All right, welcome everybody to the 1030 session, oral pathology. Thanks for taking a chance on a topic that I know you don't get training in medical school. I've been working for eight years up at the University of Utah, just up the road, telling them I would love to speak with the medical students. Give me two hours to introduce them to the mouth. And the response was, well, record it and we'll see if we can fit it in. And I declined because part of it is the interaction and let them know that as a medical doctor, future medical doctor, you should be able to communicate with dentists, help coordinate the health of a patient. So I know this might be the first time you've had a topic in the mouth at one of these conferences. I know when I was speaking with some of your organizers, that they were excited that this is something they haven't seen at a conference like this. So I'm excited to be here with you. Most of my presentation is pictures. My goal is that you don't have to take notes. I want you to just listen, learn, come up with questions. I will post the presentation with typed up slides after the showing. I was changing them up until an hour ago cuz I stress over stuff like that. I think I'm in the right group where we all tend to change stuff. And you submit it a week in advance knowing that it's gonna be irrelevant 20 minutes later, so I just didn't submit it. So we should be good to go. My name is Brian Trump. Based on the name, I've had some fun over the past few years. I used to have a bunch of Trump coins that I'd give out to people who were courageous and answered some questions they may not know. Something that I have kept doing is I have Trump hats. I found the exact brand that Trump used in this campaign, and mine says Trump make pathology great again. Cuz I travel around speaking on oral pathology, so we'll see if someone can earn that hat today. My father's name is Ronald. It's about as close as I get to being related to the Donald. But there are some teenagers in Bountiful about ten miles south of here that think I'm his nephew, and it was a Little Caesars, remember? So they asked me if I was related, and I said, yes, he's my uncle. And they were freaking out, like, you gotta come meet Donald Trump's nephew. I let it go on for a few minutes, a few handshakes. I was feeling pretty good about myself. And then I finally said, you guys, if I was related to Donald, I would be at Papa John's. I would not be in line getting a $5 hot and ready. I think I could afford the works. So that didn't go for very long, but I've had some fun with it. Today's presentation is on oral pathology. These top 30 lesions that I'm gonna share with you today, some of them we'll spend very little on, others we're gonna dive into a little bit more detail. Because they're relevant and they have significant meaning if you see them in your practices, in yourselves, in your family, whether you look in the mouth or not, I'm hoping this teaches you a lot about your own mouth. And if you ever come across something and it's one of these common lesions, you would know what to do next. So don't worry if we rush through some and we slow down on some others. But these pathologies make up about 93 to 95% of the pathology in the mouth. So as you review this list of 30, you've hit all of the common stuff. The remaining 5 to 7% is why we have specialists. So as an oral and maxillofacial pathologist, I did 12 years of training. And in the end, I got away from dentistry. I don't drill and work on teeth. I haven't for about ten years. Mine is focused on pathology from below the orbit down to the neck. So anything that happens in this area, in bone, out bone, down the throat, that's my specialty. I do surgeries, I remove things, I look under the microscope and tell patients what they have. And I work with surgeons to, when it's big surgeries, I pass it on to the surgeons who I get to work with and say, here's what I would do and here's my interpretation of what I see. So I've had a lot of fun solving the puzzle, which is why I got into pathology in the first place. So I run a clinical practice, I do oral medicine. So I kind of get to walk the lines of dental field oral health as well as medicine, and I love interacting with all of my colleagues there. So 93% of our reported cases is what we're gonna go through over the next hour and a half. We started on time and my goal is to end early and to leave time at the end in case there's any question that you've been dying to ask, either an oral pathologist or a dentist in general. It's kind of fun. Dentists don't get to often present at medical conferences, so I'm fortunate and lucky, but I also want to give you a chance to ask me anything you wanna ask. All of this, I know that some of you are generous enough to tell me that the mouth is relevant. You look in the mouth once in a while. Some of you more than others, that's okay. If you do it very rarely, again, my goal and hope is that you learn something about yourself today that helps out. But it all starts with a good head and neck exam. If you ever go to a dentist, they're good and they're on top of their game. If the first time you meet them, they tell you that they're going to do a head and neck exam. And that's where they feel around your sternocleidomastoid, your cervical lymph node chain. Basically, what we're looking for is visually, is there something different? It's very rare that by palpating, you're gonna be able to pinpoint a problem. It's usually when a patient walks into the room. And when patients are walking into your clinic or your operatory or wherever you're at, and you look for that symmetry. I kinda do a quick look to see if there's any asymmetry in the parotid, in the neck, midline. And within a moment, I know in my mind, I need to look closer at their left neck, their right neck, and stuff like that. So it really is a quick visual on symmetry, followed by a little bit of a closer exam. Palpate the lips, that we get salivary gland tumors. We've got hundreds of minor glands all throughout our lips. There's a lot of different pathologies that occur there. So don't ever just look, if you've got a good pair of gloves. Then go ahead and palpate, run your fingers across the lower lip, the upper lip, in both buccal mucosa or cheek mucosa. And you're looking for something bigger than the size of a pea. A pea and smaller, could be just a big minor salivary gland, could be a really small soft tissue lesion. But anything that gets bigger than a pea or to a marble, it shouldn't be that big. And that's when we investigate, and I go in and cut it out. You guys can either do that or refer to a colleague who's gonna do that for you. The tongue is a high risk site, so make sure you always look at the tongue. And I'm gonna show you some locations on the tongue that is my target. If I'm ever gonna look at the tongue, you have to look to a certain distance posteriorly. Otherwise, you're missing the high risk site. So I'll share that with you as well. And then, of course, having the patient open up and go, there's some lesions that kinda grow next to the uvula down the throat. We're limited in how far back we can go, but at a quick glance, we'll show you some common pathology. And then floor of mouth can have some things, and then extra oral exam on the lymph nodes is big. For me, I'm always looking at skin, I always move hair out of the way. No matter how someone combs their hair, I just tell them what I'm gonna do, and I move it because I've ran across especially some older female patients. They comb their hair to hide visually disturbing things, or bumps, or moles, or something they don't like. Well, that's exactly what we need to look for, is the change in the skin. So I've diagnosed plenty of melanoma, basal cell, and squamous cell by moving hair, and then always looking at the ears cuz of the chronic sun exposure. So lower lip and ears and scalp are probably the places where I've diagnosed things the most, just because it's chronically exposed to the sun. I'm gonna share with you today some differentials, which listing all possibilities and ranking them in order for most likely to least likely. I'm gonna go one through 30 on my presentation today. So depending on if you memorize this list, which I don't expect you to do, you're gonna rank your differential based on how high up on this list of 30 did it fall, and that's your most likely diagnosis. So trying to teach medical residents, dental students, and traveling around speaking to various doctors. It's just learning differentials, and this presentation's all about providing you with an initial dictionary of what should you be guessing. We always arrange them in order from most likely to least likely according to your list. My differential's gonna be different than yours based on experience, training. I could be totally wrong, you guys could be totally right. It doesn't really matter. Your differential is your own, and depending on your list of possibilities, you start with your first one and treat it as if it's that. If that fails, move on down that list, and usually we end up with a diagnosis at some point by testing our hypothesis. You could be watching it. How long does it take oral mucosa to shift and heal? Who knows that? You don't have to, but do you remember? It takes about 14 days for basal cells to divide, mature, migrate to the surface, and slough off. You know how we all have skin dandruff? Same for the nose. Same for the nose, mucosa. Oral mucosa heals a little bit quicker than nasal, but nasal's really close behind. The mouth is one of the fastest healing places. And on average, it's 14 days. So if you ever want to do the watch and wait, you have a two week time period. If it heals or looks significantly better, it's physiologic. If it doesn't look better, hasn't healed, it's now pathologic. And regardless of what it is, your job as a medical provider and doctor is to investigate this pathology. And it may turn out to be something physiologic that just had been there for way too long, but that's the right way to handle it. Two weeks is what I'm willing to do. We all have skin dandruff because that's our epidermal cells, our keratinocytes. They mature, they migrate, they slough off, and dandruff is just the sloughing of that cell that's lived its life. We all have mouth dandruff, we just don't see it flaking out, we swallow in our saliva. So whenever I'm hungry, I just take a nice swallow. It's keratin, it's gotta be good for my hair, my nails. No, but every time you swallow, you are swallowing some of your keratinocytes from your mouth. All right, we're gonna get started with the number one oral pathology. This is based on color, what do you guys see? Sorry, I always like lights to be down more cuz we can see these better, but what color is that? White. There's