ORAL MEDICINE AND PATHOLOGY QUIZ-CASE 6 Oral Medicine and Pathology Quiz-Case 6

Archives Of, Medicine
2009 unpublished
A 54-year-old female was referred by her dentist for evaluation of gingival and tongue lesions, causing tenderness and dysphagia. The lesions were first noticed before 5 months and considered to be due to local periodontal inflammation. The patient underwent periodontal treatment and used an over-the-counter oral coating agent without any improvement. The patient was in good health and was not a smoker. On clinical examination, erythematous, atrophic and erosive areas were noticed on the
more » ... ticed on the anterior labial gingiva of both maxilla and mandible. The gingival lesions were bordered by fine, white radiating striae and were painful on palpation. Nikolsky sign was negative. The clinical pattern could be described as desquamative gingivitis (fig. 1). Furthermore, interlacing white lines were noticed on the buccal mucosa bilaterally. On the dorsal surface of the tongue, multiple ulcerations along with non-removable white plaques were seen (fig. 2). No other oral or skin lesions were noticed. Partial biopsy of the tongue lesions was performed and the splitted specimen was submitted for histopathologic examination (in formalin solution) and for direct immunofluorescence (in normal saline solution). Microscopic examination revealed degeneration of the basal epithelial cell layer and intense band-like lymphocytic infiltrate of the underlying connective tissue (fig. 3). The direct immunofluorescence demonstrated only the presence of fibrinogen in the basement membrane zone. Based on the diagnosis rendered, initial administration of systemic corticosteroids resulted in significant improvement. Intralesional corticosteroid injection provided complete healing of the persistent tongue lesions. Application Figure 2 Figure 3 Figure 1 of topical corticosteroid cream within fabricated splints, along with meticulous oral hygiene, allowed good control of the gin-gival lesions. The patient is on periodic follow-up, occasionally using topical corticosteroids to control disease exacerbations, and remains free of symptoms. Comment Lichen planus (LP) is a relatively common, chronic mucocutaneous disease that often affects the oral mucosa. It is believed to be an immunologically mediated disorder; relationship with stress or anxiety has been suggested but remains unproven. The disease is most often noticed in middle-aged adults, with a 3:2 female predominance. It is estimated that the prevalence of cutaneous LP is around 1%. These skin lesions have the clinical pattern of purple polygonal papules, along with a lacelike network of fine, white lines (Wickham's striae). The oral counterpart is called oral lichen planus (OLP) and affects 0.1-2.2% of the population. OLP most commonly manifests with the typical asymptomatic reticular form of interlacing white lines bilaterally distributed usually on the buccal mucosa. Nevertheless, any oral mucosal site may be affected. On the other hand, the erosive/ulcerative form of OLP is frequently associated with pain, tenderness and dysphagia and may occur anywhere on the oral mucosa. Involvement of the gingiva by erosive/ulcerative