Think on the fly oral pathology case—part 2: The ending you probably didn’t expect

I referred the patient to an oral surgeon (OS), and he was seen the next day. Since I was curious as to what had transpired, I called my good colleague to discuss the case. As an aside, having a good relationship with your referral docs is hugely important—it’s a practice builder, you are assured your patients are in good hands, and you learn a tremendous amount from cases you send their way.

As I suspected, the initial diagnosis for this patient was lichen planus (LP) with ulcerative tendencies, even though there were no real prominent ulcers presenting at the time. The burning in the mouth that the patient was experiencing was more or less what initiated suspicion of the diagnosis.

The OS had a lengthy discussion with the patient and subsequently recommended a biopsy to assure a definitive diagnosis. The patient declined. His reasons were personal, and according to the OS’s office, he was concerned about finances.

Here’s a quick refresher on lichen planus. LP is an inflammatory condition that affects the mucus membranes of the mouth. Symptoms of burning, itching, pain, and overall discomfort can range from mild to severe. LP is a T-cell autoimmune disease commonly found in the fourth decade of life, and it affects men more than women.¹ The buccal mucosa, tongue, and gingiva are the most common oral areas affected.¹

Differentials include, but are not limited to, cheek chewing/frictional keratosis, lichenoid reactions, leukoplakia, lupus erythematosus, pemphigus, mucus membrane pemphigoid, erythematous candidiasis, and chronic ulcerative stomatitis.¹ Treatment is primarily palliative and consists of topical steroids (which, in this case, were not successful), injectable steroids, and immune response medications, but all of these have limitations and variable effectiveness.

After seeing the OS, the patient stopped back by my office to discuss his concerns. I informed him that I had also talked to the OS about his case. The patient’s humble honesty about his reluctance to get a biopsy (aside from his financial situation) was because he didn’t want to put himself in a situation that could potentially compromise his ability to see to his wife’s needs. Simply put, she was his priority right now, and despite the simple nature of a biopsy, he didn’t want to consider it at this time.

The patient asked if there was anything else I could suggest that would at least help with his symptoms. I offered a prescription of Magic mouthwash, which he gladly accepted. I informed him that the mouthwash is not a “solution” per se, but it could offer some relief, especially when the lesions flare up or when eating.

His gratitude was evident when he brought me flowers (with his wife’s permission, of course), saying my help and advice showed him that I respected and genuinely cared about his situation—despite him not pursuing the recommended biopsy. He furthermore said that the Magic mouthwash was helping significantly. In that respect I couldn’t be happier and advised him of the continued need to monitor the lesions. The recommendation for the biopsy still stood. At that point, I’d done everything I could and considered the case a success.

This was not a medical textbook ending or one that I was initially hoping for, but not all treatment modalities or conclusions are what we want them to be. We must always remember that our patients have autonomy with respect to their bodies. It’s our job to advise, educate, refer, and share the pros and cons of all treatment options presented. And we must document, document, document.

And now you know the rest of the story.

For those of you wondering about the Magic mouthwash elixir I prescribed, here are the ingredients: one part viscous 2% lidocaine, one part Maalox, and one part diphenhydramine 12.5 mg/5 ml. 1–2 tsp. 2–3x/day prn. I will usually give 1–2 refills with a 150 ml bottle.

Cheers to the daily grind and the adventures along the way...

—Dr. Stacey

References

1. Lavanya N, Jayanthi P, Rao UK, Ranganathan K. Oral lichen planus: an update on pathogenesis and treatment. J Oral Maxillofac Pathol. 2011;15(2):127-132. doi:10.4103/0973-029X.84474

Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles at this link and subscribe here.

More pathology cases:

• Oral pathology case: A brush with thrush...or is it?
• Oral pathology case: The common but not-so-common radiopacity
  

Stacey L. Gividen, DDS, a graduate of Marquette University School of Dentistry, is in private practice in Hamilton, Montana. She is a guest lecturer at the University of Montana in the Anatomy and Physiology Department. Dr. Gividen is the editorial co-director of Through the Loupes and a contributing author for DentistryIQ, Perio-Implant Advisory, and Dental Economics. She serves on the Dental Economics editorial advisory board. You may contact her at [email protected].