№1.

A 48-year-old woman applied with complaints of burning

sensation and roughness on the lateral surface of the tongue. She
has been under dispensary observation by an endocrinologist for
a compensated form of diabetes mellitus for the last 4 years. On
examination: on the back of the tongue and on the mucous
membrane of the cheek on the right - plaque and white plaques.
When scraping with a spatula, the plaque is partially removed.
Make a preliminary diagnosis.
Examine the patient.
Perform differential diagnosis.
Make a treatment plan

Based on the clinical presentation and medical history provided, the preliminary diagnosis
could be:

Chronic Candidiasis of the Oral Mucosa (likely associated with diabetes mellitus)

Rationale:

1. Symptoms:
o Burning sensation and roughness on the tongue are classic symptoms of fungal
infection (e.g., candidiasis).
2. Clinical Signs:
o White plaques on the tongue and cheek mucosa that are partially removable on
scraping are consistent with oral candidiasis.
3. Risk Factors:
o Diabetes mellitus (even in its compensated form) is a known risk factor for oral
candidiasis due to immune dysregulation and a favorable environment for fungal
growth (e.g., elevated glucose levels in saliva).
4. Location:
o The lesions on the tongue's lateral surface and buccal mucosa are typical areas
affected in candidiasis.

Further Investigation:

1. Microbiological Testing:
o Perform a direct smear (cytology) or culture to confirm the presence of Candida
species.
2. Glycemic Control:
o Evaluate her blood glucose and HbA1c levels to ensure her diabetes is well-
controlled.
 3. Differential Diagnoses to Consider:
o Leukoplakia: Usually not associated with burning sensation and less likely to be
partially removable.
o Lichen Planus: May present with white striations (Wickham's striae) and
burning, but plaques are not typically removable.
o Geographic Tongue (Benign Migratory Glossitis): Often presents with red
patches and burning but lacks removable plaques.
o Oral Cancer: While unlikely, biopsy should be considered if lesions persist or do
not respond to antifungal treatment.

Management Plan:

1. Topical Antifungal Therapy:

o Prescribe agents like Nystatin suspension, Clotrimazole lozenges, or
Miconazole gel.
2. Systemic Antifungals (if severe or recurrent):
o Fluconazole or Itraconazole may be necessary.
3. Improved Glycemic Control:
o Collaborate with her endocrinologist to optimize diabetes management.
4. Oral Hygiene Measures:
o Maintain good oral hygiene, avoid sugary foods, and consider using chlorhexidine
mouthwash.

If symptoms persist despite treatment, a biopsy and further investigations will be necessary.

№2
A 36-year-old man complained of an unusual appearance of his
lower lip. About a week ago, he noted an increase in body
temperature to 37.5 C. For 3 days he took a broad-spectrum
antibiotic. On examination: on the mucosa of the lower lip - 2
papules measuring 1 x 1.5 cm, surrounded by a rim of hyperemic
mucosa. When scraping with a spatula, the papules are easily
eroded. In the pharynx - a bright hyperemia. On the back of the
tongue there are areas of atrophy of the filiform and fungiform
papillae.
Make a preliminary diagnosis.
Examine the patient.
Perform differential diagnosis.
Make a treatment plan
Preliminary Diagnosis

Secondary Syphilis (Mucosal Manifestation - Syphilitic Papules)

Rationale

1. History and Symptoms:

o Fever (37.5°C) and systemic signs, which can accompany secondary syphilis.
o The patient was recently on antibiotics, but the condition persisted, which
suggests a non-bacterial etiology.
2. Oral Lesions:
o Papules on the lower lip: Characteristic of mucosal syphilitic lesions. These are
often slightly raised, surrounded by hyperemic (red) mucosa, and can erode upon
mild trauma (as seen when scraping with a spatula).
o Hyperemia of the pharynx: A common finding in mucosal syphilis.
o Atrophic areas on the tongue: Atrophy of the filiform and fungiform papillae,
also known as "bald tongue," can be associated with syphilitic glossitis.
3. Epidemiological Considerations:
o Secondary syphilis can manifest weeks to months after primary infection
(chancre).
o Lesions are highly infectious and are part of a systemic disease.