only one place we should see white in the mouth, and that's the dentition. Enamel is white, dentin is yellow, white should only be on the teeth. So if we see white, we have to stop and think, what else could it be? Now, why is the color white present? It usually means that the mucosa has thickened, or the collagen has thickened, or the vascularity has diminished. So there's different reasons to have white. The most common is that thickening of the mucosa. It could be from callus, it could be from a pre-neoplastic or dysplastic lesion, or it could be from a cancer that is starting to produce more keratinocytes and so it appears white. So a white plaque, something white that doesn't rub off, and you don't know why it's there. Anyone know that clinical term? Very good, leukoplakia. So there's the three components. It's white, I can't wipe it, and I, or you, or you, don't know why it's there. Now, in my office, I might have a pretty good idea why it's there. And so I may not call it a leukoplakia, where in your office you might say that, or vice versa. You may recognize something that I call a leukoplakia, but that's because I don't know why it's there and I need to investigate. You, if you know why it's there, test your theory, okay? So the first thing you do with white is wipe it. Why do we wipe it? Because we can rule out some other things really easily. So we're gonna go over the wipeable white lesions really quick, and then we'll get back to this leukoplakia. So this is the right ventrum, anterior ventral part of the tongue, which is, ventral tongue is a high risk site. Lateral border of tongue, ventral tongue, floor of mouth. If you see white in those areas, it's more likely to be a precancerous lesion or cancerous lesion than not. If it's on the buccal mucosa, gingiva, palate, it's more likely to be a callus than cancer. However, do we know which one of those it is? We can't know until we do a biopsy and look under the microscope. So depending on what you think it is, test your theory. We can wait two weeks, we can wait a month. If it's looking better, give it more time. If it's not looking better, at some point it's, I recommend you get a biopsy, cuz that will prove if it's on that path to dysplasia and cancer, or if it's just thickened tissue without any evidence of atypia or dysplasia. Okay, so here's our definition of a leukoplakia. One of the other key components is that it's not easily recognizable. So we're gonna go over a list of wipeable white plaques, followed by a list of readily recognizable white plaques. Something that you should look at and go, that looks like A, B, or C. All right, lesions that can scrape off. Materia alba, which is nothing more than, it's Latin for white material. It's usually a sign of xerostomia. So the patient has such dry mouth. They just ate lunch before they come in to see you. I don't know how many times patients apologize, I didn't have time to brush. You're fine, I do this all day, you don't have to brush. But it does mean if they have dry mouth, they couldn't swallow all the debris. And you'll look in their vestibular mouth and you can tell that they had wheat thins or salad. I mean, I can usually guess what they had. For myself, it's a fun game. What'd you have for lunch? And sometimes I ask them and I win. I have to know my patient well enough to know if they're not gonna be embarrassed versus, did you have some Pringles? They say yes, I'm like, yes, did you bring some for me? This is the next question. White coated tongue, again, sign of dry mouth. Their tongue papilla don't desquamate well. If we all look in the mirror right now, or you looked at your neighbor, most of us have a white coating on our tongue. That is normal. The more white or intense it gets, it's usually a sign of diminished salivary flow, which can lead to a bunch of problems such as dental caries. Means they don't have saliva to buffer the acidity, and if they drink soda, the teeth can be a mess really quick. Thermal burns or chemical burns can wipe off, cuz you're wiping off the fiber and membrane from the ulcer. Or the cauterized surface epithelial cells. Has anyone brushed with Crest ProHealth? Anyone use Crest ProHealth? Have you ever noticed a little white film after you brush with it that kind of sloughs off and it gathers in your vestibule, some part of your mouth? They have some of their ingredients from a few years ago when they first developed it, causes a chemical burn. It's not bad, it's not getting deep, it just means those surface cells that are ready to get desquamate, just kind of die and they slough off. So if you get a sloughing of your tissues when using a toothpaste, usually means it's got a chemical your body doesn't love, it's fine. If it burns, I'd avoid it. If it doesn't burn, you're fine, it's speeding up the desquamation process. But I'm sensitive to it. If I use Crest ProHealth, nothing against it, it's a great toothpaste. I got a lot of free samples in dental school, but I just noticed that my mouth sloughed, the surface tissue sloughed off. So I avoid it based on knowing my body doesn't like some of those chemicals. It's a hypersensitivity reaction. The biggest one that wipes off is pseudomembranous kandidiasis, thrush, yeast infection, whatever you wanna call it. So if you ever see white plaques, they wipe off, they look like cottage cheese, that's pretty much a good clinical test. I should treat this as a yeast infection. Treat it as such, if it resolves, you nailed it. If it doesn't resolve, go back to the drawing board, what else was on your list? Cuz now it's a white plaque that rubs off, but it didn't heal because of yeast infections. It's probably the most commonly misdiagnosed condition in our field is that everything gets called thrush when it didn't wipe off, so it shouldn't be. There's one type of kandidiasis called hyperplastic kandidiasis that doesn't wipe off. Well, that's a patient who's been on long-term antibiotics, core morbidities, a lot of health issues. They've had yeast for so long, they just have really thickened tissue. And then, like we talked about, toothpaste or mouthwash, too much of it. So any guesses what this is? This is materia alba. Actually, it's not. Materia alba is usually with really poor oral hygiene, patients who never brush and floss. They get plaque, the actual bacteria growing on their soft tissues. You'll smell it, smells delicious. This happens to be a free cookie in the faculty lounge for me. I didn't have a good picture of materia alba, so I made one. So I called one of my assistants in and made her take a picture. She was grossed out, which made my day, actually. Here's true materia alba. So we get plaque and calculus buildup on our teeth when we don't brush or floss, even for a day. We all, your teeth feel kind of slimy. Takes quite a bit to grow it on the gingiva, but it happens. I've seen patients with it. It's usually when I'm treating the lower socioeconomic status, homeless, some of the substance use disorder treatment centers. They just haven't taken care of their mouth so much. So I expect to see this. Again, it's nothing against them. It's letting them know that we need to treat this and clean their mouth a bit. So that's materia alba. This is white coated tongue. This happens to be yellow coated tongue. Depends on what they eat. I've seen green coated tongue when they have green tea. I've seen brown coated tongue, depending on if they just had chocolate or coffee. Black coated tongue, black coffee. My favorite was green tongue, Mountain Dew. Any pigment's gonna stain the bacteria that's on the tongue, and you can get whatever color you want, which is, I mean, it's super sexy, to be honest. You see that? That's awesome. Okay, they're asymptomatic treatment for anyone who has a white coating on your tongue, tongue scraper. The ones that are on the back of a toothbrush, worthless. They're tongue ticklers. These are my favorite ones here in the middle. If you're gonna do a tongue scraper, it's gotta be stainless steel, copper, two handles, flat bar, and you're doing firm, but not enough to hurt. Pressure, and then you'll be amazed at how much comes off on that metal bar. Rinse it, repeat until nothing else comes off. If you do that daily, you're gonna have a nice pink tongue. It's never gonna be white, cuz you have to physically remove that. If you don't, at some point throughout the day, we get kind of a white coating. So these are all just kind of worthwhile. I've used them all, tested them all. The best one is the stainless steel. You can go on Amazon and buy a dozen copper ones or stainless steel ones for 12 bucks. Or go to CVS, Walmart, Target, get one for five. So depends if you're like me and you're gonna lose it, your kids take it, I buy 12. Aspirin burn is a chemical burn. It's happening less and less. But my grandma, I remember she told me when you have a toothache, it's I'll just put an aspirin next to the toothache. Yes, it helps, but the acid from the medication causes a chemical burn, which causes a sloughing. So I still see it, doesn't have to be aspirin. Can be other medications that I've seen it happen with. I've had patients whose physicians told them to open up the powder capsule of their medication and dump it under their tongue. It caused a chemical burn that the patient ended up in my office, because no one could figure out why the floor of their mouth was completely white. We stopped doing that method of, she had poor absorption in her gastrointestinal tract, so that's why the doctor told her to do that. Totally made sense why. We just had to get her to swallow it for a while to prove that that white lesion that no one knew what was going on was a chemical burn from her medication. This here is called a cotton roll burn. That's nothing more than if you get dental work done at an office and they put a dry angle or a cotton roll up in your lip and they don't moisten it before they rip it off. They're just tearing your tissues off. So we stress this in dental school, don't rip a patient's mouth. Wet moisten it and you'll be good. Even for you, if you put anything in your mouth and you've got dry mouth already, it doesn't take much to tear your tissue. Just has to be wet. Toothpaste allergy, this is the sloughing I was talking about, that I get if I use Crest Pro Health. You might get it with a number of other things. Here's the pseudomembranous candidiasis, the most common pattern of yeast infection, which is the cottage cheese white plaques that wipe off. The next most common pattern is pseudomembranous, and it's just where it's just red. And it usually happens underneath a denture, if a patient wears a denture 24-7. For those who treat more of the elderly population and have patients with dentures. If you're going to do an oral exam, it's got to come out. I don't care how