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Transcribed byAmit Amin July 30th, 2014

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[DOD] [17/18] [CPC and Review Session ] by [Dr. Shah]

[No PowerPoint slide release] [title of slide][Dr. Shah]Ok good afternoon students. How are you guys? Theres a lot smallercrowd. What is it? Do you have a test? On Monday? Thats still far away. Today

basically um, btw, Im sorry I ran from clinic. Im in clinic all day Wednesday. Icouldnt leave my patient bleeding after a biopsy. I sutured him up and then I camehere. What Im doing today, Im just doing a review and cases. I did not post this b/c

this is designed to be interactive. I have the answers and all of the info in thispresentation. That is why its not posted. Many times I use similar cases every yearso I may not post this. So please take your notes. The presentation is just pictures.The information is in the interaction. Theres not much text coming from the

presentation. At least for right now, this is designed to be interactive. Im doingcases that will tie together the things Ive been over. Itll get you thinking in the

format that will be in the examination. It will be August 15th. The format of the examis not definitive yet. Would you prefer all multiple choice or short answer as well? I

think I know the answer to that. All multiple choices. Imjust being very blunt andhonest but normally I dont prefer multiple choice, b/c it does not test knowledge.

Im not going to pop out one day and say A. lymphoma, B. Mucoseal. You got to knowthese word and terms. I have done free response in the past but you guys are luckb/c Im taking a trip to the Bahamas for the week and I may not have time to grade

them. You can thank my husband for that. I will definitively let you know, but it willprobably be 75 multiple-choice questions. Very case and figure based. Lots ofpictures, radiographs. I had a couple questions on the last lecture. It was definitely alot of information. The things you dont needto know to write a prescription. Youdont need to know the dosage, the number of times/ day; you need to know theclasses, the names of the medications. Which ones are anti-fungal, which ones are

the steroids we use, which ones are anti-viral drugs. Thats mainly what you need toknow. In some cases I put a name in parenthesis. That might be the trade name/brand name. I hope Im very clear on when I mean you need to know the drugs. You

dont need to know the dosage and the amount but you need to know the names,usages, trade/ brand names. Other than that. Oh one more thing. On Friday, youll

notice in your schedule there was a lecture scheduled from 3-5. Online oral cancertime. I know youre going to be so disappointed but were actually cancelling that.You can use that time to study Im sure. What it is, theres an online oral cancer

course that weve developed that normally the 3rdyear students take in the oralpath course. We want to move it to the second year, but its not ready for that. The

paperwork wasnt done in time. Youll be taking it in next year. We had given thattime so you could take the course, but now Friday 3-5 is cancelled so you can usethat time to study. I knew you wouldnt be too upset. Ok. Before I do the cases arethere any other final questions? I hope you have enjoyed the oral path section. Youhad an oralfacial pain section. Any other questions? You know you can always emailme.

Lets do these cases guys. Again, Im going to be really evolving you. Maybeyou dont know me as well yet. If no one volunteers, then I pick on you. Im not doing

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it to embarrassed anyone. Just trying to gauge what the class knows. Heres the firstcase. We have a 54 year old that presents for a routine check up. Her medical historyshes diabetic type II, the medication shes taking is Glucotrol. Oral exam. The dentistnotes lesions on the lateral border on the tongue. The patient is unaware but notesthat the tongue feels weird sometimes. This is the picture of the lesion. Who would

like to volunteer to describe what they see. Give me the differential diagnosis andgive me the next step. Someone should volunteer. If no one volunteers, the personwho looks away the most gets called. Thats a good question. Can you wipe it off? No.

Ill penalize you for asking a question. Describe what you see here. There issomething to see. IF you cant, its all along here. Ok. Leukoplakia is a good clinical

descriptive term. Flat white areas that dont wipe off. I might call it an erythroplakia.

Theres some areas here as well. The tongue looks red here as well. You can go w/both if they are true red areas. Its diffuse and ill defined. Give me an idea of somepossible diagnosis and what you would do next. Well you dont have too much

longer to get a lot more guys. The test will creep up on you soon. Thats a good thingto do. No, it feels a little rough surface but not indurated or hard. The patient doesnt

know but for a while. Progressively getting larger for a couple monthsyear. Howabout you? The patient feels a little tingling or sensation sometimes but it doesntreally hurt. Slightly rough surface/ raised. Its not exophitic lesion or nodule but itsdefinitely a little raised and rough surface. How about you? Strange behaviors suchas what? That sounds interesting. Ok. Thats actually a very good point. Definitelylook on the other side and see if there is something similar. If you see something onthe other side, you feel more benign about it. It might be the patients anatomy orsome habit. When youre talking about strange habits, you might be talking aboutsharp or broken teeth and they might be biting their tongue. Thats all negative. Thepatient doesnt bite their tongue. None of the teeth are really sharp. Whats adifferential diagnosis guys. What could this be? If you recall either Dr. Kerr or myself

we would have said that any leukoplakia that didnt wipe off theres a standarddiagnosis of three things. What are most leukoplakias? What do they end up being?Hyperkeratosis. Hyperkeratosis is at the top of the differential diagnosis. Then what.What else are we worried about? Whats the next possibility? Epithelial dysplasia. A

pre-cancer. The worse case scenario is squamous cell carcinoma. We are in a high-risk site (ventral lateral tongue). Anytime you have a red/ white lesion in this area,you cant directly prove that its traumatic, you have to have SCC and dysplasia in

the diagnosis. What do we do next? This is where we talk about the biopsytechnique lecture. What kind do we do? Remember your four choices. What are yourchoices? Incisional, excisional. Punch is not a type of biopsy. It can be incisional orexcisional depending on the size of the lesion and the size of the pump. So those arethe four choices: brush, mucosal smear, and incisional, excisional biopsy. Which oneof the four should we do here? These are the types of questions you will get on theexam. Youll get a picture, itllask for a clinical diagnosis, type of biopsy, treatment.Things like that. Thats why we are going through the exercise here. Well be doingincisional. Where should we biopsy this? Do you guys remember the rules? Theworst looking area. Whats the worst looking area? I would personally go right here

since theres a little bit of red color here.If I saw an ulcer, I would go around theulcer. I wouldnt go straight in it but Id go around the ulcer. What if this is pure