Differential Diagnosis

1. Recurrent Herpes Simplex Infection:

o Typically presents as vesicles that rupture to form painful ulcers, often with a
history of herpes labialis.
o Papules described here do not fit herpes lesions.
2. Erythema Multiforme:
o Can present with lip involvement but typically involves painful erosions or crusts.
o Does not cause bald tongue or systemic symptoms like those seen in syphilis.
3. Candidiasis:
o Associated with white plaques that scrape off, leaving an erythematous base.
o Does not typically cause papules or systemic symptoms.
4. Behçet's Disease:
o Recurrent oral and genital ulcers, but no evidence of genital lesions here.
5. Nutritional Deficiencies (Vitamin B12 or Iron):
o Can cause glossitis but are not associated with papules or systemic symptoms like
fever.

Investigations

1. Serological Testing:
o Nontreponemal Test: Rapid Plasma Reagin (RPR) or Venereal Disease Research
Laboratory (VDRL) test.
 o Treponemal Test: FTA-ABS (Fluorescent Treponemal Antibody Absorption) or
TPPA (Treponema Pallidum Particle Agglutination).
2. Dark-Field Microscopy:
o If possible, use for direct visualization of Treponema pallidum from lesions.
3. Additional Tests:
o HIV testing (due to frequent co-infection).
o Complete blood count (CBC) and liver function tests (to evaluate systemic
involvement).

Treatment Plan

1. Antibiotic Therapy:
o Benzathine Penicillin G (2.4 million units IM in a single dose): Standard
treatment for secondary syphilis.
o For penicillin-allergic patients: Doxycycline (100 mg orally, twice daily for 14
days) or Azithromycin (2 g orally in a single dose).
2. Symptomatic Management:
o Pain management with topical anesthetics (e.g., lidocaine gel) if lesions are
painful.
o Encourage hydration and soft foods to avoid irritation of oral mucosa.
3. Patient Education:
o Explain the infectious nature of syphilis and its systemic implications.
o Stress the importance of partner notification and testing.
4. Follow-Up:
o Reevaluate after 3-6 months with serological tests (e.g., RPR titer) to ensure
treatment success.
5. Public Health Measures:
o Report the case to the appropriate health authorities as per local regulations for
sexually transmitted infections.

№3

An 18-year-old man complains of pain in the oral cavity, bleeding

gums, general weakness, loss of appetite. He fell ill acutely, 3
days ago, against the background of general malaise and an
increase in body temperature to 37.8 C. On examination: on the
mucous membrane of the cheeks, hard palate and lips - multiple
small oval erosions, sharply painful on palpation. The gingival
mucosa is edematous, hyperemic.
Make a preliminary diagnosis.
Examine the patient.
Perform differential diagnosis.
Make a treatment plan

Preliminary Diagnosis

Acute Herpetic Stomatitis (Primary Herpetic Gingivostomatitis)

Rationale

1. History and Symptoms:

o Acute onset with fever (37.8°C) and systemic symptoms (general weakness, loss
of appetite).
o Painful oral erosions and bleeding gums, which are classic signs of acute herpetic
stomatitis.
o Typically seen in younger individuals or those with no prior immunity to Herpes
Simplex Virus (HSV).
2. Clinical Examination:
o Multiple small oval erosions on the mucous membranes of the cheeks, hard
palate, and lips, which are painful to palpation.
o Gingival mucosa is edematous, hyperemic, and prone to bleeding, indicative of
gingivostomatitis.
3. Epidemiology:
o Primary HSV-1 infection often occurs in childhood or adolescence.

Examination of the Patient

Subjective Examination:

1. Onset and progression of symptoms (e.g., duration, fever, presence of vesicles before
erosions).
2. Presence of other symptoms, such as swollen lymph nodes, difficulty eating, or drinking.
3. History of similar episodes, contact with infected individuals, or other risk factors (e.g.,
stress or immunosuppression).

