Earn 2 CE credits This course was written for dentists, dental hygienists, and assistants.

Linking and Part I: Looking Beyond the Oral Cavity A Peer-Reviewed Publication Written by Lisa Dowst-Mayo, RDH, BSDH

Abstract Educational Objectives Author Profile Dental professionals are well educated in head and neck At the conclusion of this educational Lisa Dowst-Mayo, RDH, BSDH graduated magna cum laude anatomy as well as full body . We are in a unique activity participants will be able to: from Baylor College of Dentistry in 2002. She has been an active member of the American Dental Hygiene Association and has position within the healthcare community to identify 1. Review skin anatomy and physiology. held numerous leadership positions both at the state and local inconsistencies of the head and neck since we are commonly 2. Discuss the chemistry behind aging levels. She is currently a full time professor at Concorde Career spending a significant period of time with our . Ob- skin including free radical damage to College in the dental hygiene department in San Antonio, TX. Lisa serving and examining exposed areas of the head and neck cells is a published author, enthusiastic national speaker and can be enables dental professionals to provide early identification, 3. Discuss how human skin ages and why contacted through her website at www.lisamayordh.com. intervention and referral as needed. Part one of this course wrinkles, blemishes and hyperpigmen- Author Disclosure is designed to enhance the dental practitioner’s knowledge tation increase with advancing age. Lisa Dowst-Mayo has no affiliations with any company who would of common skin conditions. Part two will present treatment 4. Identify skin lesions that need referral have a gained interest in the material published in this course. options for those conditions. By integrating evidence-based to a specialist. There was no corporate sponsor in the making of this course and the author is not employed by a company that would stand to profit dentistry with evidence-based dermatology, comprehensive off the publication of this course. All research is presented in an care will improve. unbiased manner.

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Publication date: Feb. 2014 Supplement to PennWell Publications Expiration date: Jan. 2016

This educational activity was developed by PennWell’s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products PennWell designates this activity for 2 continuing educational credits. or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result Dental Board of California: Provider 4527, course registration number CA# 02-4527-13090 in the participant being an expert in the field related to the course topic. It is a combination of many educational courses “This course meets the Dental Board of California’s requirements for 2 units of continuing education.” and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. The PennWell Corporation is designated as an Approved PACE Program Provider by the Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents Academy of General Dentistry. The formal continuing dental education programs of this the most current information available from evidence based dentistry. program provider are accepted by the AGD for Fellowship, Mastership and membership Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient maintenance credit. Approval does not imply acceptance by a state or provincial board of and improvements in oral . dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to Registration: The cost of this CE course is $49.00 for 2 CE credits. (10/31/2015) Provider ID# 320452. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives by protecting against pathogens, preventing excessive water loss, At the conclusion of this educational activity participants will be temperature regulation, insulation, sensation, and the production able to: of vitamin D.34 It is imperative to protect and maintain the health 1. Review skin anatomy and physiology. of this vital organ. 2. Discuss the chemistry behind aging skin including free radical The skin contains many different structures and sub- damage to cells strates.2,10,36 (Figure 3). 3. Discuss how human skin ages and why wrinkles, blemishes 1. Epidermis: The outer layer of the skin. A basement mem- and hyperpigmentation increase with increasing age. brane separates the epidermis from dermis. It is comprised of epi- 4. Identify skin lesions that need referral to a specialist. thelial cells that form membranes of closely associated cells with an intercellular substance between them. Most epithelium has the Abstract capability of cell renewal by mitosis of the basal cells and that rate Dental professionals are well educated in head and neck is determined by the location in the body.2 Skin cell turnover rates anatomy as well as full body pathology. We are in a unique change dramatically throughout our lives, which in turn, affects position within the healthcare community to identify incon- the aging process of the skin. sistencies of the head and neck since we are commonly spend- ing a significant period of time with our patients. Observing 2. Dermis: The connective tissue layer lying just under the and examining exposed areas of the head and neck enables Epidermal Skin Turnover Rates dental professionals to provide early identification, interven- Age Cell Turnover (days) tion and referral as needed. Part one of this course is designed Infant 14 to enhance the dental practitioner’s knowledge of common skin conditions. Part two will present treatment options for Teens/20s 21-28 those conditions. By integrating evidence-based dentistry 30-49yrs 28-42 with evidence-based dermatology, comprehensive patient 50+ 42-84 care will improve.

