The Case of Intentional Tattooing

A student came up to me and told me that she needed me to look at something. I followed her back to her cubicle where she had a young Somali female in the dental chair. The student lifted her upper lip and asked me if this was racial pigmentation*.

Young Somali female with intentional tattooing

This is a type of intentional tattoo that is seen commonly in African women. They believe that darker gingiva is a sign of beauty. To accomplish this, they undergo a painful procedure that requires insertion of a black powdered substance, made with burnt oil and shea butter, into the gingiva with the help of needles. 

The patient confirmed that she had undergone this procedure. Since the incorporated material is extremely biocompatible, no management is needed.

*Racial pigmentation - Also known as physiological pigmentation is diffuse melanosis of oral mucosa usually seen in people with darker skin tones. 

The Case of Odd Looking Teeth

A 17-year-old girl in need of a cosmetic dental procedure was being seen in the Prosthodontics department. The resident in charge of her treatment was curious about the appearance of her teeth and called me for a consult.

The patient confirmed that the teeth had appeared "odd" since eruption. She was unable to recall if the primary dentition looked similar. There was history of frequent dentist visits for restoration procedures. The patient was the only child and neither of the parents was affected. Unfortunately, the parents had not accompanied the girl for the dental visit so we were unable to acquire a complete family history.

Amelogenesis Imperfecta (hypomaturation type) in a 17-year-old female

The clinical presentation and radiographs were helpful in establishing a diagnosis of amelogenesis imperfecta, hypomaturation type (see description below). Unfortunately, the resident was unwilling to share the radiographs with me for blogging purposes. The patient was given composite veneers temporarily and scheduled for permanent ones in 18 months. 

Amelogenesis Imperfecta:

Amelogensis imperfecta is a hereditary condition that results in the formation of defected enamel. The problem can occur during the phase of matrix deposition, mineralization or maturation of the enamel. 

Hypoplastic amelogenesis imperfecta is a result of insufficient or abnormal matrix formation. The defect can present as pitting or decreased thickness of enamel with either a smooth or rough surface texture. The enamel is soft and prone to attrition. 

Hypomaturation type of amelogenesis imperfecta is a failure of enamel crystals to mature properly. This results in discolored teeth of normal sizes. The enamel appears opaque and mottled. The color varies from white to brown. The enamel relatively soft and is vulnerable to chipping. 

Insufficient crystal deposition results in hypocalcified form of amelogenesis imperfecta. The teeth are of normal size at eruption but the enamel is lost over a period of time. The teeth have rough surfaces and appear yellowish-brown. 

Management of amelogenesis imperfecta usually requires restoration of caries, reducing sensitivity and improvement of esthetics. Problems associated with open bites, impactions and delayed eruption may also need to be addressed. 

The Case of Stained and Wrinkled Mucosa

A student noted "wrinkling" and some staining in the buccal vestibule of an army soldier during the initial exam. I was called on a consult. The patient had no symptoms and was not aware of the presence of this lesion. The student told me that she had inquired about his tobacco status while taking history and he had told her he did not use "cigarettes". When I inquired about his smokeless tobacco status specifically, he confessed that he had been using stuff for several years.

Smokeless tobacco keratosis in a young male

The patient was reassured and a change in placement site was recommended. I was not able to see the patient on his 2-week follow-up but I was told by the student that the lesion had resolved completely.

Smokeless Tobacco Keratosis:

Smokeless tobacco keratosis is a benign mucosal alteration that develops secondary to use of snuff, snus and other forms of smokeless tobacco. It usually has a wrinkly, semi-translucent appearance. To confirm the diagnosis of smokeless tobacco keratosis and to rule out the possibility of a premalignant process, changing of placement site is recommended. If the mucosa returns to its normal appearance  2 weeks following change of placement site, the patient is reassured. If the changes persist, then a biopsy is mandatory. 

The Case of Central Papillary Atrophy

A 63-year-old male came to the dental school for some dental work. While performing the head and neck exam, absence of filiform papillae* was noted in the central region of the tongue. Once I pointed it out, the patient reported a burning sensation in the area.

Central papillary atrophy in a 63-year-old

This condition is described as central papillary atrophy and is the most common presentation of oral candidiasis. 

