2014 self-study course four course

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ABOUT this FREQUENTLY asked COURSE… QUESTIONS… Q: Who can earn FREE CE credits? . READ the MATERIALS. Read and review the course materials. A: EVERYONE - All dental professionals in your office may earn free CE contact . COMPLETE the TEST. Answer the credits. Each person must read the eight question test. A total of 6/8 course materials and submit an questions must be answered correctly online answer form independently. for credit. us . SUBMIT the ANSWER FORM Q: What if I did not receive a ONLINE. You MUST submit your confirmation ID? answers ONLINE at: A: Once you have fully completed your p h o n e http://dent.osu.edu/sterilization/ce answer form and click “submit” you will be directed to a page with a 614-292-6737 . RECORD or PRINT THE unique confirmation ID. CONFIRMATION ID This unique ID is displayed upon successful submission Q: Where can I find my SMS number? of your answer form. t o l l f r e e A: Your SMS number can be found in the upper right hand corner of your

1-888-476-7678 monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for ABOUT your your office only, and is the same for f a x FREE CE… everyone in the office. 614-292-8752 Q: How often are these courses . TWO CREDIT HOURS are issued for available? successful completion of this self- A: FOUR TIMES PER YEAR (8 CE credits). e - m a i l study course for the OSDB 2014-2015 [email protected] biennium totals. . CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. w e b . ALLOW 2 WEEKS for processing and www.dent.osu.edu/ mailing of your certificate. sterilization Page 1 WHITE OF THE ORAL 2014 CAVITY course This course will help dental professionals familiarize themselves with common white lesions of the oral cavity and derive a differential diagnosis four for various white lesions. INTRODUCTION White lesions of the oral cavity are one of the leading reasons for which patients seek professional treatment. These lesions can have a wide spectrum of diagnoses including infectious, reactive, immune-mediated, premalignant, and malignant conditions. Patient Pseudomembranous Dr. Carl Allen, The Ohio State University College of Dentistry history, clinical presentation, and location can be very helpful in immunocompetent individuals to narrowing down the differential disseminated in diagnosis of these various white immunosuppressed patients. A lesions. variety of clinical forms of oral

candidiasis exist, including: INFECTIOUS WHITE LESIONS  Pseudomembranous  Erythematous

 Hyperplastic CANDIDIASIS  Mucocutaneous

Candidiasis is the most prevalent Among these, the two clinical oral fungal infection in humans. forms which appear white are Candida Albicans, part of the normal pseudomembranous and oral micro flora, is the causative hyperplastic candidiasis. organism. A complex interaction of immune status and mucosal Pseudomembranous candidiasis environment of the host and strain appears clinically as creamy, white of C. Albicans controls the presence plaque (similar to cottage cheese written by of candidal infection. Various or curdled milk) and is usually present on the buccal mucosa, neetha santosh, dds predisposing factors for include use of , tongue, and . This plaque xerostomia, recent broad-spectrum can be removed by scraping or antibiotic therapy, corticosteroid use wiping, which leaves an intact edited by (aerosolized inhalants or topical normal or reddened underlying mucosa. Diagnosis of alternative rachel a. flad, bs creams/gel), and immunodeficiency (HIV infection or leukemia). white lesions such as karen k. daw, mba, cecm should be considered if the evan miller Clinical Features: mucosa bleeds while scraping the plaque. The patients with The clinical features of candidiasis pseudomembranous candidiasis usually complain of mild burning c a n v a r y f r o m superficial involvement of in sensation or bad taste. The diagnosis is usually established by Page 2

