Linking Dermatology and Dentistry Part II: Treatment Options a Peer-Reviewed Publication Written by Lisa Dowst-Mayo, RDH, BSDH

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

Linking Dermatology and Dentistry Part II: Treatment Options A Peer-Reviewed Publication Written by Lisa Dowst-Mayo, RDH, BSDH

Abstract Educational Objectives Author Profiles Part one of this two part course discussed com- At the conclusion of this educational Lisa Dowst-Mayo, RDH, BSDH graduated magna cum laude from Baylor College of monly encountered skin lesions and conditions. Dentistry in 2002. She has been an active member of the American Dental Hygiene activity participants will be able to: Association and has held numerous leadership positions both at the state and local Part two discusses treatment options for a 1. Define and discuss antioxidants and levels. She is currently a full time professor at Concorde Career College in the dental variety of skin conditions including antioxidants, their benefits to dermatology and hygiene department in San Antonio, TX. Lisa is a published author, enthusiastic surgery, chelating agents, and systemic medica- dentistry. national speaker and can be contacted through her website at www.lisamayordh. tions. Dental clinicians are in an advantageous 2. Discuss anti-aging and healing capa- com or by email at [email protected]. position to identify a variety of lesions and bilities of antioxidants. Author Disclosure conditions since a significant amount of time is 3. Present treatment options for a variety Lisa Dowst-Mayo has no affiliations with any company who would have a gained spent working in and around the head and neck of common skin conditions. interest in the material published in this course. There was no corporate sponsor region of the body. Expanding our observations 4. Discuss ultraviolet radiation (UVR) and in the making of this course and the author is not employed by a company that beyond the oral cavity will enhance patient care. would stand to profit off the publication of this course. All research is presented in protection. an unbiased manner.

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Publication date: March 2014 Supplement to PennWell Publications Expiration date: Feb. 2017

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 health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to Registration: The cost of this CE course is $4900 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 BLACKHEAD/ACNE At the conclusion of this educational activity participants will be Dermatologists commonly treat patients with blackheads and able to: acne because dark spots and scars can permanently persist on the 1. Define and discuss antioxidants and their benefits to skin if interventions are not undertaken. Treating acne can boost dermatology and dentistry. a person’s self-esteem and with the wide variety of effective and 2. Discuss anti-aging and healing capabilities of antioxidants. safe options, there is no reason a patient has to suffer. Treatments 3. Present treatment options for a variety of common skin vary based on severity of the condition as well as the root cause. Oil conditions. based cosmetics should be avoided in favor of water based prod- 4. Discuss ultraviolet radiation (UVR) and protection. ucts labeled as non-comedogenic. Topical medications can reduce oils and eliminate bacteria. They carry minimal risks and some Abstract are available in over the counter (OTC) preparations. Examples Part one of this two part course discussed commonly encountered include benzoyl peroxide, sulfur, resorcinol and/or salicylic acid. skin lesions and conditions. Part two discusses treatment options Doctors will recommend OTC medications for mild acne signs for a variety of skin conditions including but not limited to; an- and symptoms but to treat moderate to severe acne, prescription tioxidants, surgery, chelating agents, and systemic medications. medications are commonly utilized.1 Dental clinicians are in an advantageous