Exercises in Oral pathology - Q and A
Question
A 28 year old man comes to the clinic with a complaint of mild burning sensation in his right cheek for the past 10 days. Oral examination revealed a mixed white and red lesion with peripheral striae on the right buccal mucosa seen in association with lower molars. However, it was also observed that the lesion was unilateral and other parts of the oral mucosa seemed to be fine. On eliciting history, it was noted that he was not taking any drugs, did not have any adverse habits, or any systemic disease.
What do you suspect the lesion to be? What would you look for, to confirm your diagnosis? Would a biopsy be required?
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Answer👇
The lesion would most likely be an oral lichenoid lesion (OLL).
What to look for
Look for an amalgam restoration on any of the lower molars (lower jaw).
Why one should look for amalgam restorations
OLLs due to amalgam manifest as reticular white striae, papules or plaques with or without erosions (red areas) or ulcerated areas. These lesions have an anatomic relationship to the restoration and are typically unilateral on the same side of the restoration and are never bilateral.
They are commonly located posteriorly on the buccal mucosa and lateral border of the tongue where the mucosa comes in contact with the restoration.
Biopsy/Histopathology
Though the diagnosis for this lesion could be made from a clinical impression, a biopsy could be done to confirm the diagnosis and rule out the presence of epithelial dysplasia.
Histopathology would show features very similar to oral lichen planus, but the key to diagnosis lies in the lesion stroma/connective tissue, where the inflammatory infiltrate would show lymphocytes and plasma cells (lichen planus would show lymphocytes predominantly).
Key to diagnosis
Unilateral lesion in close association with the amalgam restoration together with histolopathology.
📚Here are some resources for further reading
Hiremath SK, Kale AD, Charantimath S. Oral lichenoid lesions: Clinico-pathological mimicry and its diagnostic implications. Indian J Dent Res. 201;22(6):827-34.
Neville BW, Damm DD, Allen CM, Chi A. Oral and Maxillofacial Pathology. South Asian ed. Elsevier; 2016.
McParland H1, Warnakulasuriya S. Oral lichenoid contact lesions to mercury and dental amalgam--a review. J Biomed Biotechnol. 2012;2012:589569.
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