Practical oral diagnosis 2

Practical Oral Diagnosis 2

Ahmed A.Abdelazim

Total : 5 marks1-Laboratory investigations

2-Exophytic Lesions

3-Biopsy

(One question on Infection control)

Lab Investigations

Case 1A 27 year old male complains about bleeding gums and several recent onset of epistaxis. Examination revealed a pale appearance.

Investigations shows: Haemoglobin: 8.0g/dl Haematocrit: 24% MCV: 88 flWhite cell count: 2000 /mm3 Neutrophils: 20% Lymphocytes: 77% Platelets: 40.000/mm3Blood film showed normocytic erythrocytes

The most likely diagnosis is:

1- Iron deficiency anemia2-Thalasemia3-Pernicious anemia4-Aplastic anemia

Case 2A 18 year old man presented with a 3 week history of generalized gingival enlargement and painless cervical lymphadenopathy.

Which of the following investigations should be performed?1-Blood glucose level2-Panoramic x-ray3-Complete blood count4- Prothrombin time

Case 3A 28 year old lady was diagnosed with acute leukemia. She required extraction of her lower third molar. Her platelet count was found to be 15.000/mm3

What is the best action? Why?

Case 4A 19 years old man presents immediate profuse bleeding after extraction of one of his lower teeth. No local cause has been identified. On further questioning, he gives a history of chronic gastric ulcer.

Investigation shows: Hb: 6.7 MCV: 58.0 fl WBC: 13.000/mm3 Neutrophils : 10.000/mm3 Platelet: 503.000 /mm3

The most likely cause of bleeding is:

1- Thrombocytopenia2- Iron deficiency anemia3- Aplastic anemia4- Haemophilia

Case 5A 65 years old woman admitted to the hospital following a mandibular fracture that resulted from a sudden fall from her bed. -History revealed difficulty in climbing up stairs in addition to chronic fatigue. The patient reported living in a residential house. A slight lordosis have been detected.Serum calcium: 7.5 mg/dl Serum phosphate: 2mg/dl Alkaline phosphatase enzyme: 233 IU/L1- What is your D.D?

2-What other laboratory tests that may help you to reach the diagnosis?

Case 6A 55 years old man attended dental clinic complaining of several bruises related to his tongue and palate over the past week without any precipitating trauma. History revealed deep venous thrombosis 2 months ago.What laboratory tests that should be done?

2- Explain the cause of tongue bruising ?

Case 7A 30 years bank worker was seen in the dental clinic complaining of a six months history of recurrent oral ulcerations. - He reported being very stressed at work the last year and suffers from frequent attacks of bloody diarrhea. On examination he looked very tired and pale.1. What laboratory tests that should be done?

Case 8A 65-year old lady treated by antifungal for oral candidiasis. She reported being free for 2 weeks but the lesion recurs.

Investigation shows:Hb 10.5 g/dl Platelets 100.000/mm3 White blood cells 30.000/mm3 Lymphocytes 25.000/mm Neutrophils 3.200/mm

1- What is the cause of recurrence? Explain

Case 9A 55-year old lady presented to her dentist with a complain of burning sensation in her mouth especially her tongue. She also reported having tingling in her feet and hands and being fatigued. Investigation shows:Hb 4.5 g/dl (no. 11.5-15.5)Haematocrit 19 (no. 0.38-0.47) MCV 118 FL (no. 80-96) MCH 33.0 Pg (no. 28-32) Platelets 195.000/mm3 White blood cells 8.000/mm3

What is the cause of burning? Explain.

Case 10A 66-year old lady presented to her dentist for extraction of one of her upper molars. After extraction, profuse immediate bleeding occurred. History revealed chronic fatigue and nasal bleeding.

Intraoral examination revealed multiple vascular lesions related to her tongue and palate.Investigation shows: Hb 7.5 g/dl MCV 68 fl (No. 80-69) Platelets 212.000/mm3 White blood cells 6.000/mm3

What is the cause of bleeding? Explain.

