Sequoyah S. Brennan
Fall 2012
Patient Profile
56 year old American female patient of Italian descent
Medical History findings:
hypertension
general anxiety, not towards dental setting
possible allergic reaction to penicillin as child
Hx of orthodontic treatment as teenager
reports occasional gingival bleeding, food impaction
vitals within normal limits at all visits
Medications
Lisinopril
(ACE inhibitor, for HTN)
Lorazepam
(benzodiazepine, for anxiety)
Citalopram
(SSRI for general mood disorder)
Vitamin D
(supplement)
Extra and Intra Oral Findings
TMJ: left sided crepitus on open and right shift, patient reports no pain
slightly coated tongue
Angles Class I occlusion
slight attrition on #23-26, wear facets on #22, 27
25 slight overbite, 1mm overjet
decalcification on lingual of #3
Caries risk high: previous and current caries, chocolate and
fermentable carbohydrates for snacks
Oral cancer risk low: no tobacco products, occasional alcohol
No oral habits reported or evidenced on exam
moderate tetracycline stain on all teeth present
alveolar ridges: buccal gingiva adjacent to #18-21 and 28-31 shows
lacy white lines, slight erythema, asymptomatic, patient reports
no known trauma, pattern is much more pronounced on right
side, barely visible on left
Assessment Results
Clinically observed caries:#
8 D & L
Missing Teeth: #1, 16, 17, 32 extracted per patient
Restorations:
amalgams- #2 MO/DO, 3 MO, 14 MO/O/DO/OL, 18 O, 19 MOL, 29 O, 31 MOcomposites- #14 MD
root canal and pfm crown #30
Radiographs:
none available as patient would not authorize contacting her primary care dentist for copies
MGI/Furcation involvement:
none
BOP:
none
Deposit:
generalized moderate soft deposit/generalized spicules
Gingival description:
Generalized pink stippled, very slightly spongy to firm, very slightly rounded recessed tissue
Periodontal Risk/Contributory Factors:
systemic disease, hormonal, genetics, stress, calculus, faulty restorations, food impaction
Periodontal Assessment/Diagnosis:
Generalized slight inactive chronic periodontitis,The more
pronounced of
the lesions
described above
(buccal gingiva
#28-31)
-note irregular pattern
of thin white lines
superimposed on
erythema
(tetracycline staining
also evident)
Additional Pictures
Facial view of
Diagnosis
DDx:
Reticular lichen planus
Benign migratory glossitis
Reticular Lichen Planus
Diagnostic process: Diagnosis was based on distinctive clinical signs (Wickham’s striae)
and bilateral presentation visible on intraoral exam and on patient’s report of no
symptoms, and no history of trauma of any sort. Also, the patient is a middle aged
female, the most likely demographic to display this condition. Myself, Dr. Terkoski, and
Professor Lamoureux all examined and agreed on the most likely diagnosis of reticular
lichen planus.
Etiology: idiopathic; However, it is widely accepted to be a chronic inflammatory
disease related to T-cell response., and possibly mast cell activity. Increased incidence
has been correlated to certain elements, including, most notably for this case
hypertension and dental restorations. Flare up of lesions may also be linked to
psychological stress.
Treatment: In this case, no treatment is necessary as this form of the condition is benign
and asymptomatic. Also, treatment would only be palliative, which is unnecessary here.
Dr. Terkoski did not believe it warranted concern or diagnostics beyond clinical exam.
However, fastidious oral hygiene can resolve the lesions so the patient and myself did talk
extensively about ways to improve the patient’s homecare including daily flossing and
twice daily brushing with power toothbrush. Also, as lichen planus may be correlated
with increased tendency to develop squamous cell carcinoma, the patient requries very
careful intraoral exam at every visit and biopsy if any atypical lesions present.
Migratory Glossitis Traumatic Injury
Diagnostic process: clinical;
When appearing anywhere but on the tongue, benign migratory glossitis is also called ectopic geographic tongue. This appears as a white patchy, denuded area overlaying reddish tissue, which can look like white lines. It is benign and usually asymptomatic, as was the lesion in this case. It presents as Women are more likely to present with this condition than men.
Etiology:
idiopathic;Genetic tendency has been exhibited, and it has potentially been linked to stress , certain systemic diseases, diet and vitamin deficiencies.
Treatment:
Being benign, noninvasive, and asymptomatic, this condition does not require treatment, although some remedies, such as avoiding spicy foods, vitamin supplementation , or topical steroids may suppress the lesions if the patient desires to do so.
Diagnostic process: clinical;
Traumatic injury can be from a corrosive chemical exposure, scratching with a fingernail, drinking a very hot beverage, or any of innumerable other accidents. These lesions appeared similar to a burn or scratches. However, given that the patient reports that no trauma occurred as far as she
remembers and also taking into account the bilateral presentation, this would be the least likely of the rule outs in the differential diagnosis
Etiology:
caustic chemical exposure, high heat exposure, fingernail scratch, etc…
Treatment:
depends entirely on cause, although in a minor lesion like this, generally no treatment is
necessary since it will resolve spontaneously with normal healing process.
References
(all from EBSCO except the course textbook and wikipedia)
Mittal, N., S., M. G., & Palaskar, S. (2012). Role of angiogenesis in the pathogenesis of oral lichen planus.
Journal Of Oral & Maxillofacial Pathology (0973029X), 16(1), 45-48. doi:10.4103/0973-029X.92972
Pourshahidi, S. S., Ebrahimi, H. H., & Tadbir, A. (2011). Evaluation of the Relationship between Oral Lichen Planus and Stress. Journal Of Dentistry (17283426), 12(1), 6.
Hegarty, A. (2012). Oral lichen planus: aetiology, diagnosis and treatment. Dental Nursing, 8(3), 141-146. Lavanya, R., Reddy, S., & Badam, R. (2012). CURRENT CONCEPTS ON ORAL LICHEN
PLANUS. Guident,5(11), 92-94.
Janardhanan, M., & Ramesh, V. V. (2010). MAST CELLS IN ORAL LICHEN PLANUS. Oral & Maxillofacial
Pathology Journal, 1(2), 49-52.
Ibsen, O. A.C., & Phelan, J. A. (2009). Oral pathology for the dental hygienist (5th ed.). St. Louis, MS: Saunders Elsevier.
Geographic Tongue [Fact sheet]. (2012, November 14). Retrieved November 17, 2012, from Wikipedia