Objective Examination:

1. Oral Examination:
o Inspect the mucosa of the cheeks, hard palate, lips, tongue, and gingiva for
vesicles, erosions, and bleeding.
o Assess for foul breath (halitosis), common in herpetic gingivostomatitis.
2. Lymph Nodes:
o Palpate submandibular and cervical lymph nodes for tenderness and enlargement.
3. Systemic Signs:
o Assess for dehydration, fatigue, or signs of systemic infection.
Differential Diagnosis

1. Erythema Multiforme:
o Painful erosions on the lips and oral mucosa but often associated with target
lesions on the skin.
2. Candidiasis:
o White plaques that can be scraped off, leaving a raw surface; less acute onset.
3. Vincent’s Stomatitis (Necrotizing Ulcerative Gingivitis):
o Painful, bleeding gums, with grayish pseudomembrane and foul odor; no systemic
symptoms like fever.
4. Aphthous Stomatitis:
o Painful ulcers but typically localized and not associated with systemic symptoms
or gingival bleeding.
5. Hand-Foot-and-Mouth Disease:
o Painful oral ulcers, fever, but usually accompanied by characteristic lesions on the
hands and feet.

Investigations

1. Tzanck Smear:
o Cytology to identify multinucleated giant cells typical of HSV infection.
2. Viral Culture or PCR:
o Swab of lesions for HSV-1 confirmation.
3. Serological Testing:
o HSV-1 IgM/IgG levels (not typically necessary in acute primary cases).
4. Complete Blood Count (CBC):
o Assess for leukocytosis or markers of systemic inflammation.

Treatment Plan

1. Antiviral Therapy:

 Acyclovir (200 mg, 5 times daily for 7-10 days):

Start promptly to reduce the duration and severity of symptoms.
 For severe cases or immunocompromised patients: Intravenous Acyclovir.

2. Symptomatic Treatment:

1. Pain Management:
o Topical anesthetics (e.g., lidocaine gel) applied to erosions before meals.
o Systemic analgesics: Paracetamol or Ibuprofen.
2. Oral Hygiene:
o Rinse with saline or chlorhexidine mouthwash (0.12%) to prevent secondary
infections.
o Avoid irritating foods (spicy, acidic).
3. Hydration and Nutrition:
 o Encourage fluid intake to prevent dehydration.
o Use soft, bland foods to reduce oral discomfort.

3. Patient Education:

 Explain the infectious nature of HSV and the risk of recurrence.

 Emphasize proper hygiene to prevent autoinoculation (e.g., to the eyes).

4. Follow-Up:

 Reevaluate symptoms after 7-10 days.

 If lesions persist, investigate for immunosuppression or secondary bacterial infection.

№4
A 50-year-old man complained of a feeling of tightness,
roughness of the mucous membrane in the area of the corners of
the mouth. Smoked up to 2 packs of cigarettes a day for 20 years.
On examination: in the area of the mucous membrane adjacent to
the corners of the mouth - foci of clouding of the mucous
membrane, grayish in color, triangular in shape, not scraped off
when scraping.
Make a preliminary diagnosis.
Examine the patient.
Perform differential diagnosis.
Make a treatment plan

Preliminary Diagnosis

Leukoplakia of the Oral Mucosa (Smoking-Associated Leukoplakia)

Rationale

1. History:
o Chronic heavy smoking (2 packs/day for 20 years), a known risk factor for
leukoplakia.
o Symptoms of mucosal tightness and roughness are consistent with oral
leukoplakia.
2. Clinical Features:
 o Foci of clouding of the mucous membrane, grayish in color, triangular in
shape.
o Lesions are not removed upon scraping, which differentiates leukoplakia from
other conditions like candidiasis.
3. Epidemiology:
o Leukoplakia is common in individuals with chronic exposure to irritants (e.g.,
tobacco, alcohol).

Differential Diagnosis

1. Leukoplakia (Primary Diagnosis)

 Features:
o White or grayish lesions, typically well-demarcated, with a rough texture.
o Associated with chronic irritation (e.g., smoking).
o Non-scrapable, which differentiates it from fungal infections.
 Comments:
o This condition is premalignant, with the potential for malignant transformation
(especially in smokers).
o Biopsy is essential to rule out dysplasia or malignancy.

2. Candidiasis (Chronic Hyperplastic Candidiasis)

 Features:
o White plaques on the oral mucosa that may become hyperplastic.
o Plaques may mimic leukoplakia but are usually scrapable, leaving an
erythematous base.
 Exclusion:
o The lesions described here are non-removable, and there is no mention of
erythema or burning, which are typical of candidiasis.

