Skin cancer - what general dental practitioners should look for.

General dental practitioners (GDPs) are well-placed to identify incidental skin lesions when they see patients for routine dental care. Indeed, some patients with an undiagnosed skin malignancy may only see their GDP on a regular basis rather than their general medical practitioner (GMP). GDPs should be able to assess exposed areas of skin, particularly focusing on the head and neck, to identify any lesions of concern and liaise with the patient's GMP where appropriate. We provide an overview focused upon the clinical appearances of isolated benign and malignant lesions, tailored for GDPs.

Proliferative verrucous leukoplakia: a general dental practitioner-focused clinical review.

Proliferative verrucous leukoplakia (PVL) is a distinct type of oral leukoplakia which has the potential to enlarge or develop into new areas of leukoplakia coupled with areas of a warty surface texture. PVL is usually diagnosed from the fifth decade onwards and is more common in female patients. The most frequent sites involved tend to be gingivae, followed by buccal mucosa and lateral border of tongue. It is one of the oral potentially malignant conditions with a high risk of malignant transformation. It is important for general dental practitioners (GDPs) to identify such lesions to facilitate referral for further investigation and diagnosis. Management is challenging with long-term monitoring and surgical excision when appropriate; however, PVL tends to recur following surgical excision. This article provides an up-to-date review tailored for GDPs on the present knowledge of PVL and illustrates the management challenges with clinical cases.

Oral hairy leukoplakia in healthy immunocompetent patients: a small case series.

BACKGROUND: Oral hairy leukoplakia (OHL) is caused by the Epstein-Barr virus (EBV) and usually presents in patients with human immunodeficiency virus (HIV) infection and systemic immunosuppression. It is rarely seen in patients who are immunocompetent. It is clinically characterised as an asymptomatic, soft, white and corrugated lesion that cannot be scraped from the surface it adheres to. METHODS: Immunocompetent patients with OHL attending Bristol Dental Hospital within the last 6 months were identified. EBV infection was demonstrated using EBV in situ hybridization. Clinical features and medical history were determined by reviewing medical records. CASE REPORT: Four cases of OHL in immunocompetent individuals were identified. All lesions were located on the lateral borders of the tongue. DISCUSSION: OHL should be considered as a differential diagnosis for white patches on the lateral borders of the tongue in apparently healthy immunocompetent patients, even when they do not have a typical corrugated appearance. OHL should no longer be regarded as pathognomonic for HIV infection or systemic immunosuppression.

Is tocilizumab a potential therapeutic option for refractory unicentric Castleman disease?

Castleman disease is a rare lymphoproliferative disorder with 2 distinctly defined clinical forms. While multicentric Castleman disease (UCD) poses a potential therapeutic challenge, unicentric variant has historically been considered curable with surgical resection. Hence, little is known to guide management of patients with UCD, refractory to surgical resection and combination chemotherapy. We present a case of a patient, negative for HIV and HHV-8, who had an unsuccessful surgical intervention and no response to radiotherapy and chemotherapy. He had severe paraneoplastic pemphigus and was treated with tocilizumab, an anti-interleukin-6 receptor monoclonal antibody that has demonstrated good response rates in multicentric Castleman disease but demonstrated no clinical response despite 2 months of treatment. Our report is the first to describe a lack of response to tocilizumab in the rare setting of refractory UCD and discuss potential for distinct disease biology.

Oral hairy leukoplakia arising in a patient with hairy cell leukaemia: the first reported case.

Oral hairy leukoplakia (OHL) is an oral mucosal lesion that is associated with Epstein-Barr virus infection. It commonly presents as an asymptomatic, non-removable white patch on the lateral borders of the tongue in individuals who are immunocompromised. Historically, OHL was thought to be pathognomonic of HIV infection; however, it is now an established phenomenon in a range of conditions affecting immune competence. Hairy cell leukaemia (HCL) is a rare chronic B cell lymphoproliferative disease named after the distinctive cytology of the atypical cells. We report the first case of OHL arising in an individual with HCL that resolved following remission of the haematological malignancy.

