OSCE for Clinical Dental Sciences PVK Chakravarthy, Ajay Telang, Lahari A Telang, Jayashri Nerali
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Oral Pathology and Oral Medicine1

 
OSCE Station 1.1
A 58-year-old trucker came to the oral medicine clinic with complaint of a swelling on the left side of the face. He remembers that the swelling was as small as a peanut four years ago and has been slowly increasing in size since the last three years. He gives no history of discomfort, pain, discharge or fever associated with the swelling. The reason he seeks advice is because of facial asymmetry, appearance and he is worried about the fact that he is a chronic smoker for the last 30 years.
Specimen: Incisional biopsy
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Figs 1.1A and B:
 
QUESTIONS
  1. What is the histopathological diagnosis based on features noted in Figures 1.1A and B?
  2. What is the histogenesis of the tumor?
  3. What is the role of smoking in development of this lesion? What is the treatment and prognosis?
2
 
OSCE Station 1.2
A 40-year-old Indian man came to a dental clinic with a complaint of mobile teeth. On clinical examination you also notice a nonscrapable white patch on the right commissure measuring about 2 cm × 1 cm. He gives a history of smoking approximately ten cigarettes a day for the last 10–15 years. He is keen on quitting his habit and also seeks advice.
zoom view
Figs. 1.2A and B:
 
QUESTIONS
  1. Name three nonscrapable white lesions presenting in the oral cavity.
  2. What type of biopsy is indicated for this case?
  3. What is the clinical term used for diagnosis of this lesion? What is the histopathological diagnosis?
  4. Mention three microscopic features noted on the given slide (Figure 1.2B).
  5. Name one commercially available product that can help in quitting his habit.
3
 
OSCE Station 1.3
A 45-year-old man came to the oral medicine clinic with a complaint of slow growing mass in the left mandible measuring 3 cm × 3 cm. He mentions that he was told by a dentist about an impacted lower left third molar 2 years ago, but he ignored removing it as it was never painful. Now he suspects it to be the cause of the trouble. Radiographs showed a large multilocular radiolucency associated with unerupted 38.
Specimen: Incisional biopsy
zoom view
Fig. 1.3:
 
QUESTIONS
  1. Name three lesions associated with impacted teeth. Why are impacted/unerupted teeth recommended for removal?
  2. Identify the pathology based on the photomicrograph and label the marked structure.
  3. Name four histopathological types of this lesion.
  4. Which is the most common odontogenic tumor?
4
 
OSCE Station 1.4
George is a 19-year-old health science foundation student, very active sportsman with keen interest in badminton. He gets an opportunity to train with student teams from the European Union in Denmark. For visa formalities he is asked to get his routine health check up done where his dental check-up showed 3 cm ×2 cm radiolucency associated with his impacted 48.
The inscional biopsy report was dentigerous cyst and recommended surgical treatment. He is worried and fears he won't be able to make it for the training camp which is four weeks away.
zoom view
Fig. 1.4:
 
QUESTIONS
  1. What is a dentigerous cyst? What is the treatment?
  2. Do you think George will be able to attend the training camp? Why?
  3. Is the picture given consistent with the histopathological diagnosis? Justify mentioning two points. Label the marked structures.
5
 
OSCE Station 1.5
A 17-year-old girl was brought to the oral medicine clinic with complaint of a swelling on the lower lip (1 cm × 1 cm) since last three weeks. She has a history of trauma to the region a month ago.
Specimen: Excisional biopsy from lower lip.
zoom view
Figs 1.5A to C:
 
QUESTIONS
  1. What is the rationale behind doing an excisional biopsy?
  2. What is the histopathological diagnosis?
  3. What is the pathogenesis of the lesion?
  4. What is the treatment and prognosis?
6
 
OSCE Station 1.6
Mr Lee (ID No: K012345) a 44-year-old businessman visited your dental clinic with chief complaint of a growth in the mouth since last five months. He is a known case of diabetes and hypertension under medication and smokes 3–5 cigarettes a day for the last 20 years.
An asymptomatic, non-tender, pedunculated soft tissue growth measuring 1 cm × 1 cm was seen on the right buccal mucosa of normal color, texture and soft in consistency. Excisional biopsy done and submitted for histopathology.
 
