Appendix 1
Case 1: A patient presenting with oral manifestations of acute leukaemia
Patient Details: A 59-year old female patient has made a self-referral to see her oral health therapist. She usually comes for a check-up every 6 months. Although her last visit was only four months ago, she has called in for an emergency appointment because she was worried about her swollen gums.
Current Concerns: The patient complains of swollen gums and bleeding from her gums when brushing. Because of this she has not brushed her teeth for a week. General weakness and headache. Loss of appetite.
General/Physical Appraisal/Social History: Recent respiratory tract infection, 30 days prior to visit.
Medical History: Clear medical history. No allergies.
Smoking History: No history of smoking.
Dental History: 2-year recall to dentist, attends dental hygienist appointments twice every year.
Extra-oral examination: Bruise adjacent to the right lower lip. No recall of specific traumatic injury. Mild enlargement and tenderness of right cervical lymph nodes.
Intra-oral examination: Generalized gingival enlargement (Note: Figure 1 is omitted due to copy right). Discrete, bulbous enlargement particularly involving the interdental papillae. Gingival consistency is soft and generally friable. Bleeding from her gums with minor trauma (e.g., toothbrushing), confirmed with periodontal probe. White material on gums can be easily removed with a dental instrument.
The Dentist orders blood tests.
- What key information should be included on the request form? Why are these important (full name, NHI, DOB, requestor, time of collection, non/fasting etc)?
- Why are the tubes different colours and why is this important?
- What information needs to be included on each tube?
What are the consequences of an incorrectly or incompletely labelled tube or request form?
Lab results
Full blood count
|
Patient
|
Reference interval
|
Haemoglobin (Hb)
|
90
|
135-180 g/L
|
Mean cell volume (MCV)
|
87
|
80-98 fL
|
Total WBC
|
35.4
|
4.0-11.0 x109/L
|
Blasts
|
30.5
|
0
|
Neutrophils
|
1.0
|
2.0-7.5 x109/L
|
Lymphocytes
|
3.4
|
1.5-3.5 x109/L
|
Monocytes
|
0.5
|
0.2-1.0 x109/L
|
Platelets
|
20
|
150-450 x109/L
|
Blood film comment
(refer to Figures 2A & 2B)
|
86% blast cells present. Anaemia and marked thrombocytopenia is present. Blood film appearances consistent with acute leukaemia.
|
Chemical pathology
|
|
|
Creatinine
|
125
|
50-115 umol/L
|
Uric acid
|
600
|
150-470 umol/L
|
Lactate dehydrogenase (LDH)
|
1000
|
230-450 IU/L
|
Note: Figure 2A is omitted due to copy right.
|
Note: Figure 2B is omitted due to copy right.
|
Discussion points for the IPE GroupWhat referrals and investigations may be appropriate now?
- Describe the reason(s) the patient has come to visit her oral health therapist.
- Discuss the risk factors/contributing factors (including systemic factors) involved from an oral health and general health perspective.
- What is the primary role of the dental hygienist when seeing this patient? With whom will they liaise? What would be the pathway of referrals?
- What is the primary role of the dentist when seeing this patient? With whom will they liaise? What would be the pathway of referrals?
- What is the primary role of the medical laboratory scientist involved in the care of this patient? Who can they give the results to?
- Discuss the responsibility of each individual health science profession and how you could work together in managing this case.
Case 2: A patient presenting with drug-associated gingival bleeding
Patient Details: A 13-year old Caucasian female attended her dentist with her mother because of painful cracks at the corner of her mouth, mouth ulcers and a general feeling of swollen lips. This has been coming and going for over six months.
General/Physical Appraisal/Social History: Weight loss of 4kg within the last month and loose stools preceding the oral lesions.
Medical History: Jaundice at birth and numerous allergies. No history of medication. No evidence of skin or genital lesions or previous oral lesions.
Extra-oral examination: General pallor of the face. No cervical lymphadenopathy. Upper and lower lips swollen, but soft and supple on palpation with surface flaking. Bilateral cracks at corner of mouth (Figure 1A).
Intra-oral examination: Folds of hyperplastic tissue bilaterally in the buccal sulcus, with surface ulceration (Figure 1B). Generalised gingival erythema, tongue pale with patchy depapillation.
Clinical Differential Diagnosis:
Lab results
Full blood count
|
Patient
|
Reference interval
|
Haemoglobin (Hb)
|
102
|
135-180 g/L
|
Mean cell volume (MCV)*
|
86
|
80-98 fL
|
Mean cell haematology (MCH)
|
23
|
26-32 pg
|
Red cell distribution width (RDW-CV)
|
22
|
11.5-14.5%
|
Total WBC
|
4.9
|
4.0-11.0 x109/L
|
Neutrophils
|
2.2
|
2.0-7.5 x109/L
|
Lymphocytes
|
2.3
|
1.5-3.5 x109/L
|
Monocytes
|
0.4
|
0.2-1.0 x109/L
|
Platelets
|
182
|
150-450 x109/L
|
Blood film comment
(Figure 2A & 2B)
|
Anaemia is present. Blood film shows hypersegmented neutrophils and red cell anisocytosis with occasional target, pencil, oval and teardrop cells.
|
Note: Figure 2A is omitted due to copy right.
|
Note: Figure 2B is omitted due to copy right.