3. Lichen Planus (Reticular Form)

 Features:
o Presents with white striations or plaques (Wickham’s striae), typically on the
buccal mucosa.
o Lesions are bilateral, symmetrical, and painless in many cases.
 Exclusion:
o The lesions in this case are localized and lack the characteristic lacy pattern of
lichen planus.

4. Actinic Cheilitis (Chronic Sun Damage)

 Features:
 o White or grayish plaques, typically affecting the lips (especially the lower lip).
o Caused by chronic sun exposure, often in outdoor workers.
 Exclusion:
o The lesions in this case are located on the mucous membrane adjacent to the
corners of the mouth, not the lips.

5. Oral Submucous Fibrosis (Rare in Smokers, More Common with Betel Nut Use)

 Features:
o Progressive stiffening of the oral mucosa due to fibrosis.
o Associated with a burning sensation, difficulty opening the mouth, and pale,
fibrotic patches.
 Exclusion:
o Lesions in this case are not associated with fibrosis or trismus, and the primary
irritant is smoking, not betel nut use.

6. Oral Cancer (Early Stage)

 Features:
o White or grayish non-scrapable patches may represent early squamous cell
carcinoma.
o Often associated with risk factors like smoking.
 Exclusion:
o Early-stage cancer cannot be ruled out without a biopsy, but the absence of
induration, ulceration, or pain reduces its likelihood.

Investigations

1. Biopsy (Gold Standard):

o Histopathological examination to confirm the diagnosis and assess for dysplasia
or malignancy.
2. Toluidine Blue Staining:
o Aids in identifying areas suspicious for dysplasia or malignancy.
3. Additional Testing (if indicated):
o Cytology from the lesion.
o Screening for co-factors (e.g., alcohol use).

Treatment Plan

1. Smoking Cessation:

 Strongly advise the patient to stop smoking to reduce the risk of progression or
recurrence.
  Provide counseling or pharmacological support (e.g., nicotine replacement therapy,
bupropion).

2. Monitor the Lesion:

 Regular follow-up (every 3-6 months) to monitor for changes in size, color, or texture.

3. Address Local Irritants:

 Eliminate or reduce exposure to other irritants (e.g., alcohol, poor oral hygiene).

4. Surgical Management (if Dysplasia or Malignancy Confirmed):

 Excision of the lesion.

 Consider cryotherapy or laser ablation for smaller lesions.

Follow-Up

 Regular check-ups to assess for lesion regression or progression.

 Monitor for early signs of malignant transformation (e.g., induration, ulceration,
bleeding).

Early diagnosis and management are critical to preventing malignant progression in this patient.

Treatment Plan for Leukoplakia of the Oral Mucosa

1. Lifestyle Modifications

 Smoking Cessation:
o The primary focus is to eliminate the cause of irritation.
o Offer behavioral counseling, nicotine replacement therapy (NRT), or
pharmacological agents (e.g., bupropion or varenicline) to support cessation.
o Monitor progress with periodic follow-ups to reinforce smoking abstinence.
 Limit Alcohol Use (if applicable):
o Alcohol is a known co-factor for oral leukoplakia progression and should be
avoided.

2. Regular Monitoring

 Lesion Monitoring:
o Schedule regular follow-ups (every 3–6 months) to track changes in the lesion's
size, texture, and color.
o Watch for any signs of malignant transformation (e.g., induration, ulceration,
bleeding).
 Photographic Documentation:
 o Take clinical photographs at baseline and during follow-ups to monitor lesion
progression or regression.

3. Pharmacological Support (Adjunctive)

 Antioxidant Therapy:
o Prescribe antioxidants (e.g., beta-carotene, retinoids, or vitamin E) to reduce
oxidative stress, which may help reverse premalignant changes.
 Topical Agents:
o Consider topical corticosteroids (e.g., clobetasol propionate 0.05%) if
inflammation is present.

4. Biopsy and Histopathological Examination

 Perform a biopsy of the lesion to confirm the diagnosis and rule out dysplasia or early
malignancy.
o No Dysplasia: Focus on conservative management and monitoring.
o Mild Dysplasia: Continue monitoring and smoking cessation efforts; consider
excision if the lesion persists.
o Moderate/Severe Dysplasia: Surgical excision is indicated to prevent malignant
progression.