embarrassed they are. For you to be a good doctor, you have to tell them, I'm fine with it. You can take it out for me. I'll let you put it right back in. But you have to evaluate under a, I've diagnosed oral melanoma underneath a denture, squamous cell carcinoma underneath a denture. Don't ever look in a mouth where you've let them leave it, because it just means you didn't get to see what's going on. Usually it's going to be denture stomatitis, inflammation from yeast under a denture. You have to treat both the denture and the mouth with an antifungal. You'll resolve it quickly. I had a patient referred to me a couple years ago now. She'd been treated for three years with chronic yeast infections, Diflucan, Systemix, IV antifungals. She was just being treated over and over again for these infections that kept recurring right after she finished treatment. I was the 12th doctor, and I don't know how many tens of thousands of dollars later. And I was stressed, because what am I going to do that a bunch of brilliant doctors didn't figure out? So I just asked her one question. Did you ever treat the denture? And she said, did I what? I said, did you ever treat the denture? She said, I don't know what you mean. OK, she didn't. So we just taught her how to soak her denture in the Nystatin solution. And after one week, after three years of chronic infections, after one week, it was all resolved, because she kept reinserting the yeast every time she wore her denture. Her husband had never seen her without teeth. Her grandkids had never seen her without teeth. So these are patients who are just so self-conscious of the denture. And they always have a story. I mean, they lost them as a child because of an accident. I mean, it's really, you just have to encourage them. No, no, it's OK. You can choose when you take it off. But they should sleep without their dentures. They should be out at night. The tissues can breathe. They won't get a yeast infection. All right, so here's some white plaques that you should know what they are. Linea alba is nothing more than a white line. Probably 90% of us in here have them. If you go home and look in the mirror, you can have a fine white line right where your teeth come together. That's just our tissues getting in the way. We suck on our cheeks a little bit. That's just called linea alba. That's nothing you will ever biopsy. That is a clinical term to prove that it's just the white line from occlusion. So don't worry about that one. This one here is a bilateral lesion, usually seen in 70% to 90% of African-Americans. But I see it. If I were to look in all of your mouths, I'd see it in most of us. It's a little diffuse, kind of milky gray, white, opalescent appearance on the buccal mucosa. And it's called leukoedema. All it is is a little bit of water fluid, a little bit of edema or fluid gets inside the mucosa. Our mouth loves it. But when you've got darker pigment underneath the semi-transparent mucosa, it gives off this appearance. All you have to do, invert the cheek and stretch it. This will disappear. If it disappears when stretching, that's leukoedema. You never need to look at it again. If it doesn't disappear when stretching, well, now you're thinking about a white plaque that didn't disappear that looks like this. Most commonly, it's going to be lichen planus, which is a chronic dermatologic disease. But we see it in the mouth as well. This patient here smokes cigarettes all the time or cigars or pipes. And this is nicotine stomatitis. So the heat from whatever they smoke calluses the roof of the mouth. These openings are the minor glands on the roof of the mouth. And so the ductal mucosa is getting stretched open as the tissue thickens and calluses, which is why you get these little punctate dots. Nothing to worry about. This in and of itself is not a precancerous condition. You just have to recognize it as putting together the dots of you smoke a pipe or a cigar, your mouth is really white. You've got these red dots. We're pretty good. I tend to still offer a biopsy in terms of I still like to know. We don't have to worry about this. Has anyone ever had a patient who reverse smokes? You put the lit end of the cigarette in your mouth. Because they want to bypass the filter, because it's catching the good stuff. That's what a patient told me. They have an 18-fold increased risk of oral cancer. So because they've got the carcinogens and the ash falling right on their tongue, right in their mouth, but it's a thing. And it's more common in the younger generation. So if you ever, if someone smokes, you could ask, do you reverse smoke? And those who do know exactly what it is, they'll say yes. Also, you just have to look in their mouth and it's going to be raw, red, burned, and bleeding. Because it's just, they've always got that heat going on. But when I first heard it, I thought someone was joking with me. But it's a thing, because they want to bypass the filter. Heaven forbid you don't want to get some of those 122 carcinogens in your body. OK. Who can tell me what the most common presentation for bilateral white plaques on the tongue? Lateral tongue, both very common in the 80s, early 90s. It's called oral hairy. Oh, yeah. Could be thrush. This doesn't wipe off. Very good. Thrush can look like this. This didn't wipe off. So these are those leukoplakias. White plaque doesn't rub off. And this is one that we should know why it's there. But it's actually less common. This is oral hairy leukoplakia caused by Epstein-Barr virus in a patient with HIV or AIDS. So they're immunocompromised. They get infected with Epstein-Barr virus, which is human herpes virus type 4. That causes this lesion. And it's a sign that they've got poorly controlled human immunodeficiency virus or AIDS. So they have to get treated. I just signed out a case last week on this. A dentist in Jackson Hole, Wyoming sent me a picture of a 22-year-old who knows he has HIV. And he sent me this picture. He sent me a biopsy, which I was able to confirm what it was. But this is where I told the doctor, this patient really needs to get some controlled treatment. He's not on heart medicine. And so his viral load has got to be through the roof. It's the first case I've seen in five years. Usually, patients know they have it. They're getting heart regimined. And their viral load is down, so they shouldn't get this. So if you do see this, it's a sign that they need to get help. They need to get treated. And again, I promise I will post these for you after. OK, this is a patient that has a corrugated little sandy beach appearance in their vestibule. Anyone have any guesses what could be going on if they have this? They're placing something there. If you had to take a guess, what would it be? Chewing tobacco. So it can still happen with nicotine pouches. So they've quit. I've had patients that it looks like it's called tobacco pouch keratosis, or smokeless tobacco keratosis. I've had patients that I ask them, do you use chewing tobacco? They say no. What's your next question? Yeah, I mean, one is, when did you quit? Oh, it's been a year. Sometimes it was last week. OK. Yeah, but if they use the nicotine pouches, it can still cause it. I've had a patient, he was a major in the Air Force. He used shredded beef jerky. Causes the same thing. It's similar to pruning of your skin when you're in the bathtub too long. So this is from moisture staying in the same area for a long time. And so you get this appearance. But why would teeth look so nice and moist if they're growing on the shoes? Because it's probably going to rot. It would rot. Yeah, these are veneers. And then down here, because of the picture, it is hiding the fact that they brush before they came in. But usually, the smokeless tobacco will stain the teeth. If it's a patient who brushes every day, it will not stain them. They're removing that extrinsic stain. But it doesn't mean they're still not. They usually get recession from the ingredients in the smokeless tobacco. But maybe they don't use smokeless tobacco and it's the nicotine pouch. Either way, if you see this, it's, what do you place there? If they say no to smokeless tobacco, all right, well, what do you put there? I've seen it with cough drops. Patient had a cold and they'd use 20 cough drops a day. Oh, that's going to cause something. OK, now this one has kind of a spider web, lacy pattern. These are called wiccum stria. And these are associated with lichen planus. So oral lichen planus looks like a bunch of spider webs, usually on the buccal mucosa bilaterally. But it can be on the gingiva as well. And we'll talk about that a little bit later on. So lichen planus should be a recognizable white plaque. However, the current standard of care is if you expect lichen planus in the mouth, a biopsy should be performed to get a baseline because they have risk of oral cancer. And precancers can mimic lichen planus. They just tend to occur in an isolated spot. So when it's widespread, it's either lichen planus, hypersensitivity reaction, or it's due to medications, of which mood-altering drugs, sleep aids, and painkillers are probably the most likely to cause that reaction in the system. So we're back to number one, leukoplakia. If you can recognize this and this is what you walk away knowing more about, then it's a big win because this is what you're more likely to see in your patients than anything else we're going to talk about. When they have a leukoplakia, there's a range of what the diagnosis can be if you choose to biopsy it. The first one is just hyperkeratosis, extra keratin on the superficial keratin layer. That's just a callus, similar to working out in the garden or working out and you get calluses on your hands. Under the microscope, it's the same thing. It's just thicker without any dysplasia. Or they're going to get dysplasia. Now the WHO, the World Health Organization, came out in 2017 with a new grading system. It used to be mild, moderate, severe. Now it's low-grade and high-grade. So if you send a biopsy to a pathologist, you're probably going to get low-grade dysplasia or high-grade. I kind of liked the mild, moderate, severe because I like the three-tier system. It gives an in-between where I can tell a surgeon, it's not as bad as severe, but it's beyond mild. Do something about it. But that was why the WHO decided just low-grade, high-grade. If it's high-grade, you have to treat. If it's low-grade, you can actually watch it. And it's up to the patient what they want to do. This was one of my first patients in residency. He was a 30-year-old male who came in inebriated. He already had bloodshot eyes and smelled of alcohol, and he smoked two packs of cigarettes a day. So all of the checkpoints for high-risk behavior for oral cancer, we biopsied this, and it was already carcinoma in situ or