the relevant history of predisposing factors and treatment regimen of patients with dentures. If typical clinical appearance. there is no improvement post-treatment, of the area is recommended to exclude other Isolation and identification of candidal hyphae or possible conditions. A referral to the physician is yeasts by exfoliative cytology (smear), or, culture also prudent to rule out underlying systemic on Sabouraud’s agar slant (swab) can confirm the disorders. diagnosis. Hyperplastic candidiasis presents as a white plaque ORAL HAIRY that cannot be removed by scraping or wiping. It is most often present on the anterior buccal Oral is a that occurs mucosa near the commissures, as well as on the mainly in immunocompromised individuals, tongue and . Hyperplastic candidiasis cannot especially in AIDS patients. This lesion has also be clinically distinguished from routine been described in patients experiencing extended corticosteroid therapy after organ leukoplakia. The diagnosis is established by the transplantation or other systemic conditions. identification of candida by a cytologic smear or Epstein-Barr virus is the main causative organism culture and by total disappearance of plaque of oral hairy leukoplakia. following antifungal treatment. A biopsy of the area will be prudent if any white plaque has Clinical Features: remained in order to rule out the presence of true leukoplakia. Oral hairy leukoplakia typically presents as white vertical streaks or corrugated plaques on the Care should be taken to avoid confusing lateral border of the tongue. This lesion is usually coated/hairy tongue with candidiasis. Coated bilateral and can extend to the dorsal and lateral tongue is due to accumulation of and surfaces of the tongue, and can also rarely involve bacteria on the dorsal surface of the tongue, the buccal mucosa, soft palate, pharynx, and resulting in a white and thickened appearance. esophagus. Oral hairy leukoplakia does not rub Hairy tongue has a typical hair-like appearance off; differential diagnoses include hyperplastic due to elongation of and the keratin accumulation candidiasis, true leukoplakia, proliferative on the filiform papillae of the dorsal tongue. The verrucous leukoplakia, morsicatio linguarum diagnosis of coated/hairy tongue is distinguished (tongue chewing), and lichen planus. A definite by its characteristic clinical appearance. Scraping diagnosis can be established by identification of the tongue and improving is the Epstein-Barr virus within the lesion using in situ recommended treatment. hybridization or by histopathological examination of the biopsied area. Treatment: Treatment: A variety of topical and systemic antifungal agents are available to treat oral candidiasis. Most of the Usually, it is not necessary to treat oral hairy patients respond well to the topical treatment leukoplakia. There can be resolution of the lesion which include Nystatin and Clotrimazole. The if the patient is on Highly Active Antiretroviral systemic drugs available are Ketoconazole, Therapy (HAART) for HIV infection. HIV patients Fluconazole, and Itraconazole and are used usually diagnosed with oral hairy leukoplakia have higher for chronic or disseminated candidiasis. The chances of disease progression to AIDS. Since recommended dosage of Clotrimazole is to oral hairy leukoplakia is mostly seen in dissolve 1 troche (10 mg) slowly in the mouth 5 immunocompromised individuals, its occurrence times per day for 10 days. Nystatin oral in the absence of a known reason of suspension can be used by swishing 2-5 mL for immunosuppression warrants referral to a two minutes and swallowing thereafter. physician for a complete physical evaluation. Disinfection of dentures by soaking them in 10% household bleach (complete dentures) or in Nystatin oral suspension (removable dentures with metal parts) should be included in the Page 3 REACTIVE WHITE LESIONS appearance. Isolated lesions on the lateral border of the tongue without history of tongue chewing LINEA ALBA should be thoroughly evaluated to rule out HIV- associated oral hairy leukoplakia. Linea alba means “white line” in Latin and is one of the most common variations of the buccal No treatment is usually required for morsicatio mucosa. Pressure, frictional irritation, or sucking lesions. An oral acrylic shield may be fabricated to trauma from adjacent facial surfaces of the teeth protect buccal and labial mucosa from chewing are usually linked to this alteration. habits.

Clinical Features: CHEMICAL INJURIES OF THE ORAL MUCOSA

Linea alba typically presents as a bilateral white Prolonged periods of contact between various line on the buccal mucosa at the level of the drugs and chemicals and the oral mucosa can occlusal plane. It can have a scalloped appearance cause temporary white lesions. Aspirin, hydrogen and extend from the commissure to the posterior peroxide, silver nitrate, phenol, eugenol, teeth. formacresol, sodium hypochlorite, dental cavity varnishes, and acid etch materials are some of the Treatment: most common drugs and chemicals that cause oral mucosa. These white lesions are due to Diagnosis of linea alba is made by the epithelial necrosis and fibrinopurulent exudate characteristic clinical location and appearance, from the chemical injury. with biopsy not usually being necessary. Linea alba requires no treatment and it may disappear Clinical Features: on its own in some individuals. A brief exposure with chemicals causes the oral (CHRONIC CHEEK mucosa to appear white and wrinkled; prolonged CHEWING) exposure leads to epithelial necrosis and desquamation. Necrotic can be White lesions can appear on the oral mucosa due removed, which exposes erythematous to chronic cheek biting or sucking. These are underlying connective tissue and is later covered most common on bilateral buccal mucosa by a yellowish-white fibrinopurulent membrane. (morsicatio buccarum) and are also present on the The injury to the mucosa can be very extensive tongue (morsicatio linguarum) and lips depending upon the duration of exposure and (morsicatio labiorum). concentration of the chemical. The attached mucosa is more resilient to the chemical injury Clinical Features: compared to the unattached mucosa.

