INBDE CONQUER CASE BASED QUESTIONS PATIENT BOX QUESTIONS ORAL RADIOLOGY

hello everyone this is dr pratyusha chava from team inbd conquer so today we'll be basically discussing about patient boxes now what are patient boxes dr sythi must have given you an update about what patient boxes are we have so many subjects right in dentistry so in each with respect to each subject they present case scenarios to you in the form of a box now what will that box have that box will have basic demographic data of the patient the name age of the patient okay sex of the patient right what is the chief complaint and what is the background history and what are the presenting features sometimes along with all these they might or might not give you a clinical picture of the patient so you have to read the patient box completely try to understand the information given by them then if a picture is given you have to look at the picture then try to analyze after that based on that patient box they will give you a question and that question will have four options among the options you have to select which is the correct one so doctor said he must have already presented about 20 odd cases in a previous presentation i will be continuing the subject i will be dealing with this oral medicine oral radiology and oral pathology together i have combined all these three together so that you have an idea of the histological as well as the radiological presentation of a certain disease if it is given to you so today myself i will be discussing ten such questions with you okay so let us start this interesting discussion one thing i will tell you is please when i am giving putting forward the case if i say case one and i give you the patient box you don't wait for me to give you the answer you analyze and come to a conclusion as to what this case could be then it will be easy for you also then you and me both of us together will discuss the case and we'll discuss the important points related to that disease okay so be energetic throughout the video and please concentrate let us start a 20 i'm sorry yeah a 20 year old male patient so the patient data says patient is 20 year old male right chief complaint what is the chief complaint presence with a please be very attentive painless swelling of the right maxilla so here the right maxilla and the frontal bone as well of the right maxilla and the frontal bone of the left side here can you see this okay so the right maxilla is enlarged and the left side of the frontal bone and left side of the face has been enlarged okay for the past two years right so background history he has been hospitalized multiple times for broken bones so here only you should be understanding so that that is something related to a bone pathology right then the clinical findings says that the patient presented with facial asymmetry it is very evident extra oral examination revealed well-defined bony heart swelling of the right maxillary region right there was also involvement of the left frontal bone which showed prominence as it is very clear in the clinical picture intraorally also there is enlargement of the right side of the palate right can you see here intraorally can you see this huge expansion right and there is also extension medial actually how the buccal alveolar plate is extended can you see this bony heart spelling is causing extension towards the buccal side as well from one seven one one two one seven from here till here as i mark the extent of the lesion alkaline phosphatase was raised to 300 units per liter increased alp so we know it's a bony pathology we know there is increased alp and we know that multiple bones are involved and it is causing swelling now if you got the answer keep the answer with you let us let me pose the question now question what is the radiographic feature you can find in this patient a the lesions are usually radiolucent well circumscribed and may have a cotton wool appearance b lesions are usually saucer shaped radiolucency see lesions are usually radiopic not well circumscribed and may have a ground glass appearance d the lesions are usually well demarcated unilocular or multilocular radiolucencies now what is the answer bony pathology causing extensive expansion of the jaws and the other involved bones like frontal bone causing facial asymmetry with increased alkaline phosphatase causing buccal expansion of the cortex you all are right everybody i think would have guessed it by now it is fibrous dysplasia now when you have guested that it is fibrous dysplasia what should be the answer what is the radiographic presentation of fibrous dysplasia ultimately your answer goes to answer c okay so it the lesions may be radio opaque from reducing to radio opaque usually it varies and it can be ah usual presentation is that of a ground glass appearance now what are what how does fibrous displacement occur fibrils displacer is basically when a connective tissue will replace the medullary bone okay there is formation of extensive collagen okay and usually it is because of mutations of gnas one gene right and what are the forms we have monostatic right mono polyostatic right and craniofacial form right monoostatic is the most common form it is around 85 percent you see monoostatic