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white then where do you go? Not borders. No. The roughest area. Right. Remember Italked about rough vs. smooth so as dysplasias progress, the surface becomespebbly and rough and granular. If you have a plain white lesion, you want to go forthe rougher areas then the smoother areas. If you have a mixed red and white lesionyou want to go for the red areas. Remember you can do multiple biopsies. This

lesion is big enough. Its pretty diffuse. I can go one here, over here, wherever else Iwant to. You have to decide just before I answer your question. I think Dr. Kerrwould have talked about. Lets say youre completely clueless. I have no idea where Ishould biopsy this. Can you think of something that can help you decide? Sometechniques he talked about that can help you decide? Yea. Thats an idea too. You canfeel and take a firmer area. Im talking about, yea go ahead. There you go. Thevelscope and the T blue. He talked about that right? If you have no idea and even ifyou have an idea and we use these things, you can use that toluidine blue whichcorrelates well for dysplasia or the velscope, the loss of fluorescence. The green lightand look for the black areas. Is this all familiar to you? You can use those things toguide where to do biopsy as well. The velscope and the loss of fluorescence and the

T blue. We should do a biopsy. Thats the next step. This is a differential diagnosisthat we talked about. Hyperkeratosis, epithelial dysplasia and squamous cellcarcinoma. This is what you should be thinking when you see that lesion. And in thisorder. Ok. Differential diagnosis means that the realest possibility is at the top of thelist and the least likely is at the bottom of the list. This is just based on frequency. 4:5white lesions are hyperkeratosis. Considering the fact that we are on a higher risksite and not the buccal mucosa, these become more possible dysplasia andsquamous cell carcinoma. Incisional biopsy was done and this is what we see underthe microscope. You have these islands of epithelial cells going into the connectivetissue and coming from the surface epithelium. This is a high power view. This iscalled a keratin pearl. Then you have these pleomorphic cells with large dark nuclei

in the connective tissue. What do you think this is? Squamous cell carcinoma. Whereyou get infiltration in the epithelium into the connective tissue. Dysplasia is confinedto the epithelium and there is no break in the basement membrane. These has gonethrough and islands are invading into the connective tissue. This is a keratin pearl,which only squamous cells do. So you know this is a squamous cell carcinoma. Thiswas indeed a squamous cell carcinoma. What do you think will happen to thispatient in terms of management? What happens next? Ok but anything before that?Yea, I mean. We need to deal w/ this lesion. We still need to deal w/ this lesion.What would you do w/ this diagnosis after you give it to the patient before thesurgeon digs in and cuts. There is something else you have to do. Do you rememberthe staging? It needs to be staged. Does anyone know bout the TNM staging system.Did Dr. Kerr talk about that? T for tumor size, N for node involvement, M formetastasis. Stages 1-4. I think he traditionally talks about these things guys. He didbriefly? Ok. Anytime time a patient is diagnosed with a SCC they have to be stagedw/ the TNM staging system. It ultimately does T tumor size, N node involvement,and M distant mets, you break that into stage 1-4. That determines the prognosis,the 5-year survival rate, and the type of treatment the patient will get. If they havestage 1 or stage 2, then surgery w/ margin is all you need. IF you go to stage 3 youthrow radiation in. Stage 4 if you have distant mets you might put chemo in. The

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staging is really important in terms of prognosis and treatment. The patient will getstaged. How are we going to stage the patient? We need more imaging. You canpalpate for lymph nodes but also many times you cant see the deep lymph nodes.Imaging, CT Scans, MRIs. They will show you lymph nodes involved. The patient willget a complete workout and staged before the treatment begins. Most cases of SCC is

surgery w/ margins. Ok. Illgo to the next case. Case 2? Yes. Ok. So I just have to say,that this isnt a written in stone rule. It depends on the patientsmedical status. Italso depends on where the tumor is. If you have an oral pharyngeal cancer that theycant get to they might use radiation. This is not a hard and fast rule. Im not an

oncologist. Generally speaking, the stages 1 and 2 are usually surgical and when youget higher stages you add radiation. Chemo is rarely used for oral cancers. Its usedvery rarely for stage 4s. Case 2. Are there any more questions on Case 1 before I goto the next thing?

Case 2 is a 67 female patient that presents to dental clinic for new dentures.Her medical history: hypertension and is a smoker. Shes taking Norvasc, which is a

medication for hypertension. She reports she has soreness and burning pain on thetop of her mouth. When you hear soreness and burning pain you should think of 3things really. What are the things you should think of? Candidiasis. The variousforms of Candidiasis. What else? Not quite. Ulcers can be sore but burning doesnt gow/ that really. What else? Ok. Ummm. Not quite. What else? Ok. Dry mouth can leadto burning sensation, thrombo infection and lycanoid lesions. Lycanplanous,lycanoid mucositis patients will say they have soreness and burning of their cheeksor where ever their lesions are. This is what you should be thinking of just based ontheir history. The way that you should approach this is, you look at the history andyou start thinking bout things that occur in that area. Then you look at the pictureand see whats most consistent. Thats how you come up with your differential

diagnosis list and your favored diagnosis. So. Dry mouth causes burning b/c you losethat layer of lubrication that coats the oral mucosa. Alright. So, what do we havehere. Who would like to go for this one? This is the easier ones so you might want toraise your hand now. Ok. Also known as? What else can you call this? Ok. What typeof candidiasis. Erythematous (chronic atrophic candidiasis). Trophic means red andchronic meaning the patient has had it for a while. Chronic atrophic candidiasis,dentrostomitis, erythemtis candidiasis. These are interchangeable terms. Could thisbe anything else? You think of anything else this could be? Besides a dentrostomitisor a candidiasis? Anyone? Not quite. What Im going w/this is, is if it was a newdenture. What if I told you they had a new denture and then they came to see you 3-4 days later like this? Can you think of anything else? Hypersensitivity or allergicreaction. Maybe to the denture acrylic. That would certainly have to be right after anew denture was delivered. If a patient told you theyve had a denture for years, I

dont think its very realistic to put that in. Although, I there are cases wherepatients have had it from the beginning. Some sort of hypersensitivity or allergicreaction and never got it treated and kept wearing the denture. Thats a remote

possibility. What should we do next? What should we do next? Ok. Lets say wereunsure so we should do a mucosal smear right? Mucosal smear. Candidiasis is anindication for a mucosal smear. Whats the other one? Herpes. So those are good

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things to do. A smear was done. These are the fungal hyphae. These are the clump ofepithelial cells so it was definitely positive for candidiasis. What now? What do wedo for treatment? Whats next. Lets be a little more specific. Give me some names.