|
Chemical pathology
|
Ferritin
|
12
|
20-200 ug/L
|
CRP
|
15
|
<5 mg/L
|
Vitamin B12
|
60
|
211-911 pg/mL
|
Fecal calprotectin
|
64
|
<50 ug/g
|
Biopsy of hyperplastic tissue: Incisional biopsy in relation to right and left buccal mucosa revealed oedematous superficial lamina propria with dilated lymphatic vessels. Lymphocytes were scattered diffusely and in clusters along with fibrous scattered aggregates of non-caseating granuloma. Hematoxylin and eosin staining showed a parakeratinized stratified squamous epithelium along with the underlying granuloma formation under scanner view (Figure 3a) and low power view (3b and c). High power view shows scattered aggregates of non-caseating granuloma (3d and e), which are typically small consisting of macrophages, epithelioid cells surrounded by scattered lymphocytes and plasma cells (3f) suggestive of the granulomatous lesion. (Note: Figure 3a-f are omitted due to copy right.)
Discussion points for the IPE Group
- Describe the reason(s) the patient came to visit the dentist?
- Discuss the differential clinical diagnosis
- What blood tests should be ordered-describe how these tests are ordered, how the blood is obtained and handled at the collection centre and at the diagnostic laboratory
- Why would smears be taken as part of the diagnostic work-up? What are smears, how are they taken and processed?
- Discuss the handling of the biopsy specimen from when it is removed from the lesion until it is given to the pathologist to report on a slide.
- What is the primary role of the dentist when seeing this patient? With whom will they liaise? What would be the pathway of referrals?
- Discuss the responsibility of each individual health science profession and how you could work together in managing this case.
- Discuss other concerns or topics relevant to the case (i.e. complications, systemic involvement, ongoing management).
Case 3: A patient presenting with an ulcer subsequently diagnosed as oral cancer
Patient Details: A 46-year old woman is visiting her dentist for assessment of a tongue lesion that is non-resolving. She said it is painful when moving the tongue or while eating.
General/Physical Appraisal/Social History: No person or family history of recurrent oral ulceration
Medical History: Survival after acute myeloid leukemia before age 2. Incident of a cerebral venous sinus thrombosis 8 years ago. Suffers currently from epilepsy, without symptoms for a long time. Takes no medication. No known allergies. Does not drink alcohol. Has no weight changes or night sweats.
Smoking History: Has been smoking 2-3 cigarettes/day for 8 years.
Dental History: She visits the dentist sporadically, and only when she is in pain.
Extra-oral examination: Symmetric face and normal skin colour, motor and sensory cranial nerve functions within normal range. No palpable lymph nodes of either side of the neck. No limitation of the mouth opening.
Intra-oral examination: 1.5cm lesion on the right lateral margin of tongue, at about the level of the premolars. It is white and red with a somewhat granular surface with focal ulceration. It is indurated to palpation (Note: Figure 1 is omitted due to copy right).
Clinical differential diagnosis:
Traumatic ulcer
Major aphthous ulcer
Ora squamous cell carcinoma (OSCC)
Plan: Need to make a diagnosis, so biopsy or refer
Lab results
Full blood count
|
Patient
|
Reference interval
|
Haemoglobin (Hb)
|
101
|
135-180 g/L
|
Mean cell volume (MCV)*
|
77
|
80-98 fL
|
Mean cell haematology (MCH)
|
23
|
26-32 pg
|
Total WBC
|
10.4
|
4.0-11.0 x109/L
|
Neutrophils
|
6.7
|
2.0-7.5 x109/L
|
Lymphocytes
|
2.8
|
1.5-3.5 x109/L
|
Monocytes
|
0.9
|
0.2-1.0 x109/L
|
Platelets
|
245
|
150-450 x109/L
|
Blood film comment
(refer to figures 2A & 2B)
|
Anaemia is present. Blood film shows pencil cells and target cells.
|
Note: Figure 2A is omitted due to copy right.
|
Note: Figure 2B is omitted due to copy right.
|
Chemical pathology
|
|
|
Ferritin
|
12
|
20-200 ug/L
|
Biopsy of affected tissue: Nests and islands of squamous cells invading the underlying connective tissue. In some of these tumor islands, there is aberrant keratinization, forming whorls of keratin within (Figure 3A). The invading cells show nuclear pleomorphism and hyperchromatism with brisk mitotic activity (Figure 3B). There is no evidence of neural or vascular invasion. The tumour extends to the deep margin and measures 2.3mm from the surface of the specimen.
Note: Figure 3A is omitted due to copy right.
|
Note: Figure 3B is omitted due to copy right.
|
DIAGNOSIS: Squamous cell carcinoma, well differentiated, extending to deep margin
Discussion points for the IPE Group
- Describe the reason(s) why the patient has come to visit the dentist?
- Discuss the risk factors/contributing factors (including systemic factors) involved from an oral health and general health perspective.
- Discuss possible differential diagnoses and how to distinguish between them
- What is the primary role of the dentist when seeing this patient? With whom will they liaise? What would be the pathway of referral?
- Discuss the handling of the biopsy specimen from when it is removed from the lesion until it is given to the pathologist to report on a slide.
- Discuss the responsibility of each individual health science profession and how you could work together in managing this case.
- The usual treatment for oral cancer is surgery and or radiotherapy. Discuss the potential complications of these therapies, particularly in light of the age of the patient.