Pathology · patient case question
The uniformly widened periodontal ligament space around asymptomatic, firm teeth in the second patient is characteristic of:
Patient case: Punched-Out Papillae and a Tight Face
Patient: Two patients in the same session
Chief Complaint: (1) A 21-year-old student: “My gums are killing me and my breath is horrible.” (2) A 47-year-old woman referred with progressive facial tightness.
Background: Patient 1: final examinations week, sleeping four hours a night, smoking a pack a day, has not brushed properly in days. Patient 2: known systemic sclerosis, increasing difficulty opening her mouth.
Medications: Patient 1: none. Patient 2: nifedipine, omeprazole.
Vital Signs: Patient 1: T 100.6°F, HR 92, cervical lymphadenopathy. Patient 2: within normal limits.
Findings: Patient 1: punched-out, cratered, necrotic interdental papillae covered by a grey pseudomembrane, with spontaneous bleeding and severe pain. — Patient 2: taut shiny perioral skin with radial furrowing, maximum opening 26 mm, and on radiographs a uniformly WIDENED periodontal ligament space around multiple teeth which are firm and asymptomatic.
Show answer and explanation
Correct answer: C. Scleroderma (systemic sclerosis)
- A. Occlusal trauma also widens the PDL, but it does so LOCALLY at the teeth bearing the excessive load, and those teeth are typically MOBILE and often tender. This patient's widening is generalized and the teeth are firm.
- B. Osteosarcoma classically produces SYMMETRICAL widening of the PDL of a SINGLE tooth or a localized group, often with a sunburst periosteal reaction. It is localized and progressive, not generalized in a patient with known systemic sclerosis.
- C. CORRECT. Uniform, generalized WIDENING of the PDL space with teeth that remain FIRM and asymptomatic is the classic radiographic sign of SCLERODERMA. It results from excessive collagen deposition in the periodontal ligament. It is most obvious around the posterior teeth. The picture is completed by microstomia with radial perioral furrowing, a rigid tongue, xerostomia (secondary Sjögren occurs in a substantial proportion), dysphagia and reflux, and mandibular angle resorption in advanced disease.
- D. Periodontitis destroys the alveolar CREST, producing bone loss and pocketing. It does not widen the intact PDL space uniformly along the root.
Note: Dental management in scleroderma: MICROSTOMIA is the practical obstacle — short appointments, small instruments, paediatric trays, stretching exercises, and consider sectional impressions. Manage the xerostomia aggressively, elevate the chair for reflux, and expect wound healing to be slow.