form right usually presence in puberty and males are more affected than sorry females are more affected than males and usually this monostatic fibrous dysplasia is seen in the maxillary region as we saw our patient also had expansion of the right maxilla right and polyostatic as the name suggests apart from jaws other parts of the body bones are also involved where you see pathological fractures because the osteoid material of the bone is replaced by connective tissue that is the reason why there is an increase in alkaline phosphatase serum alkaline phosphatase so this poliostatic fibrous dysplasia is associated with multiple pathological factor factors in our case in the background history the patient had gone frequently to the hospital because of multiple fractures of the bones so that also is an additive uh feature how you diagnose fibrous dysplasia right and also apart from increased alkaline phosphatase please remember you also see hypophosphatemia okay hypophosphatemia is also seen in uh fibrous dysplasia now one craniofacial fibrous dysplasia is again associated with the skull as well right so uh what are the syndromes associated one more thing they can ask you is what are the possible syndromes that you can see with the fibrous dysplasia so first thing that has to go into your mind is make you an albright syndrome okay mccune albright syndrome where you see fibrous disease dysplasia associated with pigmentations all throughout the body now those pigmentations what are they called they are called as caffeiol pigmentations right caffeiol pigmentations make you albright syndrome and also this polyostatic fibrous dysplasia with the caffeine pigmentation and certain endocrine abnormalities also you can see in mecune albright syndrome right so it's fibrous dysplasia endocrine abnormalities right and what is the other type of syndrome jeffy lichenstein syndrome right jeffy lichtstein since syndrome in this also you see multiple bony lesions with caffeine pigmentation so please remember these two uh syndromes make you an albright syndrome and jeffrey lichtenstein syndrome so radiological feature as i told you it's ground glass appearance where you see that the bony trabeculae are displaced are resolved and connective tissue is formed that is the reason why you get that dot dot dot dot dot appearance can anybody tell me what is this appearance also called as apart from the ground ground glass yes you are right it's called as po the orange okay so this also they can give you for the orange appearance like the appearance of an orange skin peel you see multiple pores will be present on the orange skin so that is how it's called as pure the orange appearance okay and one more thing i want to tell you radiological feature there is something called as rind sign ri nd sign okay ring sign is nothing but when this bone is undergoing resorption centrally you see radiolucency and periphery peripherally it is surrounded by a radio opaque margin okay so this thick sly rotating margin with central radiolucency will give the appearance of a rinse sign so you see rinse sign you see ground glass and also you see per day orange appearance radiographically okay and also one more syndrome that i forgot to mention is major broad syndrome maser broad syndrome is nothing but intramuscular mixomas associated with fibrous dysplasia okay so you have fibrous dysplasia with intramuscular mixoma so you have mecun albright you have master broads and you have jeffy lichtenstein syndrome okay three syndromes three types of radiological presentations ground glass body orange or you have rin sign also and also because of this extensive expansion of the facial bones it gives a leonine feces okay leo nine appearance like a lion that is why it is called as leontiasis ossia where do you see leon diaz's aussie appearance you see in fibrous dysplasia so i hope this case one patient box if they give you this these all can be possibilities also of questions okay in instead of asking this question they can ask you okay if they give you uh like for the orange appearance or if they give you ring sign you should be able to answer or if they reframe the question and they give you apart from serum uh alkaline phosphatase increase what is the other thing you see you see hypophosphatemia so like this you should be able to answer i hope fibrous dysplasia is clear to you let's go to the next question case two please be attentive listen to me listen to this i think you can diagnose it it is it is a relatively easy one okay 52 year old male right chief complain swelling on right side of okay can you see this filling swelling on right side of palette for the past five years so it is a long duration right i usually do this whenever i'm reading or analyzing a case is case based question i underline important things and think okay long duration acute chronic pain associated symptomatic symptom less so like that you have to think it it makes in uh narrowing down your diagnosis okay so you can exclude you can follow that exclusion principle and based on that you can narrow your diagnosis right so let us see the background history of the patient the patient had undergone surgical treatment for a bony swelling at lower border of the mandible for about 