Oral Diagnosis & Oral Medicine Competency Case

1. Oral Diagnosis & Oral Medicine Competency Case Jay Joshi October 19, 2010 Team 2 Case # 547591

2. The Patient • 63 year old white male from Bentonville, AR • Patient is not currently taking any medications and has no significant health complications other than occasional bronchitis. Only allergies are to pollen and ragweed.

3. The Lesion • Patient presented with a localized unilateral red and white ulcerated lesion on the hard palate near tooth #14. Lesion was epithelial involved with somewhat ill-defined borders. • Lesion appeared a couple of days prior to photographs.

4. Intraoral Photographs

5. Intraoral Photographs

6. Patient Dialogue • How long have you noticed the lesion? (a few days) • Has this lesion resided and reoccured? Does it cause you discomfort and irritation? (I think it may be the first time, yes it’s irritating) • Have you eaten or drank anything very hot in the last few days? (maybe) • Have you experienced any trauma in the last few days such as perhaps biting yourself when eating? (maybe, I’m not sure) • Do you smoke? (Never)

7. Differential Diagnosis • Traumatic Ulcer (heat, trauma) • Very Mild Secondary Herpes Infection • Chemical Burn / Cigarette Burn • Fistula / drainage of Periodontal Origin or PA lesion

8. Provisional Diagnosis/Treatment • Traumatic Ulcer because patient has a single ulcerated lesion on the keratinized tissue of the hard palate. The patient may have irritated the epithelial tissue when he may have eaten something hot or sharp or drank something hot like coffee. Periodontal probing ruled out drainage, and x-rays ruled out PA lesion. Also, patient doesn’t smoke so its not a cigarette burn. It may still be a chemical burn. • There is no indicated treatment for traumatic ulcer. It will heal on its own with time.