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CLINICAL PATHOLOGY CONFERENCE May 20, 2009 Montreal, Quebec, Canada Moderator: Dr. Harvey Kessler Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Discussant Amanda Yen Research Fellow Tufts University Boston, Massachusetts Marc Stokes Assistant Program Director Naval Postgraduate Dental School Bethesda, MD Nadim M. Islam Assistant Professor Indiana University School of Dentistry Indianapolis, Indiana Juliana Robledo South Texas Oral Pathology San Antonio, Texas Patricia DeVilliers Assistant Professor University of Alabama at Birmingham Birmingham, Alabama Nora A. A. Odingo Clinical Assistant Professor School of Dental Medicine State University of New York at Stony Brook Stony Brook, New York Contributor Maria Fornatora Associate Professor Kornberg School of Dentistry Temple University Philadelphia, Pennsylvania Yi-Shing Lisa Cheng Associate Professor Baylor College of Dentistry Dallas, Texas Brian S. Shumway Assistant Professor University of Louisville Louisville, Kentucky Fabian Ocampo-Acosta Professor of Oral Pathology Facultad de Odontologia Universidad Autonoma de Baja California Tijuana Baja California, Mexico Eleni Gagari Director, Oral Medicine Clinic A. Syggros Hospital for Dermatologic Diseases University of Athens School of Medicine Athens, Greece Julien Ghannoum Attending Notre-Dame Hospital Montreal, Canada
Case 1 A 42 year old Caucasian female presented with extreme constant pain of the right mandible and paresthesia of her right lower lip from the commissure to the midline. Sudden severe pain began four months earlier in the right mandible and was presumed to be of endodontic origin from tooth #30. Subsequent to root canal treatment of tooth #30, the pain increased and the paresthesia began. Both were non-responsive to a short course of steroids. Tooth #30 was extracted one month prior to presentation. Following the extraction, the pain and paresthesia worsened and a swishing sound developed in her right ear. Evaluation by otolaryngology was negative.
Case 2 A 54-year-old Hispanic male had a chief complaint of dull pain and swelling in the right face that had been worsening for several months. He denied any history of trauma or past surgery, and his medical history was noncontributory.
Case 3 A 52 year old, HIV + homosexual male presented to a local dentist with a chief complaint of a one week history of gum sores, two weeks after a vacation to the southern United States. Initial examination by the general dentist revealed multiple ulcerations (0.2-0.5 cm) of the buccal gingiva and alveolar mucosa. A white lesion on the right lateral tongue was also noted. No diagnosis or definitive treatment was rendered at that time. A week later, the lesions remained, tooth #14 was prepared for a crown and a provisional restoration was placed. The patient returned to the clinic 3 days later complaining of soreness around tooth #14. At this time, specialty referral was initiated. Since his diagnosis with HIV 10 years previously, the patient had been receiving appropriate medical care, including administration of highly active antiretroviral therapy. Recent laboratory reports indicated an undetectable viral load with a CD4 count of 624 cells/mm3. General physical exam was unremarkable with the exception of slightly tender right submandibular lymphadenopathy. Vital signs were as follows: temperature, 37.1 ºC; blood pressure, 116/74 mm Hg; pulse rate, 88 beats/min; and respiratory rate, 12 breaths/min. Oral exam showed multiple ulcers of the dorsal tongue and right mandibular vestibule, a single ulcer of the left soft palate and ulcerated and inflamed gingival tissue surrounding tooth #14 (see figures).
Case 4 A 45 year old male patient presented with an asymptomatic right mandibular mass that extended from the angle to the premolar area. It had been present for 3 months at the time of initial presentation. Panoramic radiograph revealed an ill-defined unilocular radiolucency. Previous dental treatment included molar extractions and antibiotic therapy. Considerable bleeding was encountered during the incisional biopsy.
Case 5 A 58 year old Caucasian male patient was referred for evaluation of a painful lesion of the right maxillary facial gingiva. His medical history was significant for psoriasis. He had been taking acenocoumarol, interferon gamma, anti-hypertensive medication and had been prescribed metronidazole for the oral lesion, by his periodontist. Lab tests disclosed that the patient's INR had increased dangerously and metronidazole was discontinued. As soon as INR values returned to normal, a biopsy was taken. Within a week from the first visit, the original lesion increased in size and multiple painful lesions developed in the oral cavity. The patient developed dizziness and shortness of breath. A chest x-ray showed positive findings and the patient was hospitalized. Subsequent lesions:
Subsequent lesions: AAOMP 2009 Clinical Pathologic Conference Case 5 (Continued)
Case 6 A 57 year old female presented to a dermatology clinic with a 4-month history of periorbital edema. Her medical history includes type 1 diabetes, hypertension, hypercholesterolemia, hypothyroidism, bilateral carpal tunnel syndrome and multiple drug allergies. Extraoral examination revealed prominent hemifacial edema, erythematous plaques of the right side of the scalp, as well as submandibular lymphadenopathy. There were no other sites of cutaneous involvement. Intraoral examination was within normal limits. A skin biopsy was performed. The slides were reviewed on two occasions and confirmed the presence of interface dermatitis with deep perivasculitis and mucin deposition. The condition was unresponsive to topical and systemic treatment for at least 10 months.