30 years back so 30 years back he underwent some surgery at the lower border of the mandible he had a bony swelling so these bony swellings are not unusual first it was in mandible then now he is presenting with maxilla okay past medical history revealed chronic bowel upset in the form of abdominal cramps and diarrhea so now you know that systemic involvement is there multiple systems are involved it is not only confined to oral cavity we have some problem with the intestine or g gastrointestinal system as well next family history revealed that now we are coming we family history when it says that we come to a conclusion that it could be genetic also right so family history revealed that both sons of the patient had bony spellings of the job so we came to know it's a chronic thing okay systems are involved and also it is familiar okay so this is how you narrow next let us see the clinical findings on examination multiple small nodular spellings were seen on the forehead okay nodular swellings were seen on the forehead so if we see now we had gi also we have skin involvement also here right intra oral examination revealed spellings on right and left side of the palette panoramic radiograph was obtained this is the opg of the patient if you can see it revealed multiple impacted teeth okay with respect to so many things okay and you can also see that is the density of the mandible and maxilla is it normal no you can see multiple radio opacities here all throughout the mandible can you see the radio opacities so you have multiple impacted teeth with multiple radio opaque lesions all throughout maxilla and mandible gi there is some problem with the gi okay abdominal cramps diarrhea is there on the skin also you can see small nodular spellings okay okay let's come what is the most serious complication he should be concerned with when consulting his physician a odentomas b osteomas c epidermoid cyst b multiple polyps that affect the large intestine now what is your answer it is a syndrome what is that syndrome it is guard nerd syndrome gardener syndrome now gardner syndrome is a very very very very important syndrome this is probably the first syndrome that i learned when i was preparing for my post graduation because this syndrome is so important that they can ask you questions in any form okay they can ask you based on presentations okay which are the components of sin gardner syndrome like a case a case presentation like how i have given here okay they can ask you many things now what is that that we have to be concerned as a dental uh physician what is that about gardner syndrome that we should take care when we are referring that patient it is d multiple polyposes because almost hundred percent of intestinal polyps can cause colorectal adenocarcinoma okay adreno carcinoma very very very very important this is a pre-cancerous stage okay which can lead to colorectal adrenal carcinoma that is why we as dental physicians should be careful if we can get a case of gardner syndrome in our dental office we have to refer the patient for follow-up visits to a gastroenterologist now what are the components of gardner syndrome i launched it by a small mnemonic called as dop c d stands for desmoid tumors okay o stands for osteomas p stands for polyposis of intestine s stands for sebaceous cysts and i stands for multiple impacted supernumerary teeth okay impacted supernumerary teeth very very important please take it as a sure short question okay so this is very important garner syndrome you should know in and out okay so this polyposis of intestine is very important because of its potential to transform into malignancy okay apart from that also in females around 100 fold risk is there for thyroid carcinoma okay thyroid carcinoma right and one more thing can i ask you this presentation of multiple impacted supernumerary teeth where do you see other than gardeners you also see in kedo-cranial dysplasia okay so these are your important takeaway points from this case presentation so far so clear now let us go to the next case case three okay so please pay attention 13 year old boy patient data right chief complaint is spelling in relation to right cheek again right that gradually increased in size over a period of two months okay so short duration relatively not that long right he has seen a neurologist and reveals he has some calcified structures in the brain so people who looking at the case uh pictures and looking at this if you have come to our diagnosis just hold on okay clinical findings thorough general examination revealed relative macrocephaly okay with hypertalorism okay hypertelorism was seen palmar and plantar pits can you see the pits here on the hand and on the legs so palmar and plantar pitting was see radiography of the skull was taken which revealed macrocephaly and also cervical thoracic spine extra lumbar spine x-ray was taken it revealed bifid rip okay my feet drip spina bifida right and also scoliosis some vertebral anomaly scoliosis x-ray is not with us we can just see the bifid rib here in this x-ray okay and panoramic radiograph revealed three well-defined radiolucencies with the slerotic borders i am not sure if we are able to appreciate here here okay and here the radiolucences are here