Morsicatio lesions are often seen in people who Treatment: have psychologic conditions or in those who are under stress. Women are twice as likely to be The ideal treatment of chemical injuries is carried affected by these lesions. The lesions are out by preventing exposure of oral mucosa to frequently seen bilaterally on the anterior buccal potential caustic medications. If such medications mucosa along the occlusal plane and have a have to be used, care should be taken to swallow distinctive irregular and ragged appearance due the drug immediately to avoid any prolonged to constant nibbling. Similar lesions can be contact with oral mucosa. Children should be present on the labial mucosa or lateral borders of monitored as well. Healing occurs in superficial the tongue. lesions within 1-2 weeks. Deep and extensive lesions may require surgical debridement and Treatment: antibiotic therapy to quicken healing and prevent infection. Morsicatio lesions are diagnosed by the history of chewing habits and the typical ragged clinical Page 4 CONTACT Treatment:

A wide variety of agents including food, food If the patient stops the use of cinnamon flavored additives, chewing gum, candy, oral hygiene product or tartar-control toothpaste, lesions products such as toothpaste and mouth washes, should resolve within a week. The lesions will and dental treatment materials such as gloves and reoccur within 24 hours if the patient reuses the rubber dam materials, topical anesthetics, product. A topical corticosteroid can provide restorative materials, acrylic denture materials, faster recovery in some patients. Biopsy of the dental impression materials, and denture adhesive area will be prudent to rule out other conditions if preparations can cause allergic reactions in the still persists after two weeks of oral cavity. discontinuation of the offending products.

Clinical Features: FRICTIONAL

Contact stomatitis occurs more frequently in Frictional keratosis refers to a white patch on the females and can be acute or chronic. Two oral mucosa due to constant mechanical irritation. commonly occurring contact stomatitis in oral Sources of mechanical irritation can be numerous mucosa are oral cinnamon reaction and including broken tooth cusps, sharp restorations, toothpaste related sloughing. orthodontic brackets, and rough or ill-fitting dentures. Alveolar ridge keratosis is a form of Oral cinnamon reaction occurs due to the artificial frictional keratosis occurring on the crest of an cinnamon oil used as a flavoring agent in gum, edentulous ridge or retromolar pad area and candy, toothpaste, mouth washes, breath results from chronic friction from dentures or fresheners, soft drinks, processed meat, etc. mastication. Linea alba and morsicatio lesions can Patients usually complain of pain and a burning also be grouped under frictional keratotic sensation. Clinical presentation of oral cinnamon conditions. reaction varies depending upon the medium of delivery. While a diffuse reaction is seen with Clinical Features: toothpaste containing artificial cinnamon flavoring, a more localized pattern occurs with Clinically, frictional keratosis can mimic true chewing gum and candy. The buccal mucosa and leukoplakia and is analogous to a callus on the the tongue are the frequent locations affected skin. It appears as a rough hyperkeratotic area from chewing gum and candy. Oblong patches of that usually blends into the adjacent normal reddened areas with overlying white, shaggy mucosa and is seen frequently on the buccal are observed on buccal mucosa mucosa, lateral borders of the tongue, and along the occlusal plane. The tongue can also retromolar pad area. have a similar appearance involving the lateral border and dorsal surface. Diagnosis is often Treatment: made by the clinical appearance and history of artificial cinnamon use. Differential diagnosis The diagnosis of frictional keratosis is usually made includes morsicatio lesions and oral hairy by the clinical examination and evidence of a leukoplakia. source of chronic irritation. Malignant transformation has not been reported in this Dentifrice sloughing is a reaction to certain condition. Frictional keratosis is usually treated by ingredients in toothpaste, such as sodium lauryl removing the offending agent. Smoothing a sulfate, pyrophosphate (tartar-control agent), and sharp tooth or restoration and correction of the ill- artificial flavoring like cinnamon and mint. Diffuse fitting denture can reduce the mechanical of the oral mucosa along with sloughing irritation on the mucosa. Ideally, the condition of superficial layers of epithelium is seen. Typical should disappear in two weeks after removing the clinical appearance of string-like sloughed mucosa irritating factor. If the lesion still persists, biopsy of along with history of tartar-control or flavored the area is recommended to rule out true tooth paste use is good enough to make a leukoplakia. diagnosis. Page 5