QUESTIONS
  1. Please fill out the biopsy request form for this case.
  2. Which solution will you use to fix the specimen?
BIOPSY REQUEST FORM
Name:
Age:
Gender:
ID No:
Date of Biopsy:
For lab use only:
Referred by:
CLINICAL DESCRIPTION
Soft tissue lesion
Color
Morphology
  • White
  • Flat
  • Red
  • Raised
  • Pink
  • Ulcer
  • Others__________________
  • Others___________________
Tooth Number ________
Radiographic Changes________________
Hard tissue lesion
  • Lucent
  • Opaque
  • Mixed
  • Radiograph submitted ? Yes/ No
Tooth Number ________
Radiographic Changes________________
7
zoom view
Figs 1.6A and B:
TYPE OF SPECIMEN SUBMITTED
Biopsy
Cytology
Immunofluorescence
Incisional
PAP Stain (Dysplasia/Carcinoma)
Perilesional
Excisional
PAS Stain (Infectious)
Clinically normal
HPV
RELEVANT HISTORY (Include habit history)
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
DIFFERENTIAL DIAGNOSIS (Minimum two)
________________________________________________________________________ ________________________________________________________________________
8
 
OSCE Station 1.7
Following is the conversation between a dentist and his patient:
Dentist: “Hello! Mr Harry, how are you?”
Harry: “I am fine doctor. Just that I have noticed a small red and white area on my cheek that feels kind of weird and is there for the last 5 weeks”.
Dentist: “Well that looks big and abnormal. Do you still chew those tobacco products?”
Harry: “Yes I do, but I have reduced the number to 4 times a day. I keep them right next to the red area to relieve the pain sometimes”.
Dentist: “Well Harry we need to take a piece of tissue from there to find out what's happening.”
Photomicrograph of Biopsy specimen
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Figs 1.7A and B:
 
QUESTIONS
  1. What type of biopsy has been done here?
  2. What has happened microscopically?
  3. How will you motivate Harry to quit his habit?
  4. Describe the role of tobacco in the development of this lesion.
9
 
OSCE Station 1.8
Please read the following biopsy report and answer the questions below:
BIOPSY REPORT
Patient Details
Name: Ms. Katie
Age: 28 Years
Gender: Female
ID No:305-07-5112
OP. No.:3127/10
Biopsy No.:59/12
Referred by: Dr Lim (OMFS)
Date of Biopsy:06/12/12
Date of Reporting:14/12/12
Clinical Details
Patient complains of swelling in the lower right retromolar region since the last 5 years, history of previous excision with no known histopathology report. Associated mild intermittent pain aggravated on eating. On oral examination a 2 cm×2 cm solitary swelling with normal color and consistency seen.
Biopsy Details
Incision biopsy.
Histopathology
H and E stained superficial and deep sections show multiple soft tissue bits composed of overlying hyperplastic stratified squamous epithelium and connective tissue showing nonencapsulated tumor tissue composed of multicystic areas. Cystic spaces are lined by large number of mucus cells with basaloid or cuboidal intermediate cells and fewer epidermoid cells. Some solid areas show sheets of clear cells, focal areas of chronic inflammatory cells, areas of hyalinization and numerous dilated blood capillaries.
Tumor tissue shows mucicarmine positive staining for sialomucin.
 
QUESTIONS
  1. What is your histopathologic diagnosis based on the description?
  2. What is mucicarmine stain? Why is it used?
  3. What is the treatment and prognosis for this lesion?
10
 
OSCE Station 1.9
A 25-year-old pregnant woman in second trimester came to dental clinic with chief complaint of painful swelling on the gums. The swelling appears ulcerated, boggy and inflamed. Oral hygiene was poor. She requests you to prescribe medication for pain relief before deciding on the treatment options.
zoom view
Fig. 1.8:
 
QUESTIONS
  1. Mention three differential diagnoses.
  2. What is the probable pathogenesis for the lesion?
  3. Can the patient be prescribed an analgesic? Justify your answer.
  4. What is your approach to manage this case?
11
 
OSCE Station 1.10
WM Tilakratne
A 30-year-old female patient presented to periodontology clinic for routine periodontal check-up. This is the radiograph taken for the assessment of alveolar bone loss.
zoom view
Fig. 1.9:
 
QUESTIONS
  1. Identify the radiograph.
  2. Describe the radiological findings.
  3. Mention three differential diagnoses.
  4. What additional information/investigations you may require in order to arrive at the definitive diagnosis?
12
 
OSCE Station 1.11
WM Tilakratne
zoom view
Figs 1.10A to C:
Following are extracted tooth specimens that were taken from three different patients.
 