Coctrimicoltrosis. A patient can suck on these laugengous (spelling?). What is it? Iwouldnt really recommend the disc in a patient who wear dentures since they have

to wear it all day and they cant wear their denture over it. Nystatin rinse I woulduse or an ointment in the denture base. Nystatin comes in different forms. Tablet,ointment, rinse, cream. All of these other things. You can do a nystatin ointment inthe denture base and do it 3 times a day. You can have the Pt take out the dentureand do a nystatin rinse. It wont help if they are doing the rinse w/ the denture in.You can also do the coctrimicoltrosis but again the patient cant be wearing the

denture b/c you want the contact anti-fungal to contact the area to contact inquestion. I personally would be doing the nystatin ointment denture in the base b/cI know it will cover the right area. Then you would do a follow up with a patient tomake sure it was resolved. What would you do long term for management w/ apatient like this? Exactly. Keep your dentures at night. If they are poor or ill-fitting,

fabrication of new dentures. Thats the longer-term management of this. Denturestomitis, erythemtis candidiasis, and we talked about the treatment. Ok, so anyquestions on that case? Is it pretty clear? Moving on to the next case.

Middle aged male patient that presents to the oral medicine cliniccomplaining of recurrent painful oral ulcers. He denies a medical history and nomedications. He says he gets sores like these every couple of months. Before Iprogress to the picture, whats a key word in this history here? There are twoimportant words that point you in the right direction. Recurrent is an importantword. Recurrent and painful. Actually, even this last phrase. Gets sores like theseevery could months. What should you be thinking. What things are recurrent?

Herpes or apthus ulcers. Right? So, take a good look at this. Im trying to make it a bitbrighter. Who would like to describe this and come up with a differential. This sidehas been active while this side has been quiet. Who would like to volunteer andcome up with a diagnosis? Are you volunteering or stretching? Ok go for it? Ok, whydo you say that? Describe it briefly and tell me why you said that. On the soft tissue.You mean, movable non-keratinized. Based on the location, movable non-keratinized, its got a yellow white, fibrin coating. One thing you left out thats classic

for apthus ulcers is the red hallow and the shape around it (nice round oval shape).The fact that its on movable mucosa, its got the yellow white coating, its got a red

halo, its round to oval in shape. All of these things points to an apthus ulcer. In thisparticular case. Dont just zoom in on one thing. Look at everything. Is there

something else this could be? Look at the entire picture and think about some otherpossibility. Yea. Possibly, a traumatic ulcer since you have some stuff going on overhere right? Maybe there is a traumatic component to this. It has a round regularshape. And the patient tells you an important question to ask. Whats one thing also,

that will help you from the history help distinguish this from a traumatic ulcer.Whats another important question, I would ask my patient. There you go. Thats the

correct answer. Recurrent apthus ulcer patients dont get it in the same spot everytime. I would want to know where it is. Is the recurrent ulcer always in the same

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area? That would be a result of trauma. If it was recurrent in movable mucosa, Iwould point to apthus. Does that make sense? At any rate, what should we do next?Differential diagnosis? Apthus ulcer. Potentially traumatic and I just put herpetichere since its a differential for an ulcer in the oral cancer. Realistically its not a

herpetic ulcer since its on movable not fixed and its not a tiny group of ulcers like

most herpetic are. What do we do next? Whats a possibility to do next? You feelpretty good that its an apthus ulcer. Whats next? Your patient wants you to dosomething. I wouldnt use a rinse for one ulcer. You can do a topical steroid

ointment. Right? Theres another ointment called canilogin orabased (I didnt cover

but thats a possibility). Or, in many cases, if this was the only ulcer they had, I may

reassure the patient if they are health w/ no medical issue, I would reassure themthat it would heal in a week. Idk if I showed you the picture or not, but there are OTCproducts you can use but you get a worse reaction. I may have shown you a casewhere a patient put something on it and it got worse. I think they developed an EMon it. Sometimes its better to tell your patient, look this is what it is and its going toheal in a couple days. You can recommend some OTC anesthetics, OraBase,

Kanocover, things like that. If its really painful (multiple ulcers) you can give asteroid ulcer or rinse. One other question to ask you all. If this patient tells you ya Iget sores like these all the time, is there any other workup or anything that weshould do? The answer is yes. Can you tell me what else you do for this patient?Every person that gets a diagnosis for apthus ulcers needs a work up to try and finda cause. You should remember that list with the slide of all the potential systemicdiseases associated with recurrent apthus ulcers. Does anybody know any of them?Gluten sensitivity, celiac bashets, what else? Neutropenia. Right? Ok. HIV is anotherone. The GI disease is Crohnsand ulcerative colitis. For any patient that shows up inour clinic with apthus ulcers we try to find the cause. We ask about GI issues, we askabout gluten sensitivity, this and that. We always order CBC Blood work to look for

neutropenia or Vitamin deficiencies since they can be a cause of recurrent apthusulcers. We do a full workup. In some cases youll find an underlying cause. If you find

an underlying cause and treat it, the patient will be doing much better and have lessepisodes. In the majority of cases you dont find an underlying systemic cause.