okay clear with the case so we have seen that there is some phase anomaly on skeletal aluminium in the form of expansion of the maxilla right anterior maxilla posterior both mandibles huge regulation seeds are seen and palmar plantar paintings are seen also he's saying that he has some calcified structure in the brain and with the rib you see spina bifida and at the back in the vertebral column you see scoliosis right yes the panoramic radiograph may rightly reveal now what are these radiolucencies that you are seeing diagnose them is it an osteoma be keratocystic orangogenic tumor c odentoma or d denteger is cyst now give me the diagnosis what is the diagnosis yes it is knee void basal cell carcinoma syndrome also called as garland gall syndrome okay again very very important very very important garland gault syndrome nevoid basal cell carcinoma syndrome it also indicates that apart from dental anomalies like okay so what is the answer what is the dental anomaly that you see in void basal cell carcinoma syndrome yes you all are right it is kot keratosistic odentogenic so those huge radiolucences that you are seeing are kots now what are the things that comprise of nemoid basal cell carcinoma syndrome how do you diagnose garlic or syndrome there are certain criteria major and minor criteria so in major criteria major and minor okay so usually to diagnose they should be two major criteria or a combination of one major criteria plus two minor criteria please remember this ok so in major criteria you should have more than two basal cell carcinomas then you should have okc's then palma plantar pitting okay palmer plantar pitting there should be more than three pits followed by hyperkeratosis okay then calcification of fox cerebri as he already mentioned brain calcification okay that should be present right bifid rib right so these ore our major criteria now what are the other minor criteria as we can see you see macrocephaly we we have microcephaly in our patient right frontal bossing frontal passing okay hypertelorism hypertylerism ok and sometimes syndactyly also okay so these are all our components of new world basal cell carcinoma syndrome why are we alternate is very concerned with the syndrome because we can see multiple keratosistic organogenic tumors that are present in the jaws okay so we have to be concerned okay sometimes this patient can also have congenital blindness as well right so radiographically you see bifid rips okay you can see syndactyly you can diagnose macrocephaly you can diagnose calcification of fox cerebri okay and also they have vertebral anomalies in the form of scoliosis okay which our patient had so almost this case is presented in such a way that almost many of these major and minor criterias are covered okay clear about nemoid basal cell carcinoma syndrome also called as garland gall syndrome okay let's go to the next one right case 4 55 year old woman okay swelling of the left side of the face since two years okay and pain while chewing food since three months this is the only thing he gives so since two years if it is of a chronic duration definitely it must have been a painless swelling that is why she didn't bother to come to the dentist so this is how you should analyze right background history patient had altered sensation paresthesia okay paresthesia over the left cheek region she was also habit history also was there now when i say habit don't jump into the conclusion that it is squamous cell carcinoma look at the mucosa mucosa is very very normal here coming to that now habit always does not indicate that you can see something related to that like leukoplakia hydroplakia or oral squamous cell carcinoma it is not that okay just see the findings and look at the picture then think about it clinical findings on examination there was a solitary ill-defined diffuse spelling over the left middle and lower third of the face which you can see intra-oral examination revealed ill-defined solitary swelling in the left lower posterior buccal vestibule with the smooth surface there was no ulceration there there was no varuka's appearance okay that means he's indirectly telling you that dear it is not cancer right so with a smooth surface and mucosa was stretched similar to adjacent mucosal color with no secondary changes whatsoever it was non tender hard in consistency okay heart inconsistency think that bone is involved think about it okay with buccal and lingual plate expansion very clear bony swelling mucosa is not involved something is happening in the bone which is causing that swelling 3 7 3 8 are missing okay can you see only 3 6 is present 3 7 3 8 are not there now what is the most likely radiographic presentation in this case scenario do you see a cotton wool do you see a podi orange do you see a soap bubble appearance or do you see a ground glass appearance can you diagnose this don't think can you diagnose i think you must be thinking somewhere missing t directly jump into dentistry cyst okay look at the patient analyze okay i can i can uh uh if you are thinking about dentist and can you think of another one which could be possibly mandibular rama spelling most common common mandibular rama swelling in that age patient what is the diagnosis that you can