QUESTIONS
  1. Identify the anomaly with specimens (Figs 1.10A to C).
  2. What are the etiological factors responsible for above anomalies?
  3. List two clinical implications each for these three anomalies.
13
 
OSCE Station 1.12
WM Tilakratne
A 50-year-old male presented to oral medicine clinic with burning sensation and leathery feeling of oral mucosa. He gives a history of betel nut with tobacco quid chewing since the last ten years.
zoom view
Figs 1.11A and B:
 
QUESTIONS
  1. What is the most likely diagnosis that can be arrived at with the provided clinical information, clinical picture and histopathological features?
  2. List three histopathological features present in the photomicrograph that may have contributed to arrive at the above diagnosis.
  3. What is the etiology of this disease?
  4. Briefly mention the significance of close follow-up of this patient.
14
 
OSCE Station 1.13
WM Tilakratne
A 30-year-old male was seen in the oral surgery clinic who presented with a large bony hard swelling of the right body of the mandible present since the last few weeks.
zoom view
Fig. 1.12:
 
QUESTIONS
  1. What is your diagnosis? (Credit given for accuracy)
  2. List three histopathological features in support of your diagnosis.
  3. What clinical features would you expect to see in this patient?
  4. Outline the management of this patient.
  5. Comment on the prognosis.
15
 
OSCE Station 1.14
WM Tilakratne
A 40-year-old male patient presented to oral surgery clinic with enlargement of bilateral parotid gland and swelling of both lips. The patient also complained of difficulty in breathing.
Specimen: Labial biopsy
zoom view
Fig. 1.13:
 
QUESTIONS
  1. State the histopathological features you observed in the photomicrograph.
  2. What other clinical features you would expect in this patient?
  3. What are the investigations that should be carried out in this patient to arrive at the definite diagnosis?
  4. Mention two syndromes associated with this disease.
  5. List the main features of one syndrome you mentioned in Question no. 4.
16
 
OSCE Station 1.15
A 30-year-old engineer complained of dryness and soreness of the mouth since a few months. He has also observed a small swelling in the floor of the mouth at every meal time. He finds it difficult to swallow food and has to sip in a lot of water. These days the swelling is increasingly becoming painful and uncomfortable.
 
QUESTION
Please demonstrate how you would go about doing the examination of this patient.
 
OSCE Station 1.16
A soft tissue pedunculated growth was seen in the denture bearing area of the palate in a 54-year-old postmenopausal female. The growth was asymptomatic, but caused discomfort to the patient during insertion of the denture and hence forced her to discontinue the denture use since few weeks.
zoom view
Fig. 1.14:
 
QUESTIONS
  1. Identify the lesion.
  2. Outline the management for the lesion.
  3. Name two other denture-related lesions.
17
 
OSCE Station 1.17
Diffuse greyish pigmentation is seen bilaterally in the buccal mucosa of a 40-year-old female.
zoom view
Fig. 1.15:
 
QUESTIONS
  1. Name at least four systemic causes of intraoral pigmentation.
  2. List two groups of drugs that cause pigmentation of oral mucosa.
  3. Give examples of two syndromes associated with cafe-au-lait pigmentation.
18
 
OSCE Station 1.18
Mr Dan, a 67 years old male, is a controlled hypertensive and diabetic since the last 25 years. He has been on prolonged topical steroid use in his oral cavity for few months.
zoom view
Fig. 1.16:
 
QUESTIONS
  1. Name the most common oral lesion which may result after prolonged use of this drug.
  2. As a dentist, what systemic manifestations should you worry about?
  3. Name two autoimmune diseases causing oral ulcers which can be treated using this drug in the picture.
19
 
OSCE Station 1.19
The following are four different cases of white lesions in the oral cavity.
zoom view
Fig. 1.17A: A 16-year-old school girl complains of roughness of the buccal mucosa on both sides and has a habit of clenching her teeth when she plays chess
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Fig. 1.17B: A 16-year-old school girl complains of roughness of the buccal mucosa on both sides and has a habit of clenching her teeth when she plays chess
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Fig. 1.17c: Mrs Zeenath, 53 years of age, is on immunosuppressant drugs since few months following organ transplant. Her physician noticed this lesion on her palate during a routine examination. She is however unaware of its presence
zoom view
Fig. 1.17d: A 45-year-old bus driver noticed a white area in his mouth since a few weeks; he says it is not causing him any pain. He is a chain smoker
 
QUESTIONS
  1. State the reasons for white appearance of the oral mucosa.
  2. Give the most probable diagnosis for each of these lesions based on the history provided (Figs 1.17A to D).
  3. Identify the scrapable lesions from the figures (Figs 1.17A to D).
20
 