Theres also a familial or genetic component to apthus ulcers. You need to at least dothe workout to rule out other systemic cause. Recurrent apthus ulcers, treatment notreatment recommended, topical steroids, rule out underlying systemic causeswhich I just went over, immune deficiency, Crohns, ulcerative colitis, nutritionaldeficiencies, sprue, and gluten sensitivity. You really do need to know this list ofdiseases that are associated w/ recurrent apthus ulcers. Sprue is like glutensensitivity. Very similar. I dont know what the fine difference is. I think its a more

regional type of disease. Any questions on that case? The recurrent apthus ulcercase?

Case 4 is a 24-year-old male dental student who presents to the oralmedicine clinic with a bump on the lower lip. No medications, no other significantexraoral or intraoral findings. What should you be thinking even before I show youthe picture. What are the common oral lesions that could present as a bump on thelower lip. There are two that should come to mind. Fibroma and mucoseal. How do

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you tell the difference between them clinically? By palpating them. The fibroma isfirm and the mucoseal is softer and compressible. Right? Ok. Sometimes you canttell the difference w/o biopsy. Some mucoseals can develop fibrosis and keratosisaround them too. Anyways. This is what it looks like. This actually felt a bit fluctuantor soft or compressible. Which of the ones do you think? Yea. We talk about the

differential diagnosis before you feel it. This could also be a fibroma. Very rarely atthe bottom of the list, you can get minor salivary gland tumors. You have a lot ofminor salivary glands on your lower lip. They are pretty on the lower lip. Its kind ofin there, in the differential diagnosis. Mucoseal on the top, fibroma, minor salivarygland tumor (at the bottom less likely). What kind of treatment do we do? Whats

the next step? Excisional, not incisional. Here is the excisional biopsy. Remember amucoseal is not a true cyst. Its a space filled w/ mucus which often washes outduring processing. You have a compressed connective tissue wall here. Granulationtissue, and CT tissue. These are some salivary glands and this is the surfaceepithelium. Always tell your patient that there is a chance of recurrence of mucoseal.What caused the mucoseal to begin w/? Severing of the duct. How? What kind of

trauma? Usually when you bite yourself. You tend to see it in younger patients.Youd be surprised that one of the common times of mucoseal formation is when?

Think about this one. When would a kid be more likely to bite themselves. Afterdental work, after local anesthesia. The kids are like oh this feels so cool andtheyre biting their lip. Thats a time when many mucoseals do form in pediatricpatients. It doesnt have to be. Any body can get a mucoseal. I have to tell you, that

several dental students have gotten, b/c when youre stressed out, you might bite

your lip or something and cause a mucoseal. This dental student told me he wasreally stressed out. He said it was some other class. That was a mucoseal. Anyquestions on that case? Ok. Thats a good question. Would somebody else like to

answer that? Do you think that this could ever go away on its own? Not really. What

can happen and what does happen, or what most patients do is that they stick asafety pin in this and they sort of pop it. The salvia and mucus comes out anddeflates, but it almost always comes back. The truth is, is that ruptured duct is inthere. Once saliva is produced, its going to come out. When the soft tissue heals on

top, its going to enclose the saliva. W/ that being said, there are always exceptions

to the rule. There are small mucoseals on your palate (superficial) that can ruptureon their own and not reoccur. In 99% mucoseals need to be removed. You do needto treat it. Ill tell you one thing. This is a smaller mucoseal. Ive seen much bigger

mucoseals. Some patients my tell you they vary in size, depending on if its mealtime and if they salivate more and more salivate is produced. The mucoseal mayinflate and deflate. It doesnt have to, but it may change in size. Its a good clue if the

patient tells you that it changes in size regularly. You should be thinking ofmucoseal. Every time you do this excision, you have to warn your patient that thereis a chance for recurrence. When you remove this, if you rupture the mucoseal youlose the margins of it. Theres a higher chance for recurrence. Also, we tell peoplethat when you remove the mucoseal, you should pluck out the surrounding salivaryglands as well to try to get the ruptured duct w/ the mucoseal. You dont want to digin there too much or youll create another mucoseal orcreate another problem. Itsnot always the easiest to treat a mucoseal. Once you know how to do it, you do blunt

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dissection and incision here and you use your forceps to separate the fascia and takeit out as a hold. Any other questions about the mucoseal? It progressively getsbigger. Its not going to transform into a malignancy. The lip wont be destroyed or

anything like that. We want to tell our patients ideally, that they should get itremoved. Nothing terrible will happen if you dont remove it though. Keep in mind,

how do you know its a mucoseal for sure unless you take it out and look at it undera microscope. What if it was a minor salivary gland tumor and you said oh its a

mucoseal and leave it alone. Its your liability. It might often, does not have to, but

yes, when you eat the aroma causes more salivary secretion and when more saliva issecreted, obviously more is going to leak out of the broken duct. Does that makesense? Lets move on to the next case.

Case 5 is a 59 year old woman that presented to the oral medicine clinic w/ achief complaint of dry mouth w/ burning discomfort She claims that this problemhas been present for 3 months. Medical history: severe seasonal allergies. Shes

taking Benadryl and Sudafed. On examination, her mouth is definitely dry. Shes got

some changes to her tongue. So let me show you the pictures. We have a picturehere, we another one here. Ok. So who can describe what we see in these twopictures. How about you? Deep papillated tongue. Does that have a term? Yea.Fissured tongue. It is a little fissured but Im looking for something else. Whats theterm for a painful deep papillated red tongue. There is a term for it. Glossitis right?What else do you notice in this picture? There is a mild angular cheilitis. You can seeit better in this picture. This patient has mild angular cheilitis and glositis with alittle bit of fissuring as one of the students mentioned. What can be going on? Whats

a possible differential diagnosis and next step. This actually eludes to the lecture onsalivary gland pathology. Theres some stuff you should be thinking about hereright? Such as what? What could be going on w/ this patient? All the way in the back.

Sjogrens syndrome. Do you think this patients demographic is correct for thesyndrome? What kind of people usually get it? Males or females? Is it younger orolder? Older. Is it white or black? Ok. Its usually older white females that get the

disease but anybody can get it, dont get me wrong. Anyone can get the syndrome.

By far, females are more likely to develop the syndrome. Thats definitely somethingyou should be thinking. Drug related xerostomea. And shes taking two medications.