Case 11A 25-year old man presented to his dentist complaining of parathesia of his tongue. During examination, the dentist observed yellowish discoloration of his sclera, skin and oral mucosa. He asked for investigation which shows:Hb 7.5 g/dl Reticulocyte 6.28% Platelets 266.000 Bilirubin 45 mg/dl AST 36 IU/L ALT 40 IU/L

What is the cause of his complaint?

Explain ?

Case 12A 26 - year old man presented to his dentist with spontaneous gingival bleeding. History revealed six month history of fatigue and dyspnea:

Hb 7.5 g/dlPlatelets 12.000White blood cells= 300.000/mm3Neutrophils 34% (normal 60-70%)Blast 1%

What is the cause of bleeding? Explain.

Case 13A 56-year old man presented to his dentist. During examination, he observed yellowish discoloration of his sclera, skin and oral mucosa. He asked for investigation, which shows:Hb 6.5 g/dl Reticulocyte 6.2% Platelets 166.000 Bilirubin 4 mg/dl AST 20 IU/L ALT 30 IU/L

What is the cause of yellowish discoloration? Explain.

Case 14A 26 year-old man attend the dental clinic for the extraction of one of his teeth.History revealed: Spontaneous gingival bleedingInvestigations show:Hb 13.5 gm/dlPlatelets 12.000WBCs 6.000PT (13 seconds)PTT (26 seconds)

What is the cause of bleeding ?Explain

Case 1522-year-old Male presented to his dentist for Oral hygiene prophylaxis.During examination, he observed yellowish discoloration of his sclera, skin and oral mucosa.Investigation shows:Hb 14.5 g/dl Reticulocyte 0.68% (N:0.5-2.4)Platelets 266.000 Bilirubin 45 mg/dl AST 136 IU/L (N: 10-40 IU/L)ALT 240 IU/L (N: 9-60 IU/L)

What is the possible cause of yellowish discoloration

Case 1659 years old male patient presents to the dental office for the extraction of one of his lower teeth.

History reveals that he had 2 venous thrombo-embolic events and is currently taking Warfarin therapy (Oral anticoagulant) Which of the following investigations should be performed to evaluate the risk of bleeding?

Blood glucose levelESRComplete blood countProthrombin time

Case 1715 years old female patient presented to her dentist with a complaint of spontaneous bleeding and Palatal bruising

Investigation Shows:Hb 14.5 mg/dlPlatelets 17.000White blood cells 7.000PT (11 sec)PTT (23 sec) What is the cause of bleeding ?

Case 1832 years old Parenteral drug user male patient came to the dental office with mild roughness and irritation related to both lateral surfaces of the tongue.

He also reported a history of recurrent respiratory tract and skin infections during the last 3 months.

The dentist diagnosed the lesion as hairy leukoplakia1- What condition is important to exclude ?

2- What Lab. Investigation should be done?

Case 1937 years old female who has a prosthetic valve came to the dental clinic complaining of left submandibular swellingPain in the lower left quadrant was reported.On examination, a tender left unilateral swelling, limited mouth opening and partially impacted lower left wisdom were observed.

The dentist decided that this wisdom is indicated for surgical extraction1- Mention the needed Lab tests and their normal values ?

2- What is the best treatment approach based on the results of the lab investigations ?

Case 20A 18-year old female complains about gingival bleeding and epistaxis in addition to the above lesions. What are the lab investigations that should be performed?

Case 21A 32-years-old man presented to his dentist with massive submandibular space infection.History revealed that the patient is on chemotherapy for lymphomaOn Examination, he appeared unwell, He was febrile 39.5 and he was unable to open his mouth.Investigations revealed:Hb 11.5 gm/dlPlatelets 152.000WBCs 2.000Neutrophils 10 % (N:60-70 %)Lymphocytes 80 %What is the best action and why ?

Ulcers due to neutropeniaNecrosisSevere painLong periodNo pusNo red halo

Case 2215-year-old patient presented to her dentist with a complaint of spontaneous bleeding and palatal bruising.She denied having any trauma but reported having a mild viral infection a week ago

Investigation shows:Hb 14.5 gm/dlPlatelets 15.000WBCs 7.000What is the cause of bleeding ?