Introduction epidermis. The dermis plays important functions in nourishing There is no fountain of youth in this world; however, there the skin and in thermal regulation. The dermis is comprised of are ways to slow the natural aging process of the human body. two layers; the papillary and reticular layers. The dermis houses This course will help the clinician identify skin abnormalities blood vessels, nerves, receptors, sweat glands, sebaceous glands and dermatological discrepancies and suggest treatment op- and erector pili muscles.10 tions for patients. 3. Hypodermis: Made of loose connective tissue and elastin There is a strong connection between dermatology and just below the dermis. It is the location of the connection between dentistry that is not always recognized or utilized by health the skin and underlying structures such as muscles and bones. care professionals. Dentists and dental hygienists should be The hypodermis is primarily comprised of areolar and adipose at the forefront of identifying head and neck abnormalities, tissues and its purpose is to supply blood vessels and nerves. The offering referrals when needed and/or providing prescrip- primary cell types are fibroblasts, macrophages and adipocytes. tions or over-the-counter medications based on findings. The hypodermis is responsible for 50% of total body fat content.10 This course is designed to bring the clinician outside the oral 4. Hair follicle: Extends from the hypodermis to epidermis. It cavity, focusing on skin lesions that can be diagnosed upon a contains blood vessels and a portion of the surrounding connective thorough extraoral screening. We can also provide life-saving tissue which enters from the bottom of the hair bulb.10 The hair referrals when skin abnormalities are observed. Since patients follicle plays a major role in acne and other skin conditions. can spend hours in our chair, under an overhead light, why 5. Sebaceous glands: Primarily associated with hairs that would we not spend a couple of minutes scanning the epi- open into the follicles, however, some open to the free surface of dermis? Other medical professionals do not have patients in the skin. These glands consist of small clusters of cells. Sebaceous such an ideal position to view the face, neck, ears and hairline. glands produce sebum which lubricates the skin and helps prevent Figures 1 and 2 demonstrate lesions that can be observed the growth of bacteria. If the sebaceous gland does not produce with a thorough extraoral screening including lifting the hair off enough sebum, the skin is dry. On the other hand, if it produces the neckline. too much, the skin is oily. If sebum gets trapped in the pores, acne can develop.10 Anatomy & Physiology of the Skin: 6. Sebum: The oil on the surface of skin is a complex mixture The largest organ in the human body is the integumentary sys- of lipids (including glycerides), free fatty acids, wax esters, choles- tem. It is the first line of defense from external insults and it in- terol esters, sweat and environmental agents. Sebum is produced terfaces with the external environment. The skin plays a key role when a sebaceous gland disintegrates. Sebum reduces water loss

74 | rdhmag.com RDH | February 2014 Figure 1: Posterior view of neck of female patient under hair from the skin surface, protects the skin from infection and contrib- utes to body odor.10 Sebaceous glands on the forehead and chin are larger and more numerous than elsewhere on the body; up to 400-900 glands per square centimeter.28 Sebum production is under the control of sex hormones (androgens) made by the adrenal glands. In females, the role of progesterone as it relates to sebum productions is still unclear. It has been noted that more sebum is produced the week proceeding a menstrual period when proges- terone levels are higher.28 The amount of sebum can be reduced by certain systemic medications such as estrogens/ oestrogens, anti-androgens/androgen antagonists or vitamin-A derivatives such as isotretinoin which will be discussed further in Part Two of this course. Sebum composition of oils varies dramatically with age. Adult males will produce slightly more than adult females. Below is a timeline of sebum production by age. • Fetus: produces vernix caseosa, a waxy protective layer • 3-6 months old: sebum produced resembles that of an adult • 8 years: Until the age of 8, sebum has less wax and squalene Figure 2: Close up of lesion noted in Figure 1 and more cholesterol • Puberty: Sebum production increases, up to fivefold in men • 20 years: Sebum production declines in both men and women • Adult females: Sebum declines after menopause associated with the changes in progesterone and estrogen. It’s this decrease in estrogen which slows down mitotic activity in the epidermal basal layer, reduces the synthesis of collagen and contributes to the thickening of the dermo-epidermal junc- tion. These changes cause the skin to thin, atrophy, wrinkle, increase dryness and display delayed wound healing.4 7. Sweat glands (Sudoriferous): Located deep in dermis or hypodermis. The sweat gland ducts open to the surface of the skin and are under control of the autonomic nervous system.10

Figure 3: Skin Anatomy Chemistry Behind Aging Skin Among the most dangerous agents on earth are free radicals, which significantly influence the overall aging process of our bodies. They are atoms or ions with an unpaired electron or open shell configurations, which makes them highly chemically reactive. (Fig- ure 4). Free radicals are found in the air, solar radiation, foods and environmental pollutants.25,35 Since free radicals are found in the environment, they can have an adverse effect on the skin and lead to wrinkles, hyperpigmentation, dry skin, dark circles under the eyes, dull skin, and mutation of cells and DNA which can lead to cancer. The Free-Radical Theory of Aging states that an organism ages because cells accumulate free radical damage over time.15,27 Antioxidants may help fight the aging process as they are reducing agents that limit oxidative damage to biological structures by paci- fying or inactivating free radicals.32,39 Research into antioxidants has been ongoing since the 1920s and their uses in dermatological and dental conditions will be discussed in Part Two of this course.

RDH | February 2014 rdhmag.com | 75 Figure 4: Oxidation/Reduction Figure 5: Milia http://www.webmd.com/skin-problems-and-treatments/picture-of-white-bumps- milia Weinberg S, Prose N, Kristal L. “Color atlas of pediatric dermatology”. The McGraw- Hill Companies®, Inc. 2008.