What types of medications are these guys. What do you know about them? Whattypes of drugs are those? Anti-histamines right? Which are designed to reducesecretion. So you can see how dry mouth can be a side effect of those. If youre

thinking about the syndrome, what else can we check or think about. What elsewould you ask if you thought somebody had it? Dry eye. Do you have a dry eyeissue? The pt tells you yes, then maybe she does have it. If the patient tells you no,then she probably doesnt have it. For any rate, for the syndrome, whats the

workup? Whats the workup if she said her eye was dry too? Who knows what you

do for the syndrome? Yea, theres a couple more things. Thats part of it. Blood work.Honestly its a difficult diagnosis. These autoimmune disease require multiple typesof criteria. SSA/SSB is one of them. Who knows some other criteria for theysyndrome. Theres a test for eye dryness. What are some other ways of diagnosing it.A patient w/ the syndrome has bilateral parotid gland enlargement. Labial salivary

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gland biopsy. You block out some glands from the lower lip and look at it. I dontfavor that b/c even inflammation of the lip can look the same under the microscope.Thats something you can do as well. What about imaging? Is there any type of testor X ray you can do to help w/ the syndrome? Theres something called a sialogram

too. Its where you inject a dye into the duct and take a look. That can help w/ the

diagnosis of the syndrome. You do a lot of these different tests. It helps w/ thediagnosis. If the patient has another autoimmune disease you know they are at ahigher risk for another autoimmune disease. These are all things you look at. So farin this case, we have some cause for dry mouth of burning. It could be the syndrome,it can be drug related. Is there anything else that can cause these symptoms?Anything else? Candidiasis which ties in w/ the dry mouth right? Obviously if themouth is drier, the balance is off and they are more prone to developing candidiasis.In general, whats another cause of glositis. What else can cause a painful redtongue? Not dry mouth but something else that Im looking for. Vitamin B and irondelicacies. It can cause an glositis and angular chelitis. We have to ask a bunch ofquestions and do some test to come up w/ the answer in this case. This is a nice case

to tie together various things that can happen. In reality, the truth is that when yousee patients in the oral medicine clinic, it isnt always straightforward. Theres abunch of things you have to work through and piece together. This is our differentdiagnosis in this case. Medication related xerostomea, Sjogrens syndrome, glositis,secondary to iron/ vitamin B deficiency anemia, angular chelitis, and erythematouscandidiasis. You all see how these are all in the differential diagnosis. How are wegoing to work though all of this? Here I show you that the two medications, some oftheir major adverse effects s xerostema. Benadryl also causes xerophthalmia. Whatdoes this word mean? Dry eye. Now you maybe misled into thinking now that youxerostema and xeropthalmia that you didnt know if they were side effects of themedication youd think they had Sjogrens syndrome. The diagnostic process, taking

a history, knowing the medications and their side effects. Lab tests if we areexpecting Sjogrens syndrome, shell tell you her eye is also dry. Blood tests for

SSA/SSB labial salivary gland biopsy. If I think she has a glositis that is due to avitamin deficiency I would order a CBC. If you want to rule out fungal infections, youcan do a mucosal smear and microscopic exam. The diagnosis in this case, wasmedication related xerostema. It was the medications that really dried out hermouth. She did not have Sjogrens syndrome once the workup was done. She had a

secondary candidiasis. Due to the dry mouth she had a fungal infection. A smear wasdone and it was positive for a fungal hyphae. We noticed that when she stoppedtaking the Sudafed and Benadryl, she had increased salivary flow. The more salivaryflow she had and using the anti-fungal, the burning and soreness was gone. Thatswhat was going on in this case. The medications and then the secondary candidiasis.Yes sir. Thats a good question. Its a bit of complicated question. It really depends

on how confident I am based on this history I gather. For example in this case, shesaid her symptoms got a lot worse now that her allergies have gotten worse and thisand that. I probably would see if she can cut down before I did all of this other stuff. Iwould see if lowering the medications or using other types of meds can improve thesymptoms. Then again, you know, if I think she has candidiasis, most anti-fungal areharmless so I would go ahead and prescribe that too. As far as the blood and

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Sjogrens syndrome work, I wouldnt do that until I ruled out the medications.Unless I felt really, she had the enlarged glands and she said her eyes were dry and abunch of other things. Sjogrensis a pretty rare diagnosis. I would rule out otherthings that are more likely than going into something more invasive such as a labialsalivary gland biopsy or ordering SSA/SSB. Did I answer your question? It can. You

know it definitely in this case, it can. Asking about dry eye isnt really going todistinguish b/w. In that case Id want to know how long had she had a dry eye

problem. Has she noticed its been getting worse since shes been increasing herdosage when she has allergies. You try to find a correlation and that would help youmake the distinction. Youre right. The anti-histamines can make your eyes dry aswell. Yes. No. It has to go through the patients physician. We can make arecommendation. We can ask a patient to discus it and I can even get on the phoneand say look this patient has really severe dry mouth and burning and fungalinfections, can we try to change the medications. Ive written letters to physicians.We can do that kind of stuff. We cant tell the patient to just do it. We cant changeany of those prescriptions. So. Anything else? Again, thats a good question. Every

patient is different. They all come w/ different circumstances. Different ages.Different thresholds of what cause a fungal infection dry mouth or not. The olderyou get the less salivary flow you have. The patients age can be a factor. That is a

good question, but every patient is different and acts differently.

Im going to go to the next case now. The next case is a 70-year-old womanthat presented to the oral medicine clinic complaining of painful oral ulcers. Theulcers began about 6 months prior to her presentation in the clinic. The started inthe back of her mouth and have progressed to include her buccal mucosa tongueand lips. He has high b.p. She takes Propranolol (B-blocker b.p. med). Allergy: NKDA(no known drug allergies). There are a couple pictures here. This is one. This is two.

Ok. Take note of the gingiva in this picture. This is three. This a fourth picture. Andthen if Im wondering if I go to the next one if its an answer or not. Were good.