Explain ?

Case 2332 parenteral drug user male came to the dental office with a complain of mild roughness and irritation related to both lateral surfaces of the tongue. He also reported a history of frequent attacks of respiratory tract and skin infections during the last 3 months. The dentist diagnosed the lesion as hairy leukoplakiaWhat condition is important to exclude?What lab. Investigation that should be done?

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(2)Peripheral Oral exophytic Lesions

We will start with :

Normal Exophytic anatomical structures

Oropharynx showing large palatine tonsils with prominentcrypts (short arrows)

Papillae of the Tongue

The foliate papillae

Lingual tonsillar tissue

Palatine rugae & Palatine papillae

Maxillary Tuberosity

Stensen's papillae (parotid papillae)

Floor of mouth. Note :1- frenulum (solid arrow),2- submandibular duct orifices (broken arrows) 3- prominence of sublingual gland under the mucosa (star)

LESIONS1-Developmental lesions

Palatine toriIt is located on the hard palate, usually in the midline and are twice as common in female as in male patients.

Flat

Spindle

Nodular

Lobular

Management Removal is unnecessary. Indication for removal of mandibular tori:- 1. Interfere with tongue positioning 2. Speech interference 3. Prosthodontic reconstruction 4. Patient with poor oral hygiene around the lower posterior teeth 5. Cancer phobia 6.Traumatic ulceration from mastication

Torus Mandibularis

Mandibular toriare located on lingual aspect of mandible above the mylohyoid ridge, most often bilaterally in the premolar region. No differences in occurrence between genders.

Exostoses

ExostosesExostoses is excessive bone formation at any sites rather than Tori.

HemangiomaIt appears at birth or shortly after birth, although some cases develop in adults. Some of them may undergo regression.They are flat or raised soft lesions of blue to red color that blanch on pressure and the color returns shortly after releasing the pressure.

HemangiomaThey are usually asymptomatic but may bleed when traumatized.It occurs anywhere in the oral cavity

TreatmentSmall lesions: cryosurgery (cold, cell lethal temperature of 15 C) if there are episodes of bleeding on eating or brushing. Conventional surgery gives rise to severe bleeding.

Large lesions: they are not suitable for surgery and may be injected with sclerosing agent to induce fibrosis.

Lingual thyroidIt is a developmental anomaly characterized by ectopic aggregate of thyroid tissue in the substance of the tongue.

Clinical features

1) Asymptomatic 2) Symptomatic:Smooth, vascular, nodular mass in or near the base of the tongue More common in female during puberty and adolescence.The increase in size gives a feeling of fullness in the throat, change in voice, dysphagia, dyspnea or hemorrhage.

Diagnosis99m Tc thyroid scan anterior view showing lingual thyroidTechnitium 99 (Tc) thyroid scan lateral view showing lingual thyroid1- Scanning of the thyroid tissue using radioactive iodine.Thyroid function tests, Ultrasonography (US) and computed tomography (CT)2- T3,T4

LESIONS2- Inflammatory Hyperplasias

Types of Inflammatory hyperplasiasFibrous hyperplasia (FH)Pyogenic granulomaHormonal tumorEpulis fissuratum Parulis Papillary hyperplasia of the palatePeripheral giant cell lesionsPulp polypEpulis granulomatosumAcquired hemangiomaPeripheral fibroma with calcification

Fibrous Hyperplasia (FH)Traumatic or Irritation Fibroma-End product of an IH lesion - Not a true neoplasm - FH is the second most common oral exophytic lesion.

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Fibrous Hyperplasia (FH)Fibroma Clinical Features:The lesions are sessile or slightly pedunculated with a smooth contour, pale pink and firm to palpation. FH may be whitish (epithelia keratinization) due to irritational factor.

Sties: they occur on gingiva, tongue, buccal mucosa and palate.

