Diagnosis and treatment for Breakthrough Clinical oral pathology case: No. 17

A 64-year-old patient presents for her scaling and root planing appointment, concerned about ulcer-like lesions in her mouth that had developed a few weeks after her last appointment that had grown progressively bigger. Stacey Simmons, DDS, Breakthrough Clinical’s editorial director, discusses further developments with this oral pathology case and explains how complex variables acted together to affect treatment for this patient.

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This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.

Last month, I presented the case of a 64-year-old female who presented for her scaling and root planing (SRP) appointment. Prior to commencing with care, she had expressed concern over lesions in her mouth that had developed after her previous SRP appointment and that had grown progressively larger.

Clinical assessment revealed red, inflamed tissue throughout the oral cavity. Most notably present were large, ulcer-like lesions on the right and left lateral borders of the tongue. The edges were well defined; the red center slightly concave and very tender to palpation. The vestibular tissue, upon the slightest touch, sloughed and hemorrhaged easily.

Read complete case details and view additional photos—including the patient’s medication list and history—at this link.

The patient was referred to an oral surgeon where an in-depth discussion took place regarding her medical history. As mentioned previously, this patient had a history of hepatitis C, for which she has been on the liver transplant list. She had begun taking the medication Harvoni, a drug used to treat chronic hepatitis C, just three weeks prior to the SRP appointment before the lesions had appeared. The patient’s laundry list of medications was enough to induce her dry mouth, which alone put her at risk for oral lesions. However, the presence of these lesions in tandem with the chronic hepatitis C medication was too convenient. One of the side effects ofHarvoni is oral lesions and in this case—in conjunction with her dry mouth—those lesions were exacerbated. Since this medication was mandatory (for three months), the only treatment is palliative.

The patient was given a prescription of magic mouthwash, which is a common solution given to patients who are suffering from mucositis (very common with cancer patients). Magic mouthwash typically consists of three ingredients mixed in equal proportions (1:1:1): 2% lidocaine viscous solution, an antihistamine (i.e., Benadryl), and an antacid (Maalox). The oral surgeon discussed his findings with the patient’s infectious disease doctor, who concurred with the assessment and recommended care.

All invasive procedures—scaling and root planing, operative, etc.— have been postponed until the patient’s symptoms clear up. She was given detailed home-care instructions with regard to her oral health and will be followed up on as needed.

Take-home point
The take-home point with this case is to ensure that health history and medication lists are complete, accurate and reviewed every timea patient walks through the office door. Oftentimes we neglect to ask, especially if we see a patient frequently. In this particular case, the addition of one medication set the stage for a three-month battle of mucositis and delayed dental treatment.

MORE PATHOLOGY CASES . . .

This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.

Stacey L. Simmons, DDS, is in private practice in Hamilton, Montana. She is a graduate of Marquette University School of Dentistry. Dr. Simmons is a guest lecturer at the University of Montana in the Anatomy and Physiology Department. She is the editorial director of PennWell’s clinical dental specialties newsletter, DE’s Breakthrough Clinical with Stacey Simmons, DDS, and a contributing author for DentistryIQ, Perio-Implant Advisory, and Dental Economics. Dr. Simmons can be reached at ssimmonsdds@gmail.com.


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