NICOTINE STOMATITIS Clinical Features:

Nicotine stomatitis is a white lesion which is Smokeless tobacco keratosis is usually typically seen on the palate of pipe or cigar asymptomatic and is identified during routine smokers. It is also known as smoker’s palate or examination. Duration of the smokeless tobacco nicotine palatinus. This condition has not been habit, brand and type of smokeless tobacco, associated with malignant transformation and length of daily use, and amount of tobacco used most likely is due to mucosal response to high are some of the factors determining the heat associated with smoking. Interestingly, development of this lesion. The mandibular denture wearers who smoke do not have this vestibule is where the tobacco is most often in condition because the upper denture usually contact with the mucosa. Gingival recession with protects the palatal mucosa from heat. People alveolar bone destruction in the area of tobacco who drink very hot beverages have also reported contact may also be present. The mucosa appears similar lesions on the palate. grayish white and has a wrinkled appearance. The absence of tobacco in the mouth during clinical Clinical Features: examination makes the stretched mucosa appear fissured, and a “pouch” (where the tobacco was Nicotine stomatitis is reported in patients above kept) can be seen. People who chronically put 45 years of age and the palatal mucosa being the materials such as hard candy, beef jerky, sunflower characteristic location. The palatal mucosa seeds, etc. in their vestibule can also develop appears white, while multiple raised with similar mucosal changes. Typically, smokeless red centers are seen. The papules are inflamed tobacco keratosis develops within 1 to 5 years of salivary glands and the red centers represent smokeless tobacco use. With chronic use in some inflamed openings of salivary gland ducts. The individuals, the mucosa thickens to form a white overall palatal mucosa has a dried mud leathery or nodular appearance. appearance due to hyperkeratosis. Teeth with black tobacco stains are also evident, most of the time.

Treatment:

The diagnosis of nicotine stomatitis is established by the characteristic clinical presentation and correlation with the use of pipes or cigars or hot beverages. With smoking cessation, nicotine stomatitis is completely resolvable within 2 weeks. If the condition persists after 2 weeks of smoking cessation, biopsy of the area is mandatory to rule out true leukoplakia. Patients with nicotine Tobacco Pouch Dr. Kristin McNamara, The Ohio State stomatitis should also be thoroughly examined for University College of Dentistry tobacco-related changes such as true leukoplakia Keratosis in the entire oral mucosa. Treatment: SMOKELESS TOBACCO KERATOSIS The history of placing smokeless tobacco in the Smokeless tobacco keratosis is a white fissured altered mucosal site and the characteristic clinical plaque seen on the oral mucosa in the area of presentation are all that is required to make the direct contact with smokeless tobacco. It is also diagnosis. Mucosal alteration associated with known as snuff pouch, snuff dipper’s lesion, chronic smokeless tobacco use should completely tobacco pouch keratosis, and spit tobacco disappear within two weeks of habit cessation or keratosis. Chewing tobacco, moist snuff, and dry alteration of the original site. Any lesions which persist after 6 weeks without smokeless tobacco snuff are the various types of smokeless tobacco prevalent in the United States. Page 6 contact should be biopsied to rule out a true When only gingival mucosa is involved, the leukoplakia. Biopsy is also indicated for more presentation is known as desquamative severe lesions, which have leathery white plaques, and biopsy should be done to rule out mucous verrucous appearance, ulceration, or hemorrhage. membrane and vulgaris, since they have similar clinical features. IMMUNE-MEDIATED WHITE Treatment: LESIONS Diagnosis of reticular lichen planus is based on the LICHEN PLANUS clinical presentation. The classic lace-like pattern of reticular lichen planus can be obscured if there Lichen planus is one of the very common is co-infection with candidiasis. Treatment with mucocutaneous disorders. Cutaneous lesions antifungal therapy in such proven cases can reveal usually involve skin, nailS, and scalp, while mucosal the classic reticular pattern following therapy. lesions affect oral and genital mucosa. Cutaneous Once the diagnosis of reticular lichen planus is lesions are seen in 25-30% of individuals with oral established, there is no need for any treatment, as lesions. The exact cause of this lesion is presently it is asymptomatic. Reassuring the patient and unknown and is most likely due to an autoimmune periodic follow-up to monitor any clinical changes process. are all that is required.

