The Case of a Blue Lesion on Tongue

A 19-year-old female was seen in the surgery clinics today with a complaint of a blue lesion on her tongue present for as long as she could remember. The lesion was asymptomatic and she did not think that it had increased in size. The patient's medical history was positive for epilepsy. The seizures began a few years ago, but had been decreasing in intensity progressively. She had been taking medication sporadically for her condition. At present she was off all medication on the advice of her doctor. Her concern was whether the blue lesion in her mouth had anything to do with her epileptic seizures.

19-year-old with a hemangioma on dorsal tongue

Intraoral examination was insignificant except for a 12 x 10 mm purplish-blue lesion on anterior dorsal tongue. The lesion was slightly elevated and was relatively firm on palpation.

Based on the long-term history and clinical appearance, a diagnosis of hemangioma was made.

The patient was informed of this diagnosis. She was also told that the hemangioma and her epilepsy were two independent conditions. We offered to remove the hemangioma but the patient decided against it for the moment.

Hemangioma:
Hemangiomas are benign vascular tumors. They are most common in infancy. Females are more commonly affected than males. In infants, hemangiomas rapidly increase in size over a period of time. Following this drastic increase in size, most tumors begin to involute. By age 9, 90% of the lesions have resolved to some degree.

Initial lesions are usually red, older lesions tend to become darker in color. Some hemangiomas are flat and present only as color changes, while others form obvious masses of variable sizes. Bone involvement, although rare, can occur. The classic radiographic appearance of intraosseous hemangiomas is described as a multilocular defect with "honey-comb", or "soap bubble" appearances.

Histologically hemangiomas are classified into various types. Although these histological types usually don't have a significant effect on the prognosis of the lesion, they may effect the treatment plan.

For young children with hemangiomas, periodic observation may the best course of action. If the lesion fails to involute and results in significant esthetic concerns, surgical removal can be attempted. Since this lesion is vascular and there is a risk of significant bleeding, sclerotherapy should be attempted before intervention. 

The Case of Multifocal Candidiasis

A 42-year-old male was seen in the Oral Surgery clinics for a tooth extraction. During the oral examination, the student noted red and white changes in the patient's mouth. That's when he decided to call me down for a consult.

The patient was asymptomatic. He was not aware of the presence of lesions inside his mouth. His medical history was insignificant, but he had been a smoker for over 20 years. He did not wear dentures currently.

During the intraoral exam, tiny reddish bumps were noted on the erythematous palate. The tongue exhibited atrophy of the filiform papillae in the central portion and white patches were noted in the anterior buccal mucosa bilaterally. The white patches on the buccal mucosa could not be removed with a piece of dry gauze. 

Inflammatory papillary hyperplasia on the erythematous palate

Central papillary atrophy

Hyperplastic candidiasis in anterior buccal mucosa

Although the clinical features were highly suggestive of candidiasis, a culture was done to establish definitive diagnosis.

Positive candida culture on sabouraud's agar

The patient was prescribed a course of antifungals. Since Clotrimazole troches are not available here in Pakistan, we have to prescribe Nystatin drops. Solutions are a little hard to hold in the mouth for an extended period of time (the solution needs to be held in the mouth for at least 2 minutes for it to be effective). This is a significant factor in noncompliance. 

The patient was instructed to rinse and spit 2 teaspoons of the Nystatin solution five times per day. Unfortunately, the patient never returned for a followup, a dilemma that we commonly encounter with our patients here. It would have been great to include followup pictures. 

Candidiasis:

Candida albicans forms a part of the normal oral flora in approximately 40% of Pakistanis. In situations of immunosuppression, or alteration of the normal floral balance (dentures, antibiotic use, corticosteroid inhaler use etc.), it can cause visible oral changes. 

One of the most common clinical presentation of the infection is the atrophy of filiform papillae in the central portion of the tongue, also known as central papillary atrophy (previously called median rhomboid glossitis). Our patient had a very prominent presentation of this process.

In patients that wear dentures palate involvement is common, especially at the site where the denture comes into contact with the mucosa (denture stomatitis). The redness on the palate may be due to direct inoculation of candida onto the mucosa, or due to the irritation of the palatal mucosa because of the organisms on the denture. The palatal bumps are called inflammatory papillary hyperplasia. These are seen in patients with ill fitting dentures and mouth breathers. They don't necessary have to appear red and inflamed. Superimposition of candida is probably the cause behind the redness. Our patient was a little confused about his denture status but due to the presence of the small red bumps, we suspect that dentures were involved at some point. 

