case presentation 3 : LICHEN PLANUS.pptx

LICHEN PLANUS.pptx

1. CASE PRESENTATION Dr. Nitha Willy First Year PG Department Of Oral Medicine And Radiology

2. BIOGRAPHIC DATA Name : Jaseela Shaji Age :44 years Sex : F Occupation : Home maker Address : Thanickamolath Methala O P No :2971 Phone no: 9446972349

3. CHIEF COMPLAINT Patient complaints of burning sensation in mouth since two months.

4. HISTORY OF PRESENTING ILLNESS Patient complaints of burning sensation in mouth since 2 months while eating spicy food. Patient complaints that mucosa gets ulcerated which is then painful. Patient visited a dental clinic for the pain in lower mouth last day and was prescribed a dologel which was not effective in reducing patient’s complaint. Patient had consulted a gastroenterologist at Lisie hospital before one month relating problem of mouth to be associated with gastric problem and she was informed that there was no problems associated with GIT.

5. Patient has stress related to family issues. Patient has not taken any special foods, patient has not changed toothpaste. VAS score : 8/10

6. MEDICAL HISTORY H/O Hypertension and hyperlipidemia under medication for 4 years Patient doesn’t remember name of medications. Patient had no recent hospitalization history or recent episodes of fever.

7. Drug Allergy No known drug allergy

8. REVIEW OF SYSTEMS CNS: No abnormalities reported GIT: No abnormalities reported Respiratory system: No abnormalities reported CVS: No abnormalities reported Endocrine system: No abnormalities reported Genito urinary system: No abnormalities reported

9. PAST DENTAL VISIT For similar complaint two day before in a private dental clinic.

10. PERSONAL HISTORY Marital status: Married Sleep and appetite: decreased sleep and loss of appetite. Bowel and bladder movements: regular Diet: mixed Oral hygiene: brushes twice daily using tooth paste and toothbrush. No deleterious and parafunctional habits noticed

11. FAMILY HISTORY Parents and siblings are diabetic and hypertensive patients

12. GENERAL PHYSICAL EXAMINATION Patient was conscious, co-operative and well oriented with person, place, time. Gait: steady gait Built: moderately built Nourishment: moderately nourished Temperature: 37 ͦ C Pulse rate:72 beats/minute Respiratory rate: 16 beats/minute Blood pressure: 120/90 mm Hg

13. No signs of pallor, Icterus, Cyanosis/ Clubbing/ edema and no lymphadenopathy Height: 5 ft 5 in Weight: 70 kg

14. LOCAL EXAMINATION OF HEAD AND NECK Extra oral examination Head : Mesencephalic Hair : No abnormalities detected Face :Apparently symmetrical Skin : no abnormalities detected Eyes : no abnormalities detected Ears : no abnormalities detected Nose: no abnormalities detected Lips :competent TMJ : Mouth Opening Within Normal Limits, No Deviation, No Clicking/ Crepitus Muscles of mastication : non-tender Lymph nodes : not palpable Cranial nerve examination: no abnormalities

15. Intra oral examination Soft tissue examination Labial mucosa: no abnormalities detected Labial vestibule: white lacy striations with erythematous border in lower labial vestibule extending distal aspect of 32 to distal aspect of 43. Buccal mucosa: no abnormalities detected Buccal vestibule: no abnormalities detected. Lingual vestibule: A white plaque seen extending from lingual vestibule of 31,41 to lingual frenum, of size 2*2 cm. Gingiva : coral pink color, scalloped contours with knife edge margins, stippling present, gingiva is firm and resilient. Bleeding on probing: absent Periodontal pocket: absent

16. Tongue: The dorsal and lateral borders of tongue had presence of white coating. Floor of mouth: no abnormalities detected Frenal attachment : mucosal frenal attachment detected Palate: no abnormalities detected Oropharynx : no abnormalities detected Salivary gland orifices: no abnormalities detected

17. Hard tissue examination Number of teeth : 16-27,36-47 Carious teeth :0 Missing teeth : 18,17,28,38,37,48 Root stump:0 Restored tooth: 47,46,35,34,36,14,24 Fractured tooth:0 Mobility :0 Attrition : generalised

18. Examination of lesion On inspection On inspection , White lacy striations with erythematous border in lower labial vestibule extending from labial vestibule distal of 32 to distal of 43 and supero -inferiorly from mucogingival junction to labial vestibule was noted. On palpation, All inspectory findings were confirmed. Non tender, non scrappable, no bleeding or no pus discharge

19. On Inspection A white plaque of approximate size 1*3 cm extending from superoinferiorly 2 cm below the mucogingival junction of 31,41 to 3 cm into the lingual frenum and mediolaterally extending 2cm on both sides of lingual frenum. On medial aspect of white plaque, on left sublingual fold overlying the sublingual gland, peripheral radiating striations are seen and pinpoint erythematous areas seen on sublingual fold overlying the sublingual gland and sublingual caruncle On palpation All inspectory findings were confirmed. Non tender, non scrappable , no bleeding or no pus discharge

20. The dorsum and lateral borders of tongue show white lesion which is scrapable on palpation. Discrete greyish black pigmentation seen on lateral borders of tongue.

21. Case Summary/ Analysis A 44 year old female patient reported to our department with chief complaint of burning sensation in mouth since 2 months. On examination, White lacy type lesion with erythematous border in lower labial vestibule extending from labial vestibule distal of 32 to distal of 43 and supero -inferiorly from mucogingival junction to labial vestibule was noted. A white plaque type lesion with radiating striations on left on sublingual fold overling the sublingual gland and overlying pinpoint erythematous areas seen on sublingual fold overlying the sublingual gland and sublingual caruncle extending from superoinferiorly 2 cm below the mucogingival junction of 31,41 to 3 cm into the lingual frenum and mediolaterally extending 2cm on both sides of lingual frenum. The dorsal and lateral borders of tongue show white pigmentation and was scrappable on palpation.

22. PROVISIONAL DIAGNOSIS EROSIVE LICHEN PLANUS ON LOWER LABIAL VESTIBULE PLAQUE TYPE LICHEN PLANUS ON LINGUAL FRENUM AND LINGUAL VESTIBULE CANDIDIASIS ON DORSUM AND LATERAL BORDERS OF TONGUE

23. Differential Diagnosis Speckled leukoplakia : middle older age male group, associated with tobacco, unilaterally present, no striae . Hyperplastic candidiasis : presence of striae , associated with stress, negative fungal hyphae seen in cytosmear . Homogeneous leukoplakia : non scrappable, whitish patch or plaque, well demarcated borders. Thermal burn

24. INVESTIGATIONS CYTOLOGY, HEMATOLOGY AND BIOPSY Smear from dorsum of tongue showed presence of candida hyphae.

25. Treatment Plan 0.1 % Triamcinolone Acetonide topical application three times daily for 15 Days Tab oxidil(ginseng extract,lycopene , lutein, zinc oxide) 1-0-0 * 15 Days Betamethasone sodium phosphate 0.5mg( Swish and Spit )1-0-1 for 15 Days

26. FOLLOW UP