think of okay it is ameloblastoma okay amyloblastoma you people can get confused with amiloblastoma and denture resist also but then you have to consider other factors as well so this case is a case of ameloblastoma right and what is the appearance so bubble appearance right usually in third and seventh decade of life amyloblastoma presence okay and it is a painless slow growing swelling as we all know because it is present in since a long time so it is the most common odentogenic tumor in with relation to mandibular ramus area please remember this very very important okay which causes bucco lingual expansion as we saw in our case so you have what are the types you have you have multicystic unisystic ok and extra oscis multistick is usually 85 percent unicystic is 15 percent and extra ostrich is around one percent okay so these types basically you should remember okay what is the radiological presentation you see a multi-locular appearance okay multi-locular radiolucency in the form of soap bubble okay or honeycomb okay if either of these are given it will be your answer so bubble or honeycomb appearance okay and malignant usually this amyloblastoma has very rarely but it can transform into malignancy when such malignancy is present you can see that malignant amyloblastoma is spreading to lungs also this is also very important what is the most common organ in which you can see malignant amyloblastoma your answer should be lungs okay so it is the second most common orientogenic tumor the first being odentoma followed by odentoma second most common is amiloblastoma right and histologically also there are various types what are the various types histologically you see follicular you see granular acanthomatous okay basal cell desmoplastic and flexiform ameloblastoma okay so histologically also the various variants you should be aware of okay how does a amyloblastoma appear radiologically you see a multi-ocular radiolucency with a honeycomb or a soap bubble appearance okay so clear about ameloblastoma right let's go to the next case next patient box okay case five okay 77 year old woman okay chief complaint is complaints of dysphagia vomiting shortness of breath and weight loss for one month right background history there is nothing significant about the background history clinical findings physical examination revealed conjunctival power shaped nails right angular kilitis and smooth tongue so based on all this you definitely must be thinking it is some kind of anemia you are right it is some kind of anemia now apart from that they also did the gastrointestinal endoscopy can you see here endoscopy picture it revealed that there is a web here yes gi endoscopy said that there is a web okay here also they also did a barium swallow followed by that both detected webs okay in the upper portion of esophagus okay i think you must have diagnosed it by now what disease does she have aplastic anemia plummer vinson syndrome punishes anemia cushing's syndrome yes you all are right it is plummer vincent syndrome what are the components of promovinson syndrome you have iron deficiency anemia okay you have colonical you have atrophy of buccal mucosa tongue right and you also have dysphagia which by which our patient had so our patient had everything in this okay so it helps us in clearly diagnosing that it is a clear cut case of plummer vincent syndrome what are the other names of plummer vinson syndrome it is also called as paterson brown kelly syndrome okay so apart from this iron deficiency anemia you see esophageal web formation okay which causes the dysphasia so it is very difficult for patient to take in that take in food because of dysphagia and also there will be excessive burning sensation because of loss of papillae atrophy of the tongue which causes weight loss ultimately nutrition of the patient is compromised because of decreased food intake that is why weight loss also you can see which a patient had so like this you have to think about all the symptoms that are presented in the case box and then come to a conclusion so ah dysphagia was there iron deficiency was that atrophy was there okay all this was a component of plummer vinson syndrome also also you can see parasthesias at the later stage okay and the tongue is called as a beefy red tongue okay please remember this beefy red and bald tongue the tongue appearance okay it is also called as hunter's glossitis or moeller's glottal glossitis that inflammation of the tongue is called as hunters glossitis or molars glossitis and in the blood in the spirit what do you see you see whole whole jolly bodies okay cabbage rings okay and apart from a decreased iron you can see increase in bilirubin and lactate dehydrogenase okay these are the other components so questions can be framed on these also that is the reason i am asking you okay that is the reason i am telling you all these points also so if they instead of that if they frame what is the uh typical uh presentation in the blood smear if a if if taken from this patient so you should go for hobel jolie bodies cabbage rings okay all this right clear about this plummer vinson syndrome let's go to the next one next case case number six right 55 year old male patient right he complains of swelling in the