OSCE Station 1.20
Rosnah Binti Zain
On clinical examination of a 56-year-old man, you notice that the tooth 28 was carious with crown fracture and 8 mm ulcer on the left posterior retromolar area extending to posterior sulcus. Patient confirmed the presence of the ulcer for more than two weeks and also gave history of smoking for more than 20 years.
zoom view
Fig. 1.18:
 
QUESTIONS
  1. Your differential diagnosis was traumatic ulcer, recurrent aphthous ulcer and a malignant ulcer. What are the important clinical features that can distinguish each of these diagnoses?
    1. Identify two relevant facts from patient's history and suggest provisional diagnosis of a malignant ulcer.
    2. Which palpatory finding will support the above provisional diagnosis?
  2. Justify.
21
 
OSCE Station 1.21
Rosnah Binti Zain
A 23-year-old male factory worker presented at your clinic with multiple ulcerations in the oral cavity for the past six months. He had no history of chewing tobacco/betel quid and is a non-smoker.
 
QUESTIONS
  1. Your differential diagnoses are recurrent aphthous ulcerations, pemphigus vulgaris and recurrent intraoral herpes simplex virus (HSV) infection. Write one key feature that differentiates the clinical characteristics that you will be looking for in each of these diagnoses.
  2. If the diagnosis is recurrent aphthous ulcers, one of the systemic conditions which may give rise to similar ulcerations, is Behcet's syndrome. What are the additional clinical characteristics for this syndrome?
 
OSCE Station 1.22
Rosnah Binti Zain
A 45-year-old man reported with multiple painful ulcerations since a few days. He had a history of fever preceding the ulcers.
zoom view
Fig. 1.19:
 
QUESTIONS
  1. Based on the above picture, give two differential diagnoses.
  2. What is your definitive diagnosis for this case and give reason?
22
 
OSCE Station 1.23
Rosnah Binti Zain
A 21-year-old girl visits your clinic. While doing a general examination; you notice pallor and spoon-shaped nails (koilonychia).
 
QUESTIONS
  1. What does this finding indicate with regards to the patient's medical history?
  2. While conducting the oral examination, you notice the patient having atrophied dorsum of tongue. How is the atrophied tongue related to the findings in Question 1 above?
  3. You referred the patient to oral medicine specialist who did a full blood investigation. What additional blood investigation should be requested in view of the atrophied tongue?
23
 
Answers
 
OSCE STATION 1.1
  1. Pleomorphic adenoma is the histopathologic diagnosis based on the following features identified:
    1. Encapsulation with area showing normal parotid tissue and tumor tissue.
    2. Numerous ducts like structures with eosinophilic coagulum and stromal hyalinization.
  2. Pleomorphic adenoma develops from pluripotent stem cells.
  3. Smoking is not the etiology of this lesion. The treatment advised is surgical excision with preservation of the facial nerve. The prognosis of the lesion is fair to good.
 
OSCE STATION 1.2
  1. Leukoplakia, Hyperplastic candidiasis, Lichen planus.
  2. Excision biopsy is indicated as the lesion is within 2 cm × cm.
  3. Leukoplakia. Histopathologic diagnosis is Epithelial Dysplasia (Moderate grade).
  4. Basilar hyperplasia, nuclear hyperchromatism, loss of stratification and mitotic figures. All features involve lower and middle one third of the epithelium.
  5. Commercially available nicotine patches can act as smoking substitute in order to help quit the habit.
 
OSCE STATION 1.3
  1. Dentigerous Cyst, Adenomatoid Odontogenic Tumor (AOT), Odontogenic Keratocyst. Impacted teeth are recommended for removal because they can give rise to cyst, odontogenic tumor, associated infection or malocclusion.
  2. Ameloblastoma (plexiform type). Labelled tissue is stellate reticulum like tissue.
  3. Follicular, Granular, Basal cell and Desmoplastic.
  4. Odontomes are described as the most common odontogenic tumors.
 
OSCE STATION 1.4
  1. Dentigerous cyst is a developmental odontogenic cyst which is commonly associated with impacted teeth and develops from reduced enamel epithelium. The treatment is enucleation of the cyst as the size is small.
  2. Yes, George will be able to attend the training camp as the surgical wound will reepithelialize in seven days. However, the bone formation can take many weeks.
  3. Yes the histopathological picture shows a 2–4 cell layered cystic lining epithelium which resembles reduced enamel epithelium with a fibrocollagenous cyst wall features which are consistent with dentigerous cyst. The marked structures are – cyst lumen (arrow 1) and lining epithelium (arrow 2).
24
 
OSCE STATION 1.5
  1. Since the lesion is small in size and the history is suggestive of a benign lesion, surgical excision is the treatment. The complete specimen removed is sent for histopathologic confirmation thus termed excisional biopsy.
  2. Mucocele (Extravasation Phenomenon)
  3. Trauma to the region causes the severance of the salivary duct which leads to the pooling of saliva in the connective tissue and dilation of ducts. The pooled saliva is perceived as a foreign substance by the body and thus the inflammatory response surrounding the mucin pooling. This also leads to inflammation of the gland with subsequent acinar degeneration.
  4. Treatment is surgical excision with removal of the associated gland and duct. Prognosis is good.
 