To prove that's what it is, I'm including the picture of the candida culture. The white opaque on the agar slope are the fungal colonies. 

Saboraud's agar exhibiting candida colonies.

This patient was a denture wearer so I recommended a course of anti fungal therapy with Clotrimazole troches, 50 tablets need to taken over a course of 10 days. The patient was also directed to soak his denture in a cup of a water containing 1 tablespoon of bleach (the one used for laundry). This kills the organisms hiding in denture porosities.

The presentation was previously referred to as median rhomboid glossitis and considered a developmental defect. Since this process is almost never seen in children but relatively common in adults, the possibility of it being a developmental defect is remote.

Please note that the mucosal-colored, dome-like structures behind the central papillary atrophy are normal anatomical structures called circumvallate papillae**.

Candidiasis:

Candida is a very common organism that is a part of normal oral flora in over 40% of the population. It is a weak organism and is only capable of producing surface alterations in healthy individuals. 

Changes associated with candida can be seen following antibiotic therapy. It is believed that antibiotic usage can alter the normal oral environment resulting in an overgrowth of candida. This increase produces the changes that we see in the mouth. 

Another group of people commonly afflicted with candidiasis are denture wearers. The porosities in acrylic (the pink material that forms the base of the denture) become a safe haven for the organisms. Although the number of organisms in the mouth may be within normal range, the organisms hidings in denture porosities can result in redness and in rare instances papillary hyperplasia. 

Loss of immune status can also result in candidiasis. Once the immune status is restored the infection should resolve on its own. In patients with HIV, oral candidiasis is a sign of extremely low CD-4 counts and onset of AIDS. Such patients should be placed on combined anti-retroviral therapy or CART (previously HAART) immediately. 

Oral candidiasis can present as either pseudomembranous, erythematous, denture stomatitis, chronic hyperplastic and mucocutaneous. Pseudomembranous candidiasis has a whitish, milk curd-like appearance. You can remove this white material with dry gauze or a tongue depressor to reveal normal colored mucosa underneath (underlying bleeding surface is a myth). 

Erythematous candidiasis is a lot common than people expect. Our case today is a type of erythematous candidiasis. This form of candidiasis may present with slight pain or burning sensation.

Angular cheilitis is redness and cracking at the corners of the lips. The lesions are usually seen in people that keep this area moist. People using a lot of oil-based lubricants for moisturizing and patients with dentures that pool saliva in this region.

Denture stomatitis has been described briefly when the etiology of oral candidiasis was being discussed. The organisms living within the denture result in redness or papillary hyperplasia at sites covered by the prosthesis.

Chronic hyperpastic candidiasis, also referred to as candidal leukoplakia are white lesions that cannot be scraped off by rubbing. Such lesions are almost indistinguishable from a regular leukoplakia in appearance. If you perform a culture, both may produce colonies due to the presence of commensal organisms or superinfection with candida. The only way to distinguish the two if to treat with antifungals. Lesions consistent with chronic hyper plastic candidiasis will resolve completely.

Mucocutaneous form of candidiasis is extremely rare and occurs in people with severe immunogenetic defect. One of the genes involved is called AIRE. With this particular defect, the endocrine system is also affected in this process. 

Appropriate anti fungal therapy (whether local or systemic) is recommended. If the patient wears denture, soaking in bleach solution can also be recommended. In case of frequent recurrences, the spouse may also need to be treated. 

*Filiform papillae are small, white projections that can be found on the anterior two-thirds of the mouth.

**Circumvalate papillae are slightly larger, dome-shaped structures that can be found anterior to the junction between oral and oropharyngeal portions of the tongue. They vary in number between 8 and 12 and arranged in the shape of an inverted "V". These structures are mucosal colored and often contain ducts of salivary glands and taste buds. 

The Case of Linear Epidermal Nevus

This 26-year-old female came through the screening clinic for routine dental care. The first thing I noticed was her linear epidermal nevus. The lesion had been present for as long as she could remember. She had no esthetic concerns so she had never sought diagnosis and treatment.

