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Persistent Oral Tenderness

Case Challenge Number: 7

Diagnostic Information

Additional Clinical History

Review of the patient’s medical history reveals he had been diagnosed with Crohn’s disease 16 years previously. Two weeks ago he completed a course of prednisone prescribed to manage an exacerbation of Crohn’s disease. His current medications are dicyclomine hydrochloride, an anticholinergic agent, and mesalamine, an antiinflammatory agent, both for the management of this gastrointestinal disease. He also takes calcium and folic acid supplements.

Review of the patient’s dental history reveals he has worn a maxillary complete denture and a mandibular complete overdenture for 3 years. He has complained frequently of localized areas of soreness; however, in the past these have been relieved by minor denture adjustments.

Clinical Findings

Head and neck examination reveals no visible extraoral abnormalities and no palpable lymphadenopathy. Intraoral examination reveals moderate to severe erythema of the palatal and alveolar mucosa. (Figures 1, 2, and 3) The dorsal tongue exhibits moderate erythema with atrophy of the filiform papillae. (Figure 4) The intraoral soft tissues appear dry and manipulation of the major salivary glands reveals minimal salivary flow.

image showing erythamatous palatal mucosa

Figure 1. Erythematous palatal mucosa

Erythematous maxillary alveolar

Figure 2. Erythematous maxillary alveolar mucosa

bitewing xray showing slight bone loss

Figure 3. Erythematous mandibluar alveolar mucosa

Erythematous mandibluar alveolar mucosa

Figure 4. Erythema and atrophy of fillform papillae of the dorsal tongue


A cytologic preparation stained with periodic acid-Schiff stain reveals numerous fungal hyphae and occasional ovoid yeast forms. (Figure 5)

image showing photomicrograph of tissue

Figure 5.

Laboratory Studies

The patient reports he has recently undergone a complete physical examination including blood studies.

Table 1. Blood Studies

TestResultsNormal Range
Hemoglobin15 g/dL14-18 g/dL
Red blood cell count5.1 x 1012/L4.5-6.2 x 1012/L
Mean cell volume84 fL80-94 fL
Mean cell hemoglobin30 pg27-32 pg
Mean cell hemoglobin concentration33 g/dL32-36 g/dL
White blood cell count6.2 x 109/L5-10 x 109/L
Platelet count0.28 x 1012/L0.15-0.4 x 1012/L
Vitamin B12390 pg/mL>200 pg/mL
Folic acid18 pg/mL2-20 ng/mL
Fasting blood glucose88 mg/dL65-110 mg/dL
Iron94 mg/dL50-175 mg/dL
Iron binding capacity334 mg/dL250-410 mg/dL