OSCE STATION 1.6
  1. BIOPSY REQUEST FORM
PATIENT DETAILS
Name: Mr. Lee
Age: 44 years
Gender: Male
ID No: K012345
Date of Biopsy:
For lab use only:
Referred by: your name
CLINICAL DESCRIPTION
Soft tissue lesion
Color
Morphology
  • White
  • Flat
  • Red
  • Raised
  • Pink
  • Ulcer
  • Others: Normal
  • Others-: Pedunculated Growth
Tooth Number ________
Radiographic Changes________________
Hard tissue lesion
  • Lucent
  • Opaque
  • Mixed
  • Radiograph submitted ? Yes/ No
Tooth Number ________
Radiographic Changes________________
25
zoom view
TYPE OF SPECIMEN SUBMITTED
Biopsy
Cytology
Immunofluorescence
Incisional
PAP Stain (Dysplasia/Carcinoma)
Perilesional
Excisional
PAS Stain (Infectious)
Clinically normal
HPV
RELEVANT HISTORY (Include habit history)
Chief complaint of a growth in the mouth since the last 5 months. Oral examination: An asymptomatic, non-tender, pedunculated soft tissue growth measuring 1 cm x 1 cm seen on the left buccal mucosa of normal color, texture and soft in consistency.
Known case of diabetes and hypertension under medication and smokes 3–5 cigarettes a day for the last 20 years.26
DIFFERENTIAL DIAGNOSIS (Minimum 02)
  • Fibroma.
  • Neurofibroma.
  1. In the case 10% formalin is used as the standard fixative for routine histopathology specimens.
 
OSCE STATION 1.7
  1. Incisional biopsy
  2. At the microscopic level the epithelium shows a break in the basement membrane with tumor invading the connective tissue in whorls and islands. The tumor is composed of squamous epithelial cells showing atypia, moderate amount of keratin.
  3. Based on the history and clinical examination, the lesion in question is associated with tobacco habit and the patient can be motivated to quit the habit by the following:
  1. Explain the role of tobacco in development of precancer and cancer of the oral tissues.
  2. Showing photographs and health promotion pamphlets/videos.
  3. Explaining the impact of the various treatment procedures he/she would have to undergo if cancer sets in.
  4. Suggest alternatives to tobacco such as use of nicotine patches to help in quitting.
  1. Tobacco has been described by the WHO as a potent carcinogen which has the potential to cause DNA damage which could become irreparable. The association of tobacco having a dose dependent cumulative effect on the DNA has been proven. This DNA damage can transform a normal cell into a tumor cell which proliferates and also has a defective apoptosis mechanism. These changes lead to the development of squamous cell carcinoma when it affects the squamous cells of the oral mucosa.
 
OSCE STATION 1.8
  1. Low grade mucoepidermoid carcinoma (MEC).
  2. Mucicarmine is a special stain used for the identification of mucin producing mucus cells.
  3. The treatment for low grade MEC is surgical resection. The prognosis of this lesion is good compared to the other grades.
 
OSCE STATION 1.9
  1. Pyogenic granuloma, peripheral ossifying fibroma, peripheral giant cell granuloma.
  2. Poor oral hygiene and hormonal changes associated with pregnancy increase the reaction of oral tissue to minor irritation or trauma caused by dental plaque or calculus leading to the formation of the reactive lesion in this case.
  3. As she is in second trimester, she can be prescribed paracetamol 250 mg safely.
27
  1. Symptomatic treatments for pain with follow up. Elective treatment can be postponed for post delivery.
 