right corner of the lip region can you see this this is the corner of the lip there is some swelling in the oral cavity background history the lesion was first noticed four months ago which increased in size gradually any history of dental or facial trauma was not reported right the lesion was found to be painless except on digital pressure now what are the clinical findings lesion was about four into five centimeter in size it was pink in color at the corner of the mouth okay it was firm and sessile no stock form and cesar these two are very important right radiograph of that area revealed no bony involvement right the lesion was firm in consistency cell as i told you connective tissue contain numerous blood vessels which surrounded by plump vibrating proliferating endothelial cells okay and there is a dense chronic inflammatory cells like lymphocyte plasma cells macrophages are present in the connective tissue it's a very simple case your diagnosis name the most frequently and name this most frequently encountered intraoral benign neoplasm of connective tissue origin is it a leomyosarcoma is it a fibroma is it a leomyoma or a rhabdomyoma your answer is fibroma corner of the lip all of us many of us have that habit of what you do you cheek biting very common no so because of that constant irritation because of that pressure from the occlusal forces there will be formation of fibrous tissue in the form of a spelling okay firm fibrous swelling so usually it is cecile in some cases very rare cases it can be pedicular pedunculated also so it is the most common benign tumor that you can see most common tumor in oral cavity is fibroma and it is benign okay it's also called as irritation fibroma traumatic fibroma or focal fibrous hyperplasia no matter what name you call it by it is the most common tumor secondary to that constant irritating force that you see because of excessive occlusal forces on the cheek because of the cheek biting ok so histopathologically as we see we see huge number of fibrocytes ok ok so collagen fibers also can be seen right and also there will be ready plaque flattening okay flattening this can be seen so clear with this case fibromya it's a relatively simple case so you should be able to you should be in a position to be able to diagnose if they give you this let's go to case number seven okay uh old gentleman right 65 year old patient complaining of inability to open mouth pain and difficulty in swallowing with the swelling in relation to lower jaw as well as the neck for the past four days so it means it is acute so mostly i will think of an infection right i will go my brain will go in that direction infectious okay then background history an infected third molar had been extracted three days earlier so there was some procedure that was done three days ago okay followed by which he developed some huge swelling which is causing difficulty in opening mouth eating okay and severe pain okay at the presentation clinically patient had fever of 100 degree fahrenheit pulse of 80 beats per minute blood pressure was 100 by 70 respiratory rate was 22 per minute so it increased respiration right mouth opening was limited to 1.5 centimeter so decreased mouth opening extra oral swelling was indurated and non-fluctuant with involvement of submandibular and sublingual region okay can you see the ceiling here also it went from here till the neck region true statement about the severe spreading infection is it involves submental and sublingual spaces only it involves submandibular submental sublingual spaces unilaterally involves submandibular and sublingual spaces only involves submandibular submental and sublingual spaces bilaterally your answer is d and all of you are correct i think you must have guessed it by now it is ludwigs and now okay save your board like spelling of the mouth causing difficulty in breathing okay because of epiglottal edema okay the infection goes and spreads to the epic lotus causing that difficulty in opening mouth okay epic glottal edema is a very serious complication and also another serious complication is cavernous sinus thrombosis which can occur okay so this can compromise the airway of the patient that is the reason why we have to be very very careful when we treat a case of ludwig's angina so it is usually rapid in outside and it involves bilaterally both the sublingual submental as well as the submandibular spaces that is the reason it spreads to the neck it is a huge indurated swelling okay intuited spelling and it does not compress there is no compressibility there is no reducibility and when you feel the skin on the temperature skin of the swelling also you can feel it warm why because of the inflammation there will be increased temperature that is the reason why you can see that high the skin also will give that pinkish appearance okay pinkish appearance temperature will be high huge board like swelling can be seen okay and typically the patient will have that open mouth appearance okay they can ask you this also where do you see this open-mouthed appearance in which infection it is ludwig's and china okay so there'll be elevation of the tongue also drooling from the sides right christmas can be seen fever dysphagia dyspnea tachycardia right glottal