Case Studies - Pigmented Lesions
Pigmented Lesions: Case Study #1
Tongue / Floor of Mouth
History of Present Illness
A 70-year-old man presents with an unknown history of asymptomatic dark lesion on the right ventral tongue, discovered during a dental/hygiene examination. Currently, the patient denies any oral functional limitation or para-functional habits.
The patient has recently been diagnosed with diabetes, and is currently on Glyburide and Avapro. He does not smoke nor drink, and reports no history of allergies.
Peri-oral examination was unremarkable with no lymphadenopathy identified in the head and neck region. Range of motion of TMJ was within normal limit. Intra-oral examination revealed a moist oral environment. A discrete triangular homogenous pigmented macule measuring 5mm x 8mm was found on the right ventral tongue/floor of mouth. No adjacent erythema identified. History of coronal restoration was evident juxtaposing the lesion. Autofluorescence examination showed no significant findings. The rest of the oral mucosal tissue was unremarkable, and dentition was grossly intact.
Clinical Implications & Recommendations
The clinical finding was compatible with amalgam tattoo or melanotic macule, a benign process in response to previous trauma. However, ongoing monitoring is advised, and size and color changes should warn a tissue biopsy.
Pigmented Lesions: Case Study #2
Right Buccal Mucosa
History of Present Illness
A 56-year-old woman presents with chronic lesions on the right posterior buccal mucosa. She is unable to recall any traumatic event on the area. Although asymptomatic, she is worried about the potential pathology. She has a history of amalgam restoration at the upper right dentition, followed by a crown and bridge replacement.
The patient is currently taking Lipitor and Synthyroid. She does not drink nor smoke. She reports an allergy to sulfur drugs, to which she reacts with skin eruptions. The patient’s family has a history of cancer. Her mother has a recent diagnosis of squamous cell carcinoma and melanoma on the right arm. Her sister has a history of breast cancer. Her father has a history of lung cancer.
The patient was relaxed. No palpable lymphadenopathy was identified at the head and neck regions. Peri-oral examination was unremarkable. Intra-oral examination revealed a moist oral cavity. A diffused bluish/dark pigmented lesion, measuring approximately 1cm, was found at the right posterior buccal mucosa. Another similar lesion, measuring <4mm at its greatest dimension, was found at the right anterior buccal mucosa. The lesion juxtaposed the occlusal plane. The rest of the oral mucosa, including the palate, floor of the mouth, and bilateral ventral tongue, were within normal limits.
Clinical Impressions / Management Suggestions
Patient's clinical presentation is highly suggestive of amalgam tattoo. However, due to her family history of cancer, tissue biopsy was performed to rule out any potential malignancy.
The biopsy result confirmed amalgam tattoo. Re-examination of the biopsy site showed well-healed mucosal tissue. Due to the benign nature of the ongoing lesion, no further active management is recommended at this time.
Case Study #2: Presentation under White Light and Fluorescence
Case Studies - Oral Candidiasis
Oral Candidiasis: Case Study #1
Tongue / Hard Palate
History of Present Illness
A 50-year-old female presents with a five-month history of persistent "dry mouth." The symptom began right after the use of Symbicort for bronchilitis management. In additional to oral dryness, she also experiences non-specific oral pain. Multiple systemic and topical antifungal managements were tried, alleviating 50% of symptoms. The patient has also tried pilocarpine with additional perceived effect. Lab test from medical colleagues, including TSH, glucose, iron, and oral yeast culture, showed normal findings.
Currently, the patient's dry-mouth-related dysphagia can be managed by sipping water. She denies any change of tastes, oral para-functional habits, or changes in diet/oral hygiene products. She also denies any active cutaneous, ophthalmic (dry eyes), or constitutional symptoms.
The patient is medically stable. She suffers from migraine headaches twice a week. She denies any alcohol, smoking, or allergy history.
Peri-oral examination was unremarkable with no lymphadenopathy identified in the head and neck regions. No parotid gland enlargement was noticed. Range of motion of TMJ was within normal limit. Intra-oral examination revealed a dry oral environment with foamy saliva coating the mucosa. Major saliva gland openings were patent with limited clear saliva excretion. A subtle erythematic area was found on the mid posterior hard palate. Autofluorescence examination revealed heavy bacterial/yeast colonization at the posterior tongue juxtaposing the palatal erythema. Other mucosal sites, including FOM, tongue, and buccal mucosa, were within normal limits. Food debris was also noticed at the cervical area of dentition. The remaining dentition was grossly intact.
The clinical findings and history suggest probable atrophic oral candidiasis and an evidence of salivary gland hypofunction. Early presentation of Sjogren syndrome has also been considered.
Treatment Plan & Recommendations
The clinical findings were reviewed with the patient. The following plan was discussed:
Oral clotrimazole troches for 21 days
Doubling the dose of current pilocarpine usage
Re-evaluation in 3-4 weeks. Discussion of dry mouth complications and management will be explored in detail
Sjogren investigations including ophthalmatology consultation, minor salivary gland biopsy, and auto-antibodies testing will be considered if symptoms persist.
Case Study #1: Presentation under White Light and Fluorescence