PAGD Keystone Explorer Spring 2021

Case I Amalgam tattoo, likely created during preparation and placement of her crowns on teeth #14 and 15. Differential diagnosis should include blue nevus, melanotic macule, and possibly oral melanoma, however the proximity to previous dental restorations suggests implanted metallic debris. Small debris may or may not be visible on a radiograph. No treatment is required, but the lesion should be documented and monitored over time. Case II Erythema Migrans (geographic tongue). While the patient’s vitamin deficiency is notable, the appearance is pathognomonic for geographic tongue. To verify, the lesion should be followed over a short period and would be expected to change in size, shape, or number. The xerostomia and tingling sensation of the lips and tongue make it prudent to suggest a swab culture for candidiasis, and an antifungal suspension would be appropriate. Reassure the patient that this is a common and harmless condition that will wax and wane periodically. Avoiding acidic and spicy foods will help if flair ups are uncomfortable. Case III This is an example of erosive lichen planus, determined histologically after incisional biopsy of numerous sites. Biopsy is indicated, and your differential may include chronic candidiasis, proliferative verrucous leukoplakia, and verrucous carcinoma. The diseases associated with desquamative gingivitis may also be considered, but the lace-like, white striae make this less likely. Oral corticosteroid ointments and gels can be helpful to manage painful flair-ups, but the extensive presentation seen in these photographs is better managed with systemic steroids. Referral to PCP or rheumatologist would also be appropriate to investigate systemic conditions. The patient should be monitored on a regular basis and any change in texture of the lesions should be carefully scrutinized for new biopsy as there is a slight risk for malignant transformation. Keystone Explorer | Spring 2021 13 dentistry issues Q Answers