Quiz 37: What is your diagnosis?

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Diagnosis: Quiz 37

Quiz 37

Answer: Keratosis oris (lichen simplex chronicus of an oral mucous membrane or the tongue)

Criteria for diagnosis clinically:  A discrete, white, well-circumscribed plaque is consonant with keratosis oris.

Differential diagnosis clinically:  Because, theoretically, a lesion such as this one could be infectious, such as induced by pseudohyphae of candidias, or neoplastic, such as constituted of abnormal keratocytes of squamous-cell carcinoma, biopsy is essential to establish a diagnosis with surety.

Criteria for diagnosis histopathologically: The findings of compact orthokeratosis, slight epithelial hyperplasia, and a patchy infiltrate of plasma cells in the upper part of a slightly fibrotic lamina propria are those of keratosis oris.

Differential diagnosis histopathologically: There is none.

Clinicopathologic correlation: The plaque is formed of the thickened surface epithelium and of the widened lamina propria, the whiteness represents maceration of corneocytes in the markedly compact zone of orthokeratosis, and the hint of redness at the periphery is a consequence of dilation of venules and capillaries in the lamina propria, they, in vivo, having been filled with erythrocytes. 

Options for therapy predicated on knowledge of histopathologic findings: It is crucial to determine how the dorsum of the tongue of this youngster came to be rubbed so persistently and for so long, if an effort successful is to be made to interdict the trauma. In this youngster, the vehicle for rubbing chronically was thought to be an orthodontic appliance known as a "palate expander." The antidote is removal of it.

1) Keratosis oris is a synonym for lichen simplex chronicus of a mucous membrane of the oral cavity or of the tongue.

2) Oral pathologists and oral surgeons not only continue to employ terms vague like keratosis oris, but ones opaque such as "leukoplakia" and "dysplasia." Keratosis oris is understood by the  cognescenti  to be a synonym for lichen simplex chronicus, but "leukoplakia" is a generic for any white plaque on any mucous membrane or on the tongue, such as is the situation here. In most instances, what oral pathologists and oral surgeons refer to as "leukoplakia" actually is squamous-cell carcinoma and should be diagnosed with specificity as that.

3) "Dysplasia" has no more meaning for oral pathologists than it does for general pathologists and dermatopathologists. It is a word that should have no place in the lexicon of dermatology, general pathology, dermatopathology, or oral pathology because it has yet to be defined in agreed-on fashion, lucidly and crisply, that, after more than a century of its use ubiquitous. And so, too, it is for the terms "eczema" and "atopic dermatitis." All of them are impediments to understanding and, that being so, should be discarded in the interest not only of the discipline of dermatology, but in that of patients.

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