Oral medicine case book 53: radiation - induced xerostomia

A 76-year old male presented at the Oral Medicine Clinic, complaining of a persistent feeling of a dry mouth, subsequent to having undergone surgery, chemotherapy and radiation therapy for nasopharyngeal carcinoma, 18 months previously. Other than the cancer, he had no systemic problems of note and was otherwise in good physical health. Upon further questioning, the patient reported that the dry mouth condition was affecting his quality of life and that he was losing weight due to difficulty in eating. He further emphasised that his mouth felt dry within five minutes of rinsing his mouth with the palliative agents suggested by his dentist and oncologist. The regimen he followed to relieve his symptoms included glycerine BP oil, Candacide© (a nystatin containing product), Biotene© mouth spray and mouthrinse (these products contain lactoperoxidase, glucose oxidase, lysozyme and lactoferrin), Orbit© sugar free gum and an increased frequency of water intake.Department of HE and Training approved lis

Oral medicine case book 67: Oral manifestations of Evans syndrome: a presenting feature of HIV infection?

A 19 year old female presented with spontaneous intra - oral bleeding of two days duration. The patient reported that she was, until recently, in good general health and also that she had an uncomplicated parturition three years ago. She recently started noticing blood in her stools and felt increasingly lethargic. There was no history of trauma or intra-oral intervention that may have initiated the bleeding. The clinical examination revealed marked pallor of the facial skin and multiple small petechiae were seen on both of her forearms. The intra-oral examination identified marked halitosis and multiple haemorrhagic lesions with a variable appearance, being plaque-like on the lip, nodular on the tongue and fungating and exophytic on the palate and in the retromolar regions. Even delicate manipulation of the tissues produced profuse bleeding.DHE

Oral medicine case book 69: Burkitt lymphoma of the oral cavity

A 25-year-old female was referred to the Haematology Unit at Tygerberg Hospital for further management of a rapidly expanding and large submandibular mass which on fine needle aspiration was suggestive of lymphoma . Five months earlier she had been diagnosed with pulmonary tuberculosis and was confirmed to be HIV positive with a CD4 count of 17. She was placed on anti-retroviral (ARV) and antituberculous therapy (the ARV therapy included efavirenz, emtricitabine and tenofivir). Her CD4 count, at the time of the current consultation, was 204 and the viral load was suppressed. Lumbar puncture was normal. Significant clinical findings were a large right submandibular mass and right cervical and axillary lymphadenopathy. The submandibular mass was removed and submitted for histological examination.DHE

Oral medicine case book 61: Oral malignant melanoma

A 45-year old male patient presented at the Oral and Maxillofacial Clinic, Tygerberg, with a pathological fracture of the left mandible following an extraction. The medical records of the patient revealed a history of multiple myeloma that was treated with Aredia (pamidronate disodium, an intravenous form of bisphosphonate), cyclophosphamide (an alkylating agent) and dexamethaxone (an anti-inflammatory and immunosuppressant drug). An orthopantomograph revealed osteonecrosis and pathological fracture of the left mandible, thought to be due to the earlier biphosphonate administration. The patient received conservative management for the osteonecrosis and was stable at the time of the publication, (19 months after the initial presentation with the pathological fracture).DHE

Oral medicine case book 68: Oral ulceration caused by rifampicin-resistant tuberculosis

A 53-year old female was referred by her local general medical practitioner to an oral medicine specialist for the management of a persistent ulcer on the left side of her tongue. The lesion had been present for at least three months and was not responding to treatment by topical antiseptic agents. The earlier removal of a molar in close proximity to the lesion, in an attempt to exclude the possibility of traumatic ulceration, had also yielded no beneficial effects. Upon examination, the patient appeared clinically healthy but presented with a history of emphysema due to chronic cigarette smoking. The emphysema was currently being managed by oral inhalation steroids. Even though smoking cessation had previously been advised, she failed to comply and was currently still smoking more than 10 cigarettes per day.DHE

Oral medicine case book 47: oral neurofibroma

A 29-year-old male patient presented at the Oral Medicine Clinic with the complaint of slow-growing growths on his tongue, causing discomfort. Extra-oral examination revealed several painless soft tissue nodules on his face (Figure 1 and 2), trunk (Figure 3), back (Figure 4) and arms. The patient reported that the lesions had appeared during childhood and had since increased in size and number. He was unaware of any family history of the disease. Intra-oral examination showed two soft tissue nodules on the midline of the dorsal surface of the tongue, 3,5cm and 0,5 cm in diameter respectively (Figure 5).Department of HE and Training approved lis

Oral medicine case book 46: squamous cell carcinoma of the tongue

A 38-year-old-female presented at the Oral Medicine Clinic complaining of pain under her tongue that became worse during chewing, and radiated to her right ear. The pain started two months earlier and gradually increased in intensity. The patient reported that she smoked about twelve cigarettes per day, a habit that she maintained for the last twenty years. She also admitted that she consumed alcohol as a social habit, mainly over the weekends. Her medical history revealed no other abnormalities and she was not using any chronic medication.Department of HE and Training approved lis

Oral Medicine Case Book 56: Oral Manifestations of aplastic anaemia

A 22-year old female patient was referred to the Oral Medicine Clinic from the Haematology Ward at Groote Schuur Hospital for evaluation of a painful oral ulcer, which had been present for three weeks. The patient reported that, six weeks ago, she had sought treatment from her own dentist for painful and bleeding gingivae. The dentist performed a scale and polish and prescribed a combination of amoxicillin and metronidazole, at normal adult doses, for seven days. The gingival bleeding had not resolved by the time she presented for her recall visit, two weeks later. The patient also reported the presence of 'small, purple spots' on her lower limbs and trunk.DHE

Oral medicine case book 52: pleomorphic adenoma of the upper lip

A 46-year old female presented at the Oral Medicine Clinic complaining of a large and painless swelling of her upper lip. The lesion had slowly enlarged over the past year and was causing an increasing aesthetic and speech impairment. Her medical history revealed nothing of note. Extra-orally, the patient presented with a swelling involving the right side of the upper lip and extending from the right alar of the nose, to the right commissure (Figure 1). The intra-oral examination revealed a firm and well circumscribed mass in the upper right labial mucosa, opposite the upper second incisor, canine and first premolar. The mass was approximately 2x3 cm in size and the overlying mucosa was of normal consistency and colour for the region (Figure 2). A fine needle aspiration biopsy (FNAB) of the mass was performed (Figure 3).Department of HE and Training approved lis

Oral medicine case book 49: plasmablastic lymphoma

A 25-year-old male patient presented at the Oral Medicine Clinic with a painful bleeding lesion on the palate causing him discomfort during speech, mastication, and sleep. The lesion started approximately five months earlier as a small growth that gradually increased in size. The patient was rather vague about his medical history and habits but he did reveal that he smoked two cigarettes per day as well as using cocaine, a habit for which he was receiving therapy, for drug-induced hallucinations, at a local psychiatric hospital. He was not aware of any other medical conditions or allergies. The extraoral examination revealed nothing of note, however, on intraoral examination a large and firm pedunculated exophytic soft tissue mass was seen on the hard palate. It covered a large portion of the hard palate extending from the back of the upper incisors posteriorly onto the anterior part of the soft palate and into the right vestibule. It extended laterally to the gingival margins of all the teeth in the first quadrant, resulting in an appearance of gingival hyperplasia. The growth had an erythematous appearance with surface patches of necrosis and other areas that easily bled on touch (Figure 1).Department of HE and Training approved lis