Clinical Features: Erosive lichen planus is usually biopsied to get a histopathologic and immunofluorescent diagnosis Lichen planus is seen more commonly in middle- in order to rule out chronic ulcerative stomatitis aged women. Skin lesions are characterized by and systemic erythematosus. purple, pruritic, polygonal papules on the flexor Corticosteroids are used to provide relief to the surface of extremities. Fine, white interlacing lines patients. One of the recommended corticosteroids called Wickham’s Striae are seen on the skin is Diprolene gel (betamethasone dipropionate gel papules. 0.05%). The patient should apply a thin film to the affected area 4-6 times a day until the issue is Orally, the lesions are seen on bilateral buccal resolved. It is important to exclude other lichenoid mucosa. Other sites such as the tongue, labial mucositis conditions such as lichenoid drug mucosa, gingiva, and palate can also be affected. reaction, lichenoid amalgam reaction, and graft- The two forms of lichen planus seen in oral mucosa versus-host disease. are reticular and erosive. LICHENOID MUCOSITIS Reticular lichen planus is more commonly presented than the erosive type. It is Certain drugs, dental restorative materials such as asymptomatic and usually affects the posterior amalgam, and artificial food flavoring can present buccal mucosa. It gets its name because of the similar histopathologic pattern as lichen planus. typical pattern of interlacing white lines. These These immune-mediated reactions are classified as lesions may wax and wane very often. Lichen lichenoid drug reaction, lichenoid amalgam planus on the dorsal surface of the tongue does reaction, or oral cinnamon reaction, depending on not have characteristic reticular white lines and the causative agent. These conditions should be instead manifests itself as smooth, white plaque separated from lichen planus as they are linked to with of papillae. a specific cause; they will be resolved if the

causative agent is eliminated, whereas in lichen Erosive lichen planus is a painful condition planus no specific causative factor has yet been compared to the reticular type, causing patients to identified. seek medical care frequently. The lesions usually present as reddened areas with ulceration on the bilateral buccal mucosa. The margins of the reddened area usually have white lace-like striae; the tongue and gingiva also can be affected. Page 7 Clinical Features: PREMALIGNANT WHITE LESIONS

Lichenoid drug reaction usually presents as LEUKOPLAKIA irregular erosions on the posterior buccal mucosa and lateral borders of the tongue. Clinically, these Leukoplakia means “white patch” and is described may resemble erosive lichen planus. There have by the World Health Organization (WHO) as “a been numerous prescription and over-the-counter white patch or plaque that cannot be drugs linked to lichenoid reaction. NSAIDs such as characterized clinically or histopathologically as Ibuprofen, Naproxen and Fenclofenac, any other disease”. It is the most common antihypertensives such as ACE inhibitors, precancerous lesion in the oral cavity. The term Chlorothiazide and Propranolol, oral hypoglycemic leukoplakia is a clinical description, and agents such as chloropropamide and tolbutamide, histopathologically it can include atypical oral antimicrobials such as amphotericin, ketoconazole, epithelium, mild epithelial dysplasia, moderate chloroquine, pencillamine, streptomycin, and epithelial dysplasia, severe epithelial dysplasia, and tetracycline are few among the extensive list of carcinoma-in-situ. Clinical diagnosis of leukoplakia medications which can cause lichenoid drug should be rendered only after white lesions such reaction. as lichen planus, morsicatio lesions, frictional

keratosis, tobacco pouch keratosis, nicotine Lichenoid amalgam reaction affects the oral stomatitis, , and white sponge mucosa which comes in contact with amalgam are excluded by history, location, and clinical restoration. White patches with radiating borders appearance. If in doubt, biopsy of the area is is the common clinical presentation. The altered necessary to evaluate if there is any evidence of mucosa will always be in contact with amalgam precancerous changes. restoration of adjacent teeth. Buccal mucosa and lateral borders of the tongue are typical sites of occurrence.