high-grade dysplasia. And he was my age at the time. So here's a 30-year-old that, in my opinion, not a matter of if, but when he gets oral cancer. So I told him that. I said, I just have to let you know that if you keep your current behavior, it's not a matter of if, but when. So please keep coming back. He came back and saw me for two years where I'd laser off the pre-cancer because it wasn't invasive. So I could laser. I can burn that top layer off. He quit coming back at some point. I'm sure it was finances or he just stopped caring because his pre-cancer kept coming back. I lost track of him. I tried to call his number for four years after I moved here to Utah after residency, and I never got through to him because, again, he was the same age. I'm a twin. I have a twin brother. And I kind of took on that patient as, if this was my twin brother, I want to make sure he's taken care of. But I did lose track of him. This was a patient. He was a 75-year-old male who had been diagnosed with oral lichen planus when he was 30. So he had about 45 years of just being diagnosed with oral lichen planus. He never got it treated. Well, what is lichen planus? It's a chronic inflammatory process. It's immune-mediated. It's not autoimmune, but it's a bunch of T lymphocytes that get sent to different places in the body. Chronic inflammation. Anytime you have chronic inflammation, you have high cell turnover. Anytime you have high cell turnover, one bad cell, that's pre-cancer that leads to cancer. So he came in and saw me telling me I just have oral lichen planus. And I said, well, you did. Now you've got something else. We biopsied it, and it was carcinoma in situ. So on its way to becoming invasive. This one here is actually squamous cell carcinoma of the gingiva in a patient that used smokeless tobacco. So smokeless tobacco still has a risk of oral cancer. It's lower than smoking and alcohol. Alcohol is the number one, followed by smoking, followed by smokeless tobacco. However, having said that, one of the biggest categories on the rise in my practice is middle-aged females with no risk factors. It's still a small group, but it's the group with the sharpest rise in cases. I've diagnosed a lot of pre-cancer in women my wife's age, 40s, 50s. Never smoked, never drank, never did anything. And they've got a pre-cancer. So it's why we want to know what a white plaque looks like and we get it looked at. This hasn't changed much. This was one of the first reports done in 1975. I have more recent literature, but it didn't change. High-risk places, floor of the mouth, lateral and ventral tongue, and the lower lip. If you want to try and catch pre-cancer, that's where you do a thorough exam at. When you do a biopsy, the degree of dysplasia is the best guide to progression. So if it's low-grade, chances are it's going to stay low-grade. If it's high-grade, it's probably going to progress. About 12% progress beyond the point where you diagnose it. So if it's high-grade, about 50% of that point progress. But if it's low-grade, only about 12% move on, which is, I mean, 1 in 10 chance. Still means you don't know what patient that is. Are they the one or are they the nine? So I still follow them up and I watch them. In this systematic review, they looked at about 1,000 patients. The malignant transformation rate is 12%. So 12% of these leukoplakias actually become cancer. It happens over the course of 4.3 years. So these are patients, if you ever diagnose a leukoplakia, that's not a one and done. You have a leukoplakia, we're good. You've got to come back and see me in six months. You've got to see someone. Talk to your dentist. Someone should be looking in their mouth because it can happen four years down the road. All right, we're on number two. We've been a half hour and I'm on number two out of 30. I better pick it up a bit. All right, these are firm, bony, hard bumps that can be on the roof of the mouth or on the lower mouth. They're called tori. They can be a sign of clenching or bruxism. Someone who's got anxiety and clenches and bruxes at night, they've got wear on their teeth and they have these. They're not tumors. They're just abnormal bone growth based on that friction because as you clench and brux, your teeth flex. Your body lays down a thicker foundation of bone to stop that flexing from happening because the teeth don't like it, the body doesn't like it. So we get these bumps. Not a big deal. The only time you ever treat them is if they become painful because my older brother, his were so big that they touched and his tongue couldn't go in the floor of his mouth. So he actually developed a little bit of a lisp before he finally, he wanted me to cut him off and I said, I'm not working on my brother. This is the same brother who beat me up as a kid so I should have said yes. I had a chance. That was a really good chance to cause some pain. But I didn't want to because I didn't want to blame you for it. But we treat them when they get irritated or if a patient needs a denture because dentures can't fit over those bumps. But they're firm, bony, hard, midline hard palate or on the sides of the mandible. If it's in another spot, it can happen. You just have to look at it a little bit more closely. So firm, bony, hard salivary gland tumors can look like this but it's gonna be the difference between soft and firm and bony, hard. We call it a palatal torus. This one I actually call the torus penis palatinus. If I have to explain that, I'm not going to. But sometimes you see cool things and I name them. Unfortunately for my dental students, I also show this and to tease them and let them laugh a little bit. There were four female dental students my first year of teaching eight years ago who thought that was the name. And every patient they had, they were telling them they had a torus penis palatinus. I didn't know if I should be proud or I didn't communicate good enough. I was both, it actually was pretty funny. But I told them no, it's a palatal torus. The other part was just funny, that was just me. All right, the most common pathology number three, inflammation or irritation. Patient bites their tongue. We've all done it before. Usually it's around Thanksgiving, holiday season. We're eating a lot of food, you bite your tongue. Depending on the patient's immune response and how bad they bit their tongue, they get a small ulcer or a big one. And the bigger it gets, anyone have a guess how deep under the surface of your tongue is skeletal muscle? One millimeter. You've got a half millimeter of mucosa, half millimeter of connective tissue, and then you're into muscle. If muscle gets inflamed, it can't regenerate, it dies. And it has to be phagocytized, taken care of, and new muscles form. That's a slow process. And now you're on a tongue that moves when they eat, when they drink, when they speak, and it's just an uphill battle to try and get that to heal without help, which is either injectional steroids, Kenalog 40 is one of my favorites, topical steroids, clobetazole, propionate gel, dexamethasone, elixirs, a rinse they can soak in, anything to decrease inflammation, to give the body a chance to heal. But skeletal muscle is right under the surface. Under the microscope, sometimes I have to cut these out. There's so much inflammation, there's so much granulation tissue, it's not gonna heal unless I remove it, get primary closure, and then it'll heal up just fine. When I look under the microscope, the muscle's so damaged, when muscle gets damaged, it releases a chemical called eotaxin, which is a chemoattractant for eosinophils. So it's one of the few things on the microscope in the mouth where there's a bunch of eosinophils. It's usually allergy, fungal infection, or muscle damage is when we see eosinophils. So that's a traumatic ulcer. This is a patient who came in to see me. She bit her tongue on Thanksgiving, this was February. So we're now two, three months down the road. What two things should you always think of if a patient tells you, I've had a sore in my tongue for longer than, what's our timeframe? Two weeks. If it's longer than two weeks, all right. A month evens kind of, well, is it bigger or smaller? If it stayed the same or bigger after a month, the waiting period's done. You don't get to start the clock over. But if they say it's about half the size, oh, all right, it's trying to heal. Let's give it some help with some topical steroids. It's when patients come in and they say it's been there for three months. It's either a traumatic ulcer that has granulation tissue or what's the second one? Usually at that point, it's usually cancer. But yes, pre-cancer, very good. So if you ever have a non-healing sore anywhere in the mouth, you should always think of those two things, trauma or cancer. Well, traumatic one that hasn't healed for three months needs a biopsy to remove the dead muscle tissue. If you think it could be cancer, it needs a biopsy to prove whether it is or isn't. So we're still back to the same point. Patient will be taken care of as long as you treat it. Now for this patient, she gave me such a good story of I know it wasn't there until Thanksgiving, I bit my tongue on Thanksgiving, I was eating a chicken wing. I mean, it wasn't even turkey, it was chicken. And it was such a good history, I'm like, all right, I'm gonna believe you, it's traumatic. So first step, waiting period's over, but let's go ahead and inject it with some Kenalog, some trimicidinol and acetonide intralesional steroid injection. I like Kenalog 40 because you need 10 milligrams of steroid per centimeter of lesional tissue. So in Kenalog 10, it's 10 milligrams per milliliter, or in Kenalog 40, it's 0.25 milligrams per milliliter. Well, if you inject a milliliter of liquid into a tongue, it's gonna be a big marble for a couple of hours to let that liquid absorb, and they might bite their tongue, which is counterintuitive. So I like Kenalog 40 because I can use just a little bit and it goes a long way. So I numb them up a little bit with some lidocaine or anesthetic, then I inject 0.25 milliliters, and within a week, something that had been there for three months was gone. That's just a great day. Cancer doesn't heal, so it wasn't cancer, it was a traumatic ulcer, so we took care of it. Other inflammatory conditions, perichoronitis, someone has a tooth, usually teenagers, young adults, where all their teeth haven't quite erupted, especially third molars, they get infection and inflammation around that tissue right in the back of their mouth called perichoronitis, hurts like hell, but it's just inflammation. You can, oftentimes, I'll go and just cut off the flap, you can also treat it with an anti-inflammatory like dexamethasone, it'll help it feel better until that tooth erupts all the way, which sometimes they won't. And