position to identify a va- Many prescription products utilized in acne treatment are riety of lesions and conditions since a significant amount of time is based on a variety of Vitamin A derivatives which help promote spent working in and around the head and neck region of the body. cell turnover and prevent the clogging of hair follicles. Isotretinoin Expanding our observations beyond the oral cavity will enhance is in the retinoid drug class and is used primarily for severe cystic patient care. acne vulgaris and acne that is nonresponsive to other treatments. These medications are classified as FDA Pregnancy Category X Introduction and ADEC (Australian Drug Evaluation Committee) Category Dental clinicians are in a unique position to examine the head and X because of the risk of birth defects, miscarriage, and inflam- neck for a variety of skin lesions and conditions. In addition to matory bowel disease. Alternatives include antibiotics in the case routine intraoral cancer screenings, clinicians should incorporate of bacterial infections and oral contraceptives if acne is caused by frequent examinations of the skin as well. Early identification and hormonal influences.1 intervention improves the prognosis of virtually every disease entity. There are many areas of the head and neck that cannot be MOLES (NEVI) visualized when looking in the mirror. Patients respond favor- Treatment recommendations will depend on the condition. A ably when areas beyond the oral cavity are examined, lesions are dermatologist may remove moles through surgery if cancer is noted and a referral is made for intervention to a specialist such suspected or for esthetics. as a dermatologist. There is a confusing array of over the counter products that address a wide variety of skin conditions. Providing AGE SPOTS care beyond the oral cavity is facilitated by increasing one’s knowl- Treatment options can include products that contain either hydro- edge of some of the most commonly encountered skin lesions and quinone (prescription bleaching cream), emblica, kojic acid, de- conditions. oxyarbutin, glycolic acid or retinoids.2 Many of these products can lead to skin irritation so the use of a moisturizer may be necessary. MILIA Emblica is an antioxidant derived from the fruit of a deciduous Estheticians, cosmetologists or dermatologists can remove milia tree. It may have potential activity against certain cancers and is by extraction in adult patients, most commonly for cosmetic pur- used clinically as an anti-inflammatory agent due to its high con- poses. Extractions involve piercing the milia with a sterile lancet centrations of L-ascorbic acid (vitamin C). or scalpel, then removing the lesion with a comedone extractor. Kojic is a chelating agent produced by several species of fungi. Other treatment options may include topical retinoid creams Chelating agents are organic compounds that form soluble com- or a series of chemical peels/microdermabrasion procedures to plex molecules with specific metal ions, inactivating the ions so enhance the individual’s appearance. An accurate diagnosis by a they cannot normally react with other elements or ions to produce medical professional is necessary prior to treatment. precipitates. It is used to lighten the skin and to treat diseases such as melasma, which is also commonly referred to as “the mask of WHITEHEAD pregnancy.” This condition occurs when the skin color darkens in Whiteheads are an esthetic nuisance for the patient which will response to pregnancy, hormone replacement therapy (HRT) or usually resolve without medical intervention. There are many through the use of oral contraceptives. It is characterized by dark, products to help prevent whiteheads including antioxidants or irregular, well demarcated hyperpigmented macules to patches cleansing agents which remove excess sebum, dead skin cells and commonly occurring on the cheeks, nose, lips or forehead. Kojic cosmetic residue. inhibits the formation of pigments in plant and animal tissues. It

