An 85-year-old female patient, under my continuous care since 1990, presented in June 2011 due to pain and bleeding of the gingiva in the region of the lower incisors. She complained that the pain prevented her from eating and brushing her teeth.
Clinical examination revealed swelling and redness of the gingiva from teeth 43 to 33, with deepened periodontal pockets and bloody-purulent discharge, which had never been previously observed in this patient. Until then, her gums had always been pink, shiny, and smooth, as seen in the photographs from 2010 (Fig. 1, Fig. 2). In her medical history, the patient reported a long-standing cardiovascular disease. One week prior to the visit, she had experienced a night episode of high fever, profuse sweating, and marked weakness.
Standard therapeutic procedures were implemented, including mechanical removal of soft deposits, rinsing with chlorhexidine solution, and the use of the Carident preparation. One month later, the patient returned. She was undergoing antibiotic therapy for a urinary tract infection. Examination revealed no purulent discharge, but gingival inflammation persisted. In August, the patient came in for another hygiene appointment. She complained of recurrent fevers with high peaks followed by severe weakness. Due to the hectic fever pattern and urinary tract issues, I suggested a renal ultrasound. In October, ultrasound examination revealed a solid tumor in the right kidney. A right-sided nephrectomy was performed. Histopathological examination confirmed marginal zone B-cell lymphoma, stage II B.
In 2012, the patient came under oncological care. After completion of treatment, the condition of her gums improved.
Regular dental check-ups over the next five years revealed no abnormalities: the gingiva appeared healthy and caused no complaints. A follow-up OPG in October 2017 showed no alarming findings except for a deepened periodontal pocket between teeth 26 and 27 (Fig. 3).
However, in November 2017 (six years after the nephrectomy), shortly after a follow-up visit to the oncologist—who, based on laboratory tests, declared the cancer cured—the patient began to complain of recurrent aphthae. As part of treatment, all sharp restoration edges were smoothed, but in December, a massive outbreak of aphthae occurred on the tongue and buccal mucosa. Mouth rinses and gels dedicated to the treatment of aphthous stomatitis offered little relief. Additionally, swollen and painful lymphoid nodules appeared on the posterior part of the tongue, which was especially distressing during the Christmas season. In January, a painful swelling developed on the left side of the neck, extending from the ear to the clavicle along the sternocleidomastoid muscle. Ultrasound examination of the area revealed enlarged lymph nodes and nodules suggestive of lymphoma. Biopsy confirmed the diagnosis. The patient underwent chemo- and radiotherapy. After two weeks of irradiation, the gingiva appeared pale and free of inflammatory changes (Fig. 4). In the third week, aphthae reappeared on the tongue and in the vestibule (Fig. 5), accompanied by a range of distressing subjective symptoms: pain, burning, stinging, intolerance to all tastes, as well as to food that was too hot or too cold. Swallowing solid food became impossible. For half a year, the patient subsisted on mild purees without spices. Later, the symptoms resolved.
Currently, the patient feels well and, despite being 93 years old, inspires those around her with her admirable optimism.
This case clearly demonstrates that concerning symptoms in the oral cavity may be an early manifestation of developing neoplastic disease—and may even precede changes in blood test results. In such situations, if the dentist remains vigilant, they may contribute to the timely detection of both cancer and its recurrence.
AUTHOR: Mirella Kowalczyk, DDS, private practice
Article published in issue 3/2019 of Nowy Gabinet Stomatologiczny magazine. See full table of contents.
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