Fibrous Hyperplasia (FH)

ManagementRemoval of any source of irritation.An excisional biopsy is the indicated treatment. Recurrence is less frequent than Pyogenic Granuloma

Pyogenic GranulomaPyogenic granuloma is an IH lesion that becomes ulcerated because of trauma during mastication and then becomes contaminated by oral flora and liquids. As a result, an acute inflammatory response occurs.

Clinical FeaturesAsymptomatic reddish papule, nodule or polyp shows at least part of its surface to be rough, ulcerated and necrotic.

Sitesgingiva particularly the anterior segment. Other locations are the lips, tongue, buccal mucosa, palate, vestibule and alveolar mucosa in edentulous regions. Female patients are affected more than male patients.

Differential Diagnosis & Management DDPregnancy tumor peripheral giant cell lesion fibroma

Management:Removal of any source of irritation.An excisional biopsy is the indicated treatment. The lesion has a potential for recurrence

Pyogenic Granuloma

Pregnancy tumor (Hormonal Tumor)IH lesions occur during puberty and pregnancy (particularly during the first and second trimester). The increased incidence during these periods may be related to the higher levels of sex hormones (increased levels of estrogen and progesterone). Oral hygiene is a more important causative factor than hormone levels.Clinical features are similar to pyogenic granuloma.Sites: gingivae involve the interdental papillae.

Pregnancy tumor (Hormonal Tumor)

Give reasons Pregnancy tumor postponed after delivery 1-Because stress may cause delivery 2- The pregnant women cant bear surgery3- Causes still present (hormones)

Epulis FissuratumEpulis fissuratum is an IH lesion observed at the borders of ill-fitting dentures. In most instances the dental flanges overextend secondary to alveolar bone resorption and settling of the denture.

Clinical FeaturesThe exophytic, often elongated lesion has at least one cleft into which the denture flange fits with a proliferation of tissue on each side. Most of these lesions are asymptomatic. Sites: there is a greater incidence in the maxilla than in the mandible and the anterior regions of both jaws are more often affected than the posterior regions. The lesions occur under the buccal and labial flanges and are seen predominantly in female patients.

Differential Diagnosis squamous and verrucous carcinomas minor salivary gland tumors metastatic tumors osteosarcoma maxillary sinus malignancies.

Epulis Fissuratum

Parulis (gum boil) A parulis is a small IH type of lesion that develops on the alveolar mucosa at the oral terminus of a draining sinus. This lesion accompanies a draining chronic alveolar abscess in children.

Clinical FeaturesSlight digital pressure on the periphery of a parulis may force a drop of pus from the sinus opening.Sites: The upper labial and buccal mucosa are the most frequent sites but the lower mucosa and palate may also be involved.

Parulis (gum boil)

Papillary Hyperplasia of the Palate (PHP)It occurs on the palate beneath a complete or partial removable denture. Approximately 10% of the people who wear maxillary dentures have this condition and most wear their dentures continuously.Etiology It appears to be related to the frictional irritation produced by loose-fitting dentures on the palatine tissues. Candida albicans may play an etiologic role.

Clinical Features A small region in the vault or the whole palatine mucosa under the denture may be covered with numerous small, painless papular or polypoid masses that are seldom over 0.3 cm in diameter. As with all the other IH lesions, these masses are red and soft and bleed easily in the inflammatory stage, when they become fibrosed; however, they are firm and pale pink.

Papillary Hyperplasia of the Palate (PHP)

The difference between Papillary hyperplasia of palateNicotinic Stomatitis

Nicotinic stomatitis

Pulp Polyp (chronic hyperplastic pulpitis)

Epulis Granulomatosum

Peripheral Giant Cell Lesion

3- Retention phenomena

Mucocele, Ranula and Eruption cystThe mucocele and ranula are retention phenomena of the minor salivary glands and the sublingual (major) salivary glands, respectively.

Mucocele, Ranula and Eruption cystSites: 80% of the time of mucoceles on the lower lip and rarely on the palate. Ranula is a mucous retention cyst in the sublingual salivary gland that appears in the floor of the mouth.

Etiology: TraumaObstructed minor salivary gland duct

Mucocele

Ranula

Mucocele Ranula Place minor salivary glandssublingual (major) salivary glands sitelower lip floor of the mouth.