76 | rdhmag.com RDH | March 2014 Figure 1: Laser treatment of hyperpigmentation alcohol, scents, dyes, fragrances or other chemicals. These prod- Photo courtesy of Tiffini Stratton, DDS ucts should be applied to the skin shortly after bathing and towel drying. A humidifier can help keep the air moist to avoid further drying of the skin. Systemic medications are generally not used unless other treatments have proven unsuccessful. Medications that suppress the immune system such as cyclosporine, methotrexate or mycophenolate have been utilized in more severe cases. Phototherapy has proven successful in some cases and antibiotics are used if an infection is co-occurring on the skin due to scratching.

ROSACEA There is no cure for rosacea; however, there are treatments that can help with the clinical signs and symptoms. These include; laser surgery, sunscreen, chemical peels, topical products that diminish redness, vitamin A or topical antibiotics.4 Patients are advised to Figure 2: Age spots avoid triggers such as sun exposure, stress, spicy foods, alcohol, hot beverages, wind or hot baths.

ORAL LICHEN PLANUS (OLP) There is no cure for OLP and treatment options are strictly therapeutic or palliative. Patients should be advised to improve oral hygiene and minimize local irritants. Corticosteroids are usually the first line of defense. Other treatment options include; topical immunosuppressives, systemic medications (corticosteroids, retinoids, thalidomide, levamisole, tacrolimus), use of low-level frequency lasers, antioxidants or biologics.1,5 Recent research has suggested some patients with OLP , especially the erosive form, may be at increased risk for the development of squamous cell is used commercially to help prevent the oxidative browning of carcinoma.5 If a dentist or dental hygienist identifies oral lichen fruits, to preserve the pink and red color of seafood and has anti- planus, referral to an specialist is indicated.1 bacterial and antifungal effects. Other treatment options for age spots include; chemical peels, PSORIASIS dermabrasion, laser resurfacing (Figure 1) or freezing (cryother- Diagnosis is made based on clinical presentation and visual apy); all of which can involve multiple treatments and carry side inspection. Biopsy is rarely needed unless it is indicated to effects.3 The best treatment is prevention, most notably avoiding rule out another condition. Treatments are aimed at control- sun exposure or wearing a sunscreen with zinc oxide and an SPF at ling the signs and symptoms and to prevent infection. Topical least 30 but less than 50. agents such as; lotions, ointments, creams, shampoos, steroids, Figure 2 is a photo of a 56 year old white female with moderate moisturizers, topical vitamin A/D or oatmeal baths are recom- sun exposure over a period of years. The left hand has been treated mended to start. If these agents do not prove successful then for one month with a cream containing 2% emblica and 2% kojic doctors may utilize systemic medications; most commonly acid. The right hand has not received any treatment. Note the methotrexate, cyclosporine, retinoids or biologics. Photother- lightening of the age spots and the decreased number of hyperpig- apy by exposing skin to UVA or UVB light has been successful mented lesions. in some clinical trials.