Treatment:

The diagnosis of lichenoid drug reaction is usually made by the history of offending drug usage and clinical presentation. Elimination of the suspected medication should result in complete disappearance of the lesion; however, reoccurrence can happen if the drug is consumed again. Temporary relief can be provided by application of corticosteroids on the affected area Leukoplakia Dr. Kristin McNamara, The Ohio State until the medication is completely eliminated from University College of Dentistry the body. Biopsy of the area is prudent if lesions Clinical Features: persist after cessation of the suspected medication.

Leukoplakia tends to affect people above 40 years Lichenoid amalgam reaction is diagnosed by the and has a stronger male predilection. Tobacco presence of an amalgam restoration in contact usage is the most common cause of leukoplakia. with altered mucosa. Removal of the adjacent Alcohol use with tobacco and sanguinaria are amalgam and replacement of the filling by among the other causative factors. Although most nonmetallic restorative materials can provide a leukoplakic lesions are seen on buccal mucosa, complete resolution in two weeks. If the condition lips, and gingiva, the lesions on the tongue and does not improve, biopsy of the area should be floor of the mouth often have precancerous or performed to exclude other possible conditions, cancerous changes. Clinical presentations can such as true leukoplakia.

Page 8 vary from person to person, along with time. The affected area of actinic . It is seen usually in white patches may appear translucent or thin, fair-skinned individuals older than 40 years old homogenous or thick, granular or nodular, and and who have a history of chronic skin exposure. verrucous. One of the most important features to is normally presented as white look for is the sharply demarcated borders from the patches on lips with loss of normal normal mucosa. dermatoglyphics. Presence of scales and fissures are also common. Proliferative verrucous leukoplakia (PVL) is a type of leukoplakic lesion which is more aggressive than Treatment: leukoplakia and has multiple leukoplakic patches in the oral cavity. PVL is more prevalent in women The main treatment for actinic cheilitis is surgical compared to men and they usually do not have a excision and submitting the tissue for history of tobacco use. The mean age of histopathological diagnosis. The patient should occurrence of PVL for men is 50 years of age, and be followed up periodically and should be re- 65 years for women. The buccal mucosa (in biopsied if there is any clinical change or women), the hard and soft palate, the alveolar reoccurrence, as 35% of the lesions can undergo mucosa, the tongue (in men), and the floor of the malignant transformation to squamous cell mouth are the common sites of occurrence. The carcinoma. process starts as a hyperkeratotic area and, with time, enlarges to form warty lesions and become MALIGNANT WHITE LESIONS multifocal.

SQUAMOUS CELL CARCINOMA Treatment:

Over 90% of oral malignancies are squamous cell Biopsy of leukoplakia is mandatory to obtain a carcinoma. Tobacco smoking (with or without histopathologic diagnosis because the treatment alcohol usage) is the causative factor associated depends on the diagnosis. Small lesions can be with 75-80% of oral . The removed completely by surgical excision and other 20-25% typically occurs on the lateral should be sent for histopathological analysis. tongue of younger people and gingiva of older Biopsy of multiple sites should be performed if the women, and are not linked with any risk factor. lesion is large. If there is epithelial dysplasia

(especially moderate or severe) in a large lesion, Clinical Features: complete removal should be done by surgical excision, , electrosurgery, or laser Squamous cell carcinoma usually occurs in older excision. The patient should be followed up adults and more commonly affects men. The periodically and should be biopsied if there is any lateral border and ventral surface of the tongue clinical change or recurrence, as 35% of completely and floor of the mouth are the most frequently excised lesions can reoccur. PVL lesions should be affected sites. It can be seen clinically in several monitored more vigorously as they have higher forms such as exophytic fungating mass, chances of having epithelial dysplasia and endophytic ulceration, or as mixed red and white transformation into verrucous or squamous cell patches (early presentation). Surface ulceration, carcinoma. induration on palpation, and rolled borders are

some of the common features of squamous cell ACTINIC CHEILITIS carcinoma. This condition is asymptomatic in the

beginning, which prolongs the time before Actinic cheilitis is a premalignant white lesion on seeking medical treatment. Sometimes the tumor lips due to prolonged sun exposure. A similar type can destroy the underlying bone and cause moth- of lesion that affects the sun exposed skin is called eaten radiolucencies. .