OSCE STATION 1.10
  1. Intraoral periapical view of lower anterior region.
  2. Multiple radiolucent lesions in relation to periapical area of lower central and lateral incisors. Some lesions are well defined but all are noncorticated. There is an ill-defined radiolucency at the periapical area of the lower right canine. Interradicular alveolar bone loss is also present.
  3. Multiple periapical granulomas, early cysts or periapical abcesses or periapical cemental dysplasia.
  4. In order to exclude the common lesions of the first category, teeth should be nonvital. Therefore, history should be explored to find out any cause leading to nonvital teeth such as trauma, previous orthodontic treatment, etc. Vitality test should be performed. If the teeth are vital, the most likely diagnosis is periapical cemental dysplasia and previous radiographs if any available should be reviewed in an attempt to identify early lesions. Follow up radiographs are recommended in six months to one year intervals to observe the radiographic changes ranging from radiolucent to mixed radiodense and finally to radio-opaque lesions.
 
OSCE STATION 1.11
  1. Specimen 1.10A: Hypercementosis
    Specimen 1.10B: Dilaceration
    Specimen 1.10C: Concrescence
  2. Etiological factors
    1. Hypercementosis: Common causes: Occlusal trauma, inflammation in and around roots, isolated unopposed teeth. Rare causes: Paget's disease of bone, acromegaly, thyroid goiter, rheumatic fever.
    2. Dilaceration: Most cases are attributed to trauma to the primary predecessor in the form of intrusive or avulsive injury. It can rarely happen as a secondary event such as presence of odontomes, supernumerary, cyst or a tumor in relation to the developing tooth. However, occasional cases can be idiopathic.
    3. Concrescence: Space restrictions during development, divergent roots, local trauma, excessive occlusal force or local infection after development are the suggested causes.
    1. Hypercementosis: Extraction of teeth with hypercementosis leads to fracture of roots which need surgical exposure for removal. Orthodontic movement of teeth with hypercementosis may create difficulties depending on the severity of the problem.
    2. Dilaceration: Clinical implications depend on the severity of dilaceration. The dilacerated teeth with delayed eruption may need to be surgically exposed and orthodontically moved into correct position. Orthodontic movement is not indicated and not possible in severe cases. Endodontic treatment in these teeth should be performed with caution in order to prevent root perforation.28
    3. Concrescence: Extraction of these teeth leads to fracture of roots or fracture of the maxillary tuberosity. Oro-antral fenestration is another common complication when trying to extract these teeth.
 
OSCE STATION 1.12
  1. Oral submucous fibrosis (OSMF).
  2. Atrophic stratified squamous epithelium, Juxtaepithelial hyalinization, extensive fibrosis of the corium and replacement of muscle by fibrous tissue.
  3. Arecoline present in arecanut via multiple pathways cause imbalance between collagen formation and degradation leading to accumulation of collagen.
  4. As this is an oral potentially malignant disorder, regular follow up is mandatory in order to identify early changes of the condition leading to malignancy. Because of the poor visibility of the oral mucosa due to restricted mouth opening diagnosis of subsequent cancer may be delayed as the patient is not in a position to see the early lesion. Therefore, frequent professional examination is mandatory.
 
OSCE STATION 1.13
  1. Ameloblastoma; Unicystic luminal type.
  2. Cystic lesion lined by odontogenic epithelium comprised of elongate basal cells mimicking the appearance of ameloblasts, basal cells are hyperchromatic and show reverse polarity, surface cells of the epithelium are vacuolated and similar to stellate reticulum cells.
  3. Slow growing painless swelling, no inflammatory changes on the surface mucosa, anesthesia or paresthesia of the lower lip, buccolingual expansion, drifting and mobility of adjacent teeth.
  4. Treatment of ameloblastoma varies depending on the type. Solid multicystic type and unicystic mural type need more radical treatment such as removal of the affected segment of the mandible in most cases. Luminal type of unicystic ameloblastoma needs more conservative treatment such as enucleation and proper curettage of the surface bone. However, enucleation as a treatment modality for any type of ameloblastoma is questionable according to current literature. Regular follow up is mandatory after surgical treatment.
  5. Prognosis of unicystic ameloblastoma, especially luminal type is much better than solid multicystic type. Although, the recurrence rate varies according to the type of treatment, it may be up to 30%. Majority of the recurrences appear during first 5 years after surgery.
 
OSCE STATION 1.14
  1. Numerous granulomas comprised of epithelioid macrophages without any evidence of central caseous necrosis. Lymphocytic aggregates are also present in between granulomas.
  2. Clinical features depend on the involvement of different parts of the body. However, the common features such as fatigue, malaise, arthralgia, chest pain and weight loss are seen in most patients. Some patients may not develop obvious symptoms for many years. Tender erythematous nodules referred to as erythema nodosum is a common skin manifestation. Ocular symptoms are also present in some patients. Xerostomia and xerophthalmia may also be present.29
  1. Radiological investigations especially chest X-rays, elevated serum calcium levels, Kveim test, negative findings for culture and special stains for organisms, elevated serum angiotensin'converting enzyme levels and increased ESR. Sarcoidosis is the most likely diagnosis.
  2. Heerfordt's syndrome (Uveo-parotid fever) and Lofgren's syndrome.
  3. Heerfordt's syndrome: Facial paralysis, anterior uveitis, parotid enlargement and fever.
Lofgren's syndrome: Bilateral hilar lymphadenopathy, erythema nodosum and arthralgia.
 