Causes TraumaObstructed minor salivary gland duct TraumaObstructed minor salivary gland duct

Treatment excisionmarsupialization

Eruption cystIt appears as bluish grey swelling of the mucosa over an erupting tooth, it may enlarge and submerge the erupting tooth if untreated.It is a cyst within the oral mucosa arising by the separation of the follicle from around the anatomical crown of an erupting tooth.Treatment is by surgical excision of a wedge of the mucosa to expose the tooth crown.

Eruption cyst

4- Viral infections

A-Verruca vulgaris Verruca vulgaris, the common wart of the skin, is not a common oral lesion. The superior surface is a firm, horny, white, rough plateau. Oral mucosal lesion develops as a result of autoinoculation with warts on the finger in children.The lesion is associated with human papilloma virus (HPV).Most common sites lip, palate and commissures.Mean age is approximately 15 years.

Specific Infectious Lesions A-Verruca vulgaris Histologically, they consist of papillary processes of proliferating, acanthotic, hyperkeratoticsquamous epithelium supported by thin cores of vascular connective tissue. The hyperplastic rete ridges around the margins usually slope inwards towards the centre of the lesion.

1-Verruca Vulgaris

Verruca Vulgaris

2- Oral papillomaIt is benign, rough-surfaced exophytic hyperplasias of epithelial tissue caused by human papillomavirus (HPV) that belong to the papovavirus group.The oral papilloma is recognized as a relatively common oral lesion. Oral papillomas are papillomatous (cauliflower) in shape, it have a pebbled surface with prominent clefting. The oral papilloma is seldom larger than 1 cm in diameter. Approximately a third of these lesions occur on the tongue; the remaining sites are the palate, buccal mucosa, gingiva, lips, mandible ridge and floor of the mouth. Most cases occur in patients ages 21 through 50 years with an average age of 38 years. Oral papillomas do not show a tendency for malignant change.

2-Oral papilloma

3-Condyloma Acuminatum (CA) CA is known as the common venereal wart that is seen in the oral cavity. Oral CAs are particularly common in HIV-positive individuals. It is caused by human papillomavirus (HPV). Clinically and microscopically oral papillomas and oral CAs cannot be differentiated, although if genital warts are present this would suggest that oral lesion is probably a CA.

3-Condyloma Acuminatum (CA)

Management of Papillomas, verrucae vulgaris and CAsSingle lesions are best removed by surgery including blade excision, laser, heat cautery or cryosurgery. Any excised tissue must be submitted for microscopic study. Podophyllin resin can be used to manage multiple lesions. One or two topical applications may be given per week over 4 to 8 weeks. Although interferon is very effective against HPV with intralesional injection, this costly and painful procedure should be used only as a last treatment. (sofosbuvir)

4-Focal epithelial hyperplasia (Heck's disease)Soft, well-circumscribed, flat, sessile (non-papillomatous) papules, common in Eskimo and rare in Caucasians. Anywhere in the oral mucous membrane. It caused by caused by human papilloma virus. TreatmentThe lesion requires no treatment.

4-Focal epithelial hyperplasia (Heck's disease)

5- Fungal granulomatous lesionIn chronic mucocutaneous candidosis, the fungus penetrates to the connective tissue and results in both hyperplastic and inflammatory response that appear as multiple granulomatous reaction affecting the skin, mucous membrane and nail folds.

5-Benign & Malignant tumors

Lipoma

Myoma (tumor in muscles)

Peripheral nerve tumorsNeurofibroma :

Traumatic neuroma

2- Oral Nevus A nevus is a benign tumor of the melanocytes that occurs on the skin but seldom intraorally. It is pigmented ranging from gray to light brown to blue to black. There are four types of oral nevi: intramucosal, junctional, compound and blue.The most common location for oral nevi is the hard palate (40%), followed by the buccal mucosa (19%). The vermillion border, gingiva, labial mucosa, soft palate, and retromolar pad are next in order of frequency. Women, The mean age is 32 years More than half of the lesions are very small, measuring from 0.1 to 0.6 cm.