ECZEMA/ATOPIC DERMATITIS/DRY SKIN SEBORRHEIC DERMATITIS (SD) Diagnosis is made by clinical presentation and biopsy is indicated Treatment options normally include the use of antifungal agents, when trying to rule out other conditions. Treatment is aimed at steroids, immunomodulators and/or keratolytics. minimizing signs and symptoms. Patients are advised to avoid scratching the skin and to use moisturizers, topical steroid creams ANGULAR CHEILITIS or oral antihistamines. Patients should keep fingernails short and Treatment is aimed at controlling the source of infection by consider nighttime gloves to avoid scratching. All topical creams using antifungal agents or antibiotics. If recurrent infections or moisturizers should be used 2-3 times per day and be free of are an issue for the patient, a referral to rule out other underly-

RDH | March 2014 rdhmag.com | 77 ing medical problems may be necessary.5 Daily use of prod- Figure 3: Actinic Cheilitis ucts that help keep the lips moisturized to prevent cracking http://www.dermis.net/dermisroot/en/20474/image.htm © 1996-2013. or subsequent infections should be recommended to patients as well.

ACTINIC CHEILITIS (AC) Treatment options are aimed at removing or destroying the abnor- mal epithelium. They can include topical application of 5-fluorouracil, chemical peels with trichloroacetic acid, cryotherapy, electrocauterization, laser ablation or photodynamic therapy.5,6 Excisional biopsy (vermillionectomy) is indicated when loss of the sharp line demarcating the red color of the lip from the normal skin is seen, changes in the texture of the lip to palpitation or when there is a change in the thickness and presence of ulceration. Bi- opsy is the only way to allow for a histopathological review of the tissues (Figure 3). Figure 4: Post-op Mohs surgical procedure of 65 year old Caucasian male for removal of squamous cell carcinoma of the lower lip. NON-MELANOMA SKIN CANCERS: BASAL CELL CARCINOMA (BCC) Early intervention is critical but unfortunately BCC treatment is commonly delayed because of misdiagnosis or lack of recogni- tion. Differential diagnosis may include a wide variety of lesions including; scars, eczema, freckles or nevi because of BCC’s vast array of clinical features. Skin biopsy is necessary to confirm the diagnosis and will help define treatment options. Doctors may excise the lesion, perform curettage, electrodesiccation, Mohs surgery or cryosurgery, prescribe skin creams or provide photodynamic therapy. If these treatments prove unsuccessful then radiation may be necessary.

SQUAMOUS CELL CARCINOMA (SCC) SCC is another form of non-melanoma skin cancer. A skin bi- risk of developing skin cancer. Despite this information, many opsy is used to confirm diagnosis and treatment will depend on Americans are still tanning indoors. Healthcare providers should the location and severity. Common treatments include; excision, be aware of the risk factors associated with this type of intense UV electrodesiccation and curettage, cryosurgery, prescription medi- radiation (UVR) exposure and be examining their patient’s skin cations, Mohs surgery or photodynamic therapy (Figure 4). closely. The ozone layer of the earth does not provide protection from SOLAR DAMAGE/PROTECTION all forms of UVR. UV radiation is believed to be responsible for UV-induced generation of reactive oxygen species (ROS) occurs up to 90% of photo-aging.9 UV rays penetrate glass such as car when the skin develops oxidative stress. Reactive oxygen species windows. For those who spend a significant amount of time driv- are chemically reactive molecules containing oxygen. Oxidative ing or commute by car, sunscreen protection of the arms is recom- stress is the cumulative damage to cell structures caused by ROS. mended.7,8 There are 3 types of UV rays, ultraviolet A, B and C. When the formation of ROS exceeds the antioxidant defense UVA is the most common on earth’s surface and penetrates beyond capabilities of the skin cells, free radicals can potentially cause the top layer of human skin. UVB rays are mostly absorbed by the damaging changes to the skin. Free radicals indirectly cause DNA ozone layer and don’t reach as far into human skin; however, they damage which can lead to malignant melanoma.7,8 Healthcare pro- are still dangerous and are responsible for most sunburns. UVC fessionals and the FDA recommend sunscreen for anyone who is rays are extremely dangerous, are absorbed by the ozone layer and outdoors, especially between the hours of 10 AM-4 PM when UV do not reach the ground. light is most intense. The Skin Cancer Foundation recommends an SPF of 30 but According to the American Cancer Foundation, the leading no higher than 50 for adequate protection. Sunscreens currently cause of skin cancer is UV radiation from the sun and artificial UV on the market contain a wide array of chemicals; however, they radiation from tanning beds. According to the CDC, individu- do not all provide the same level of protection from UV radia- als using tanning beds before the age of 35, have a 75% increased tion.