Another cause of palatal involvement is due to transfer of organisms from the tongue to the palate. The infected area becomes erythematous. Such lesions are referred to as kissing lesions. 

White lesions associated with candidiasis commonly rub off when attempts are made to remove them with a piece of dry gauze or a tongue depressor. This form of candidiasis is known as pseudomembranous and was not evident in our patient. White lesions that cannot be removed in a case of candidiasis are called hyperplastic candidiasis or candidal leukoplakia. The most common site of occurrence in anterior buccal mucosa, exactly the site where our patient presented with the lesions. 

The reason as to why this patient developed such a florid presentation of candidiasis remains unknown. It could be due to some medical condition that he's currently unaware of or refuses to inform us of, or it could be simply because of the failure to maintain proper hygiene. 

The Case of Ameloblastoma

A 58-year-old female patient came to surgery department with a panoramic film that had a well-defined, unicystic radiolucency in the lower right premolar region. The incional biopsy was signed out as ameloblastoma. The surgeons performed an excisional biopsy with extensive curettage and sent the specimen to our service for histopathology. They told us that the clinical presentation was unremarkable.

Radiograph exhibiting a well-defined, unilocular radiolucency in the right premolar region
(Courtesy: Dr. Sidra-tul-Muntaha)

Multiple large nests of odontogenic epithelium with tall, columnar cells at the periphery. Squamous metaplasia can be noted in the central portion of the islands. 

On histopathology, tumor cells appeared to be organized in the form of nests were seen. The cells at the periphery of the nests were tall and columnar and had nuclei exhibiting reverse polarity. Center of the nests were more loosely arranged, resembling stellate reticulum of a developing tooth bud. These features are characteristic of ameloblastoma, more specifically follicular type in this case. Interestingly, a few tumor nests with squamous metaplasia were also noted, a feature that is prevalent in acanthomatous types of ameloblastomas.

High-power view exhibiting reverse polarity in the peripheral tumor cells

 I called this follicular ameloblastoma exhibiting areas of squamous metaplasia.


Dr. K's Comments:
Ameloblastoma:
Ameloblastoma is a benign odontogenic tumor that is seen exclusively in the jaws, because that is the only site where odontogenic epithelium exists. It is seen in individuals over the age of 40 and does not demonstrate any sex predilection. It appears as a painless mass, that can continue to grow to large proportions if not removed timely. Posterior mandibular area is the most common site of involvement.

The radiographic presentation can vary from a well-demarcated, unilocular radiolucency to large multilocular defects. Resorptions of roots in the vicinity of the tumor may also be noted.

Diagnosis can only be confirmed through incisional or excisional biopsy, depending on the size of the lesion. Although the literature describes 6 distinct histological types of ameloblastomas, suggesting that each tumor falls in either one category or the other, there is rarely a tumor that demonstrates less than two histological types. In our case the predominant type was follicular, but we also saw a small area with a plexiform appearance and some tumor islands with acanthomatous change.

The preferred form of management is marginal resection. Simple enucleation followed by curettage can leave some tumor islands behind.

The Case of Palate Ulcer

A 24-year-old patient came to the department with the complaint of pain in the roof of his mouth. While taking history, I discovered that his pain started a few days after the extraction of the tooth at the site where local anesthesia was administered. Oral examination revealed a well-circumscribed ulcer, about 10 x 5 mm in size, and reddish-yellow in color on the hard palate.

My differential diagnosis included anesthetic necrosis and necrotizing sialometaplasia. The clinical findings, with support from history helped confirm my diagnosis of anesthetic necrosis.                                                                

Notes from Dr. K

Anesthetic Necrosis:

Anesthetic necrosis is usually a result of excess pressure application during local anesthesia administration in attempts to deposit an increased amount of anesthetic solution. Localized ischemia results that presents as a well-circumscribed, deep ulcer. The ulcer heals over a period of time. In persistent lesions a small degree of intervention can encourage healing. As Dr. M says, the history and clinical presentation were highly suggestive of this diagnosis.  

Necrotizing sialometaplasia was easy to rule out in this scenario, the ulcer was on the hard palate (no salivary glands there), there was absence of the classic history of "palate falling off", and the condition usually takes a couple of weeks to evolve from a swelling to a crater (our case was only a few days old judging from the condition of the healing socket).