Diagnosis and treatment for Breakthrough Clinical oral pathology case: No. 11

Dr. Stacey Simmons, editorial director of Breakthrough Clinical, gives her diagnosis and recommended treatment for last month’s oral pathology case. A 62-year-old female presents for her biannual cleaning and checkup. Health history is noncontributory. During her routine oral screening and exam, a 9 mm x 3 mm white leukoplakic patch of tissue on the left ventral surface of the tongue was noted. It was not tender to palpation, could not be scraped off, and the patient was unaware of its presence. At the follow-up appointment two-and-a-half weeks later, the lesion was still present.

Feb 3rd, 2016
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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 this oral pathology case . . .

A 62-year-old female presents for her biannual cleaning and checkup. Health history is noncontributory; she is taking Vitamin D supplements and reports no other changes or concerns.

During her routine oral screening and exam, a 9 mm x 3 mm white leukoplakic patch of tissue on the left ventral surface of the tongue was noted. It was not tender to palpation, could not be scraped off, and the patient was unaware of its presence. It was recommended that the patient come back in two to three weeks to assess for continued presence.

At the follow-up appointment two-and-a-half weeks later, the lesion was still present.


Here are the differentials, my diagnosis, and the recommended treatment for this case . . .

Differentials: lichen planus/lichenoid dysplasia or squamous cell carcinoma (SCC)

The patient was referred to an oral surgeon where evaluation and an excisional biopsy were performed.

Definitive diagnosis:keratosis with lichenoid chronic inflammation

The presence of leukoplakic lesions in the oral cavity is always cause for evaluation and follow-up. The World Health Organization defines leukoplakia as “a white patch or plaque that cannot be characterized clinically or pathologically as any other disease.” (1) Leukoplakic lesions are one of the more common forms of epithelial dysplasia, typically discovered during routine exams; they are usually asymptomatic and represent 6.2% of all oral biopsy specimens. (1) Leukoplakia and squamous cell carcinoma share many of the same etiology factors (1), and approximately 5.4% of leukoplakic lesions become SCC. (2) It is, therefore, imperative that the following steps be considered: (1)

  1. Assess etiologic factors (table 1)
  2. Categorize the lesion as a high- or low-risk specimen (table 2)
  3. Assess differentials (table 3)
  4. If warranted, biopsy lesion for a definitive diagnosis

In this particular case, the patient was a nonsmoker, and the etiology of the lesion was unknown; this alone put her in a high-risk category.

The diagnosis of lichenoid chronic inflammation is a form of “epithelial dysplasia with an associated dense infiltrate of lymphocytes that bears a striking resemblance to the dermatologic/mucosal condition of lichen planus; when an epithelial dysplasia has multiple histologic features in common with lichen planus, it is termed lichenoid dysplasia.” (2) Treatment for these types of lesions is palliative unless they become widespread, persistent, or uncomfortable, in which case the use of topical steroids is common and effective.

Since the lesion in said patient was benign and excised completely, no further follow-up was recommended.


ADDITIONAL READING …
Diagnosis and treatment for Breakthrough Clinical pathology case: No. 9
Diagnosis and treatment for Breakthrough Clinical pathology case: No. 10

Do you have an interesting pathology case you would like to share with Breakthrough’s readers? If so, submit a clinical radiograph or high-resolution photograph, a patient history, diagnosis, and treatment rendered to: DEbreakthrough@pennwell.com. We will let you know if we select your case!

Join our Facebook group to discuss this case and more.

ALSO BY DR. STACEY SIMMONS |
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References
1.Wood NK, Goas PW. Differential Diagnosis of Oral and Maxillofacial Lesions. Mosby;1997:75–77,98–103,106–107.
2. Saap JP, Eversold L, Wysocki G. Contemporary Oral and Maxillofacial Pathology. Mosby;1997:164–165,170,250–253.

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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