Skin Conditions Figure 6: Blackhead http://www.medicalnewstoday.com/articles/71615.php Awareness of common skin conditions will help dentists and den- tal hygienists provide accurate differential diagnoses when a lesion or imperfection is identified extraorally. By performing a thor- ough screening of a patient’s skin while you are working in their oral cavity, the dental clinician will be better able to notice those less obvious or innocuous-appearing lesions on a patient’s skin that may otherwise go unnoticed. Accurately identifying lesions and thoroughly examining patients will save lives through early intervention and specialist referrals. Early diagnosis improves the patient’s prognosis Milia: Tiny keratin-filled cysts just below the epidermis. They are common in newborns. Common locations include; the face, nose, around the eyes or roof of the mouth. Milia are completely benign lesions but may bother a patient cosmetically. Referral to a dermatologist or esthetician for removal can be recommended if a patient desires. (Figure 5) Whitehead: Medically termed a “closed comedo,” and lay termed a “pimple” or “zit.” A whitehead has no opening to the Figure 7: Acne Picture courtesy of the American Academy of Dermatology. http://www.aad.org/dermatology- skin surface as does a blackhead. Since there is no opening, no oxi- a-to-z/-and-treatments/a---d/acne dization will occur. Whiteheads can occur in groups or as a single lesion anywhere on the body. Blackhead: Medically termed an “cpen comedo.” It is the most common finding in acne vulgaris and is caused by excessive oils that accumulate in sebaceous gland ducts. The lesions contain keratin and modified sebum and darken as they ionize. (Figure 6) They are most commonly associated with clogged hair follicles and appear as yellowish-brown or blackish dome-shaped lesions on the skin. This condition can be painful and pose a major cosmetic concern for patients. If blackheads are a chronic issue, especially accompanied by acne, referral to a dermatologist is indicated. Acne: Affects 85% teenagers and is the most common skin condition in the United States. It is on the rise in adult women and occurs commonly during pregnancy, menopause or when women stop taking birth control pills due to the fluctuations in

76 | rdhmag.com RDH | February 2014 Figure 8: Freckles hormone levels (see section above on sebum). Common locations for women are on lower part of the face; around the mouth, chin and along the jawline. Acne develops when excess sebum, skin cells or bacteria accu- mulate on the skin. It is not just a pimple and can be accompanied by pain, multiple black/whiteheads, papules, cysts and/or infec- tions. (Figure 7). Acne cases are graded 1-4 by dermatologists, based on severity. Most treatments take 4-8 weeks to become ef- fective and will be discussed further in Part Two of this CE course.

FRECKLES Freckles are clusters of concentrated melanin that are most often Figure 9: Common moles (Nevus) visible in individuals with fair complexions. They are medically termed "ephelids" and are not associated with an increased num- ber of melanin producing cells (melanocytes) as moles are (Figure 8). People with freckles are more susceptible to the harmful ef- fects of UV radiation. Research suggests they avoid overexposure to the sun, tanning beds and use sunscreen daily. It is important for dental professionals conducting extraoral cancer screening to be proficient in distinguishing freckles from moles so they can correctly identify higher risk lesions that need to be referred to a specialist for possible biopsy and further examination.

MOLES (NEVI) Moles, medically termed nevi, are a very common condition. Figure 10: Spitz mole on back Almost every adult has at least a few moles, some have 10-40. Ac- cording to the Mayo clinic, if a patient has more than 50 moles on their body they are at higher risk for developing melanoma. Moles are clusters of melanocytes that commonly occur on sun-exposed parts of the body. According to the American Academy of Derma- tology, there are four different types of melanocytic nevi and some types increase a patient’s risk for developing melanoma. Common mole: Common moles generally do not turn into melanoma. Common moles are usually present at birth although can be acquired until about the age of 40. (Figure 9). Traits of a common mole include: 1. Color: brown, tan, black, red, pink, blue, skin-toned, or colorless 2. Shape: round, flat, slightly raised or dome-shaped 3. Size: less than 5mm 4. Consistency: looks the same month-to-month Figure 11: Age Spots Atypical mole: Can look like a melanoma but it is not. They are generally larger than a pencil eraser, have an irregular shape, and display more than one color. If a dental professional suspects this type of mole, referral to a dermatologist is indicated to rule out melanoma. Atypical moles can appear anywhere and are com- mon on the trunk, head, neck or scalp. Congenital mole: Roughly 1 out of 100 people are born with congenital moles and they vary in size from small to giant. Cindy Crawford and Marilyn Monroe are two well known celebrities with moles on their cheeks that many refer to as “beauty marks.” Having multiple giant moles does increase the risk of melanoma.

RDH | February 2014 rdhmag.com | 77 Spitz mole: Commonly resemble melanoma. They are often Figure 12: Lentigo next to a common mole on forearm pink, raised and dome-shaped, but can be brown, black or red as well as bleed or ooze. Spitz nevi commonly occur in the first two decades of life (Figure 10). A referral to a dermatologist is indi- cated to correctly diagnose and rule out a more serious condition. All dental professionals should know the ABCDE’s of a mela- noma to help distinguish a typical or low risk mole from a poten- tially malignant mole.

A Asymmetry One half is unlike the other Irregular, scalloped, poorly defined or B Border demarcated Varies from one mole to another. C Color Shades of tan, brown, black, white, red Figure 13: Eczema or blue Melanomas are usually greater than 6mm (the size of a pencil eraser) D Diameter when diagnosed although they can be smaller A mole that looks different from others E Evolving or changes in size, shape, color or consistency

A differential diagnosis could include a multitude of disorders including; seborrheic keratosis, pigmented basal cell carcinoma, squamous cell carcinoma, hemangioma, sebaceous hyperplasia or lentigo.

AGE SPOTS Age spots, also referred to as sun spots, liver spots, lentigo, or len- tigines; will appear as flat, oval, hyperpigmented lesions with well demarcated borders that are gray, brown or black (Figures 11,12). Figure 14: Psoriasis around the ear They usually occur in sun-exposed areas of the skin such as hands, A.D.A.M Medical Encyclopedia http://www.pennmedicine.org/encyclopedia/em_ feet, shoulders and upper back. Age spots are very common after PrintArticle aspx?gcid=000822 the age of 40 but can occur in younger patients. They are the re- sult of years of exposure to UV light from the sun or tanning beds which accelerated the production of melanin within the base of the epidermis.45 A differential diagnosis could include a melanoma, freckle, nevi, lentigo maligna also known as lentiginous melanoma or seb- orrheic keratosis. Diagnosis is made based on clinical appearance and generally requires no treatment but many doctors will perform a skin biopsy to rule out more serious conditions.