then this one's just abscess, a very common oral lesion is a sinus tract. They've got an infected tooth, has to drain somewhere, depending on where it drains, depends on if they have a big problem or not a bad problem. Root canal or extraction usually is going to happen, but that's just pus, so an abscess. So under inflammation, traumatic ulcer, pericarditis, or abscess, of which traumatic ulcer is the most common. So just take a good history. How long has it been there? What were you doing? Most patients who have precancers cannot tell you exactly when it started. They give you a vague window of time, and it's not symmetrical. This one here, symmetrical, fits with trauma. This one here, I actually thought was going to be a cancer, but my differential was still trauma versus cancer. What came first, a cancer creating a bump that they bit, or they bit their tongue creating a bump that looks like cancer? You don't know which one. So I biopsied this one thinking it'd be cancer, and it was just traumatic ulcer. That's a great day. And then this one, I knew what it was going to be. But then I biopsied some that I thought were going to be just trauma, and it was cancer. So you can't always tell, even based on symmetry. Number four, corner of the mouth, fibrous, firm bump. Anyone have a guess what that is? Yeah, like an epuless or fibrous tissue. We call it a fibroma. Oma, benign tumor, fibrous, fibrous connective tissue. It's scar tissue, usually along the occlusal plane because cheat gets in the way. We bite hard, causes inflammation. Inflammation stimulates fibroblasts. Fibroblasts poop out collagen, creating a bigger bump that they bite again and again and again until you get this bump here on the buccal mucosa. If it's too high up on the cheek, it can't be a fibroma because you can't bite up there. This is a reactive lesion due to trauma. And if it's too high up in the vestibule or too down low, don't think fibroma. Now you're thinking of a true tumor, lipoma, neuroma, something like that, salivary gland neoplasm. But most common, benign neoplasm of the oral cavities and the fibroma can happen on the gingiva, friction, anywhere where you can get friction or irritation. They can come in different shapes. They can look like a polyp. They can be pedunculated, which is where you can move them around. Usually they're sessile or they've got a broad base and you can't really move them. These are little yellow bumps all over the mouth. 80% of us have these. Anyone know what these are called? You're going to see them all the time. And it's just knowing what they are. They're called Fordyce granules. They're ectopic sebaceous glands. We have oil glands, sebaceous glands associated with every hair follicle. But for whatever reason, we have them all over our lip mucosa and all over our mouth in some individuals. And it's just knowing, oh, the little yellow pimplish looking things, they're Fordyce granules. And you just can ignore them. My job is to teach you what they are so you don't worry about, what is that yellow plaque? Should I know what that is? Should I biopsy it? Well, if they're speckled like this and they're yellow, Fordyce granules, you're done. Under the microscope, they're just sebaceous glands. They can occur buccal mucosa. Lips is another common place for them. Just recognize them. 80% of us have them. No treatment necessary. OK, this is where a patient has a purple bump on their lower lip. Most likely diagnosis? What? Yeah, venous lake, vascular malformation, varicose, varicosity. First thing you're going to do is a test. It's called dioscopy. You take anything that's clear that you can see through, put pressure on the lesion. If it blanches, you've confirmed that it's a vascular anomaly. Whether it's a tumor or just a venous lake or a varicose, you just confirmed it. And then it's up to the patient whether or not they want it treated for cosmetics or not. If it's a mass and a big growth, it's probably hemangioma. That's a true tumor. That should be taken care of. But a little purple one on the lower lip, probably a varicose. Just confirm that it blanches and you feel good about it. If it doesn't blanch, salivary gland neoplasm, mucosal, hematoma, if they bite somewhere and it leaks red blood cells out of the blood vessel, it'll cause a bruise. So hemangioma is number six most common oral pathology. In the mouth, hemangioma will be more of a mass versus a varicose, which looks almost like a freckle on the lower lip, but it'll blanch. OK. I bet someone in here has had this. Ulcer that come on if you eat too much salt or if you have too much fruit, you get them about every two months or so, apthis ulcer. So this is called recurrent apthis stomatitis. Patients will call them canker sores. Cold sores are viral-related on the lip. Canker sores are what we're talking about here. These are called apthis ulcers. When patients have these, they usually give a pretty good history of, I get them every once in a while. I get them twice a year. I get them if I have too much of this or that. I get them if I have too much pineapple. My wife gets them if she has too much chocolate or anything acidic. And everyone in here has a different way of getting them. So it's immune-mediated. Your immune system just gets a little bit hyperactive. And it's usually something that I will treat for patients who get them frequently. If a patient gets them once or twice a year, they have a choice. I can still treat it or don't worry about spending the money on a prescription. Heals within 7 to 10 days. So it's either deal with it. Some patients will go to their doctor and get it cauterized with Dibacterol, which is silver nitrate. That just burns. But it gets them out of pain really quick. But the healing process gets delayed because they just cauterized and necrosed all the tissue. I like medication. This would be a topical steroid gel like clobetazole propionate or dexamethasone. If you get these yourselves all the time, dexamethasone or clobetazole are wonderful. I have some at home because I get these, again, based on my eating habits. I love food. So we can treat them. So no patient with these recurrences. It really goes a long way to help them. They love you when you treat it because they're not even in pain. They know when they're coming. They kind of can feel a canker sore coming on. Start treating it at that point and they won't even form. Affects about one in four of us. Aptisulcers occur on non-bound down tissue. So this is going to be lip, cheek, tongue. It's not going to occur on gingiva or palate. That's where something else occurs. So if it's in those locations, don't think aptisulcer. Think traumatic ulcer from flossing, from hitting it with something, but not aptis. This is one on the ventral part of the tongue. Right buccal mucosa. And it's nothing more than an ulcer that will heal soon. I always look under the microscope to see if there's any viral change to make sure it's not herpes simplex or it's not something else going on. There's different theories. Most common for me in my practice, it's usually hypersensitivity. Patients can pinpoint, it's whenever I eat this. All right, you've got two options. Keep eating it and get them and I'll treat it and you'll be fine. Or avoid that type of food and you'll be surprised at how you won't get these as much. I have half and half. Some patients are like, no, no, give me the medicine. Others are like, oh, really? I just have to stop eating tomatoes? Yeah. And they do it and they don't have problems for months. Again, it depends on your patient. It's like, you tell me what you want and I'll do it. I'm not here to convince you to not eat Mexican food, but they come in telling me what's causing it, but they won't give it up. Treat with liquid lidocaine. Yeah, so liquid lidocaine. If you treat with liquid lidocaine, you're going to, it's symptoms, and you're going to treat it for 20 minutes at a time. Wonderful solution for getting them out of pain, doing nothing to heal them. So I like to use Magic Mouthwasher liquid lidocaine as a, OK, we'll make it to where you can actually tolerate eating and speaking. They love it, but then we're going to throw in dexamethasone or clobetazole, topical steroid, and I can heal it within two to three days. So they love you for healing it, but numbing it's big for them because it's immediate relief so that they can eat. Yeah. Do you have a clobetazole gel available? It is. Yeah. So clobetazole comes in a cream, ointment, or gel. If you're in the mouth, ointment and cream, it does not adhere to the mucosa. It doesn't absorb well. It's not made to. It's supposed to be on the skin. So patients just swallow a glob of it and it's basically now systemic steroid. So gel, if you ever use clobetazole gel, tell your patients to. So let's say they have a canker sore or an aphthys ulcer. Let's go back to these ones right here. These are herpetiform. They look like herpes. Wrong place. So this is one of my dental students right before an exam. I cause canker sores. I love it. I cause herpes, too. Type 1. Topical steroid, like tacrolimus, flucinonide? Yeah. Tacrolimus, flucinonide, or Lidex. There's a whole bunch. I like clobetazole because it's the most potent gel on the market. So if I'm going to try and help someone heal, I'm giving them the good stuff because it's going to heal quicker. But they all work well. The key is, if you're in the mouth, tell them to dry the affected area. If you dry the tissue first, which I usually say hair dryer on cold blast, or you just have to blow on it. I joke with them. And there's a lot of ways to do it. Why do you not want to use gauze? Good. You're going to tear off the fiber and membrane. Healing process just started over. So if it was on day five, it's back to day zero. So don't rub it. I don't like Q-tips. I don't like gauze. I don't like cotton. I like air because that way it just dries it. And then they take the gel, massage just a little bit. It comes in a tube that's aluminum. So if they press too hard, it just oozes out. You can't get it back in. So tell them to be careful. You only need a little dab. Dry the tissue. Massage it in. Three applications a day for two to three days, they're healed. If they do more than that, you have to always let a patient know, chance for oral yeast infection, because it's changing the oral microflora balance from bacteria to yeast. We all have yeast. We all have bacteria. But once you start using steroids, that balance gets off a little bit. And so just be careful. Clobetazole comes with a black box warning that says for external use only. If you don't tell a patient, it's fine in the mouth. No one's just paid $6 billion to get FDA to approve it. You're fine. Otherwise, they go to the pharmacy. And the pharmacist will say, did you know this warning? And if they didn't know