History of Present Illness
Ms. Fernandez is an 82-year-old Argentinian female who presents for her routine 6 month check-up. She relates no specific complaints. She has been successfully using a topical steroid rinse (dexamethasone 0.5g / 5mL) 2-3 times per day as needed to control her oral lichen planus, which was diagnosed 5 years ago. A review of her medical history reveals:
Extraoral examination: (+) crepitus on left TMJ, no limitations or pain on opening, no lymphadenopathy. Intraoral examination: an irregular-shaped area of thick keratosis surrounding a granular appearing erosion is present on the lower left alveolar ridge in the area of #17 (Figure 1). Gentle palpation of this area provokes sponateous bleeding with no discomfort. A panorex is ordered and reveals non-restorable #2 and #3 and a supererupted #15, but no obvious osseous pathoses affecting the lower mandibular region (Figure 2). An incisional biopsy is performed in the lower left alveolar ridge area and the tissue is submitted for histopathologic examination.
The histologic sections of the incisional biopsy show infiltrating cords and islands of atypical squamous epithelium arising from dysplastic surface mucosa. There is a supporting fibrovascular connective tissue stroma with lymphocytic interface chronic inflammatory infiltrate. The epithelial cells displays pleomorphic round to oval nuclei with finely dispersed to vesicular chromatin, prominent nucleoli, increased nuclear to cytoplasmic ratio and pink focally dyskeratotic cytoplasm. There are numerous abnormal mitotic figures and focal single apoptotic cells.