ECZEMA/ATOPIC DERMATITIS A chronic skin disorder that involves itchy, rash-like, or scaly patches (Figure 13). It is caused by a hypersensitivity reaction in the skin and is common in patients who also suffer from and/or asthma.5 Patients may lack a certain protein in the skin which can contribute to a greater sensitivity to atopic dermatitis and is commonly thought to be an inherited disorder.

78 | rdhmag.com RDH | February 2014 Figure 15: Seborrheic dermatitis on elbow or may not clear up within 1-2 years.23 These lesions may leave pigmented spots on the skin after they disappear, as do many in- flammatory lesions. OLP is usually diagnosed based on visual presentation; however, many health providers will biopsy to confirm the diagnosis and rule out other conditions. A differential diagnosis may include; epithelial dysplasia, squamous cell carcinoma, lichenoid drug reaction, mucosal reaction to allergens such as cinnamon, foreign body or amalgam reaction, lupus erythematosus, dysplasia, can- dida, chronic ulcerative stomatitis or autoimmune diseases such as pemphigus.23

PSORIASIS A chronic, immune-mediated skin that also has systemic manifestations.24 The lesions may appear as with silver-white patches called scales or red-flaky patches that are itchy. It may look According to the American Academy of Dermatology, dry rash-like, be smooth or rough depending on the type (There are skin can affect any part of the skin but is common on the cheeks, 5 types.) Psoriasis is not contagious and appears to be genetically scalp, forehead, eyelids or under eyes, knees, elbows, hands or feet. linked.5 The progression of psoriasis is as follows: Dental professionals may have issues with eczema on their hands 1. The immune system sends faulty signals to skin cells causing due to the number of times hand washing takes place and/or due them to grow too rapidly. to the type of antimicrobial soaps used. Scratching excessively can 2. The new skin cells form in days rather than weeks and the lead to infection, disturbed sleep or could cause the skin to thicken body does not shed the excess cells. and darken permanently. 3. The cells pile up on the surface of the skin and patches of psoriasis start to appear clinically. ROSACEA Psoriasis can be triggered by infection, dry air/skin, trauma, Rosacea is a chronic skin condition which manifests as redness of medications (beta-blockers, lithium), stress, sunlight (too much the skin and may cause swelling and skin sores that resemble acne. or too little) or alcohol. The patches are common on the head and Rosacea involves swelling of the blood vessels just under the skin neck, especially along the hairline or back of the neck5 (Figure 14). and is of unknown origin. It is common in individuals 30-50 years Identifying psoriasis will help dental professionals decide whether of age, in fair skinned individuals and occurs more commonly in they are looking at a simple, benign condition or a more dangerous women.39 The clinical appearance is generalized redness, blush- condition that needs referral to a specialist. ing easily, spider-like blood vessels (telangiectasia) of the face, red nose, acne-like sores that ooze or crust, burning or stinging of the SEBORRHEIC DERMATITIS (SD) face and irritated or blood-shot eyes. SD is defined as a chronic, benign relapsing inflammatory skin disorder clinically characterized by scaling, poorly defined ery- ORAL LICHEN PLANUS (OLP) thematous patches or greasy yellow flakes in areas of high seba- Defined as a chronic, benign inflammatory condition involving ceous gland activity; especially on the head and neck, scalp, hair destruction of basal cells of the surface epithelium.3,22 OLP can line chest and upper back 1, 7 (Figure 15). affect any lining mucosa in the body including the mouth and skin. The etiology is not fully understood, but it is thought to be caused Some research links OLP to an autoimmune response, however, by Malassezia yeasts, androgen hormones, sebum levels or immune no particular antigen has been found. Its etiology and host suscep- responses and it affects 5% of the population. SD is exacerbated by tibility still remain unclear. stress, cold temperatures and drugs. A differential diagnosis may Statistics show OLP is more common in middle-aged women and include; warts, moles, actinic keratosis, and skin cancer. affects 0.1-4% of the population in the United States, with 40% of the patients having cutaneous involvement.19,34 OLP can require VERMILLION BORDER DETERIORATION long term management and treatment; however, patients may go The vermillion border represents the change in the epidermis through periods when they are symptom free or the disease clears from highly keratinized external skin to less keratinized internal on its own within a couple of years. skin. According to the UK Cancer Research group, lower lip can- Intraorally, OLP can present on the cheeks, tongue, lip and/ cer accounts for 5% of all new squamous cell carcinoma diagnoses. or mucosa. Cutaneous lesions will appear as purple, polygonal, The vermillion border and lips can be damaged by sun exposure pruritic papules that are usually found in small clusters on flexor and dental professionals should recommend a lip balm with zinc aspects of the extremities but tend to be self-limiting and may oxide to their patients.

RDH | February 2014 rdhmag.com | 79 ANGULAR CHEILITIS Figure 16: Basal Cell Carcinoma http://www.medicinenet.com/image-collection/basal_cell_carcinoma picture/picture.htm Angular cheilitis is a chronic inflammatory process most com- Wolff K, Johnson R, Suurmond D. “Fitzpatrick’s color atlas and synopsis of clinical monly located on the labial commissure where deep cracks/splits, dermatology.” The McGraw-Hill Companies® ulcers, bleeding or crusting can occur. It is commonly caused by candida organisms, bacterial infections and/or nutritional defi- ciencies.19 Treatment options will be presented in Part Two of this course.