about it, I've had patients not pick it up. And then they call me. And it's taking a phone call, calling back after hours. So just save yourself some time and just say, there is a warning. Ignore the warning. Just don't overdo it. And we're not going to cause a yeast infection. We'll be fine. And that lidocaine is an excellent. I prescribe lidocaine when I tell them, it's not doing anything to heal you, but it's temporary relief. Do you want it? They say, yes, done. I'll do it. I like to mix it with Maalox and Benadryl because it provides a base that helps hold the lidocaine on longer so it can absorb better. Plus, if they refrigerate it, it soothes the sore. So whatever you give them to numb, tell them to refrigerate it because it's like an ice cube. It numbs it initially. And they really like the feeling. So RecurNap, the sulcers, bunch of different prescriptions. Find what works for you. I've got my favorites just because I've had patients after 10 years tell me that worked in two days, that worked in one day. All right, I'm going with that. My goal is to heal them as quick as I can, safely. OK, here's the next pathology. Looks like a little Bowser shell. Looks like a little flower, little finger-like projections. Anyone have any idea what this is? Sometimes it looks like cauliflower. I just want to get some liquid cheese, dump it on it, and eat it when I see this. Pathology makes me hungry. That tends to be how pathologists are. Called a papilloma, squamous papilloma, caused by human papilloma virus. However, it's low. It's no risk subtype, 6 and 11. You don't have any risk of malignant transformation with these. I've had specialists, doctors, physicians call me up and say, oh, man, thank you for that diagnosis. I talked with the 16-year-old female and her parents about sexually transmitted diseases. I'm glad you had that conversation. You didn't need to, because yes, there are risks. You can transfer human papilloma virus sexually. However, these squamous papillomas are not premalignant in any way, shape, or form. So it's one of those, pick your poison. Do you want to start making insinuations? Or do you just let it go with, it's a papilloma, don't you worry about it? Yes? Is shaving part of the pathology? OK, if you're going to treat this, you're talking to a pathologist. I like to confirm what it is. So if you're going to cut it off, don't cut it off at the stalk. I mean, they flap around. You want to cut it off at the base where it attaches, because the virus lives down in the base. So if you're going to remove this, pinch it, get a little bit of tissue, cause a little bit of bleeding, and you're going to remove where the virus resides. That one's not going to come back. I use a stainless steel blade. I mean, I just cut it off, cause a little ulcer, heals within three days. They don't need any. I don't suture these all the time. They're usually pretty quick. But you can cauterize it if the patient really wants it. Anytime you cauterize, you're delaying wound healing by about four days. Not a big deal in the grand scheme of things, but I don't. So you just want to remove the base, otherwise you're leaving some virus behind, and within a month or two, they might have one come back. Well, it's because the virus was still down there causing the reaction of the epithelium, which is what a squamous papilloma is. So this was a 19-year-old patient who came up to the dental school. One of my dental students called me down and said, Dr. Trump, there's something growing on their gums. Went down, and I always try and, I want the student to answer. It's like, what do you think it is? They just couldn't come up with this. I'm like, okay, it's a squamous papilloma. Let's cut it off, take care of it. We asked this 19-year-old how long it's been there, and he said, I've never noticed it before. Part of me was like, bless you. You are the least narcissistic man I've ever met. Because I look in that, and I'm like, it's like you've got a booger between your teeth. I just want to cut it off. If I see those, I honestly have to hold myself. I've been at SeaWorld in San Diego and saw a patient with a Wharton's tumor. Smoking a cigar, what else could that be? I just want to go up and be like, do you know you have a Wharton's tumor? Can I take a picture? My wife's like, you will not do that. So I actually did the next best thing, which is how do I walk in front of him and selfie? It was blurry, I was so bummed. But I love finding pathology. So we cut it off, gave him a mirror and said, what do you think? He's like, what do you mean? How does it look? Looks okay. He should have been so much more excited about that turnout. Healed perfectly, no recession. And the student did it, so I was proud of the student too. So whenever you see a squamous papilloma, your differential always should include Verruca vulgaris, which tends to be human papilloma virus on the skin. So squamous papilloma occur in the mouth, Verruca vulgari occur on the skin. They can occur in different locations. They do look differently. Some are, the finger-like projections is a papilloma, Verruca vulgaris is more smooth surfaced and a little bit rough. Condyloma cuminata. If you're treating children who have more than one papilloma, you have to at least consider sexual abuse. Doesn't mean it is, doesn't mean you have to report it right away, it just means you have to think, does it fit? I get called over to Primary Children's Hospital, which is the children's hospital up the road all the time with doctors who are like, can you look at this case for me, what do you think? I've diagnosed several hex disease, which is multifocal epithelial hyperplasia from human papilloma virus 13 and 32. It's something they're born with. It's family history, dad had it, siblings had it, and so we know what that was. It wasn't sexual abuse, but it looks like it. So it always makes me question, I don't wanna miss that child who's being abused, but I don't wanna jump to a conclusion until I've looked at everything. So if there's just one, usually not condyloma cuminata or sexual abuse. If there's more than one, I always have to consider it. So here's Verruca vulgari. Usually in children, they self-inoculate. Once they itch a little bit, when the virus replicates, it itches, so they peel it off their skin, then they pick somewhere else, pick their nose, and that's how you get it elsewhere. But they tend to be a little bit more flat-based versus the papilloma. The condyloma cuminata, multiple lesions, most commonly I see these in patients with HIV AIDS, immunocompromised, with a sexually transmitted disease, and we can't take them all out. They tend to come in to see me and they just, I tell them to point to the two that bug them the most. I cut those off and they come back every few months to get the next one cut off, because there's just too many of them to treat. And this is Hecks disease or focal epithelial hyperplasia. You see it in children. Adults have it too, they just usually know what they have. They can tell you, I have Hecks disease, you don't worry about it. In children, it's always that. Do I need to be concerned or not? Okay, this is a patient who wears a denture. The denture, so dentures are supposed to last around seven years. I feel like dentists don't do a great job at always explaining to their patients this appliance, this crown, this whatever. The average lifespan is this. For a denture, it's about seven years. I have patients who come to see me and their dentures are 25 years old. They're so loose that the patient can't talk without them clicking. And when they rub around, they cause a fibrous hyperplasia of the tissue. So this is called an epulis fissuratum. It's extra tissue growth around the flange of a denture because the denture rubs, causes inflammation. Inflammation stimulates fibroblasts, fibroblasts create a mass. So it grows around. So if you ever see this, epulis fissuratum. They need a new denture and you have to remove that epulis, otherwise they can't take a good impression for the next denture. And this will be in the slides that I give you. Floor of the mouth, varicosities. This is more surgical. For those who do any surgeries or in the mouth, I just always wanna, you just have to be aware that all of us have varicosities running longitudinally along our ventral tongue. So that if you're doing a biopsy there, if you nick this, it's gonna bleed pretty good. It'll be fine. You suture it up and it'll be good. But it's more, just know that that's what they are. Most of us, we can see them. Some of us, they're deeper under the surface. You don't see them. They're still there. They're just deeper. Everyone has varicosities. What's this called? Very good. Some of you caught, there's a little bit of geographic tongue. So this one, I'm gonna start with one of them. You're right. The first one is called fissured tongue where you've got the deep grooves. The other name for it's actually called scrotal tongue. Self-explanatory. But when you get those deep grooves, you can't clean that out. So these patients tend to complain of burning tongue. It's not the true neuropathic burning tongue that's a neurologic condition that's hard to treat. This is a simple one where you've got deep grooves. Usually we have a carbohydrate-rich diet. Carbohydrates get down in the grooves, feed the bacteria. Bacteria convert that simple sugar into lactic acid. And they are. Their pH has dropped, so their mouth burns. If they can brush those grooves, you can't scrape them, it doesn't get down there. But if they can brush the grooves, sometimes that burning can reverse and they're just fine. So it's a sign of xerostomia. So if a patient has a fissured tongue, usually they're dry or it's genetic and they just have deep fissures. They just need to keep them clean. 50% of patients with fissured tongue have geographic tongue. We talked about that. This is geographic tongue. This is the classic form where it's yellow serpentine borders with a little bit of red and they move around. If you ever want a patient to confirm, that's what it is. Just tell them to email you a picture seven days later and it's gonna be in a totally different spot or totally healed. If it hasn't moved, it still could be geographic tongue, but in me that's different. Most patients, it moves around. So that's what I talk to a patient about. Let's try and treat it. If it burns, treat it with dexamethasone with a topical anti-inflammatory. 