These are your pictures. Who would like to go for this one? I want to see if anyoneelse volunteers. Someone different guys. Havent you? Are you a new volunteer? Okgo ahead. Pemphigus. So first tell me what are you seeing in these pictures. How doyou describe all of this stuff. What are you seeing? How did you get to pemphigus?You just remember what? Ok. Pealing is good. Erythema, bleeding. What is thatword for the sign that points towards pemphigus or pemphigoid? Nikolsky whenyou rub the tissue it kinds of peals off. There was a positive Nikolsky sign. Whatsthe term for this though? Desquamative gingivitis. Thats the clinical term for this

presentation. When you have red pealing gingiva. And then, this in and of itself alongw/ other ulcers and peeling should lead to a differential diagnosis. You got one ofthem. There are four things that you should think of. I wont leave you alone until

you come up w/ at least one more. Pemphigus is the least common. There are twoother things that are more common. Pemphigoid is one. Erosive lichen planus andthat sort of ties w/ pemphigus at the bottom. Whats the fourth thing? Erythemamultiforme can present as a disquamative gingivitis. All of these pictures. If I gaveyou no other history and I just showed you these pictures, you could use all four ofthese diagnosis. The thing w/ erythema multiforme whats the most important

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clinical feature of EM that distinguishes it from these 3 other disease? The bloodcrusted lips but thats not it. Target lesions. What about the length of time the

patient has had it. Erythema multiforme tends to be acute. All of this happened inone week. You can tell from the history I gave you that the lady had been sufferingfor 6 months and the ulcers are getting worse. That rules out EM but you can have

patients that have recurrent EM. They wont heal in b/w outbreaks. EM is sort of outhere. In this particular case if youre thinking about erosive lichen planus, you dont

see any striations on any of these lesions. You may not but it doesnt 100% rule it

out. Since I dont see any, I would put it on the side. Since its chronic I would put

erythema multiforme on the side. Really focus on pemphigus and pemphigoid onthis patient. What is the next step? What do we do next? Where? Where are wegoing to biopsy? Perilesional. Around the effected area. I might just go somewherearound here on the gingiva. Not straight into the lesion. Maybe a border of it. Mayberight here .You can even go on the lip over here. I would prefer to go on gingivarather than lip. Definitely a perilesional incisional biopsy. What else should we do torule out pemphigus and pemphigoid. Well Nikolskys sign we do it, and it sloughs

yes. Im talking about another definitive test. Whats a standard test?Immunofluorescence. Realistically you should do two biopsies although people willdo one and split the tissue in half. You shouldnt do that. You should do two

perilesional and send one for routine microscopy and one for immunofluorescence.So, the differential diagnosis. Pemphigoid is a lot more common than pemphigus. Its10 times more common. I put these two at the top. Lichen planus and EM are here.EM is at the bottom b/c this is more of a chronic process than an acute process.Lichen planus, even its the most common cause of disquamative gingivitis in this

particular case, based on the fact that I didnt see straie anywhere, I decided to putthis third. The differential is a bit fluid based on what you see. This was the orderthat I liked for this presentation. Than an incisional biopsy was done and here you

see peeling of the epithelium separation from the connective tissue but the basalcells are still attached. Which one do we favor? Do you favor pemphigus orpemphigoid. I heard half and half. Lets see if we can clear it up w/ the

immunofluorescence. This is described as a chicken wire effect. This is CT.Pemphigus vulgaris right? Where is the attack in it? Whats attacking what?Autoantibodies are attacking? What? Desmoglands 1/3 which are proteins indesmosomes that hold epithelial cells together. The epithelium is just falling apart.Remember the basal cells are still attached since the hemidesmosomes dont havethe desmoglands 1/3. If you think about this, it makes sense. Really try to thinkabout why things happen and whats going on here. That was pemphigus vulgaris.What is going to be the treatment for this? What happens next? Thats a favoriteanswer. Refer. Refer to who for what? Hopefully you refer to me. What would I thendo? High dose steroids. You cant keep a patient on it for long b/c of Cushings

syndrome and all the negative side effects. You then try to wean them off and gotowards other suppressant meds. Such as micophenalate. Theres some othertreatments I talked about (IVIG). Remember I talked about rituximab and these newmonoclonal antibody treatments. There are a couple things going on for pemphigusand autoimmune diseases in general. Refer patient to specialist, high dose steroids,IVIG steroids meds. Its important that we regularly their lab values their

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desmogland 1/3 antibody titers so we know whats going on inside rather than justlooking at clinical manifestations. I mean monitor their blood count, their glucoselevel. Any of these medications are doing something to the CBC and the metabolicpanel. You need to keep up w/ the blood work. Routinely check for and ask aboutextraoral involvement. You all should know that pemphigoid and pemphigus can

have extraoral manifestations. You can get vesicles and blisters anywhere on theskin, the eye, or in the genital mucosa. There can be many other sites involved. Youroutinely have to ask the patient. When they develop these you send them to thedermatologist that can deal w/ extraoral manifestations. That was pemphigusvulgaris. Any questions on that case? Yea whats your question? Did youjust raiseyour hand? Lichen planus is the most likely diagnosis for disquamative gingivitis. Itsthe most common cause. Then I would say pemphigoid and then pemphigus are a tieat the bottom. But I changed it in this case since I didnt see striae anywhere.Generally in lichen planus you see the white striae but you can have erosive whereits so red and ulcerated that you dont even see it. Based on frequency and

likelihood, yes it should be at the top. Any other questions about this case? Ok. It

would for systemic steroids. It does. Thats for sure. But still, if the patient does stilldevelop any extraoral lesions while youre treating them, you have to involve otherspecialist for skin lesions. They have some other things that they are doing.Certainly any systemic med is going to have effects outside just the oral cavity. Ok.Im going to move on to the next case.