edema epiglottis edema right and what do you see you first you have to ah secure the airway of the patient followed by that you can do an incision drainage and put the patient on antibiotics so this is very very very very important space infection with relation to dentistry okay please be very attentive right so ludwig's antenna can be one of your question coming to case number eight tired please don't be because all these cases are going to help you in your inbd preparation okay please be attentive we have eight nine ten three more cases to go right case number eight 81 year old male okay he complains of increased volume in the mandibular symphysis region can you see this which had evolved over the period of seven months again something chronic something bony okay chronic lesion there was no significant background history clinical finding suggested that the swelling was hard in consistency with no alteration in the local cutaneous tissue and patient complained of paresthesia of the lower lip the lateral panoramic radiograph of the skull showed an extensive or the lateral radiographic skull showed osteolytic lesions in the skull and also the panoramic radiograph showed multiple punched out radiolucencies ill-defined punched out radiolucencies can you see throughout the border of the mandible histological analysis revealed plasma cytoid cells with round eccentric nuclei fine granular chromatin and evident nucleolus so we know that it is something related to plasma cell right plasma cell disorder when we know that it is something related to plasma cell causing punched punched out bony radiolucencies okay and also causing a huge bony swelling okay what can we think an elderly patient you will refer this patient to the physician suspecting of what disease is it non-hodgkin's lymphoma hodgkin's lymphoma multiple myeloma langerhans cell histiocytosis so what is your answer plasma cell directly close your eyes go for multiple myeloma multiple myeloma is the plasma cell tumor right plasma cell tumor usually you see in african american patients okay most commonly and males are most commonly affected than females usually in 60 to 70 years of age okay in jaws are usually affected in 30 percent of cases okay usually in posterior mandible but our patient had anterior mandibular swelling right and this punched out lucencies is the pathognomic appearance punched out radio lucencies right and also there is one more very peculiar diagnostic feature that means if i say that see this is present you can say ma'am it's multiple myeloma what is that yes you are right in urine you see something what do you see ben's jones proteins right ben stones proteins okay also you can see monoclonal monoclonal gamma pathy okay m spike it is main spike monoglonal gamma pattern okay intraorally one more important thing i want to tell you is you can see in amyloidosis also in in tongue and oral mucosa okay please remember this is one additive point that i am telling you amyloid deposition also can occur as a part of your plasma plasma cell tumors like so i like a multiple myeloma okay clear about multiple myeloma let's go to the next question case number nine oh huge lesion on the tongue right 26 year old female patient main complaint is there is a tongue lesion i have a huge tongue lesion so she has come so background is three she has been smoking for eight years two to three cigarettes per day but does not consume alcohol there is no weight chain weight loss or night sweats are not there so basically the doctor asked to rule out your hodgkin's lymphoma right so that is also ruled out that is not there right clinical findings give that there is a 15 into 20 to 15 millimeter lesion ok which is exophytic okay with a central ulcer appearing to infiltrate the tongue musculature right oral mucosa also showed some signs of leukoedema okay there was no limitation of mouth opening and normal dentition was apparent now here i am presenting that huge exophytic lesion on the tongue associated with the habit history so what should you think of very good i think everybody will think of squamous cell carcinoma because it is the single most common causative etiol causative thing when an etiology like smoking or beetle nut showing is present if you have any etiologies like that and you see a huge exophytic ulcer in the oral cavity you have to first and only think of squamous cell carcinoma so what is the most likely diagnosis is it adenoid cystic carcinoma muco epidermoid carcinoma basal cell carcinoma squamous cell carcinoma your answer is squamous cell carcinoma so squamous cell carcinoma is the most common type of oral cancer around 90 percent of cases you see oral cancer is squamous cell carcinoma males are commonly affected than females and lower lip is the most common site actually okay and the site if if that parmesal carcinoma is present in a particular site which has least favorable prognosis that is floor of the mouth floor of the mouth has least prognosis okay please remember this because these are also very very important points okay lower lip is the most common side it is the most common tumor okay of oral cavity right and one more thing is uh floor of the mouth has least favorable prognosis right you can also see like in this