ACTINIC CHEILITIS (AC) Actinic cheilitis presents as a loss of sharpness around the bor- der of the lip, atrophy of the vermillion border and darkening at the junction of the lip and skin of the face. AC is considered a potentially malignant disorder, which could turn into squamous cell carcinoma. Research results on the percentage of actinic cheilitis cases converting to cancer are controversial. Estimates vary dramatically from 1.4%-36 %.40 Identification and treatment are commonly delayed because health care professionals overlook the condition as a harmless chronic inflammatory issue or dismiss to x-rays or other forms of radiation, family history of skin cancer, changes as appearing non-threatening or alarming. If a dental pro- tanning bed use or frequent sunburns in early years of life.44 fessional sees such changes around the lips, an immediate referral BCC presents clinically as a dome-shaped lesion with a pearly to a specialist is needed. or wax-like appearance with rolled borders that may be white, light The highest risk groups for AC are fair-skinned individuals pink, brown or flesh-colored. Lesions may bleed occasionally; with high levels of UV/sunlight exposure which accumulates have visible blood vessels in or around the skin, oozing, crusting throughout the lifetime. Clinical changes frequently occur around and/or an inability to heal. The lesion may flatten or sink in the the 5th decade of life; however, this condition can occur at any center and have an absence of well-defined borders (Figure 16). age.19, 40 The lip is insufficiently protected from radiation because of its thinner epithelium, thin layer of keratin, lower concentrations SQUAMOUS CELL CARCINOMA (SCC) of melanin and lower secretions from sebaceous glands. Smoking There are 700,000 new cases of squamous cell carcinoma diag- may also increase a patient’s risk for actinic cheilitis. Dental pro- nosed each year in the United States. It tends to develop on skin fessionals are in a unique position to thoroughly evaluate the lips that has been exposed to the sun for years and is most frequently while our patients are in a supine position, with an overhead light seen on the head, neck, mouth, lips or back of the hands. Other illuminating the area. risk factors include advanced age, light-colored skin, blue/green/ grey eyes, many previous x-rays or chemical exposures. Lesions NONMELANOMA SKIN CANCER on the leg are common in women and will spread to other parts of Skin cancer can be divided into 2 categories: melanoma or non- the body if not treated aggressively. People who use tanning beds melanoma. Basal cell carcinoma and squamous cell carcinoma are are at greater risk and also contract SCC earlier in life. Early diag- the most common forms of nonmelanoma skin cancers. According nosis is critical and with correct treatment, SCC is very curable. to the CDC, there were more than 2 million cases of skin cancer in Clinical presentations of SCC are nodules that grow, do not the US in 2012. There were 76,250 new cases of melanoma with heal on their own, have a rough, scaly surfaces and/or flat reddish more than 9,000 fatalities. The CDC also estimates 65-90% of patches over 1 inch in diameter. Some lesions will appear as a melanomas are caused by UV light. pre-cancerous growth called an actinic keratosis (AK). In adults 40+ years of age, about 40-60% of SCCs begin as AK.(6) AK le- BASAL CELL CARCINOMA (BCC) sions clinically present as small, pink, rough, dry, scaly patches Basal cell carcinoma is the most common form of skin cancer, ac- or growths on the skin. They can itch or burn or be completely counting for more than 80% of cases. Most commonly affected asymptomatic. AK may present as a sore that doesn’t heal or heals sites include areas of the skin that are frequently exposed to the sun and returns at a later date. AK lesions can easily be mistaken for a such as; the face, scalp, nose, ears, around metal eyeglass frames or multitude of other, non-cancerous dermatological issues because the back of the hands. BCC grows slowly and occurs in the basal of their presentation and locations. They can occur in areas that cells located in the lower epidermis. BCC rarely metastasizes and are difficult to observe such as; behind the ears, along the hair- is usually asymptomatic. line or under the collar of a shirt. It can be challenging for dental Higher risk groups for BCC are individuals over the age of 40, professionals to find and identify these lesions as AK and they people with light-colored or freckled skin, blue/green/grey eyes, may dismiss these growths as age spots, normal anatomy or non- blonde or red hair, a high number of moles (> 50), over-exposure threatening lesions in some situations. Dental providers need to