78 | rdhmag.com RDH | March 2014 Compounds that are commonly incorporated in OTC sun- wide variety of commonly encountered oral conditions. They can screen products include: be used as an adjunct in the treatment aphthous ulcers, xerosto- 1. Avobenzone (Parsol 1789®) mia, periodontal disease, oral lichen planus, and to provide pain 2. Ecamsule (Mexoryl®) and sensitivity relief. 3. Octinoxate Below are descriptions of many common antioxidants that help 4. Octisalate repair damaged skin and are incorporated in many prescription 5. Octocrylene and OTC products. A comprehensive discussion of antioxidants 6. Oxybenzone (Benzo-phenone-3) is beyond the purview of this course. More information is available 7. Octyl-Dimethyl PABA from a variety of journals, textbooks and online sources. 8. PABA (para-aminobenzoic acid) 1. Acai oil 9. Titanium dioxide The acai berry has an abundant supply of essential fatty acids such 10. Zinc oxide as Omega 3, 6 and 9. This berry also contains vitamins B1, B2, B3, vitamins E and C as well as minerals such as phosphorus, calcium, Zinc oxide is the only compound that provides protection potassium, polyphenols, anthocyanins which help preserve the against all three forms of UVR.(10,11) It is the preferred ingre- skin, and phytosterols. The oil derived from the berry has anti- dient for protection as recommended by the American Academy aging effects, decreases wrinkle formation and promotes healthy, of Dermatology and the EPA. Zinc oxide provides the broadest youthful skin. protection of all the compounds listed above. It is an FDA Cat- egory 1 skin protectant which means it is safe and effective for 2. Alpha-lipoic acid (LA) compromised or environmentally challenged skin which is also LA is a powerful antioxidant which reacts with free radicals. Ac- why it is the leading compound in baby products. When purchas- cording to the University of Maryland Medical Center, research ing sunscreens, be sure to read the ingredients; many brands do suggests LA can also interact with other antioxidants including vi- not contain zinc oxide. tamins C and E and glutathione by aiding in regeneration as their quantities are depleted. It scavenges reactive oxygen species and ANTIOXIDANTS is promoted commercially to erase fine lines, decrease wrinkles Antioxidants are natural substances comprised of vitamins and and diminish pores. It is also known as thioctic acid and is a natu- minerals. They have an ability to fight and neutralize free radi- rally occurring compound that is synthesized in small amounts cals before they can attack the body and to strengthen cells when by plants and animals, including humans. Due to LA’s diverse applied directly to the skin. Studies show topical application of pharmacological and physiological actions in the body, research antioxidants can provide up 96% reduction of sunburned skin cells is ongoing for its use in the treatment of diabetes and periodontal and prevent the formation of thymine dimers in UV radiated skin, disease, among others. providing a younger and healthier appearing skin tone.11,12,13,14 The use of the topical antioxidants discussed below can aid in 3. Coenzyme Q10 (CoQ10) prevention of oxidative stress, enhance DNA repair which can With advancing age, the level of CoQ10 the body produces dimin- potentially decrease the risk of developing skin cancer, increase ishes, which may increase susceptibility to free radical damage.16 the youthfulness of skin color and contour and reverse the aging Skin care products containing Coenzyme Q10 can aid in replen- changes of the skin.15 ishing the CoQ10 that has been lost and slow photo-aging of the A variety of factors can contribute to skin damage including; skin. A study published by Hoppe et al demonstrated, “CoQ10 ionizing radiation, severe physical and psychological stress, alco- penetrated into the viable layers of the epidermis and reduced the hol intake, poor nutrition, overeating, environmental pollution, level of oxidation. Furthermore, a reduction in wrinkle depth fol- and exposure to UV radiation. The biology behind aging skin is lowing CoQ10 application was also shown. These results indicate founded in many different physiological processes. The reduction that CoQ10 has the ability to prevent many of the detrimental in collagen and elastin production with advancing age makes the effects of photo-aging.”17 skin thinner and more easily damaged. Many bodily processes Another study published by Inui demonstrated, “the use of diminish with time including the ability to fight infection and 1% CoQ10 cream for five months reduced wrinkle score grades heal. Glandular activity and general blood flow also decrease with observed by a dermatologist and contributes to protecting dermal increasing age.10 Multiple studies have demonstrated that topical fiber components from degradation, leading to rejuvenation of antioxidants are one of the best ways to diminish the impact of wrinkled skin.”18 certain UV rays and fight the oxidative stressors noted above.7 A variety of factors also cause a decrease in oral antioxidants. 4. Vitamin A Among them are aging, increased inflammation including the This vitamin, when applied topically, has been shown to decrease inflammatory component of periodontal disease, smoking and hyperpigmentation and increase skin tone and color. The biologi- frequent alcohol intake. Topical oral antioxidants can address a cally active form, retinoic acid, binds to nuclear receptors that aid