Malignant neoplasms1-Squamous cell carcinoma (SCC) red indurated lesion, white indurated lesion, red and white lesion, exophytic lesion, indurated ulcer and crust (lower lip). SCC is the most common oral malignancy

1-Squamous cell carcinoma (SCC)Exophytic carcinoma occurs most often on the lateral borders of the tongue, the floor of the mouth and the soft palate. The lesions are painless and firm on palpation and bleeding is not an early characteristic.Cervical lymph node involvement is the usual route of metastasis.

Squamous cell carcinoma

Differential DiagnosisVerrucous carcinoma: less common and slower growing than SCC. Pyogenic granuloma : It is softer on palpation and bleeds readily and usually its instigating irritant can be found.

Differential DiagnosisPapilloma and condyloma acuminatum: is an uncommon oral lesion and its small size and characteristic verrucous appearance with a horny "crown" distinguishes it from SCC

Differential DiagnosisAmelanotic melanomaPeripheral malignant mesenchymal tumors Peripheral metastatic tumors

Fibrosarcoma Amelanotic melanomaSCC

Differential DiagnosisMany rare oral exophytic lesions, including syphilis, fungal diseases, sarcoidosis and tuberculosis, may be confused with exophytic SCC.

Gumma ChancreTB

Verrucous carcinoma

Malignant Melanoma

Minor salivary gland tumors

Case 122 years old female pregnant patient presented to you suffering from a red bleeding lesion on the surface of the gingiva opposite to the maxillary central incisor

1- What is your probable diagnosis?

2- Management ?

Case 2A 55-year-old female presented with a mass in the gingiva which has been present after extractionShe has no history of any systemic disease. Upon examination: The patient presented with a pink exophytic mass extruded from the socket of extraction.

1- What is the diagnosis ?

2- What is the cause ?

3- What is the treatment ofThis lesion ?

Case 3Twenty-five year old male patient, came to the oral medicine department with a complaint of intense pain associated with a tongue lesion, with a duration of two months.Upon examination: an extensive ulceration was observed, with largest diameter of 2.5 cm. It has an irregular border and a necrotic background (approximately 8 mm in depth), surrounded by an erythematous atrophic area and located at the lateral borders of the tongue. A cervical lymph node was detected which was fixed and not painful. Patient denied history of smoking.

1- What is the differential diagnosis ?2- What is the diagnosis ?3- What are other forms of this lesion?4- This lesion couldnt be diagnosed as a Malignant salivary gland tumor, because

Case 4A 77-year-old patient presented to your clinic suffering from multiple painless pink papules (0.3 cm in diameter)

History revealed that the patient is wearing the denture all the time and never takes it off at night

1- What is the diagnosis ?

2- What organism isAssociated with thisLesion ?

3- Management ?

Case 5This is a 32-year old white female who presented at the Oral & Medicine Clinic with a 3-month history of a painful, slowly enlarging ulcer on the left ventral/lateral border of the tongue. She is a heavy smoker and alcohol abuser.Cervical lymph nodes were hard, palpabable and fixed to the underlying structures

1-Diagnosis

2- How to Confirm yourDiagnosis ?

A 57 year-old man presented with this ulcer of 6 weeks duration.What is the clinical diagnosis?

Case 6

Case 7Patient presented to the clinic complaining from this lesion which started one month ago after treatment of carious lower six. The lesion is painless1-what is the name of this lesion ?

2-What is your treatment plan ?

Case 8A nineteen-year old woman presented to our clinic with a 2-year history of difficulty in swallowing, hoarseness and a foreign body sensation in the throat. On physical examination, there was a mass covered with smooth mucosa, located on the base of the tongue and measure 3X4 cm in length.

1-What is the diagnosis ?

2-How can you confirm the Diagnosis?

3-What is the treatment ?

Case 9Patients presented to the clinic complaining from this lesion which started one month ago after wearing a new denture. The lesion is painless1-What is the name of this lesion ?2-What is your treatment plan ?

Case 10A 32-year-old female complains of soft pink mass in the floor of the mouth

1-What is the clinical diagnosis ?