80 | rdhmag.com RDH | February 2014 27. Nelson N. “The Free Radical Theory of Aging.” Department of Physics, Ohio check all areas of skin on the head and neck carefully during ex- State University. Accessed September 4, 2012 from http://www.physics.ohio-state. edu/~wilkins/writing/Samples/shortmed/nelson/radicals.html traoral screenings; being sure to check behind the ears, around the 28. Oakley A. Sebum. Department of Dermatology Health Waikato. Accessed December 1, clavicle and having long hair pulled up off the neck so the hairline 2012 from http://www.dermnetnz.org/acne/sebum.html. 29. Oresajo C, Stephens T, Hino PD, Law RM, Yatskayer M, Foltis P, Pillai S, Pinnell SR. and scalp can be visualized. “Protection Effects of a Topical Antioxidant Containing Vitamin C, Ferulic Acid and Phloretin Against UV-Induced Photodamage.” J Cosmet Dermatol. Dec 2008. 7(4):290-7. 30. Packer L, Witt EH, Tritschler HJ. Alpha-Lipoic Acid as a Biological Antioxidant. Free Conclusion Radic Biol Med. 1995 Aug;19(2):227-50 Due to our existing knowledge and education of the head, neck 31. Pinnell SR. “Topical L-Ascorbic Acid: A Percutaneous Absorption Study.” Dermatol Surg. Feb 2001.27(2):137-142. and skin anatomy, dental professionals can be leaders in identify- 32. Pinnell SR. “Photodamage and Oxidative Stress and Protection Provided by Topical ing head and neck lesions and skin abnormalities. Antioxidants.” J Am Acad Dermatol. 2003. 48(1):1-19. 33. Pinnell SR. “A Topical Antioxidant Solution Containing Vitamins C and E Stabilized by Early detection and referral to a specialist for any suspicious Ferulic Acid Provides Protection for Human Skin Against Damage Caused by Ultraviolet Irradiation.” J Am Acad Dermatol. 2008. 59(3):418-25. lesions of the skin, regardless of how innocuous they may appear, 34. Stoopler T, Sollecito TP, DeRossi SS. Oral Lichen Planus for the General Practitioner. NY cannot be overstated. Part 2 of this course will present current, State Dental Journal. June-July 2003;69(9):26-8. 35. Poljsak B, Dahmane R. Free Radicals and Extrinsic Skin Aging. Dermal Rsrch and Practice. research-based treatment options and educate clinicians on the use 2012. Hindawi Publishing Sorporation. Accessed January 4, 2013 at www.hindawi.com/ of antioxidants for the skin and the mouth. journals/drp/2012/135206/. 36. Rhoades & Pflanzer. Human Physiology. 3rd ed. Orlando, Saunders College Publishing. 1996:73-105/805-812. References 37. Shu YY, Maibach HI, Estrogen and skin: therapeutic options. Am J Clin Dermatol. 2011 Oct;12(5):297-311. 1. Aschoff R, Kempter W, Meurer W. Seborrheic dermatitis. Hautarzt. Apr 2011;62(4):297-307. 38. Symone M, Miguel S, Opperman L, Allen E, Zielinski J, Svoboda K. “Antioxidants 2. AveryJ. Essential of Oral Histology and Embryology, A Clinical Approach. 2nd ed. St. Counteract Nicotine and Promote Migration via RacGTP in Oral Fibroblast Cell.” Louis: Mosby, Inc; 2000:16-19. J.Periodontol. Nov 2010. 81(11):1675-90. 3. Bagan J, Compilato D, Paderni C, Campisi G, PanzarellaV, Picciotti M, Lorenzini G, Di 39. Symone M, Miguel S, Opperman L, Allen E, Svoboda K. “Reactive Oxygen Species and Fede O. Topical for Oral Lichen Planus and the Efficiency: A Narrative Review. Antioxidant Defense Mechanisms in the Oral Cavity: A Literature Review.” Compendium Curr Pharm Des. 2012;18(34):5470-80. of Continuing Education in Dentistry. Jan/Feb 2011. 31(1). Online access only p.10-15. 4. Bensaleh H, Belgnaoui FZ, Douira L, Berbiche L, Senouci K, Hassam B. Skin and 40. Vieira R, Minicucci E, Marques M, Marques S. Actinic Cheilitis and Squamous Cell Menopause. Ann Endocrinol. 2006Dec;67(6):575-80. Carcinoma of the Lip: Clinical, Histopathological and Immunigenetic Aspects. An.Bras. 5. Berman K, Zieve D. (2011). Psoriasis. A.D.A.M. Medical Encyclopedia. ADAM, Inc. Dermatol. February 2012;87(1). Accessed December 4, 2012 from http://www.scielo.br/ Accessed December 8, 2012 from www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001470/ pdf/abd/v87n1/v87n1a13.pdf 6. Berman K, Zieve D. (2011). Squamous Cell Carcinoma. A.D.A.M. Medical Encyclopedia. 41. Vorvick L, Zieve D. (2011). Rosacea. A.D.A.M. Medical Encyclopedia. ADAM, Inc. ADAM, Inc. Accessed December 14, 2012 from www.ncbi.nlm.nih.gov/pubmedhealth/ Accessed December 8, 2012 from www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001882/ PMH0001832/ 42. Weinstein G, McCullough J, Ross P. “Cell Proliferation in Normal Epidermis.” J.Invest 7. Bukvic Mokos Z, Kraji M, Basta-Juzbasic A, Lakos Jukic I. Seborrheic dermatitis: an Dermatol. 