5. Surgical or Minimally Invasive Management (if Needed)

 Indications for Surgical Intervention:

o Lesions with confirmed moderate or severe dysplasia.
o Persistent leukoplakia that fails to regress despite eliminating irritants.
 Options:
o Surgical excision with clear margins (gold standard for dysplastic lesions).
o Cryotherapy or laser ablation for smaller, non-dysplastic lesions.

6. Oral Hygiene and Irritant Avoidance

 Improve Oral Hygiene:

o Educate the patient about proper oral care to minimize secondary irritation or
infection.
 Avoid Irritants:
o Discourage the use of strong mouthwashes with alcohol or highly acidic foods.

Follow-Up Schedule

1. Initial Phase:
 oReassess 1 month after smoking cessation to evaluate regression of lesions.
oPerform a biopsy during follow-up if no regression is observed.
2. Long-Term Monitoring:
o Continue follow-ups every 3–6 months, depending on biopsy results and clinical
presentation.

Prognosis

 With smoking cessation and proper management, non-dysplastic leukoplakia often

regresses or remains stable.
 Dysplastic lesions have a higher risk of malignant transformation, necessitating vigilant
follow-up and intervention.

By addressing the underlying cause and regularly monitoring the patient, the risk of malignant
progression can be significantly reduced.

№5
A 27-year-old young man complained of a long-term non-healing
fissure. On examination: a crack with a bright red surface was
found in the corner of the mouth on the left. Palpation is painless.
At the base of the crack is a dense infiltrate. Surrounding tissues
of normal color.
Make a preliminary diagnosis.
Examine the patient.
Perform differential diagnosis.
Make a treatment plan

Preliminary Diagnosis

Chronic Angular Cheilitis with Suspected Secondary Syphilis

Rationale for Diagnosis

1. Clinical Features:
o Persistent fissure at the corner of the mouth, long-lasting and non-healing.
o Bright red surface with a dense infiltrate at the base, suggesting chronicity and
possible specific etiology.
o Painless on palpation, which raises suspicion for a systemic condition (e.g.,
syphilis).
2. Systemic Conditions to Consider:
o Chronicity, induration, and a painless nature are highly suspicious for secondary
syphilis.
 o Angular cheilitis (caused by fungal, bacterial, or nutritional deficiencies) must
also be considered.

Examination of the Patient

1. General Examination:

 Assess for systemic signs of syphilis:

o Skin rash (especially on palms and soles).
o Generalized lymphadenopathy.
o Mucous patches or condylomata lata in the oral cavity or perianal region.
 Look for risk factors: sexual history or previous STIs.

2. Local Examination of the Lesion:

 Inspect for other fissures, ulcers, or erosions in the oral cavity and surrounding areas.
 Check for fungal infection (white plaques that scrape off) or bacterial infection
(erythema, purulent discharge).

3. Neurological Examination:

 Screen for any neurological symptoms (late-stage syphilis).

4. Laboratory Tests:

 Darkfield Microscopy: To check for Treponema pallidum in exudate (if available).

 Serology for Syphilis:
o Nontreponemal test: RPR or VDRL.
o Treponemal test: FTA-ABS or TPPA (for confirmation).
 Microbiological Tests:
o Fungal culture or KOH test (to rule out Candida).
o Bacterial culture and sensitivity (if purulent discharge is present).

5. Blood Work and Nutritional Assessment:

 Test for iron, vitamin B12, and folate levels (to rule out nutritional deficiencies).
 Screen for HIV or other immunosuppressive conditions, as syphilis often coexists with
these.

Differential Diagnosis

1. Secondary Syphilis (Most Likely)

 Features:
o Painless, chronic fissure with induration.
o Often part of a systemic presentation (rash, lymphadenopathy).
o Positive syphilis serology.
2. Angular Cheilitis (Candidiasis or Bacterial)

 Features:
o Redness, fissures, and irritation in the corner of the mouth.
o Often bilateral and associated with Candida (Candida albicans) or bacteria
(Staphylococcus aureus).
o Exclusion: Lesion here is unilateral, painless, and indurated without surrounding
erythema.

3. Actinic Cheilitis (Premalignant Lesion)

 Features:
o Chronic fissures or ulcers, typically on the lower lip, due to long-term sun
exposure.
o Exclusion: No history of sun exposure or predilection for the lip.