patient usually did not have any pre-cancerous presentation in the form of leukoplakia or erythroplakia but you can see those also developing usually it progresses from a leukoplakia to a cancer but this patient we did not get to see any such appearance of leukoplakia but please look out for leukoplakia also if such a case is given to you paresthesias are also seen so apart from tobacco also certain viruses like hpv 16 and 18 can cause oral squamous cell carcinoma right so this is very very important and very easy to diagnose when they give you a condition like this it is definitely going to be oral spam a cell carcinoma so clear about that case so today this is the last case for this presentation we have come to the end okay so let us score a 6 with this also it's case number 10 right a very simple case i put at the end 58 year old caucasian female okay complains of acute pain burning and mastication and feeding difficulties right she is a heavy smoker and clinically when you see you saw you see inter-crossed streaks of web-like aspect they found on the buccal mucosa okay typical of we can't striate ah victims has told me so where you can see completely oral lichen plan is right also clinical examination revealed that she had such lesions in the genital area as well usually you see lichen planners it's an autoimmune condition which can affect other parts of the body also like skin and also in the genital area especially in females females are most commonly affected and you can see lichen plane is associated with genital areas as well so this will help us in diagnosing better also on the skin in this patient you saw something called as purple plaques were seen okay with white proriatic lines on both upper and lower limbs so i you diagnosed that it is a oral lichen planus now what is the question i am asking you what is the characteristic histological presentation of this disease colloid bodies highland bodies max dose of spaces civic bodies all of the upper what is your answer your answer should be all of the upper so this is oral lichen planus it is an autoimmune disorder right you see you see we can stray okay on the buccal mucosa where you see web like interlacing white lesions okay on both usually it is bilateral but it is not a thing that it has to be bilateral map or like in planets that did not give bilateral not necessarily i myself in my career i have seen many cases where you have you can see unilateral uh like in planets as well so it is by being bilateral is not pathognomic of diagnosing oral like in planets please remember that okay so females are usually more more affected than males okay and what are the types you see reticular like in planners erosive bullets popular atrophic and clock like six types of clinical presentations based on how they appear clinically they are divided like that okay and you as you know buccal mucosa is the most common area of presentation and histological presentation is very important because you diagnosed it only after doing a biopsy so what do you see histologically you see something related to keratin what is that hyperkeratosis hyper keratosis is very important it can be ortho or para keratosis okay and what i have not mentioned here is you also see saw tooth ready picks ok and there is degeneration of basal layer basal layer okay then you see colloid bodies you see collide bodies or civic bodies are one and the same you see highland bodies highland bodies and collide bodies are basically uh given those name based on where they are present if they're present in the epithelium they're called as highland bodies or colloid bodies if they're present in connective tissue they are called as so if they're called as color or civil bodies if they're present in connective tissue they're called as highland bodies so they're just based on the differentiation based on location where they are present they are given that name you see max joseph spaces also so all these are histological presentations of oral lichen planners and also they can ask you one more question what are the five piece or the six piece associated with lichen planus so what are the piece you see through rytic itching polygonal they are usually polygonal purple in color plaque like okay and planar okay so these are the usually purple proritic polygonal planar blacklight and uh that's it right proritic polygonal planar purple plaque like popular so these are the six piece of oral lichen planus okay so this is the thing so in this presentation i have discussed ten beautiful patient boxes okay and i have given all the pictures along with it it is not necessary please be careful that they can give you picture always when they ask you in your inbda exams they can also give you without a picture so please if if a picture is there definitely it will be useful in diagnosing but even if you don't have a clinical or a radiological picture please look at the patient box please write try to read each and every data and narrow down the diagnosis like i have explained how you have to do it okay and then read the question properly answer it okay i hope and i pray that you people do very well in your exams okay and i hope that these will be very helpful to you in your preparation okay thank you so much take