Vestibular Schwannoma Presenting as Oral Dysgeusia: An Easily Missed Diagnosis.

We present a case of a fifty-year-old male patient who was referred to the Oral Medicine Department with a complaint of a salty taste. History taking subsequently revealed that the patient was also experiencing intermittent numbness of his left lower lip, tinnitus, and a feeling of fullness in the left ear. Magnetic resonance imaging was performed which revealed a large vestibular schwannoma affecting the left vestibulocochlear nerve, which was treated surgically. This case shows the importance of taking a detailed history in a patient presenting with an initial complaint of oral dysgeusia. It also highlights the possibility of significant underlying pathology, presenting with initial low level, nonspecific complaints such as an altered taste, and the rationale for imaging patients who report unilateral facial hypoesthesia.

Oral verruciform xanthoma.

Verruciform xanthoma (VX) of the oral cavity is a benign mucosal growth that often presents as a pink, yellow or grey raised plaque or papule with granular, papillary or verrucous surface morphology. Intraorally this often presents on the masticatory mucosa and extraorally often involves the skin and anogenital mucosa. There are several proposed aetiological factors and the clinical features of VX can be misleading; clinically it can resemble malignancy. Histopathological diagnosis is a key for the correct management of this lesion. Excision of this lesion is curative.

Treatment of mucous membrane pemphigoid with the combination of mycophenolate mofetil, dapsone, and prednisolone: a case series.

Mucous membrane pemphigoid (MMP) is an autoimmune blistering disorder characterized by inflammation, blistering, and scarring and predominantly occurring at mucous membranes. Successful treatment can be challenging, and uncontrolled disease may result in significant morbidity with scarring of the conjunctiva and oropharynx leading to blindness and dysphagia, respectively. We report safe successful treatment of 6 patients with significant MMP-related oral inflammation with the use of a previously unreported combination of mycophenolate mofetil, dapsone, and prednisolone given at relatively low doses. We propose that this combination of treatments should be investigated further.

Oral hairy leukoplakia in a patient on long-term anticonvulsant treatment with lamotrigine.

We describe a case of oral hairy leukoplakia that presented with an atypical appearance in a patient on long-term anticonvulsant treatment with an aromatic antiepileptic, lamotrigine. Recent medical history was also significant for recurrent respiratory tract infections requiring treatment with oral antibiotics. Immunologic investigations revealed inverted CD4/CD8 ratio, mild hypogammaglobulinemia, and poor specific antibody titers. Combined immune deficiency caused by long-term treatment with lamotrigine was suspected after other known factors and conditions (including retroviral infection) leading to acquired immune deficiency were excluded. Withdrawal of lamotrigine resulted in complete resolution of oral hairy leukoplakia. There was no significant improvement in immunoglobulin levels. The effect of lamotrigine and other aromatic antiepileptics on the immune system should be considered in a patient presenting with otherwise unexplained oral hairy leukoplakia.

Recurrence of Wegener's granulomatosis with de novo intraoral presentation treated successfully with rituximab.

We describe a unique case of a recurrence of Wegener's granulomatosis (WG) that presented with oral pain involving a left maxillary molar, which thereafter led to an extraction. Oral lesions with a classical appearance of strawberry gingivitis developed following the extraction. The primary disease did not have any oral manifestations. Both the primary disease and recurrence responded to rituximab, a monoclonal B-cell depleting antibody. Rituximab is emerging as a drug with significant potential to improve treatment of primary and, as described in this case, recurrent WG.

Dermographism and delayed pressure urticaria.

There are few papers in the literature that describe pressure urticaria in the maxillofacial region. We present 2 cases and discuss the significance and principles of management. One case describes the diagnosis of pressure urticaria and the second describes the dental management of a patient with severe pressure urticaria.