case_images: PMC11250689_01
case_images: (a) Initial presentation of the patient's oral mucosa: whitish patches enveloping the gingiva. (b) Extensive distribution of white plaques: whitish in hue, they extend seamlessly across the lateral palate, palatine wrinkles, and the alveolar ridge. (c) The epithelium presents atrophy of the epithelial ridges, accompanied by selective thinning of the spinous layer in some regions. A prominent superficial layer of orthokeratin overlays all, alongside disarray within the basal layer. Within the dense underlying connective tissue, pockets of angiogenesis intermingle with a moderate chronic inflammatory infiltrate (H&E:40x). (d) Same area as (c) on higher magnification (H&E:100x).
case_images: CRID2024-9166581.001.jpg
case_images: PMC11250689_01_CRID2024-9166581.001.jpg
case_images: fig1
case_images: Whitish, nonscrapable lesions of varying sizes could be seen on intraoral examination, some being circumscribed and others diffuse, distributed over the buccal mucosa, gum (Figure 1(a)), palate, and upper sulcus, close to the upper right molars. In some sites, a verrucous aspect was observed (Figure 1(b)). An incisional biopsy was conducted on the posterior palate (Figure 1(b) (arrow)) for histological analysis. The underlying connective tissue was dense and with areas of angiogenesis and moderate chronic inflammatory infiltrate (Figures 1(c) and 1(d)).
case_images: (a) Evolution after a year: the clinical image demonstrates the lesion's thickened state and its encroachment into the gingival tissue surrounding lower teeth. (b) Progressive thickening and expansion: patches in quadrants 3 and 4 display a notable increase in size. (c) Progressive thickening and expansion: lesions in quadrants 2 and 3 display a notable increase in size. (d) Expansive transformations: patches and plaques intensify and thickening, while a diffused erythroplakic region emerges posteriorly on the right side. (e) Microscopic view of alveolar ridge: the mandibular alveolar ridge exhibits bulbous projections towards the connective tissue. This is coupled with stratification loss, an augmented granular layer, and a thick stratum corneum featuring a parakeratin layer. Additionally, basal layer anomalies manifest as pleomorphic cells characterized by abundant cytoplasm and nuclear hyperchromatism (H&E:100x).
case_images: CRID2024-9166581.002.jpg
case_images: PMC11250689_01_CRID2024-9166581.002.jpg
case_images: fig2
case_images: After a year, the patient reappeared with increased lesions (Figures 2(a), 2(b) (arrow), and 2(c)) and an erythroplakic area near the prior biopsy site (Figure 2(d) (black arrow)). Although hesitant about another palatal biopsy, the patient underwent 2 incisional biopsies at different mandibular sites: the alveolar ridge and close to the lower left premolars (Figures 2(b) and 2(c) (white arrows)). Anatomopathological examination (Figure 2(e)) showed changes in the lining epithelium characterized by blunt bulbous projections from the connective tissue, loss of stratification, hyperplastic granular layer and stratum corneum with a thick layer of parakeratin and loss of characterization of the basal layer, pleomorphic cells with ample cytoplasm, and nuclear hyperchromatism.
case_images: (a) Progression at six months: frontal clinical depiction postulates an amplified area of gingival lesions after six months, following the last incisional biopsies. (b) Lateral evolution: the right lateral view demonstrates lesion progression, serving as a comparative reference to Figures 2(a) and 2(b). (c) Posterior palate clinical display: depiction of the clinical status of the right posterior palate region. (d) Wider clinical perspective: displaying the overall clinical appearances of the palate. (e) Wider clinical perspective: displaying the overall clinical appearances of the mandible. (f) Wider clinical perspective: displaying the overall clinical appearances of the left buccal mucosa. (g) Microscopic detail of S4: histological insight reveals acanthosis, exocytosis, basal layer disorganization, and an intraepithelial keratin pearl (arrow) (H&E:100x). (h) Microscopic observation of S2: highlights include connective tissue projections, acanthosis, hypergranulosis, and a substantial layer of orthokeratin within the histological context (H&E:100x).
case_images: CRID2024-9166581.003.jpg
case_images: PMC11250689_01_CRID2024-9166581.003.jpg
case_images: fig3
case_images: After 6 months of the second and third biopsies, due to the gradual increase of the lesions (Figures 3(a), 3(b), 3(c), 3(d), 3(e), and 3(f)) towards previously free areas, the thickening of the oldest lesions and the recurrence in the previously biopsied areas result in the decision to perform new incisional biopsies for follow-up of the evolution, especially regarding the dysplastic areas. Four samples were taken: S1, left jugal mucosa (Figure 3(f)); S2, left alveolar ridge in the maxilla close to the second molar (Figure 3(d)); S3, buccal gingiva between right premolars (Figure 3(b)); and S4, alveolar ridge close to the right third molar (Figure 3(d)). The anatomopathological examination of S4 (Figure 3(g)) showed intense acanthosis, exocytosis, intraepithelial keratinization in the form of a keratin pearl (arrow) and in the form of individual keratinization, a thick layer of orthokeratin on the surface, and disorganization of the basal layer. In the connective tissue, deposition of dense collagen fibers was visualized (Figure 3(h)).