Pathology · patient case question
For Patient B, what is the FIRST step?
Patient case: An old root filling and a sharp cusp
Patient: Two patients
Chief Complaint: Patient A: “This tooth is tender and there is a bad taste.” Patient B: “I have had a sore on my tongue for two weeks.”
Background: Patient A, 48 years old: tooth #30 was root treated twenty-two years ago and obturated with SILVER POINTS. Patient B, 57 years old: the distolingual cusp of #32 fractured a fortnight ago and has not been treated.
Findings: Patient A: a periapical radiolucency at both roots of #30, a sinus tract on the buccal, tenderness to percussion, and a defective coronal restoration. The canals appear negotiable coronal to the points. Patient B: a sharp fractured cusp edge, and an ulcer with a slightly rolled margin on the lateral border of the tongue lying directly against it.
Show answer and explanation
Correct answer: A. Smooth or restore the sharp cusp and review in 10 to 14 days
- A. CORRECT. This is a traumatic ulcer with an obvious mechanical cause lying immediately against it. The governing rule in oral medicine is REMOVE THE CAUSE FIRST, THEN REVIEW. Smooth the sharp cusp by selective grinding, or restore the tooth, and re-examine at 10 to 14 days. A genuinely traumatic ulcer heals within that window once the irritant is gone.
- B. Excisional biopsy of an undiagnosed ulcer with a rolled margin is the worse of the two biopsy errors — if the lesion is malignant, excising it compromises staging and definitive surgical management.
- C. Biopsy is not the first step when a plausible and removable cause is present — but it becomes MANDATORY if the ulcer has not healed at the review appointment. A non-healing ulcer on the LATERAL BORDER OF THE TONGUE in an adult is squamous cell carcinoma until proven otherwise, and that site is the commonest intra-oral location for it. The rolled margin described here makes the review non-negotiable.
- D. A topical steroid applied without a diagnosis suppresses the inflammation, may mask progression, and delays the diagnosis of a potentially curable cancer.
Note: ⚠️ The recall recorded the two candidate answers as ‘take biopsy’ and ‘restore the cusp’, and settled on no biopsy. That is right AS THE FIRST STEP — but the answer is only safe if the review appointment is booked and kept. Removing the cause without arranging follow-up is the version of this that misses a carcinoma.