Case 7 is a 43-year-old male patient that presents w/ painful ulcers on therough of the mouth. He denies any medical history. He is a smoker and is worriedabout oral cancer. Again, what you should be thinking here. Ulcers in the mouth. Ishould think about 3 types of ulcers. Which are? Apthus, herpetic, and traumatic.This is what you should be thinking instantly. Then you look at the picture. And you

see something here. Who wants to go for this one? Go for it. Nicotinic stomatitis.Thats a good thought, this patient is a smoker, we are on the palate, but these arent

red spots. They are pinpoint ulcers ok? Some of them have fused together intolesions. Im sorry what? Herpetic. Ok. Is this the right area for herpetic ulcers? Fixedkeratinized right? Intraoral. Most locations are the palate and the gingiva. You havemultiple tiny red, punctate ulcers on the hard palate. You should think of herpetic.Multiple like a group we call it a crop of ulcers. Lets say youre unsure. Youre just

not convinced. Someone is looking at me like theyre skeptical. If youre unsure what

can you do? What type of biopsy? Remember on any exam I give, biopsy isnt goodenough. What kind and where. What type of biopsy? What can we do to diagnosethis as herpes? A mucosal smear. Im going to make one comment though. Mucosal

smears work much better earlier on. If this has been around for a while you mightget a false negative. The smears work best when you see the fluid filled blisters orfreshly ruptured. After a while you dont see the tzanck cells youre looking forunder the microscope. Tzanck cells. So you do a mucosal smear. This is what thesmear looked like. This is a tzanck cell. Multi-nucleated. We now diagnose that thispatient has intraoral herpes. The patient says ill gross but now what do we do? Doyou think we should prescribe Valtrex right now? Im sorry what? Carry on. Anyone

else? Whats that? Ok. Iguess where Im going w/ this, at this point its probably too

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late for these lesions. You just have to reassure and let it heal. What you do is ask thepatient and see if there is a correlation w/ anything. Dental work. Trauma,injections, dental work can bring this on. The stress can trigger this. If a patient getsa herpes outbreak every time you do dental work you may suggest a prophylacticregimen of Valtrex where they take 2g at the time of the appointment and 2g 12

hours later. So 4 tabs and 4 tabs. Definitely for future outbreaks. What else can yourecommend to a patient who gets recurrent herpetic lesions. What are some otherthings besides Valtrex use regularly? Remember, you tell them these things workbest when they feel the tingling and before they have the outbreak. What are someother things you can suggest? Lysine supplements since it effects the viralreplication ratio. Zinc promotes epithelial turnover when they have lesions but itwont protect an outbreak. Essentially looking for a trigger, minimizing the trigger.Some patients get herpes labialis due to cold or wind (protection might help). Icemay also help since it slows down the viral replication. Prophylactic Valtrex andlysine supplements. These are things I recommend. You have to let your patientknow that at this point its just going to come and go but for future out breaks. If a

patient gets constant recurrent herpetic lesions, you can do herpes antibody titer tohelp w/ the diagnosis. You can find that in the blood as well, HSV1/2 antibody titers.There you are, mucosal smear. Intraoral herpetic ulcers and we talked abouttreatment. Any questions before I go to the next case.

The next case is a 51-year-old female patient that presents a dental officestating the inside of my right cheek is sore and very sensitive to hot or spicy foods.The patients has blood pressure and hypercholesterolemia. Takes Atenolol andLipitor. The social history is smokes a half pack a day. Theres some key medical

history in this clinical history. Sensitive to hot or spicy foods. What else? What else isimportant in this history? Whats that? The patients grievance is with their right

check but you cant tell if its unilateral or not. Anything else? Ok. Where I was goingw/ this is the medication list is important here. Theres a blood pressure andcholesterol medication. Especially Lipitor. Keep this in your head as we go throughthe case and youll see what were talking about. This is a clinical picture. Who wants

to go for this? I want a completely new volunteer. Volunteer or I will pick on you.First describe what you see here. You always want to be able to describe thingsbefore you jump into a diagnosis. Which are called what? There is a term for thosewhite lines. Wickham striae. There are definitely radiating white lines and there aresome red areas too. Do you see some erythema in the background. Whats the

differential diagnosis. Could this be anything else? The answer is yes. It could besomething else. Can you think of anything else in lieu of the patients medical historyit could be thats similar to lycan planus. Its called lichenoid reaction or lichenoidmucositis. Related to b.p. and cholesterol meds (esp. Lipitoir). The can also becaused by amalgam or cinnamon sensitivity. Keep in mind lichen planus is an actualautoimmune disease process that can effect the skin as well or vaginal mucosa.Lichenoid mucositis is a confined local reaction in the mouth due to certainmedications. They carry different prognosis. If you have to pick b/w lichenoidmucositis and lichen planus I would pick lichenoid mucositis since planus isautoimmune and can occur on your skin and it can increase your chance for oral

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cancer. Plus w/ lichenoid mucositis if you can find your cause, you can eliminatethat and cure yourself. It doesnt always work out though. But many times you can.Whats the next step? The same student. Im going to pester you one last time. What

do we do next to make our diagnosis. Incisional biopsy. Where are we going to dothis? Tell me the area you would go in. Would you go for a red area or an ulcer? Not

in this case. Anyone else have another idea? When youre trying to diagnosesomething lichenoid you go for the straie. The red is inflammation in thebackground. Its not going to help w/ the diagnosis in anyway. If youre trying to

rule out if its cancerous you might go for the red area. If youre unsure go for the

white/ red area both. The real thing to do is to go for a white straie. Lichenoidmucositis that are drug related have a strong red component to them and aresymptomatic. I have soreness or burning when I eat something spicy or acidic. Thisis a biopsy. It was indeed lichenoid mucositis. You have degeneration of the basalcells. You have a mixed infiltrate. You remember when I talked about planus therewas a band of lymphocytes. The cells are all scattered. If you look at them, they areplasma cells and lymphocytes. They go around blood vessels. You can see some

inflammatory cells deep around the vessels. This is very characteristics of alichenoid mucositis or drug reaction and not planus where you have that band oflymphocytes. It was indeed lichenoid mucositis and most likely drug related. Whatwould be the treatment for this patient. What should we do to treat this patient?Topical steroids right? clobetasol ointment or clobetasol ointment. Theres alsoother things. Please note that we discussed in this class are the most commonly usedthat work well but note there are other ones. If its diffuse I would prefer the