25% of patients with geographic tongue complain of burning tongue. Well, it's burning because of this acute inflammatory response. Under the microscope, geographic tongue looks just like psoriasis. So on the skin, it itches. In the mouth, it burns. So if they complain of burning tongue with geographic tongue, treat it with dexamethasone where they can soak that tongue in that rinse. Do that twice a day for a few days. They will love you because their burning is no longer there and it really controls their thoughts. They don't want to speak. They don't want to be out with friends. Catch it early and it can save neuropathy or neuropathic pain. I call it, well, it's called geographic tongue because it can look like a map. Yeah, I had to put that in there because it took me two hours on Photoshop. Nothing should take me two hours on Photoshop, but it did, so I'm putting it in because I was so ticked that I couldn't figure it out. So that's my version of North America. OK, this is my wife. She gets geographic tongue if she has too much pineapple. I was lecturing in front of a group of 450 doctors a few years ago, and I knew that the next slide was my wife's. But it wasn't. It was a mouth with a mustache. But I said, and this is my wife. I've never had such a big laugh in my life. And I turn around, I'm like, that is not my wife. She doesn't have a beard. So I'm always careful to know if I put that one in or not. This is the other form. This is atrophic geographic tongue. So this one back here causes a hyperplasia. So the white is thickening of the tissue. This one is where you don't get the yellow. You actually just get red. So this is more of the atrophic glossitis. So there's different forms. If you see it, ask them if it doesn't burn. You don't need to treat it. It's because they're sensitive to something they're eating, not a big deal. If it burns, well, you have a choice as their doctor to say, oh, we can treat that. Just use the rinse. When it burns, when it doesn't burn, put it away. And it usually just cycles around depending on what they eat. It's usually citric food, so oranges, pineapples, anything tomato-based, and then spices, if they really like Mexican food, Indian food, Thai food. Just when you get those spices mixing, a lot of patients have a reaction to it. So here's a patient with fissured tongue along with geographic tongue. That's what you're looking. Usually, they go hand in hand. If you see one, look for the other, and then ask them if their mouth burns. If it does, treat it. If it doesn't, you just tell them what they have. Right here, very subtle. The fissured tongue stands out. Geographic tongue, not so much. There's a name for it when it's not on the tongue. You can't call it geographic tongue if it's not on the tongue. So we call it erythema migrans, redness that migrates. But it looks just like it. And these patients inevitably have geographic tongue. You'll just look elsewhere and like, oh, it's on the mucosa as well. Not a big deal. Just treat it. This is the atrophic form in contrast to the one that has the yellow border. So don't be confused by it. How do you know the difference? Over here. Does it have any relationship to erythema migrans on the skin? No, not to erythema migrans. Well, to erythema migrans on the skin? Not that one. The mouth one is, I mean, they're both an immune reaction. The mouth is due to topical hypersensitivity to foods and chemicals. The skin could be topical, but it's usually more immune-mediated. So cousins, but not directly. Just because they have one doesn't mean they're going to have the other. This patient, what do you think they wear? A denture. What do you think they wear 24-7? The denture. So in contrast to, usually there's two forms of issues with dentures. One is the denture stomatitis, which is the red yeast infection because of the denture. Well, if that gets left alone too long, then the epithelium starts to become hyperplastic, creating these little bumps. So this is called inflammatory papillary hyperplasia. Inflammation causing little papillary projections on the palate. Well, it's still due to wearing a denture too much and a yeast infection. So papillary hyperplasia, tell them they need to take their denture out at night. Initially treat the denture with antifungal and their mouth. And this one should resolve just fine. The bigger the papillations are, I mean, they can get to pretty big bumps. Those need to be surgically taken care of in order to resolve it. So denture papillomatosis is another term. One in five patients who have a denture. And it's because they wear it too much. So you just have to educate them. Their dentist should be educating them. It shouldn't be your job. But in case that's the case, just tell them, you wear your denture too much, let's treat both. And you're going to help get them taken care of without them needing to schedule a follow up. Unless you feel like they probably should see their dentist, use that as that little trigger of, here's what you have. I want you to see your dentist. And hopefully that gets them in for a patient. But now you have someone on your team that's treating the patient as well. So I can do a lot of these things. I do a lot of surgeries. But if it's on the skin, I tell them to go see their dermatologist as a way of, get to your doctor. They're going to have you do stuff and look out for you in ways that I can't as a dentist. OK, now we've got little ulcers on the palate. Kat, do you know the difference between geographic tongue and ulcers? So do you remember one of the geographic tongue or erythema migrans was just red? What's in the center of an ulcer? You guys have mentioned it before. It's what we don't want to wipe off when we apply a steroid. The fibrin. Fibrin is always yellow to white-ish. So if you ever have a yellow to white center with a red halo, that's some type of an ulcer, whether it's an aptis ulcer or herpetic ulcer. If it's a red center with a yellow border, that's usually erythema migrans or geographic tongue. That's a quick, they're inverses of each other. OK, so it's bound down. This is herpes simplex type 1. So intraoral herpes. A lot of people get it on their lip. It's usually due to sun exposure. I get it every spring when I start helping my wife garden. I tell her I'm allergic to gardening. It hasn't worked so far. But I get them. I treat them. But some patients don't get it on their lip. They get it inside their mouth. And it depends on where the virus resides, whether it's on the facial nerve and outside on the dermatome or if it's in the trigeminal ganglion inside the mouth. It's wherever the virus wakes up. Herpes is Latin for to creep. So who in here, if you're brave enough, I get cold sores. Do you get prodrome? Anyone who gets them, do you get the tingling? That's the virus replicating. That's when you want to treat it. If a patient has prodrome, the tingling sensation, if you can give them a bolus of Valtrex or Valicyclovir within those first 12 hours, you can prevent the whole outbreak and they can heal within five days. Without that, if you miss that, it's going to be 10 to 14. Even without medicine, you're not going to do much. So intraoral herpes, you're not going to be doing a topical treat with systemic. Herpes labialis, treat with a topical unless they get them all the time, then treat with systemic. So here's herpes labialis, okay. Recurrent herpes, almost always on bound down tissue, palate or gingiva. If it's elsewhere, think traumatic ulcer or aptis ulcer. Okay, this is me. This is me in residency. I took a selfie every hour for about 14 days. I really, it was embarrassing, but I was going to get the best collection of herpes anyone's ever had. Herpes type one. Type two is below the waist. Okay, so at 6 a.m., I woke up and I felt tingling. I knew it was coming. By 9 a.m., you can see the vesicles. So I started putting on Abreva. Disclaimer, it was three years expired, but I paid 26 bucks for that Abreva, so I was using it. So I did, it didn't do any good, but it made me feel better. When it's in the vesicular form, when it's a vesicle, if that vesicle ruptures, the virus is shedding. Pretty contagious, I mean, define contagious. It's not gonna kill anyone, but you're going to pass along. I have no doubt that I got my herpes type one from my mom, because when I was a little boy around eight years old, I remember having an outbreak. I always stole little sips of her Diet Coke. And I have no doubt she had a lesion, was on the straw. I went and stole one as a kid. That's how I, most time it's from mom to child, just because of that nature of sharing a little bit more. So yes, it's contagious. It's hard from a patient to doctor. Is that what you're talking about? So if you're gloved, it used to be, dentists got this all the time called herpetic whitlow, which is herpes infections on their fingers, because they were gloveless 30 years ago. Now that we have gloves, not a big deal. You want to be careful with aerosolizing it. So dentists will go, some dentists used to go and treat these with a laser and ablate it. I would never do that because it's fluid filled vesicle, hit it with a laser, it's going to aerosolize. When I've got a virus spreading in the air, that's a little bit more, I wouldn't do that. But it takes intimate contact. If you're going to catch herpes simplex type one is from intimate contact, kissing someone who has herpes. Type one. Okay, by 11.30, 1.30, 5.00 p.m., 7.00 p.m., this is 12 hours later. So that virus was doing its job. It was replicating to survive and pass along its progeny. Ruptured, dried up, four days. I didn't show you every picture over the 14 days. Figured that was excessive. I wanted to, but time constraint. So 11 days later, it was finally healed. That was with expired Abriva. So about 10 to 14 days is the normal healing time if you do nothing. I've done lavender essential oils. I've done oregano, wasn't supposed to, but I thought my wife said oregano. Burned like crazy, don't do oregano. Tea tree oil, yes, that's antiviral. That one can work, I used the wrong one. My favorite is Target Up and Up brand Maximum Strength Cold Sore Therapy. Sold at Target, they're Up and Up brand, and it uses benzoylcolonium chloride. I've got students who I always say, this isn't an official assignment, I'm not telling you you need to do this, but if you get herpes labialis, I'm gonna give you a list of things to try. And the one that worked within four days was benzoylcolonium chloride. So that's my favorite, works on me too. Abriva was the same as acyclovir ointment. So there's various ones. But the Target brand, $7.50. Abriva, $27 to $30. So for seven bucks versus 30 bucks, that's why I send my patients to get that one. Works just as good. If they get them all the time, they can do daily L-lysine amino acid. For half of my patients that works, for me it never did. If I take daily L-lysine, I still get them, didn't work for me. For my mom and my brother-in-law, if they take about 500 milligrams L-lysine daily and about four grams when they start feeling prodrome, they never get a full-on outbreak. All right, that works for some. For me, I'm more of a, put the topical on. All right, we've