Diagnostic Information

History of Present Illness Mr. Chappin is a 79-year-old white male who presents for an evaluation of his “mouth sores.” He first noticed having difficulty wearing his lower denture about one month ago and it has progressively gotten worse. He points to the molar area of his lower left mandibular ridge. He had an immediate denture placed nine months ago and up until a month ago he was doing fine. A review of his medical history reveals: Medical History - Adverse drug effects: none

- Medications: zoledronic acid 4mg q 3 months, Lupron Depot 22.5mg q 3 months, pironolactone 100mg qd, losartan 50mg qd, asprin 81mg qd, Centrum Silver qd.

- Pertinent medical history: metastatic prostate cancer x 3 years with metastases to pelvis, right hip and lower back (managed with irradiation/chemotherapy); HTN x 20 years.

- Pertinent family history: paternal – prostate cancer, died at age 66; maternal – fatal stroke age 82; brother nonfatal MI at age 72.

- Social history: 20 pack year history of cigarettes, stopped age 35; 1 glass of wine per night x 40 years; denies recreational drug use Clinical Findings Extraoral examination is unremarkable. Intraoral examination reveals a 3 x 3mm ulceration with exposure of alveolar bone and evident purulence on the facial aspect of the lower left alveolar ridge #20 area (Figure 1). Approximately 1 cm distal to this lesion is a small parulis from which pus is easily expressed when applying gentle pressure (Figure 2). Both areas are tender to palpation. The panorex reveals sclerotic healing of the recent extraction sites and a slight cupping of the alveolar bone in the lower left mandibular molar area (Figure 3). A biopsy and debridement of the areas in questions were accomplished under local anesthesia.

Figure 1. Small purulent ulceration with osseous exposure.

Figure 2. Purulence expressed from parulis distal to area of osseous exposure.

Figure 3. Panoramic image; note sclerotic healing socket sites and slight cupping of alveolar bone #20 area.

Histopathologic Findings Histologic sections of the biopsy show a segment of necrotic bone exhibiting empty osteocyte lacunae, ragged peripheral resorptive defects, and heavy surface overgrowth of bacteria. There are associated portions of soft tissue consisting of acute and chronically inflamed edematous, congested, granulation tissue containing interspersed vascular channels lined by plump reactive endothelial cells. The soft tissue is focally surfaced by reactive hyperplastic, spongiotic, stratified squamous epithelium exhibiting neutrophilic exocytosis.

Figure 4. Histologic image of associated acute and chronically inflamed granulation tissue with interspersed congested vascular channels lined by plump reactive endothelial cells. There is a portion of reactive squamous epithelium exhibiting neutrophilic exocytosis.

Figure 5. Histologic image showing a fragment of nonvital lamellar bone exhibiting empty osteocyte lacunae, ragged peripheral resorptive defects and heavy surface overgrowth of bacteria.