clobetasol ointment. If its more localized I would go w/ clobetasol ointment. Anyquestions on that case. You have to know the difference b/w lichenoid mucositis andplanus. Clinically you cannot not for sure until you do a biopsy. Just b/c they aretaking a million med and Lipitor, it doesnt mean its lichenoid mucositis. You still

have to do a biopsy. You have to make the distinction. It effects the prognosis. Itsautoimmune and it does slightly increase the risk for oral cancer. If you somethinglichenoid you should be asking your patient do you have any skin rashes or any skinlesions. For females Im straight up do you have any vaginal mucosal lesions or

burning or pain there. Its so often misdiagnosed as a yeast infection. Ok. Any

questions? Ok. Id like to think that you guys are really piecing this together ratherthan youre terrified and you feel overwhelmed. I hope this process is helping youguys tie it together and think the right way and the way youre approaching the

subject. Its not just memorizing useless random facts. My purpose is to ensure thatyou guys are competent enough that when you see patients that have these diseasesyou know what to do. Can you recognize something and help your patient do right?Thats how Im approaching this material.

Case 9 presents with a chief complaint of a large annoying bump on myupper gums. The patients denies pain and says the bump is slow growing. Nomedical history or meds. What should you be thinking right away? What are thecommon oral lesions that occur on the gingiva? Before you even look at the gingiva?Who knows what these common lesions are? Who knows? Ok. So the three P lesions.Pyogenic granuloma, Peripheral ossifying fibroma, and peripheral giant cell

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granuloma. 90% of all gingival lesions are one of these 3 reactive gingival lesions.This is what you should be thinking about. The truth is you can clinically look at itand put those 3 in, in order but you cant be sure what it is w/o taking it out and

looking at it under the microscope. Do you see the big bump on the gums. Ill ask youout of the 3 P lesions, think about the names, which do you think is the most likely

diagnosis about the 3. Does anyone remember anything about the pyogenicgranuloma? It bleeds easily, its spongy and red usually. Its associatedw/ pregnantpatients. You dont have to be pregnant to get it though. The other two lesions,

peripheral ossifying fibroma (forms bone and calcifications) meaning it will be veryhard, firm, and fibrous. The third, peripheral giant cell granuloma is a bluish-purplish in b/w lesion. Which one would you favor? Its not red and spongy right?

Like it would bleed easily? Not really. I wouldnt go w/ a pyogenic granuloma. Does

it look fibrous and might be hard if you feel it? Yes. Does it look bluish purplish andit might be middle consistency? No. I would put $1,000 on peripheral ossifyingfibroma if I was at the casino. Thats what you would think but you have to do anexcisional biopsy. You have to take it out and look at it under the microscope. Heres

the differential. I just put this as the standard 3 Ps differential. Pyogenic granulomais the most common. But in looking at this case, I would put POF before pyogenicgranuloma since it doesnt look red as if it would bleed. Theres always standard

differential diagnosis and then theres some that are particular to your case. Yes sir.For the peripheral giant cell granuloma. Generally yes, but it doesnt have to be. Im

trying to give you guide lines but not all giant cell is blue/ purple. But thats what

you look for. If you look at this w/ certain angulation I guess, but not quite. If youlook at the overall picture its really very fibrous, pale, white, and it feels firmhard. What type of biopsy do we have to do for this? Brush, mucosal smear,incisional, excisional. Excisional. You have to take out the whole thing no matterhow big it is. Many of them are pedunculated and the stem is a lot smaller than the

top of it. Its actually a lot easier than it looks to remove this. This is your differential.This is what it looks like. This is a fibrous background. This is bone formation andcalcifications. Therefore it definitely is diagnosed as a peripheral ossifying fibroma.Its also important for these 3 P lesions to not only remove the lesion but it was

caused by plaque and calculus deposits in the pocket of the teeth. To preventrecurrence you want to teach them good OHI and really floss in the area. At the timeyou remove the lesion you should perform scaling and root planning of bothinvolved teeth. W/o fail youll pull out calculus. If you dont do that and you removeall of this the patient comes back and its like you never did anything at all. It was a

part of your imagination. You really need to remove the underlying cause with theselesions. Always tell your patient that there is a chance for recurrence. Any questionon the 3P lesion? We have our last case coming up? You guys look really dead man.

Before you totally collapse lets get through the 10thcase. A female ptpresents w/ a growth on the lower lip. It has been present for a while but it isgradually increasing in size. Medical history: hyperthyroidism and arthritis. Whatare some potential growths on the lower lip? What is it? I didnt hear. Fibroma,whats another one? Mucoseal. Its actually 1/3rdpossibility that we havent focusedon. If I dont show you a picture you should think of something else you can find on

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the lower lip. I also want to say in many cases, viral lesions. Warts. When I talkedabout common oral lesions, whats the most common site for HPV lesions? Do you

remember? Its the soft palate and the oral pharyngeal area. HPV likes the tonsillarcrypts. The lower lip can also have it. If you find a rough surface or finger likeprojections on the lower lip, you should think about the HPV viral lesion or wart.

This is what the lesion looks like. Who wants to describe this and give me adifferential on what they would do next? Its the grand finale. Im going to pick on

the gentleman in the corner there. Are you w/ us? What do you think here? Lookslike a bump. Ok sounds good. Whats your differential diagnosis? Lets go there.

What is the next thing you would do w/ this? Do you want to phone a friend? Im

just trying to involve you sir. I would palpate this next. Lets say it felt firm. Nowwhat? Excisional biopsy is the way to go. What are we favoring here? Fibroma iswhat were favoring here. It feels kind of firm but it rules out mucoseal. You should

be thinking of a fibroma. You should do an excisional biopsy. Does it look sessile orpenduculated. You would do an excisional biopsy. We went over the differentialdiagnosis. Its a little beyond the scope of this course but there really are some other

soft tissue tumors that this could be. By far the most common is fibroma andmucoseal. This is what the biopsy shows. Dense connective tissue and hyperplasticepithelium and keratin formation. Very dense CT. This was a fibroma. Alright guys, ithas been a pleasure. Ill keep you postedabout the exam. Let me know if you haveany questions. No class on Friday.

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