Oral Dysplasia and cancer cases

Question 1

38 years old
Risk factor - topical tobacco (snuff)
Otherwise fit and well

Answer 1

Thickened keratotic lesion, red patches, red spots

Biopsy - benign

Recommendation - stop smoking, regular review

Question 2

64 year old
Unaware of the lesion left commissure
Risk factors - 20 cigs a day since 16 yrs, 10 pints beer per week, eats processed foods with little fresh fruit and vegetables.

Answer 2

Keratotic lesion (thickened in appearance), painless, very speckled.

Biopsy - Candidal leukoplakia
Treatment - Systemic antifungals,

Second biopsy - Squamous cell carcinoma
Treatment - Surgical excision with a margin of 1cm of normal tissue , 5 yr follow up review.

Question 3

32 yr old
Left sided tongue white patch
Risk factors - smoker 10 a day since 18 yrs
1 bottle of vodka per week

Answer 3

White patches, red patches.

Biopsy - severe dysplasia (lesion will all become cancerous if not excised)
Treatment - excision with 5 mm normal tissue, smoking cession, alcohol reduction, long-term regular follow up.

Question 4

47 yr old
Multiple white patches
Asymptomatic
Risk factors - none identified

Answer 4

Mapping biopsies
Close clinical follow up
Self examination

Question 5

78 yrs old
Multiple white patches: bilateral buccal mucosa, lower right gingivae, right soft palate.

Answer 5

Mapping biopsies
Moderate to severe dysplasia
Treatment excision of lesions with 5mm normal margin

Question 6

58 yr old
asymptomatic
white patch lingual alveolus FOM (“ebb and tide” pattern)
risk factor - binge drinker

Answer 6

Biopsy: Severe dysplasia

Treatment: Excision with a perimeter of 5mm normal tissue, follow up, repeat biopsy, risk factor reduction

(second biopsy after 1 year as a follow up)

Question 7

73 yrs
Long history of lace like white patches inside both cheeks
not symptomatic
Risk factors - none identified

Answer 7

Lichen planus (potentially malignant condition)

Investigation - incisional biopsy

Question 8

52 yrs
painful left cheek for several months
former smoker, stopped 6 year before was 15 cigarettes per day since age 20 yrs

Answer 8

Lichenoid reaction in the mouth (shouldn’t be confused with a lichen planus) as a result of amalgam restorations.

Question 9

54 yrs
20 year history of oral white patches bilateral; buccal mucosa and left soft palate onto hard palate
Risk factors - alcohol <10 units per week

Answer 9

Thick, keratotic lesion, indurated margins

Question 10

62 yr old, rheumatoid arthritis (taking strong immunosuppressants) and Sjorgrens syndrome.
Asymptomatic white patch right lateral tongue
No risk factors

Answer 10

Striated pattern
Hairy leukoplakia (can be associated with HIV)

Question 11

65 yr painless lesion on right side of the tongue
unknown duration
Smoker 20 a day for 40 years
alcohol 4 bottles of wine per week

Answer 11

Indurated, squamous cell carcinoma, large

Question 12

78 yrs old, asymptomatic white patch on the left gingivae in the LL5 and LL6 region, found by his own dentist on routine examination.
No risk factors
Medically - well controlled hypertension with amlodipine and statins.

Answer 12

Heterogenous patches

Question 13

73 yr old, lesion on right side of tongue
Patient noticed an ulcer 6 weeks previously
not painful
noticed a lump in the right neck for the past month not painful
risk factors - none identified

Answer 13

White patch with red speckles, heat thick white patch, exophytic (growing out the way)

Question 14

34 yr old, vague right side jaw and neck pain
present for 6-7 months
her glands were up and had not come down for a few months
the dentist suggested that her symptoms were due to her impacted wisdom teeth
medically she was fit and well, never smoked and consumed less than 10 units of alcohol per week.

Answer 14

Cancer

Question 15

Treatment for cancer

Answer 15

Question 16

A homogeneous white patch of the left buccal mucosa measuring 2cm in diameter is found on routine examination of a new patient. Immediately adjacent is amalgam restored molars. The patient was not aware of this white patch. They do not smoke or consume a lot of alcohol. What is the most likely diagnosis?

Answer 16

lichenoid reaction

Question 17

A 69 year old male patient comes for a routine assessment and you note a red/white speckled area of the anterior floor of mouth that the patient was not aware of. He is partially dentate but does not wear anything over that area. He has smoked roll -up cigarettes for the past 50 years and drink 5 days per week usually 3 pints per day. What do you think the most likely diagnosis is?

Answer 17

Potentially malignant lesion

Question 18

A patient comes with a constantly painful area on the left cheek of 10 days duration. He is aware that there is a broken filling in the area and is concerned that it does not seem to be getting better. He suffers from mouth ulcers but they usually only last 5-7 days and get better. You see a 1 cm ulcer with a erythematous perimeter which is very tender to touch at the level of a fractured amalgam in the UL7. What is the most likely diagnosis?

Answer 18

trauma causing ulceration

Question 19

A 47 year old female patient attends as a new patient to your practise. You notice that she has white patches on her ventrolateral tongue on the right side, soft palate on the left side and the anterior attached gingivae. When you ask her she says she can see the white gums at the front but they have bee like that for years and her previous dentist did not think that they were anything to be concerned about. She does not smoke or drink except a sherry on a special occasion. What do you think the diagnosis might be?

Answer 19

field change

Question 20

A 47 year old female patient attends as a new patient to your practise. You notice that she has white patches on her ventrolateral tongue on the right side, soft palate on the left side and the anterior attached gingivae. When you ask her she says she can see the white gums at the front but they have bee like that for years and her previous dentist did not think that they were anything to be concerned about. She does not smoke or drink except a sherry on a special occasion. What do you think the diagnosis might be?

Answer 20

field change

Question 21

Breaking bad news stages

Answer 21

1. Setting (physical settings, body language etc.)
2. Listening skills (open questions)
3. Perception of condition (gauge patients level of understanding/anxiety)
4. Invitation (how much information does the patient they want)
5. Knowledge (understandable, no jargon, give info in small chunks, respond to patients reactions, explore denial)

Question 22

Empathetic response when breaking bad news

Answer 22

Identify emotion
Identify the cause or source of the emotion
Respond in a way that shows that you have made a connection

Question 23

Strategising at the end of breaking bad news

Answer 23

Next steps
Patient expectations
Ensure patient understands
Agree on a plan

SUMMARISE: any more questions to discuss? Make a clear plan for next context.