RDH | March 2014 rdhmag.com | 79 in transcription and ultimately leads to its physiological effects. formation and aids in anti-inflammatory and immunostimulatory Retinoids include the natural and synthetic derivatives of vitamin effects in the body. It can be used to treat yellow nail syndrome, A which are structurally related to compounds, such as retinol, discoid lupus erythematous, dystrophic epidermolysis bullosa, retinol esters and retinoic acid.1 granuloma annulare or minor atopic dermatitis issues.1 Research When retinol is applied topically, it is converted into retinoic indicates that vitamin E works best when combined with other acid which interacts with skin cells.12,14 Skin biopsies have revealed antioxidants including vitamins C and/or A. retinol increases the production of glycosaminoglycan and procol- lagen which are structural components of the skin. This is the These next 3 antioxidants are plant-based botanicals and are mechanism of action of the decrease in fine lines and wrinkles with the main ingredients in medically researched skin care products the use of Vitamin A.19 that are available by prescription or over the counter formulations. Vitamin A research dates back to the 1920s making it the most well known antioxidant on the market today. It has been proven 1. Alpha-hydroxy acid (AHA) to increase cell regeneration, exfoliation as well as dermal collagen These are naturally occurring acids that include glycolic acid, synthesis which plumps the skin. It also lightens solar lentigines lactic acid, citric acid and/or tartaric acid. Glycolic acid is and reduces the size and number of actinic keratosis lesions (which the original, the most popular, and has been proven to remove is the precancerous growth discussed in Part One of this course). dead skin cells. AHA’s are used to exfoliate the skin, decrease Dermatologists use retinoids for a variety of conditions including fine lines, age spots, acne scars and hyperpigmentation.13,14 acne vulgaris, psoriasis, rosacea, lichen planus, cutaneous lupus Estheticians and dermatologists use high concentrations (15- erythematosus, disorders of keratinization, striae, ichthyosis, 30%) for chemical peels which can cause deeper penetration of photo damage, enhanced wound healing and for skin cancer the acid into the skin. Home use products such as in creams prevention. Retinoids do not cure skin cancer, however, through and lotions come in concentrations of 5-10%. AHAs increase continued use, it may help prevent the formation of new lesions.1 sensitivity to the sun and may cause drying of the skin if im- Vitamin A is required for the proper functioning of many proper concentrations are used. Patients must use sunscreen important metabolic and physiologic body activities, including and moisturizers when using these products for skin rejuve- vision, gene transcription and immune system/skin cell differen- nation. tiation. Both excessive and deficient levels of vitamin A will lead to poor functioning in the human body.1 Systemic retinoids are 2. Hyaluronic acid teratogenic and are prescribed with caution and close monitoring This is a natural acid in the human body and keeps tissues cush- by medical professionals.20 ioned and lubricated. It is found in joint fluid, connective tissues and the skin. Smoking and an unhealthful diet will decrease the 5. Vitamin C (L-ascorbic acid) body’s production of hyaluronic acid. When applied topically, hy- Similar to vitamin A, vitamin C increases collagen production, aluronic acid will smooth the skin. Best results are achieved when plumps the skin and decreases wrinkles and fine lines. Vitamin combined with vitamin C. C has multiple benefits for the skin; it neutralizes reactive oxygen species, provides protection from UVB and UVA radiation, regu- 3. Salicylic acid lates vitamin E and the absorption of other antioxidants, stimu- Salicylic acid is found in OTC and prescription products and lates collagen growth, prevents UV immunosuppression and also is also used in dermatological chemical peels. Salicylic acid is a acts as an anti-inflammatory agent.14 versatile compound with several clinical applications. It is used The active form of vitamin C, L-ascorbic acid, is a water solu- to treat acne because of its ability to penetrate pores. It can also ble molecule. It scavenges and quenches free radicals and regener- decrease the incidence of blackheads and whiteheads. Salicylic ates vitamin E from its radical form.1 By replenishing vitamin E, acid is used for exfoliation and to decrease the signs of aging skin.16 vitamin C indirectly inhibits lipid peroxidation which minimizes When patients are undergoing chemical peel treatments with UV damage to the skin. Vitamin C aids in wound healing and is these products in-office or with over-the-counter preparations safe, even in high doses because of its water solubility.1 The opti- (lower concentrations than in-office), sunscreen must be used due mal level for topically applied vitamin C is 20% and it appears to to the enhanced sensitivity to UV light. This protocol also applies work best when combined with a low pH.12 to many other dermatological treatments and/or product use. Minimizing exposure to the sun to avoid the skin damaging effects 6. Vitamin E of free radicals is advisable for everyone. This is a lipid or a fat-soluble antioxidant. Vitamin E is beneficial Antioxidants deliver the required vitamins and minerals to for tissue repair, to promote healing and as a natural anticoagulant. the skin. They are inhibited by UV exposure, alcohol, analgesics, It protects against UV damage and prevents UV immunosup- oral contraceptives, antidepressants and anticoagulants.21 These pression.14 It scavenges free radicals 1 to reduce skin photo-aging agents improve the immune system response, stimulate collagen effects, decreases wrinkling after sunburns, prevents skin cancer regrowth and have anti-inflammatory effects.