Clinical Features:

The lower vermilion zone of the is the most Page 9 Treatment: squamous cell carcinoma. Post-treatment, patients should be followed-up regularly and Biopsy is mandatory on all clinically suspicious should be re-biopsied if there is any clinical lesions including non-healing ulcers of the oral change or reoccurrence. cavity. After confirming the diagnosis of squamous cell carcinoma, wide surgical excision and/or CONCLUSION radiation therapy are the first choices of treatment. Since most patients are diagnosed at the late stage, White lesions can have various clinical survival rates are very bad and metastasis to presentations, ranging from reactive to malignant regional lymph nodes are very common. After conditions. A correct diagnosis of white lesions is treatment, patients should be followed-up very important as it can change previous periodically and should be re-biopsied if there is treatment plans. Biopsy of the lesion and any clinical change or reoccurrence. submission of the tissue for histopathological examination is mandatory if clinical diagnosis is in doubt. Patients with premalignant and malignant conditions should be referred to an oral and maxillofacial pathologist as they should be monitored regularly for any clinical change or reoccurrence.

REFERENCES

1. Neville B, Damm D, Allen C, Bouqot J. Oral & Maxillofacial Pathology. 3rd ed. Philadelphia, PA: Saunders Company; 2009.

Squamous Cell Dr. Neetha Santosh, The Ohio State 2. Greenberg M, Glick M, Ship J. Burket’s Oral Carcinoma University College of Dentistry Medicine. 11th ed. Hamilton, Ontario: BC Decker Inc.; 2008.

VERRUCOUS CARCINOMA

Verrucous carcinoma is a less aggressive type of ABOUT THE AUTHOR squamous cell carcinoma. Smokeless tobacco use NEETHA SANTOSH has been linked to the development of this carcinoma. NEETHA SANTOSH GRADUATED SUMMA CUM LAUDE FROM Clinical Features: CHRISTIAN DENTAL COLLEGE, INDIA; WHERE SHE FURTHER COMPLETED HER GENERAL PRACTICE RESIDENCY. SHE THEN PURSUED A POSTDOCTORAL FELLOWSHIP IN ORAL BIOLOGY AT Verrucous carcinoma usually affects older men. INDIANA UNIVERSITY SCHOOL OF DENTISTRY. CURRENTLY, SHE IS The alveolar mucosa, hard palate, and buccal DOING HER RESIDENCY IN ORAL AND MAXILLOFACIAL PATHOLOGY mucosa are the most frequently affected sites. It AT THE OHIO STATE UNIVERSITY. HER RESEARCH AT OSU PRIMARILY FOCUSES ON IDENTIFYING BIOMARKERS THAT CAN presents clinically as thick-white or mixed red and PREDICT THE PROGRESSION OF ORAL PREMALIGNANT LESIONS TO white plaques with -like surface proliferations. SQUAMOUS CELL CARCINOMA. HER FUTURE CAREER PLAN IS TO JOIN It is usually asymptomatic which prolongs the time ACADEMICS WHERE SHE CAN TEACH AND PRACTICE ORAL AND before seeking medical treatment. MAXILLOFACIAL PATHOLOGY. NEETHA SANTOSH CAN BE CONTACTED AT Treatment: [email protected].

Wide surgical excision is the preferred choice of treatment of verrucous carcinoma. One-fourth of verrucous carcinoma can show areas of routine Page 10 post-test instructions - answer each question ONLINE - press “submit” - record your confirmation id - deadline is November 16, 2014

Erosive lichen planus is more painful than 1 T F reticular lichen planus and often requires treatment.

2 T F The exact cause of lichenoid mucositis, like lichen SUBMITplanus, is unknown. Oral hairy leukoplakia can be removed by 3 T F scraping or wiping which leaves a normal or reddened underlying mucosa.

Proliferative verrucous leukoplakia is a more 4 T F aggressive form of leukoplakia and needs to be ONLINEmonitored closely for malignant transformation.

Frictional keratosis has been observed to exhibit 5 T F malignant transformation. d i r e c t o r john r. kalmar, dmd, phd [email protected]

6 Actinic cheilitis is a premalignant lesion due to SUBMITT F excessive tobacco use. a s s i s t a n t d i r e c t o r karen k. daw, mba, cecm [email protected] Smokeless tobacco keratosis should completely 7 T F disappear within two weeks of habit cessation or channel coordinator alteration of the original site. rachel a. flad, bs [email protected]

The ventral surface and lateral border of the ONLINEtongue are the most common locations for oral 8 T F squamous cell carcinoma. Page 11