4. Tuberculosis (Scrofuloderma or Lupus Vulgaris)

 Features:
o Chronic non-healing ulcer or fissure with induration.
o History of TB exposure or pulmonary symptoms.
o Exclusion: Rare in the corner of the mouth; requires biopsy for confirmation.

5. Squamous Cell Carcinoma (Oral Cancer)

 Features:
o Non-healing ulcer or fissure with induration, especially in smokers or those with
chronic irritation.
o Exclusion: The patient is young (27 years), and there is no mention of risk factors
like smoking or alcohol use.

Treatment Plan

1. General Measures

 Educate the patient about the importance of completing investigations for systemic
causes.
 Maintain oral hygiene and avoid irritants like spicy foods or tobacco (if applicable).

2. Etiological Treatment

 If Syphilis Confirmed:
o First-Line Treatment:
 Benzathine penicillin G 2.4 million units IM as a single dose (for early
syphilis).
 For penicillin allergy: Doxycycline 100 mg orally twice daily for 14 days.
 If Fungal Infection Confirmed:
o Topical antifungals: Clotrimazole 1% cream or Nystatin ointment applied
twice daily.
 o Oral antifungals (e.g., Fluconazole 150 mg once weekly) for extensive
involvement.
 If Bacterial Infection Confirmed:
o Topical antibiotic: Mupirocin 2% ointment applied to the lesion twice daily.

3. Supportive and Symptomatic Treatment

 Topical Barrier Creams:

o Zinc oxide or petroleum jelly to protect the fissure and reduce irritation.
 Nutritional Support:
o Supplement with iron, vitamin B12, or folate if deficiencies are detected.

4. Surgical Intervention (if Necessary)

 Consider biopsy for histopathology if the lesion persists despite appropriate treatment to
rule out malignancy or other chronic conditions.

Follow-Up Plan

1. Short-Term:
o Reassess 1–2 weeks after initiating treatment to evaluate response.
o Monitor lesion for healing, reduction in size, and symptom resolution.
2. Long-Term:
o Regular follow-ups every 3–6 months if associated with systemic disease (e.g.,
syphilis, TB).
o Monitor for recurrence or malignant transformation if the lesion persists.

By addressing the underlying cause and ensuring regular follow-up, the patient's condition can
be effectively managed.

№6
A 40-year-old woman complained of pain in her tongue,
aggravated by talking and eating, an increase in body temperature
up to 37 C in the evening during the last month. On examination:
the patient has a hyposthenic physique. Submandibular lymph
nodes are enlarged, painful on palpation. On the back of the
tongue - an ulcer with uneven, undermined, soft edges, on the
bottom - a yellowish, granular coating. Ulcer palpation is painful.
Make a preliminary diagnosis.
Examine the patient.
Perform differential diagnosis.
Make a treatment plan

Preliminary Diagnosis

Tuberculous Ulcer of the Tongue

Rationale for Diagnosis

1. Symptoms:
o Persistent pain in the tongue, aggravated by talking and eating, accompanied by
subfebrile fever for a month.
o This chronic course and systemic symptoms point to a possible infectious
etiology.
2. Clinical Findings:
o Ulcer on the tongue with uneven, undermined, and soft edges and a yellowish,
granular coating is characteristic of a tuberculous ulcer.
o Enlarged, painful submandibular lymph nodes are suggestive of regional
lymphadenitis, often associated with tuberculosis (TB).
3. Patient's Physique:
o Hyposthenic physique (thin, frail) could indicate chronic illness like TB.

Examination of the Patient

1. General Examination:

 Assess for systemic symptoms of tuberculosis:

o Chronic cough, weight loss, night sweats, and malaise.
 Look for signs of extrapulmonary TB, such as lymphadenopathy, skin lesions, or joint
pain.

2. Local Examination of the Ulcer:

 Size, depth, and characteristics of the ulcer (edges, base, discharge).

 Examine other areas of the oral cavity for additional lesions.

3. Examination of Lymph Nodes:

 Palpate cervical and submandibular lymph nodes for enlargement, tenderness, and
consistency.