80 | rdhmag.com RDH | March 2014 12. Pinnell SR. “Topical L-Ascorbic Acid: A Percutaneous Absorption Study.” Antioxidant gels, rinses, toothpastes and mouthrinses are Dermatol Surg. Feb 2001.27(2):137-142. increasingly a part of the dental clinician’s armamentarium. They 13. Pinnell SR. “Photodamage and Oxidative Stress and Protection Provided by Topical Antioxidants.” J Am Acad Dermatol. 2003. 48(1):1-19. have the ability to address a variety of oral conditions and to en- 14. Pinnell SR. “A Topical Antioxidant Solution Containing Vitamins C and hance the level of patient care. E Stabilized by Ferulic Acid Provides Protection for Human Skin Against Damage Caused by Ultraviolet Irradiation.” J Am Acad Dermatol. 2008. 59(3):418-25. Conclusion 15. Poljsak B, Dahmane R. Free Radicals and Extrinsic Skin Aging. Dermal We can provide a great service to our patients by identifying Rsrch and Practice. 2012. Hindawi Publishing Sorporation. Accessed skin lesions, providing skin care recommendations and refer- January 4, 2013 at www.hindawi.com/journals/drp/2012/135206/. 16. Haywood R. “Sunscreens Inadequately Protect Against UVA-Induced Free rals. Combining head and neck dermatology with head and neck Radicals.” J Invest Dermatol. 2006. 12(1):862-68. dentistry, promotes total body health and wellness, bridging the 17. Hoppe U, Bergemann J, Diembeck W, Ennen J, Gohla S, Harris I, Jacob J, Kielholz J, Mei W, Pollet D, Schachtschabel D, Sauermann G, Schreiner V, gap between dentistry and medicine. Expanding our profession Stäb F,Steckel F. Coenzyme Q-10, A Cutaneous Antioxidant and Energizer. beyond the oral cavity enables us to provide real comprehensive Biofactors. 1999;9(2-4):371-8. care for our patients. 18. 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. Biofactors. 2008;32(1-4):237-43. References 19. Kafi R. Vitamin A Helps Reduce Wrinkles Associated With Natural Skin 1. Keller K, Fenske N. “Uses of vitamin A,C,E and Related Compounds in Aging. Arch Dermatol. 2007;143:606-612. Dermatology: A Review.” J Amer Acad Dermatol. 1998;39(4-6):6111-625. 20. Chapman MS. Vitamin A: History, Current uses, and Controversies. 2. Zieve D. (2011) Liver Spots. A.D.A.M. Medical Encyclopedia. ADAM, Semin Cutan Med Surg. 2012 Mar;31(1):11-6. Inc. Accessed December 27, 2012 from www.ncbi.nlm.nih.gov/ 21. Symone M, Miguel S, Opperman L, Allen E, Zielinski J, Svoboda K. pubmedhealth/PMH00002126/ “Antioxidants Counteract Nicotine and Promote Migration via RacGTP in 3. Mayo Clinic. Age Spots (Liver Spots). Accessed December 27, 2012 from Oral Fibroblast Cell.” J.Periodontol. Nov 2010. 81(11):1675-90. www.mayoclinic.com/health/age-spots/DS00912. 4. Vorvick L, Zieve D. (2011). Rosacea. A.D.A.M. Medical Encyclopedia. ADAM, Inc. Accessed December 8, 2012 from www.ncbi.nlm.nih.gov/ pubmedhealth/PMH0001882/ Author Profile 5. Ibsen O, Phelan J. Oral Pathology for the Dental Hygienist. 6th ed. St.Louis, Lisa Dowst-Mayo, RDH, BSDH graduated magna cum laude Saunders, Elsevier Inc; 2014, p.93-124. from Baylor College of Dentistry in 2002. She has been an active 6. Vieira R, Minicucci E, Marques M, Marques S. Actinic Cheilitis and Squamous Cell Carcinoma of the Lip: Clinical, Histopathological and member of the American Dental Hygiene Association and has Immunigenetic Aspects. An.Bras.Dermatol. February 2012;87(1). held numerous leadership positions both at the state and local Accessed December 4, 2012 from http://www.scielo.br/pdf/abd/v87n1/ levels. She is currently a full time professor at Concorde Career v87n1a13.pdf 7. Dreher F, Maibach H. “Protective Effects of Topical Antioxidants in College in the dental hygiene department in San Antonio, TX. Humans.” Curr.Probl.Dermatol. 2001. 29:157-64. Lisa is a published author, enthusiastic national speaker and can 8. Epstein J, Wang S. “Understanding UVA and UVB.” May 2012. Skin be contacted through her website at www.lisamayordh.com or by Cancer Foundation. http://www.skincancer.org/prevention/uva-and- uvb/understanding-uva-and-uvb email at [email protected]. 9. Symone M, Miguel S, Opperman L, Allen E, Svoboda K. “Reactive Oxygen Species and Antioxidant Defense Mechanisms in the Oral Cavity: Author Disclosure A Literature Review.” Compendium of Continuing Education in Dentistry. Jan/Feb 2011. 31(1). Online access only p.10-15. Lisa Dowst-Mayo has no affiliations with any company who 10. Haywood R. “Sunscreens Inadequately Protect Against UVA-Induced Free would have a gained interest in the material published in this Radicals.” J Invest Dermatol. 2006. 12(1):862-68. course. There was no corporate sponsor in the making of this 11. Oresajo C, Stephens T, Hino PD, Law RM, Yatskayer M, Foltis P, Pillai S, Pinnell SR. “Protection Effects of a Topical Antioxidant Containing course and the author is not employed by a company that would Vitamin C, Ferulic Acid and Phloretin Against UV-Induced Photodamage.” stand to profit off the publication of this course. All research is J Cosmet Dermatol. Dec 2008. 7(4):290-7. presented in an unbiased manner.

