The Case of Herpes Simplex Virus

A 22-year-old female presented to the department with a complaint of small, painful ulcers on her gums and the inside of her lips. The ulcers had appeared as small bumps that had ruptured to form ulcers. Constitutional signs were absent. As far as she could remember, this was her first episode of anything like this. 

During her intraoral examination, we noted small ulcers on the gums and labial mucosa.They were small in size approximately 1 to 2mm with reddish appearance. A few of them appeared to have coalesced together and seemed bigger than the rest.

Herpetic ulcers on the gingiva and labial mucosa
Photo credit: Dr Amber Kiyani

Multiple tiny small ulcers, a history of "tiny bumps" rupturing into ulcers supported a diagnosis of herpetic stomatitis. To help confirm this diagnosis, a cytology was done. The results were consistent with a herpetic infection. 

Cytology fo herpes simplex virus
Photo credit: Dr Amber Kiyani

Since the infection had already manifested, we did not prescribe antiviral therapy, we just recommended topical anesthetic agents to help with the pain. The patient was seen on followup 7 days later. The lesions had cleared up until then. 

The Case of Fibrous Dysplasia Encroaching the Orbital Floor

A 47-year-old female was seen in the oral surgery clinics with a complaint of vision and hearing disturbances that had developed over the past few months. The patient had a diagnosis of fibrous dysplasia from several years ago. She was offered surgical trimming of the lesion at the time of diagnosis, which she refused. 

Slight asymmetry in a 47-year-old patient with fibrous dysplasia

Only slight facial asymmetry was noted during the extra-oral exam. A bony hard bulge was palpable in the left buccal vestibule. It was not prominent enough to be photographed. The patient was requested to return with imaging studies. 

CT scan of a patient with fibrous dysplasia
(Courtesy Dr. Asma Pervez)

On her CT scan, a radio-opaque mass was noted to obliterate the maxillary sinus and encroach the nasal wall and the orbital floor. 

The oral surgeons in the clinic offered the patient hemimaxillectomy. They believed that since the disease process was active, and continued to involve more tissue, it was best to remove it completely. The defect would be filled with a specially designed obturator. This would obviously result in suboptimal esthetics, much worse than what the patient was presenting with. However, the patient's sight would be preserved, and future complications, such as involvement of the base of skull, would be prevented. 

As extreme as this sounds, this was the best approach in my opinion. However, I did speak to the surgeons about the possibility of a relatively conservative plan, possibly removing the orbital plate and contouring the lesion involving the maxillary sinus. They said leaving any part of this lesion would be asking for recurrence.

The patient was not happy with this treatment plan. She hasn't returned to schedule surgery.

Fibrous Dysplasia:

Fibrous dysplasia is a developmental condition that results in replacement of normal bone with fibro-osseous tissue. It is linked to a mutation in GNAS 1 (guanine nucleotide-binding protein), which plays an important role in development of bone, endocrine system and skin pigmentation. The severity of bone involvement depends on the time when the mutation takes place, mutations during early embryonic development can cause multiple bone involvement. 

Fibrous dysplasia is broadly classified into polyostotic (multiple bone involvement) and monostotic (one bone involvement) types. 

Monostotic type is more common. The lesions present as a slow-growing, painless swellings. Patients are usually in their teens at the time of diagnosis. Jaws are a frequent site of involvement. The maxilla is more commonly affected than the mandible. For fibrous dysplasia of the maxilla, the use of the term craniofacial fibrous dysplasia is preferred. It is not uncommon for bones in the vicinity to get involved. 

Radiographically, the lesions of fibrous dysplasia are described as having a "ground glass" appearance.   The margins of the lesion are ill-defined and merge with the adjacent normal bone. Diagnosis is confirmed by biopsy. 

In most cases, fibrous dysplasia stabilizes once the skeletal growth ceases. Our case is an obvious exception. Surgical contouring is done to correct minor asymmetries. Rate of recurrence after the procedure vary between 25-50%. Larger lesions may require surgical resection. Bisphosphonate therapy helps to control polyostotic disease. 

The Case of Suspected Bilateral Squamous Cell Carcinoma

A 48-year-old male reported to the oral surgery department with a complaint of teeth in the lower left side. During the intraoral examination the dental student noted an ulcer in close proximity, the patient told her that the sore had been there for a while but it did not bother him much. Preoperative radiograph of the area showed radiolucency around lower molars. These teeth exhibited grade 3 mobility and were easily extracted. 