1984. June:82(6):623-8. update. Acta Dermatovenrol Croat. 2012;20(2):98-104. 43. White J. “Oral Antioxidants: A Weapon in Wound Healing.” Dentistry IQ. Aug2011. 8. Canto A, Freitas R, Muller H, Santos P. “Oral lichen planus: clinical and complementary http://internal.periosciences.com/openbox-erp/control/pdfDoc?file=dentistry_iq_ diagnosis.” An Bras Dermatol. 2010;85(5):669-75. article_8-10 9. Chapman MS. Vitamin A: History, Current uses, and Controversies. Semin Cutan Med 44. Zeive D. (2011). Basal Cell Carcinoma. A.D.A.M. Medical Encyclopedia. ADAM, Surg. 2012 Mar;31(1):11-6. Inc. Accessed December 14, 2012 from www.ncbi.nlm.nih.gov/pubmedhealth/ 10. Davenport S. Anatomy and Physiology in Focus. 2nd ed. San Antonio: Link Publishing; PMH0001827/ 1996:103-107. 45. Zieve D. (2011) Liver Spots. A.D.A.M. Medical Encyclopedia. ADAM, Inc. Accessed 11. Dreher F, Maibach H. “Protective Effects of Topical Antioxidants in Humans.” Curr. December 27, 2012 from www.ncbi.nlm.nih.gov/pubmedhealth/PMH00002126/ Probl.Dermatol. 2001. 29:157-64. 12. Epstein J, Wang S. “Understanding UVA and UVB.” May 2012. Skin Cancer Foundation. http://www.skincancer.org/prevention/uva-and-uvb/understanding-uva-and-uvb 13. Felippi C, Oliveria D, Stroher A, Carvallo AR, Van Etten EA, Bruschi M, Raffin RP. “Safety and Efficiency of Antioxidants – Loaded Nanoparticles for an Anti-Aging Application.” J Author Profile Biomed Nanotechol. 2012 Apr. 8(2):316-321. Lisa Dowst-Mayo, RDH, BSDH graduated magna cum laude 14. Graber E. “Choosing Skin Care Products: Know Your Ingredients.” Accessed February 12, 2012 from www.webmd.com/healthy-beauty/cosmetic-procedures-products-2. from Baylor College of Dentistry in 2002. She has been an active 15. Harman D. “Free Radical Theory of Aging: an Update: Increasing the Functional Life Spa.” Ann N Acad Sci. May 2006. 1067:10-21. member of the American Dental Hygiene Association and has 16. Haywood R. “Sunscreens Inadequately Protect Against UVA-Induced Free Radicals.” J Invest Dermatol. 2006. 12(1):862-68. held numerous leadership positions both at the state and local 17. Hoppe U, Bergemann J, Diembeck W, Ennen J, Gohla S, Harris I, Jacob J, Kielholz J, Mei levels. She is currently a full time professor at Concorde Career W, Pollet D, Schachtschabel D, Sauermann G, Schreiner V, Stäb F,Steckel F. Coenzyme Q-10, A Cutaneous Antioxidant and Energizer. Biofactors. 1999;9(2-4):371-8. College in the dental hygiene department in San Antonio, TX. 18. Howard D. “Structural Changes Associated with Aging Skin.” The International Dermal Institute. Accessed September 4, 2012 from www.dermalinstitute.com/vs/library/11_ Lisa is a published author, enthusiastic national speaker and can article_structural_changes_associated_with_aging_skin.html 19. Ibsen O, Phelan J. Oral Pathology for the Dental Hygienist. 6th ed. St.Louis, Saunders, be contacted through her website at www.lisamayordh.com. Elsevier Inc; 2014, p.93-124. 20. Inui M, Ooe M, Fujii K, Matsunaka H, Yoshida M, Ichihashi M. Mechanisms of Inhibitory Effects of CoQ10 on UVB-induced Wrinkle Formation In-Vitro and In-Vivo. Author Disclosure Biofactors. 2008;32(1-4):237-43. 21. Kafi R. Vitamin A Helps Reduce Wrinkles Associated With Natural Skin Aging. Arch Lisa Dowst-Mayo has no affiliations with any company who Dermatol. 2007;143:606-612 would have a gained interest in the material published in this 22. Kalmar JR. Diagnosis and Management of Oral Lichen Planus. J.Calif Dental Association. June 2007;35(6):405-11. course. There was no corporate sponsor in the making of this 23. Keller K, Fenske N. “Uses of vitamin A,C,E and Related Compounds in Dermatology: A Review.” J Amer Acad Dermatol. 1998;39(4-6):6111-625. course and the author is not employed by a company that would 24. Kim IH, West CE, Kwatra SG, Feldman SR, O’Neil JL. Comparative Efficiency of Biologics in Psoriasis: A Review. Am J Clin Dermatol. Dec 2012;13(6):365-74. stand to profit off the publication of this course. All research is 25. Marnett L. Peroxyl Free Radicals: Potential Mediators of Tumor Initiation and Promotion. Carcinogenesis. 1987;8(10):1365-1373. presented in an unbiased manner. 26. Mayo Clinic. Age Spots (Liver Spots). Accessed December 27, 2012 from www. mayoclinic.com/health/age-spots/DS00912.