26-year-old female with linear epidermal nevus

(I apologize for the picture being slightly askew, I took this on my phone)

Linear Epidermal Nevi:

Linear epidermal nevi are rare, brown colored multiple papules that are present at birth. They are a result of epidermal hyperplasia (increased thickness of the top most layer of skin). It is important to note that these lesions present in the oral cavity, both independently or with a cutaneous component. The lesions can be classified into various types based on the extent of skin involved and the appearance. A more pronounced version of this process involving one side of the body is referred to as nevus units lateris. Ichthyosis hystrix is the most severe form of this condition. It is characterized by bilateral involvement and significant deformity. 

Rarely, linear epidermal nevi present with systemic involvement, most commonly of brain, eyes and bones. In such instances, the condition is referred to as linear epidermal syndrome.

Treating epidermal nevi can be challenging. Topical therapy and surgical excision are the two options.

The Case of Suspected Melanoma

An 82- year-old female patient came into the student clinics with a self-diagnosis of melanoma. The "black" spot had been present for a "long time". Although the lesion was asymptomatic, she thought that there had been a recent increase in size.

The patient was reasonably good health, especially considering her age.

The extra-oral examination was unremarkable. Intra-oral examination revealed a 7 x 6 mm grayish lesion in anterior maxillary gingiva.

82-year old female with amalgam tattoo

I asked the patient if there was any history was treatment in the area, she responded in negative. I told the student to get radiographs.

Radiographic presentation of an amalgam tattoo

I hope you can see the radio-opacity in the anterior region corresponding to the site of the lesion. My final diagnosis was an amalgam tattoo. 

I explained to the patient that a previous procedure had led to incorporation of amalgam particles in the gingiva. The material is biocompatible and no treatment is warranted unless she has esthetic concerns. The patient decided to keep her tattoo.

Amalgam Tattoo:

Amalgam is a silver-colored filling material that is used to restore teeth. Amalgam particles can get embedded in the mucosa during placement or removal of the filling material. It has also been used to restore root apices following a retrograde root canal procedure (also known as apicoectomy). Although the patient was unable to provide a good dental history, I believe that the patient had undergone an apicoectomy procedure on one of her incisor leading to large deposit of material in the area.

It is important to note that not all amalgam tattoos have particles that can be identified through radiographs. In such instances, a biopsy may be mandated. Amalgam tattoos have a characteristic histologic appearance. 

The Case of Swollen Lips

I got an interesting consult the other day. A 29-year-old man reported to the oral surgery clinic with a complaint of swollen lips. The lips had been swollen for over 5 years, he had seen numerous doctors and according to him tried every single remedy under the sun. He was currently using a low dose of corticosteroids but they were not working. 

The man appeared to be in great health otherwise. 

Orofacial granulomatosis (courtesy Dr. Asma Pervez)

The labial swelling was firm on palpation and there was no pain associated with it. During the intra-oral exam, gingival hyperplasia was noted anteriorly. 

Orofacial granulomatosis (Courtesy Dr. Asma Pervez)

The tissue from both sites was biopsied and submitted for histopathologic examination. The tissue from the lip showed presence of some acute and chronic inflammatory cells. The specimen from the gingiva exhibited granulomatous inflammation. Because we can assume that both changes are part of the same process, we concluded that the patient most likely has oro-facial granulomatosis.

Intra-lesional steroid injections were recommended as management. I have not heard back from the surgeon yet about results. I'll update the post once the results become available. 

Oro-facial Granulomatosis:

Oro-facial granulomatosis is an abnormal immune response that presents as swelling on the lips and tissues in the anterior region of the mouth.  Additional features, such as linear vestibular ulcerations, "bumpy" edema of oral tissues known as cobblestoning and hyper plastic tissue folds may also be encountered. The condition manifests in the third and forth decades of life. The condition is currently characterized as idiopathic. A dietary link has been suggested but there is very little evidence to support this claim. Histopathologic examination exhibits granulomatous inflammation which may not be evident in the first section. Several sections may be needed to confirm the presence of granulomas.

Oro-facial granulomatosis brings a couple of things in the differential diagnosis. Clinical and histopathologic changes of oro-facial granulomatosis are identical to those of Crohn's disease. We confirmed absence of intestinal disease to rule out this possibility. This step usually requires referral to a good gastroenterologist.

Melkersson-Rosenthal syndrome is a triad of oro-facial granulomatosis, fissured tongue and facial paralysis. Since the later two were absent in our patient, this was an easy possibility to rule out.