Preoperative radiograph of the 48-year-old

The student then went to the clinic supervisor to report that the extractions were complete. During her report she mentioned the ulceration at the site. The clinic supervisor reviewed the patient's history form that was absent of any red flags. She then asked the patient if there was any significant social history. The patient revealed that he had been using smokeless tobacco (niswar in the local language) for several years. Since this side was sore, he was now placing the quid on the opposite side. Intervention at this point was difficult due to the bleeding socket, the patient was instructed to return for a follow up visit in one week's time.

On one week's follow up, the patient presented with a distinct ulcer on the buccal side of the alveolar mucosa.

Ulceration at the site of extraction

A panoramic film was taken. It showed areas of radiolucency bilaterally at the sites of quid placement. The one on the left side was ill-defined and ragged in appearance, highly suggestive of malignancy. The clinic supervisor performed an incisional biopsy at this point. 

Histopathological findings showed a soft tissue specimen consisting of dyspalstic oral epithelium with fibrovascular connective tissue and a malignant neoplasm demonstrating epithelial differentiation. The tumor was invading the underlying connective tissue in nests and cords. The nests exhibited prominent keratin pearl formation in the central areas.

Keratin pearl formation in oral squamous cell carcinoma

Based on the histological findings, a diagnosis of oral squamous cell carcinoma was made.

The patient did not take the news of his cancer well. It took us a while to convince him to let us biopsy the other side. Another incisional biopsy was done in the right mandibular site of placement following extraction of teeth in the region. On histopathology sections, we saw stratified squamous epithelium in association with connective tissue and occasional fragments of bone. The surface oral epithelium showed prominent parakeratinization and what Dr. K calls a "busy" basal layer. The underlying connective tissue showed a chronic inflammatory infiltrate. Dr. K did not like the look of this tissue, she did not think that the cells were maturing appropriately, so she called this tissue atypical and made a comment of close clinical follow up. 

Hyperkeratosis with epithelial atypia, and chronic mucositis

The patient was asked to bring in his imaging studies and was offered partial mandibulectomy with selective neck dissection. He hasn't been back since. If he returns, we might have more images of his resection to share with you. 

The Case of Aphthous Ulcers

A 21-year-old female dental student reported to the oral surgery department with a complaint of painful ulcers in the mouth. On taking history we discovered that the ulcers appeared 2-3 days ago and she had been in extreme pain since then. The patient told us that the ulcers had appeared once before on the labial mucosa but had healed within a week. Her medical history was clear of any significant medical illness.

21-year-old female with aphthous ulceration on right buccal mucosa

Intraoral examination revealed 2 small ulcers less than 1 cm in size on the buccal mucosa. Both ulcers had a characteristic red halo around it.

Based on the patient's history (spontaneous onset, history of previous ulcers healing in 7 days) and clinical appearance of the lesions (presence on unattached mucosa, distinct red halo around the ulcers), a diagnosis of aphthous ulcers was made. 

Kenalog Orabase gel was prescribed to the patient with directions to apply it 4 to 6 times a day. The patient recovered within a few days.

Notes from Dr. K:
Aphthous ulcers, AKA canker sores, are a common oral pathology with reported incidences of up to 25% in the general population. They fall in the category of autoimmune processes. A variety of etiologies have been proposed as an initiating factor for this process, including allergies, genetics, good disorders, hormonal disorders, nutritional problems, smoking cessation, and following trauma.  Scientific evidence on all these is equivocal. An increased incidence of aphthous ulceration has been reported with systemic diseases, such as nutritional deficiencies, immunodeficiencies, gastrointestinal diseases.

Aphthous ulcers tend to occur in young adults more frequently, especially those who lead high stress lives. The ulcers are classified into three types, minor, major and herpetiform. The case that Dr. M's shared today is an example of the minor type. The ulcers are usually multiple, between 3-10 mm in dimensions, and exclusively involve parakeratinized mucosa (everything except for the alveolar ridge and hard palate). The lesions often appear at one site, heal over a period of 7 days and occur elsewhere. Patients may have one episode in a lifetime, or may not experience a day of relief without the ulcers.

The diagnosis is usually made on clinical grounds, on the basis that Dr. M states with the case above.  Potent topical corticosteroids help in a faster recovery. They also seem to help in decreasing the frequency of ulceration. In patients with continuous episodes, it may be worthwhile to undergo a complete systemic evaluation.

Another case of aphthous ulcers: http://mydayinclinic.blogspot.com/2015/02/the-case-of-two-pathologies-part-1.html