talked about herpes. The initial exposure is called acute herpetic gingivostomatitis. It's usually around 15 years old, or five years old, sorry. But most of those go subclinical. So most five to eight-year-olds actually who've been exposed to herpes simplex, they don't have a clinical outbreak. It's the other 20% where they're, you're gonna see them in your practices with just swollen tongue, inflamed lips, can't eat, can't sleep, in a lot of pain, and they're between five and eight. It's probably primary herpes. And then under the microscope, there's different changes that herpes causes to the cells to where I can tell a patient, yeah, it's herpes simplex. This little child got hit in the face with a ball and he had braces. He got what we call mucocills, which is where trauma to the region where you sever a salivary gland duct. It's like breaking a sprinkler pipe. The water doesn't make it outside the grass. It flows up under the grass and you get that little bubble that you can jump on. Same thing in the mouth, spit flows under the surface, gathers up in a balloon, and you get a mucosal, which is a spit blister, a spit balloon. The only way to treat these usually is, you can't just remove the bump because all you're doing is removing the spit. You have to remove the feeding gland whose duct got cut because once you remove that gland, it doesn't need that duct anymore and you heal it. A lot of doctors will go in and just remove the bump. I call it a mucosal and I always tell them there was no minor glands. That's my subtle way of saying you didn't get it. It's probably gonna come back. However, if there are glands there, I'll tell you that you got them and it's probably the feeding gland. So when I go in to remove these, I'll remove the bump and then you do a little bit of blunt dissection, find the glands right in the area, remove those, and you usually resolve the mucosal. They can happen on the floor of the mouth. They can happen anywhere we have minor glands. Anterior ventral tongue is a place where we have minor glands as well. Tends to be in younger children with history of trauma. That could have been a fibroma, but I'm gonna place my bet of how long did it take to grow and like it's been there for a few weeks, mucosal. Fibromas take a long time to grow, to form, I guess. Scar tissue, we're gonna breeze through. It just looks yellow, looks thick, and they're gonna have a history of surgery or radiation. All right, you guys know this one. Patient has, yeah? Yep, angular chelitis or angular chelosis. Usually I use the term angular chelitis just because inflammation of the lip. Itis inflammation, chelolip at the angles, angular. So you're just defining they've got an infection of the corners of their mouth caused usually by what? Yeast, it's actually 60% of cases are staph aureus and yeast. 20% of cases are just staph aureus, 20% of cases are just candidiasis. So I like to treat it with triamciniline, mycolog-2, which is triamciniline acetonide and nystatin because I'm steroid for the micro part, antifungal part. I like that one. However, nystatin ointment works just as well. Yeah. Yes, yeah. So if a patient has this and they wear a denture, I know it's because they're playing of occlusion clothes and they get pooling in their corners and they just, they salivate and it pools there, perfect for yeast. But if I can't, if they've got a full mouth of dentition, it's not from dentures, my first thing is, when did you see your doctor? I'm referring you to your physician to get a blood workup because you're looking at usually vitamin B2, 6 and 12 are the most common ones. But if you, you know, either way, get the blood workup. In the meantime, treat it with a topical antifungal or that mycolog-2, help them out. Until that's healed, it burns, it cracks and it bleeds and it's miserable. Okay, this is the part where if you look in someone's mouth and you're doing a tongue exam, you want to look back to the posterior base where you see these little bumps. Everyone has them. Some are bigger than others. They usually should be symmetrical. These are called lingual tonsils. We all have tonsillar tissue or lymphoid tissue on our tongue. If you visualize those, you've gone as far back as you can go on an oral exam that any one of us would perform. Beyond that, you have to have tools that an ENT would have. So don't worry about that. But if you don't look for and see these little bumps, you haven't seen everywhere where you could see. When metastatic disease occurs into the mouth, it's usually the tongue, this is where it would go. So if you're not seeing it, you might be missing something. But if a patient's not in pain, it's unlikely. Usually it hurts. But I always look for the lingual tonsil. Hematoma, history of biting, blood leaks out of the vessels. It's just a bruise. We're back to smokeless tobacco, tobacco pouch keratosis. This patient just happened to use that shredded beef jerky. So whatever they put there, just ask what it is. This was the major in the Air Force where I asked him and he's like, I quit five years ago. Don't be afraid to say, okay, what else do you put there? Something's going there. You don't have this appearance without putting something there. And then of course there's times where I've got the spouse of a patient where I'm asking him, did he quit? He said yes, and the spouse is saying, no, he didn't. It's like, all right, let's just be honest. Because if this doesn't go away after moving the tobacco pouch around, first thing you're gonna do is say, what do you put there? Smokeless tobacco. All right, just move. Do you guys know the different names for smokeless tobacco? Dip, Dap, and Dinger, dental students. They're the best. This one grew up on a ranch. Dip, lower lip. Dap, upper lip. Dinger, under the tongue. I just like the name Dinger. I don't know why, but it sounds hilarious. So I don't tell a patient, where do you put smokeless tobacco? Inevitably they put it there. Move it to another site for two weeks. Just don't put it there. It should go away. If it goes away, tobacco pouch keratosis, you don't need to do anything else. If it leaves behind a leukoplakia, now you're looking back to a precancerous lesion until proven otherwise. So best thing is to stop the dipping. This is a 26-year-old male with ADHD. The only thing that helped control his hyperactivity was smokeless, according to him, and I'm not here to change what he believes. I just told him to put it on one side of his frenum. He did it, he came back, and one side completely healed, the other side stayed. I proved that it wasn't progressing towards precancer. So we were good, and I just told him to keep doing that, keep moving it, make sure it goes away. If it ever doesn't, come back to see me. So it's kind of on him now, because he hasn't been back to see me in six years, so I'm assuming he knows what he's doing. But patients who use smokeless tobacco eventually can get precancer. It tends to become varicose carcinoma. But it occurs everywhere they put it. It's white, doesn't go away, really looks off. Number 21, patients who bite their cheek. Looks rough, looks ragged. You can usually tell because it's wherever their teeth can pull their tissue. So chronic cheek chewing is a big deal. This was one of my patients who came in. He was referred from a physician's office who said they were afraid he had oral cancer. I was able to happily tell him, I don't think it's that. I think you're chewing the heck out of your cheek, so let's start with that theory. So he quit chewing his cheek. For him, he wore a rubber band. I told him I could make him a mouth guard. I told him we could do various things. He said he'd think he could remember. He just didn't know he was doing it. So just by making him aware of it, he was able to stop. Well, he hasn't stopped yet. Tongue, he was biting everything. I mean, he was eating himself. This was one week later. He went from this to this just by him flicking a rubber band and realizing he was biting his cheek. So you just wanna prove that it heals and goes away. This was his right buccal mucosa went from this to nothing. So pretty good just for him stopping a parafunctional habit. For other patients, I'll ask them, if they really can't stop, I make them a tray. I take an impression, make a mold like a bleach tray, and they wear these trays, and you can't bite your cheek when you're wearing these two plastic trays. And so it took care of it. So there's other tricks we can do. This patient has lichen planus, Wickham's stria, it's number 22 on the list, autoimmune or immune-mediated disease that usually occurs on the skin, but it can occur in the mouth. Usually, you have to distinguish lichen planus from a lichenoid drug reaction. Tends to be antihypertensives, mood-altering drugs, and sleep aids, and pain medicine. Those are the four categories that tend to cause this. Longer a patient's on it, the more likely they are to get it. A patient could have been on a medication for 10 or 15 years with no issues, and all of a sudden they have this. It's still a buildup of metabolites, and their body's just reacting to the medication. So if a patient's on any of these medications, this is, there's 1,000. This was just the highlighting, the ones that I see most commonly in my practice. Then I have to always tell a patient, you look like you have lichen planus, but it's likely from your medication. It's still treated the same. We have to control the inflammation. I'm not gonna tell a patient to go off all their medications that are controlling their bipolar, controlling their depression. That's, I don't think any of us would do that. It's more of a, all right, we could be one or the other, treatment's the same. They either have reticular that looks like spiderweb, or erosive that has a big ulcer in it. Treatment, anti-inflammatories. You're not gonna cure them of it, but you can make them more comfortable. Reticular, erosive, and then different treatments. We've talked about these, whether it's canker sores, these, you just have a bunch of options. My favorite, again, are decadron or dexamethasone, and clobetazolepropionate, which is the Timavate. Those are my two, because they're strong. They do the job, okay? All right, even though we only made it to number 23, the rest of them are really, they're really minor. You won't see them near as much as these first 23. I wanted to leave a couple of minutes in case you had any questions. If not, I hate going the full time. I always try and end early, because you're all done, too. Any questions for me? Okay, thanks, everyone. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

oral pathology

communication

oral lesions

ulcers

fibromas

Fordyce granules

venous lake

recurrent aphthous stomatitis

topical steroids

patient's history

treatment options