4. Additional Investigations:

 Histopathological Examination:
o Perform a biopsy of the ulcer for granulomas and Mycobacterium tuberculosis.
 Microscopy and Culture:
o Acid-fast bacilli (AFB) staining from the ulcer base.
 o Culture for Mycobacterium tuberculosis.
 Imaging Studies:
o Chest X-ray to rule out active pulmonary TB.
 Blood Tests:
o Complete blood count (CBC) to check for anemia and leukocytosis.
o Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) to assess
inflammation.
 Tuberculin Skin Test (TST) or Interferon-Gamma Release Assay (IGRA):
o To evaluate for latent or active TB infection.

5. Differential Diagnoses to Consider:

 Squamous cell carcinoma (oral cancer).

 Syphilitic ulcer.
 Deep fungal infection (e.g., histoplasmosis).
 Traumatic ulcer or aphthous ulcer.

Differential Diagnosis

1. Tuberculous Ulcer (Primary Diagnosis):

 Features:
o Chronic ulcer with soft, undermined edges and yellowish, granular base.
o Associated systemic symptoms (low-grade fever, lymphadenopathy).
o Positive AFB test or biopsy confirming granulomas.

2. Squamous Cell Carcinoma:

 Features:
o Chronic non-healing ulcer with indurated and rolled edges.
o Often painless initially, with risk factors like tobacco or alcohol use.
o Negative AFB and biopsy reveals malignant cells.

3. Syphilitic Ulcer (Tertiary Syphilis):

 Features:
o Painless ulcer with indurated edges, usually associated with systemic syphilis
findings.
o Positive treponemal tests (FTA-ABS, TPPA).

4. Deep Fungal Infections (Histoplasmosis or Blastomycosis):

 Features:
o Ulcerative lesions in the oral cavity, particularly in immunosuppressed patients.
o Diagnosis confirmed by fungal cultures or histopathology.

5. Traumatic or Aphthous Ulcer:

 Features:
o Painful, acute ulcers with no systemic symptoms.
 o History of local trauma or stress-related recurrence.
o Heals spontaneously within 7–10 days.

Treatment Plan

1. Confirm Diagnosis:

 Perform a biopsy of the ulcer and AFB staining to confirm tuberculous etiology.
 Conduct chest X-ray and systemic TB workup.

2. Anti-Tuberculosis Therapy (ATT):

 If confirmed, initiate a standard first-line anti-tuberculosis regimen:

o Intensive Phase (2 months):
 Isoniazid (INH) + Rifampicin (RIF) + Pyrazinamide (PZA) + Ethambutol
(EMB).
o Continuation Phase (4 months):
 INH + RIF.
 Dosages are based on body weight.

3. Pain Management:

 Topical anesthetics (e.g., lidocaine gel) for symptomatic relief during eating and
speaking.
 Systemic analgesics (e.g., paracetamol or ibuprofen) if needed.

4. Nutritional Support:

 Ensure the patient receives adequate caloric and protein intake to support healing and
recovery.
 Supplement with vitamins (e.g., vitamin C, B-complex).

5. Monitor and Manage Complications:

 Regular follow-ups to monitor response to ATT (clinical healing of the ulcer and
improvement in systemic symptoms).
 Address any adverse effects of anti-tuberculosis drugs (e.g., hepatotoxicity or
neuropathy).

6. Public Health Measures:

 Notify public health authorities if active TB is confirmed (as per local guidelines).
 Screen close contacts for TB infection.

7. Follow-Up:

 Assess the ulcer every 2–4 weeks for signs of healing.

 Reassess systemic symptoms and ensure adherence to ATT for the full duration.
With prompt diagnosis and effective treatment, the prognosis for a tuberculous ulcer of the
tongue is excellent, provided systemic TB is managed appropriately.

№7

A 55-year-old woman consulted a dentist complaining of

soreness, dryness and burning sensation in her mouth. She took a
broad-spectrum antibiotic for angina for 10 days. On
examination: the mucous membrane of the mouth is fiery red, dry,
shiny, the filiform papillae of the tongue are atrophied. Saliva
viscous, frothy.
Make a preliminary diagnosis.
Examine the patient.
Perform differential diagnosis.
Make a treatment plan

Preliminary Diagnosis

Oral Candidiasis (Erythematous Form)

Rationale for Diagnosis

1. Symptoms:
o Soreness, dryness, and burning in the mouth.
o Symptoms began after prolonged antibiotic use, which disrupts normal oral flora
and predisposes to fungal overgrowth.
2. Clinical Findings:
o Fiery red, dry, shiny mucosa and atrophy of the filiform papillae of the
tongue suggest erythematous candidiasis.
o Viscous, frothy saliva is a common sign of reduced salivary flow and candidal
infection.