RDH | February 2014 rdhmag.com | 81 Online Completion Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions

1. Which of the following is a function of the skin? a. One half is unlike the other a. Angular cheilitis a. Protection from environments factors b. Irregular borders b. Actinic cheilitis b. Temperature regulation c. Less than the size of a pencil eraser (<6mm) c. Actinic keratosis c. Production of Vitamin D d. Both a & b d. Squamous cell carcinoma d. All of the above 14. Another term used to describe age spots is: 23. Which of the following is the most common 2. The skin structure responsible for nourishing a. Nevi form of skin cancer, accounting for more the skin and for thermal regulation is the: b. Ephelid a. Epidermis c. Lentigo than 80% of skin cancers? b. Dermis d. Common mole a. Squamous cell carcinoma c. Hypodermis 15. Which of the following skin conditions b. Basal cell carcinoma d. Sebaceous glands c. Melanoma is defined as a chronic skin disorder that d. Oropharyngeal caner 3. As an infant, epidermal skin turnover rate is: involves itchy, rash-like or scaly patches a. 14 days 24. According to the UK Cancer Research b. 21-28 days usually diagnosed before age 6? c. 28-42 days a. Eczema group, which area of the oral cavity accounts d. 42-84 days b. Rosacea for 5% of all new squamous cell carcinoma c. Oral Lichen Planus 4. Which of the following is true regarding the d. Psoriasis diagnoses? a. Tongue hypodermis? 16. According to the American Academy of a. Makes up 50% of total body fat b. Upper lip b. Made of areolar and adipose tissues Dermatology, eczema on the head and neck c. Lower lip c. Supplies blood vessels and nerves commonly occurs on the: d. Buccal mucosa d. All of the above a. Cheeks 25. A loss of sharpness around the border of b. Scalp 5. Which of the following is the stage of life of c. Eyelids the lip, atrophy of the vermillion border dramatically increased sebum production ? d. All the above and darkening at the junction of the lip and a. 3-6 months b. 8 years 17. A chronic skin condition that makes the skin of the face which could be a precursor c. Puberty skin red and may cause swelling and sores is to cancer descries which of the following d. Over 20 years of age defined as: conditions? 6. Free radical damage in the human body can a. Acne a. Basal cell carcinoma lead to which of the following? b. Eczema b. Vermillion border deterioration c. Rosacea c. Angular cheilitis a. Cancer d. Seborrheic dermatitis b. Wrinkling of the skin d. Actinic cheilitis c. Dull skin 18. Which of the following terms is used to d. All the above 26. The CDC estimates 65-90% of melanomas define a chronic, benign inflammatory con- are caused by: 7. Free radicals are found in the: dition implicating cell-mediated cytotoxicity a. Air a. Being over the age of 50 b. Food supply and involving destruction of basal cells of the b. UV light c. Environmental pollutants surface epithelium? c. Having light, fair colored skin d. All the above a. Seborrheic dermatitis d. Multiple sunburns throughout life b. Oral lichen planus 8. Which condition is defined as tiny white c. Squamous cell carcinoma 27. A dome-shaped lesion with a pearly or wax- bumps on the skin that are common in d. Psoriasis like appearance with rolled borders that may newborns and children? 19. Oral lichen planus can occur on which be white, light pink, brown or flesh-colored a. Milia describes which of the following condition? b. Whitehead areas of the head and neck? c. Blackhead a. Lip a. Actinic cheilitis d. Acne b. Oral mucosa b. Basal cell carcinoma c. Skin c. Squamous cell carcinoma 9. The medical term for freckles is: d. All the above d. Actinic keratosis a. Lentigines b. Nevi 20. Seborrheic dermatitis consists of silver- 28. Which of the following risk factors c. Ephelid white or red-flaky patches. Psoriasis is increases the likelihood of squamous cell d. Milia characterized by erythematous or greasy carcinoma development earlier in life? 10. The medical term for a blackhead is: yellow flakes of the skin. a. Use of tanning beds earlier in life a. Closed Comedo a. Both statements are TRUE b. Having light, fair colored skin b. Open Comedo b. Both statements are FALSE c. Having blue, green or grey eyes c. Nevi c. The first statement is TRUE, the second is FALSE d. Having multiple sunburns throughout life d. Ephelis d. The first statement is FALSE, the second is TRUE 29. Actinic keratosis is a pre-cancerous lesion 11. Blackheads can contain which of the 21. Psoriasis can be triggered by infection, associated with which form of skin cancer? following structures? beta-blockers, sunlight or alcohol. The patches a. Keratin a. Squamous cell carcinoma b. Modified sebum are common on the head and neck, especially b. Basal cell carcinoma c. Cysts along the hairline or back of the neck. c. Melanoma d. Both a & b a. Both statements are TRUE d. Oropharyngeal Cancer b. Both statements are FALSE 12. Which of the following increases the risk of c. The first statement is TRUE, the second is FALSE 30. Actinic keratosis lesions clinically present as melanoma development? d. The first statement is FALSE, the second is TRUE small, pink, rough, dry, scaly patch or growths a. 50+ moles on the body on the skin that come and go. They are always b. Absence of moles on the body 22. A chronic inflammatory process most c. Fair skin and blue eye color commonly located on the labial commissure asymptomatic. d. Both a & c where deep cracks/splits, ulcers, bleeding a. Both statements are TRUE b. Both statements are FALSE 13. Which of the following descriptions of a or crusting can occur describes which of the c. The first statement is TRUE, the second is FALSE mole should alarm a dental professional? following conditions? d. The first statement is FALSE, the second is TRUE

82 | rdhmag.com RDH | February 2014 ANSWER SHEET Linking Dermatology And Dentistry Part I: Looking Beyond the Oral Cavity

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If not taking online, mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp. 1. Review skin anatomy and physiology. P.O. Box 116, Chesterland, OH 44026 2. Discuss the chemistry behind aging skin including free radical damage to cells or fax to: (440) 845-3447 3. Discuss how human skin ages and why wrinkles, blemishes and hyperpigmentation increase with increasing age. 4. Identify skin lesions that need referral to a specialist. For IMMEDIATE results, go to www.ineedce.com to take tests online. Course Evaluation Answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. 1. Were the individual course objectives met? Payment of $49.00 is enclosed. Objective #1: Yes No Objective #2: Yes No (Checks and credit cards are accepted.) Objective #3: Yes No Objective #4: Yes No If paying by credit card, please complete the following: MC Visa AmEx Discover Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Acct. Number: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. Date: ______3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Charges on your statement will show up as PennWell 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 7. Was the overall administration of the course effective? 5 4 3 2 1 0 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 10. Do you feel that the references were adequate? Yes No 11. Would you participate in a similar program on a different topic? Yes No 12. If any of the continuing education questions were unclear or ambiguous, please list them. ______13. Was there any subject matter you found confusing? Please describe. ______14. How long did it take you to complete this course? ______15. What additional continuing dental education topics would you like to see? ______AGD Code 734

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