OSCE STATION 1.15
  • The symptoms of the patient point towards a problem in the submandibular region. An intermittent swelling in the floor of the mouth at meal time is most commonly suggestive of a submandibular salivary gland duct swelling. Following are the steps towards examination of the patient:
  • Greet and introduce yourself to the patient politely.
  • Seat the patient comfortably upright on the dental chair.
  • Explain the procedure and take permission.
  • Stand behind the patient, tilt the patient's head towards the side to be examined. Cup your fingers around the mandible and palpate the submandibular region for the swelling.
  • To confirm the intraoral extent of the swelling, palpate the floor of the mouth with gloved fingers. The extent of the swelling both intraorally and extraorally can be confirmed by bi-manual palpation. This technique also helps distinguishe between a submandibular gland, sublingual glands and submandibular lymph node.
  • Salivary flow can be examined intraorally by milking the gland and observing the salivary flow from the orifice. Saliva can be expressed from the submandibular gland by compressing the gland with bimanual palpation and by pressing towards the orifice.
 
OSCE STATION 1.16
  1. Epulis/epulis fissuratum
  2. Excisional biopsy of the lesion should be done keeping the size of lesion in mind. Denture hygiene instructions are given to the patient. Fabrication of new dentures has to be done.
  3. Denture related lesions: Denture stomatitis, Traumatic ulcer.
 
OSCE STATION 1.17
  1. Systemic causes of intra-oral pigmentation:
    • Addison's disease30
    • Cushing's syndrome
    • Hyperthyroidism
    • Primary biliary cirrhosis
    • Vitamin B12 deficiency
    • Peutz-Jeghers syndrome
    • HIV/AIDS associated melanosis.
  2. Drugs causing pigmentation of oral mucosa:
    • Antimalarial
    • Phenothiazines
    • Oral contraceptives
    • Cytotoxic drugs
    • Antimicrobials like Minocycline.
  3. Syndromes associated with cafe-au-lait pigmentation:
    • Neurofibromatosis
    • McCune –Albright syndrome
    • Noonan syndrome
    • LEOPARD syndrome
 
OSCE STATION 1.18
  1. Oral candidiasis.
  2. Systemic manifestations of raise in blood pressure and increased blood sugar levels may be expected.
  3. Pemphigus, pemphigoid.
 
OSCE STATION 1.19
  1. The reason for white appearance of oral mucosa:
  • Hyperkeratosis
  • Acanthosis (abnormal but benign thickening of stratum spinosum).
  • Accumulation of fluid- intra and extracellular.
  • Necrosis.
  • Pseudomembrane- e.g. Oral thrush
  1. Diagnosis of the lesions:
  1. The scrapable lesions are chemical burn and oral thrush.
 
OSCE STATION 1.20
  1. In order for this lesion to be a traumatic ulcer, there must be a cause and effect relationship where in the history of this patient it was described as a crown fracture with 28, thus the possibility of a traumatic ulcer. The characteristic presentation of an aphthous ulcer is usually an ovoid or round, yellowish or white centred, with a red halo. However, a major aphthous ulcer may present with raised borders as in this picture. A malignant ulcer would also have the characteristics of a raised border which is evident in this picture.
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    1. Firstly, the patient had a history of smoking for 20 years. Smoking is a known risk factor for oral cancer. Secondly, the ulcer has not healed for over 2 weeks.
    2. The clinician can palpate the ulcer border and a firm indurated ulcer border will support the provisional diagnosis of a malignant ulcer.
  2. Firstly, traumatic ulcer must be ruled out. This is done by eliminating the cause which may be a rough tooth edge of the carious tooth 26. There are many ways to eliminate the cause namely, doing a restoration and/or smoothening the sharp cusp, or tooth extraction if the tooth is broken. A provisional diagnosis of a malignant ulcer can be made after a review of 2 weeks if the ulcer showed no signs of healing.
 