Examination of the Patient

1. Local Examination:

 Inspect all areas of the oral cavity (tongue, palate, buccal mucosa, gingiva):
o Look for erythema, atrophy, or white patches that scrape off easily, leaving a raw
surface (pseudomembranous form).
  Assess for angular cheilitis (redness and cracks at the corners of the mouth).

2. Saliva Assessment:

 Evaluate salivary flow (xerostomia contributes to candidiasis).

3. Systemic Assessment:

 Review for underlying conditions (e.g., diabetes mellitus, anemia, or

immunosuppression).
 Check for signs of secondary fungal infection in other parts of the body (e.g., vaginal
candidiasis).

4. Laboratory Tests:

 Direct Microscopy:
o Smear from the affected mucosa examined with KOH or Gram stain for Candida
albicans.
 Fungal Culture:
o If necessary, to confirm diagnosis and identify the species of Candida.
 Blood Tests:
o Check for blood glucose levels to rule out undiagnosed diabetes.
o Complete blood count to check for anemia or leukocytosis.

Differential Diagnosis

1. Oral Candidiasis (Primary Diagnosis):

 Features:
o Burning sensation, fiery red mucosa, and atrophy of tongue papillae.
o Strong association with prolonged antibiotic use.
o Positive fungal smear or culture confirms diagnosis.

2. Xerostomia (Dry Mouth):

 Features:
o Reduced saliva flow, dryness, and discomfort, often secondary to medications or
conditions like Sjögren's syndrome.
o Exclusion: Erythema and papillary atrophy are not typical features unless
secondary candidiasis develops.

3. Nutritional Deficiencies (Iron or B-Vitamins):

 Features:
o Atrophic glossitis with burning and soreness.
o Exclusion: Typically associated with systemic symptoms (fatigue, pallor), no
frothy saliva.

4. Lichen Planus (Erythematous Form):

  Features:
o Fiery red mucosa and discomfort, but often accompanied by white striations
(Wickham’s striae).
o Exclusion: Lack of classic reticular or erosive features.

5. Allergic or Irritant Reaction:

 Features:
o Burning and erythema due to allergens or irritants (e.g., dental materials).
o Exclusion: No history of exposure to irritants, and saliva changes are not typical.

Treatment Plan

1. General Measures

 Eliminate Predisposing Factors:

o Discontinue antibiotic use if not absolutely necessary.
o Encourage proper hydration to reduce dryness.
 Oral Hygiene Improvement:
o Brush teeth twice daily and rinse mouth with plain water after meals.
o Avoid alcohol-containing mouthwashes that can exacerbate dryness.

2. Antifungal Therapy

 Topical Treatment (First-Line):

o Nystatin Suspension: 100,000 units/mL, rinse and hold in the mouth for 2
minutes, 4 times daily for 7–14 days.
o Clotrimazole Lozenges: 10 mg dissolved in the mouth 5 times daily for 7–14
days.
 Systemic Treatment (For Severe or Recurrent Cases):
o Fluconazole: 100–200 mg orally once daily for 7–14 days.

3. Xerostomia Management

 Saliva Stimulation:
o Use sugar-free chewing gum or lozenges to stimulate saliva.
o Salivary substitutes (e.g., carboxymethylcellulose-based products).
 Address Underlying Conditions:
o Screen and manage contributing factors like diabetes or Sjögren's syndrome.

4. Nutritional Support

 Provide vitamin or mineral supplementation if deficiencies (e.g., iron, folic acid, B12) are
identified.
5. Monitor and Follow-Up

 Reassess after 1–2 weeks to evaluate response to antifungal therapy.

 If symptoms persist, repeat fungal culture to rule out resistant strains or an alternative
diagnosis.
 Consider biopsy if the lesion does not resolve despite appropriate treatment.

Prognosis

 With prompt antifungal therapy and management of underlying factors, oral candidiasis
typically resolves completely.
 Prevent recurrence by minimizing antibiotic use, maintaining good oral hygiene, and
addressing systemic conditions.