Notes

RDH | March 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. Studies show topical application of 12. Which group of plant-based botanicals a. Both statements are TRUE antioxidants can provide up 96% reduction does glycolic acid belong to? b. Both statements are FALSE of sunburned skin cells and prevent the a. Alpha-hydroxy acid c. The first statement is TRUE, the second is FALSE b. Hyaluronic acid d. The first statement is FALSE, the second is TRUE formation of which of the following in UV c. Salicylic acid radiated skin? d. Lactic acid 23. The use of the 5-fluorouracil, chemical a. Ultraviolet dimers b. Thymine dimers 13. The range of concentrations of alpha- peels with trichloroacetic acid, cryotherapy, c. Aging dimers hydroxy OTC products is: electrocauterization, laser ablation or d. Amine dimers a. 2-5% b. 5-10% photodynamic therapy or vermillionectomy 2. As the human body ages, which of the c. 20-30% can be used to treat a patient with: following decreases? d. 35-50% a. Production of collagen a. Angular cheilitis b. Production of elastin 14. The best plant-based botanical to use if a b. Actinic cheilitis c. Ability to fight infection patient has easily irritated skin is: c. Actinic keratosis d. All of the above a. Alpha-hydroxy acid d. Psoriasis b. Hyaluronic acid 3. Which of the following antioxidants has c. Salicylic acid 24. Which of the following can be used to treat been most thoroughly researched? d. Lactic acid a. Vitamin A basal cell carcinoma? b. Vitamin C 15. Which of the following is found in the a. Mohs surgery c. Vitamin E human body, keeps tissues cushioned and b. Johns surgery d. Vitamin B lubricated and is found in joint fluid? c. Cryosurgery 4. The biologically active form of vitamin A is: a. Alpha-hydroxy acid d. Photodynamic therapy a. L-ascorbic acid b. Hyaluronic acid b. Retinoic acid c. Salicylic acid 25. The percentage of SPF protection recom- d. Lactic acid c. Sulfuric acid mended by the Skin Cancer Foundation is: d. Citric acid 16. Antioxidants are inhibited by: a. 15% 5. Vitamin A is required for the proper a. Alcohol b. 30% b. UV Radiation functioning of many important metabolic c. Tobacco c. 55% and physiologic body activities. Excessive d. All the Above d. 60% amounts of vitamin A will have no adverse 17. Which of the following treatment options 26. According to the CDC, the percentage of effects on the body. are commonly used for people with acne? increased risk of developing skin cancer from a. Both statements are TRUE a. Water-based products labeled as non-comedogenic b. Both statements are FALSE b. Benzoyl peroxide indoor tanning before the age of 35 is: c. The first statement is TRUE, the second is FALSE c. Vitamin A a. 25% d. The first statement is FALSE, the second is TRUE d. All of the above b. 50% 6. Vitamin C regulates the absorption of: 18. Which of the following compounds can be c. 75% a. Vitamin E d. 100% b. Vitamin B used to treat age spots? a. Hydroquinone cream c. Vitamin D b. Emblica 27. UV radiation is believed to be responsible d. Vitamin A c. Kojic acid for as much as: d. All the above 7. The biologically active form of vitamin C is: a. 50% of photo-aging a. L-ascorbic acid b. 70% of photo-aging b. Retinoic acid 19. Which of the following agents is sold c. Sulfuric acid commercially to help prevent the oxidative c. 90% of photo-aging d. Citric acid browning of fruits, to preserve the pink and d. 100% of photo-aging 8. When applied topically to the skin, the opti- red color of seafood and has antibacterial 28. Which of the following ultraviolet rays are mal level needed for vitamin C absorption is: and antifungal effects? extremely dangerous, absorbed by the ozone a. 10% a. Hydroquinone cream b. 15% b. Emblica layer and do not reach the ground? c. 20% c. Kojic acid a. UVA d. Glycolic acid d. 30% b. UVB 9. Vitamin C is a water soluble vitamin. 20. Topical creams or moisturizers indicated c. UVC Vitamin E is a fat soluble vitamin. for the treatment of eczema should be used: d. UVE a. Both statements are TRUE a. 1-2 times per day b. Both statement are FALSE b. 2-3 times per day 29. UV Light is most intense between the c. The first statement is TRUE, the second is FALSE c. 3-4 times per week hours of: d. The first statement is FALSE, the second is TRUE d. 5+ times per week a. 9:00AM – 12:00PM 10. Vitamin E is best absorbed when it is 21. Rosacea can be triggered by: b. 9:00AM – 2:00PM a. Stress c. 10:00AM – 1:00PM combined with: b. Alcohol a. Vitamins A & C c. Cold beverages d. 10:00AM – 4:00PM b. Vitamins B & C d. Both a & b c. Vitamins D & C 30. According to the EPA, which of the follow- d. Vitamins B & D 22. There is no cure for oral lichen planus-like ing is the preferred ingredient for protection conditions of the skin; treatment options 11. Which of the following is NOT a plant- from UV rays in sunscreen products? based botanical? are strictly therapeutic or palliative. OLP a. Titanium Dioxide a. Hyaluronic acid may cause a patient to be at an increased b. Salicylic acid b. Zinc Oxide c. Alpha-hydroxy acid risk for the development of squamous cell c. Avobenzone d. Vitamin A carcinoma. d. Oxybenzone

82 | rdhmag.com RDH | March 2014 ANSWER SHEET Linking Dermatology And Dentistry Part II: Treatment Options

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Educational Objectives If not taking online, mail completed answer sheet to 1. Define and discuss antioxidants and their benefits to dermatology and dentistry. Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp. 2. Discuss anti-aging and healing capabilities of antioxidants P.O. Box 116, Chesterland, OH 44026 3. Present treatment options for a variety of common skin conditions or fax to: (440) 845-3447

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