been reported.

Erythema migrans is seen in patients of all ages. Tongue is not the only site of occurrence, rarely, other oral sites may exhibit involvement. Symptoms are infrequent with this process. Occasionally, a complaint of pain or sensitivity to food may be encountered. 

No treatment is required if the patient is symptomless. For patients experiencing an intense amount of pain, topical steroid application may be recommended. This seems to heal the lesions quickly and provide relief. 

The Case of Two Pathologies - Part 1

A 32-year-old female came to the clinic with a complaint of pain on her tongue. The sore on her right lateral tongue had appeared a few days ago and was extremely painful. She was having trouble eating. As far as she could remember, this was the first time she had experienced something like this. 

The patient was great health otherwise.

Extra-oral exam was unremarkable. Intra-oral exam revealed three ulcers, on right lateral tongue in varying states of healing. One of the ulcers had a prominent red halo around it. Geographic tongue was also noted (See post, The Case of Two Pathologies - Part 2).

32-year-old female with aphthous ulcers

 The lesions were diagnosed as aphthous ulcers. Some topical anesthetic (Colgate's Orabase in this case) was applied to alleviate the pain and the patient was given some samples for home application. The patient was also directed to return if the episodes are recurrent for a topical corticosteroid prescription. The patient called me a few days later to let me know that the lesions had healed.

Aphthous Ulcers:

Aphthous ulcers are characterized by the appearance of recurrent painful ulcers with prominent red halos on parakeratinized areas of the oral cavity. They are believed to be an autoimmune process with unknown trigger factors. They are usually seen in a younger population, especially those leading high stress lives. 

Aphthous ulcers are classified into three type depending on their sizes; herpetiform (less than 3 mm), minor (3-10 mm) and major (>10 mm). Herpetiform and minor aphthae have a shorter healing time, about 7 to 10 days. Major aphthae can take up to 6 weeks to heal completely. 

The rate of recurrence is highly variable. Some patients may present with new ulcers before the previous ones have healed completely, while others may have recurrences decades later. 

For patients with regular recurrences, application of topical corticosteroids on active lesions is recommended. This allows the ulcer to heal a lot faster. It also decreases the frequency of recurrences in such patients. 

For patients who develop lesions once in a blue moon, topical anesthetic may be prescribed to help with the pain. In such patients, there is no need to prescribe topical corticosteroids.