2-What is the treatment of this condition

Case 11A 5-year-old girl who was referred to the outpatient clinic, complaining of progressive dysphagia to solid foods. Upon examination, the patient presented a solid, pink, spherical mass, covered with intact mucosa on the posterior part of the tongue.

1-What is the diagnosis ?2- How can you confirm the Diagnosis ?

3-Is it possible to a havea biopsy from this lesionor not and why ?

Case 12A 72 year-man reported a gingival enlargement with 12 months of evolution with oral discomfort using denture. On Oral examination, a fibrous mass of 3x2 cm, with folds, and normal mucosa coloration was located on maxillary vestibular sulcus.

1-What is the lesion ?2- What is the cause ?

Case 13

The patient has been edentulous for many years.

1-What is the lesion ?2-What is the cause ?

Case 14

A 22-year-old male complaint of soft pink mass in the floor of the mouth

1-What is the clinical diagnosis ?2- What is the treatment of this condition ?

Case 15

This is lower lip swelling has recurred three times in the last year1-What is the clinical diagnosis ?2- What is the treatment of this condition ?

Case 16Pregnant patient presented to the clinic complaining from this lesion which started one month ago. The lesion is painless

1-What is the name of this lesion ?2- What is your treatment plan ?

Case 17A 13-year-old female patient presented to at the oral medicine department with a primary complaint of a blue-colored lesion located on the tongue. Intraoral examination revealed a lesion that was purple colored, with sessile attachment, intact mucosa and easy bleed when traumatized.

1-What is the diagnosis ?2- How can you confirm the diagnosis ?

3-What is the treatmentof this lesion ?

Case 18A 16-year-old woman has a compressible, non-tender, 2x2 mm soft tissue enlargement of the lower labial mucosa.The patient states that she has been aware of the lesion for 2 months and that it has increased and decreased in size during eating.

1-What is the diagnosis ?2- How can you confirm the diagnosis ?

3-What is the treatmentof this lesion ?

(3)BIOPSY

Types of biopsy:

1- Oral cytology.2- Aspiration.3- Punch biopsy.4- Incisional biopsy5- Excisional biopsy

Exfoliative cytology

Exfoliative cytology (brush biopsy)

Exfoliative cytology

Exfoliative cytology Uses1- For rapid evaluation of an oral lesion

2- For sequential laboratory evaluation of an area of mucosa that has previously been treated by excision or radiation to remove a malignancy

3- evaluation of vesicular lesions (herpes simplex, pemphigus and pemphigoid) .Where facilities for the rapid evaluation of a Tzanck smear are not available

2- Toluidine Blue DyeMechanism : High affinity to DNA and sulfated muco-polysaccharides

Indications or uses:1- suspicious large lesion2- helps to clinical judgment3- If patient doesnt want biopsy

3- Aspiration biopsy Uses1-Large masses that are relatively inaccessible 2- lesions whose clinical character suggests that they are soft/ semi fluid in consistencyNo aspiration solid lesionPus inflammatory lesionYellowish fluid CystBlood Vascular lesion (Hemangioma)

4- Punch biopsy Uses1- Inmultiple screening, when ideal clinical facilities are not available.

2- Whenlesion is uniform in appearance and area to be biopsied not very large

Punch biopsy

Excisional biopsy UsesIt is the removal of the whole lesion for histopathological examination

It is = Treatment + BiopsyUses1- small exophytic masses in accessible areas2- Isolated lesions3- Any tissues removed surgically should be examined

Excisional biopsy

Excisional Biopsy

Biopsy forceps

Incisional BiopsyAn incisional biopsy is a biopsy that samples only a particular part of the lesion. Indications:

1- If the area under investigation appears difficult to excise because of its extensive size 2- Whenever there is a great suspicion of malignancy.3- Conditions such as multiple ulcers that cannot be eliminated by surgical excision.

It is much better to take a deep, narrow biopsy rather than a broad, shallow one, because superficial changes may be quite different from those deeper in the tissue

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Education

Practical oral diagnosis 2