Forum for Clinical and Surgical Oral Pathology

Case BBOPF 12-2

Hello, BBOP. Briefly, I am a 2nd year resident over here in NYC at Columbia University.

Today, a 7 year old girl, who in July received a bone marrow transplant (for sickle cell anemia), presented with a normal, unremarkable oral mouth, according to the GPR who examined her. She was sent to the dental clinic by an alarmed Pediatric Oncology three days prior, because she presented with the changes in her mouth (see attached picture). The girl only complains of itching, otherwise, there is no pain, no burning, no difficulty in swallowing, nor breathing. Pediatric Oncology performed cultures (though not sure where) that returned NEGATIVE for viral, fungal, and bacterial. When I arrived, the GPR had already performed the exam and stated that everything was normal. I thought about re-examining the girl, but she looked scared, so I took the GPR for her word, and told the mom to return when her daughter presents with the changes again. In addition, I was able to elicit some history from the mom and also ask the girl about how her mouth felt when it looked like the picture, so I wasn't completely useless.

I suspect that what we have here is an oral manifestation of GVHD and so the basic premise to my posting here is what can I really do for this patient when she next presents with the changes? I am slightly biased in that I just feel that there is not much that I can do, but re-assure the mom and educate her of the risks of malignancy with GVHD.

Would taking a biopsy to confirm lichenoid changes and thereby GVHD be of value here? Do I prescribe steroids? Or do I simply reassure the mom telling her that the changes in her daughter's mouth are likely due to the barrage of medications and the body's response that receiving BMT entails and will come and go as long as her daughter's on immunosuppresion/chemotherapy and her body reacts to the foreign bone marrow? Do I mention the risk of malignancy and recommend periodic evaluation?

What I hope I can get from BBOP is a rough structure on how to approach interaction with this family from those who have been in the game awhile, as the young, cool kids say.

Eugene Ko, DDS
Oral Path resident, PGY2

Images

Case prepared by Dr. Alfredo Aguirre (BBOP Manager) and Daniel Emmer (Web Administrator, University at Buffalo School of Dental Medicine).