ORAL & MAXILLOFACIAL PATHOLOGY II

DB 3702

Nadarajah Vigneswaran BDS,DMD. Dr.Med.Dent.UTSD 3.094G

Tel: 713-500-4410

Topic: Diagnostic Pathology: Oral Manifestations of Mucocutaneous Diseases

MICROSCOPIC DIAGNOSIS ORAL MUCOCUTANEOUS DISEASES

Clinical information is crucial for accurate, diagnosis of oral mucocutaneous diseases

Representative biopsy: non-ulcerated perilesional mucosa

Detection of tissue-bound and/or circulating autoantibodies with direct and indirect IF testing, respectively

Case based discussion

•70‐YOF presented for evaluation and management of chronic oral ulcerations, mucositis and recent weight loss.  Currently, she is unable to eat any solid, spicy or acidic food. She has lost more 30 lbs within the last four months.      

Patient consulted her dentist for oral ulcers who treated her with Triamcinolone cream without any significant improvement. She consulted her family physician who treated her with lidocaine/mouth wash which was not effective in resolving her pain or oral ulcers. She was evaluated by an oral surgeon. Treated her with an ointment which was also not effective. She consulted an otolaryngologist : Performed laryngoscopic/endoscopic examinations and reported that her larynx and esophagus are not affected by these ulcers.

She consulted an Infectious Disease Specialist at the Baylor clinic who performed a number of laboratory studies to rule out various infectious agents: HSV, acid fast bacilli, treponema pallidum and HIV. Treated her with Valtrex 500 mg but her ulcers did not heal.

She was subsequently referred to a Dermatologist for evaluation. An incisional biopsy from the lesional area in her lower lip was performed and submitted for immunofluorescence studies. The biopsy specimen failed to show any mucocutaneous-disease-specific immunolabeling for IgG, IgA, IgM and C3.

Diagnosis: Lichen planus

Pre‐treatment 

Post‐treatment 

62YF: Presents with chronic oral mucosal ulcerations and erosions. Duration: 6-months

Consulted a number of physicians and dentists.

Consulted an OMFS: Recommended a biopsy to rule out oral cancer. Because of insurance issues, the oral surgeon could not do the biopsy.

Consulted an ENT physician Admitted her to a hospital Oral mucosal biopsies (n=5) were taken in the O.R as an inpatient.

Diagnosis: Erosive Lichen Planus

Lichen Planus-Plaque TypePVL??

Erythematous/erosive forms of Lichen planus

LICHEN PLANUSHISTOPATHOLOGY

LICHEN PLANUSHISTOPATHOLOGY

Subepithelial cleft/bulla At level of basement membrane Direct immunofluorescence

-- Fibrinogen @ BM-- Apple green fluorescence

dropping down from b.m.

Fibrinogen

History: 52-year African American female presents with brown pigmented lesions in her right and left buccal mucosa.

Diagnosis: Post inflammatory pigmentation in lichen planus

Lichen planus - post inflammatory pigmentation

LICHEN PLANUS: LOOK-ALIKE LESION

1. Lichenoid drug reaction2. Contact stomatitis to cinnamon

flavoring3. Chronic graft-versus host disease

(GVHD)4. Lupus erythematosus5. Proliferative verrucous leukoplakia

65YOF: Presented with 1-year history of white patches in her cheeks and tongue which are painful and sensitive to acidic and spicy food. She was treated with multiple courses of antifungal medications by her dentist and dermatologist with no improvement. The patient reported that she had been a long-term smoker but discontinued smoking two years ago. After she stopped smoking, the patient relates that she began developing these lesions.

Contact stomatitis to cinnamon flavoring

• Acanthosis with elongated rete-ridges• Thinning of suprapapillary plates• Hyperparakeratosis with neutrophilic exocytosis• Lymphoplasmacytic interface mucositis with occasional eosinophils• Perivascular lymphoplasmacytic infiltrate

Lichenoid reaction to cinnamon gum

55YOM underwent allogenic HSCT for cutaneous T-cell lymphoma; cGVHD

24YOM underwent allogenic HSCT for AML

cGVHD

Bx Bx

Proliferative verrucousLeukoplakia (PVL)

LP- PVL-OSCC

Lichen planus (25%) Mucous membrane Pemphigus vulgaris (18%) pemphigoid (64%)

DESQUAMATIVE GINGIVITIS(DERMATOSIS-RELATED GINGIVAL DISEASES)

Desquamative gingivitis-Mucous membrane pemphigoid

62YOF: c/c pain, bleeding and sloughing of gum, non-responsive to periodontal Rx

IgG

Mucous membrane (Cicatricial pemphigoid)

66-YOWM with a history skin rash and ulcerations. Multiple skin biopsies were performed yielding various descriptive diagnoses. Recent biopsies from right ala of the nose and anterior to tragus of the left ear were diagnosed as squamous cell carcinomas. He was scheduled for surgical resections of these lesions.

IgG

Pemphigus vulgaris

Follow-up

2010

2011

•43‐YOM with severe chronic oral ulcerations and mucositis. •Rx:  Mouth rinses, anti‐microbial and anti‐fungal medications without any significant improvement. •Weekly penicillin injections by his physician. 

IgG

Dx: Pemphigus vulgaris