OSCE STATION 1.21
  1. Recurrent aphthous ulcers usually present as shallow ulcers with whitish-yellow ovoid centers with a red halo. They usually are present on non-keratinized mucosa and are recurrent in nature.
    • Pemphigus vulgaris usually presents as superficial erosions and ulcerations of the oral mucosa. Vesicles precede the lesions. Skin lesions may develop after the oral lesions.
    • Recurrent intraoral HSV infection usually appears as multiple small ulcers on keratinized mucosa, for example the hard palate or gingiva. There is usually a prodromal symptom of burning sensation prior to the appearance of the lesions.
  2. Behcet's Syndrome is a rare syndrome which also presents with recurrent genital ulcerations, eye lesions, skin and other systems involvement including the joints.
 
OSCE STATION 1.22
  1. Differential diagnosis:
    • Erythema multiforme, which may be preceded by a fever from a herpes simplex virus (HSV) infection.
    • Herpes zoster virus infection which is usually also preceded by a fever from a HSV infection.
  2. The definitive diagnosis is the herpes zoster virus infection because there are superficial irregular ulcerations of the oral mucosa and skin along one branch of the trigeminal nerve which in this case is the maxillary branch.
 
OSCE STATION 1.23
  1. The koilonychia is indicative of anemia, which has been present for a long time.
  2. Anemia may cause atrophy of the tongue papillae.
  3. Atrophied tongue may also be related to deficiencies of iron, folic acid and vitamin B12. Thus, serum iron, folic acid and vitamin B12 levels should be requested in addition to the full blood investigation.
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History Taking and Examination
A 55-year-old man came to your practice complaining of soreness in the mouth. You are the attending dentist and you must make a diagnosis and institute treatment.
Exercise: Conduct a patient-dentist consultation
ANSWER
Basic components of patient-dentist consultation are:
  1. Initial encounter
  2. Conducting interview
  3. Responding to the patient
  4. Negotiate treatment plan
  5. Closure of interview
 
INITIAL ENCOUNTER
First impression is always the best impression and will lay the foundation for the future dentist patient relationship. Patient during the initial moments will decide if he/she will be comfortable with the consulting dentist or not.
  • Greet and introduce yourself to the patient politely and then obtain patient's name. When welcoming the patient, make eye contact and shake hands.
  • Using a formal title to address the patient (e.g., Mr James, Ms Mary) is always best. For children or adolescents, avoid surnames unless you have permission from the patient or family. If you are unsure how to pronounce the patient's name, don't be afraid to ask.
  • Set the patient at ease and develop rapport.
 
CONDUCTING INTERVIEW
As the patient explains the chief complaint and the history of the present illness, you can question the patient using the following examples:
  • Ask the patient the purpose of the dental visit by using statements like “How can I help you…… “What problems bring you to the dental office today?”
  • If patient has number of concerns, ask to prioritize them.
  • Encourage the patient to tell the story in chronological manner from the start.
  • Use open ended questions to gather to more information like Describe the pain……
  • Use direct or closed ended questions as follow up to open ended like “Does the pain spread to other areas……
  • Avoid asking leading questions. Always ask one question at a time otherwise the patient will be confused. Give adequate time to the patient to think before answering the questions.
  • Listen to the patient attentively, allowing to complete the statement without interruption. During the interview, you can repeat or rephrase the statements said by patient. This tells the patient that you are listening and understanding what he/she is telling.
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  • Keep the interview organized and use transition statements when proceeding to another topic. These transitional statements prepare the patient of what is coming next.
  • For example, “I think I've got a pretty good idea of your main problem and how they developed. Now I would like to ask you some questions about your past health”.
  • Learn about the patient and his/her family during the course of interview (social and family history).
  • Create opportunities to the patient to ask questions during and after the consultation.
 
RESPONDING TO THE PATIENT
  • Pay attention to patient's verbal and nonverbal cues (body language, speech and facial expressions).
  • Express empathy to patient's concerns, which will help to develop trust between the patient and the dentist.
  • Do not be judgemental.
  • Be aware of your nonverbal cues. Your body language should be such that you are paying close attention to the patient's statement.
 
NEGOTIATING TREATMENT PLAN
  • After history taking, examination and testing; explain to the patient in the language they can understand (avoid jargon) what do you think the problem is and what will be the next steps.
  • Make sure that the patient understands the information provided.
  • Explore and discuss all available treatment options.
  • Collaborate with the patient to decide upon a mutually acceptable treatment plan.
 
CLOSURE OF INTERVIEW
At the end of interview:
  • Summarize the encounter to establish that both you and the patient understand the problem and agree upon the treatment plan.
  • Answer patient's questions and provide additional information.
  • Set up a follow up appointment.