White Patches – When to Refer + Diagnoses ORAL MED – PDP206

Teaser:
Sometimes you get patients that are very anxious and as soon as you use the C word, that’s all they’re going to see, that’s all they’re going to hear, they can’t sleep for two weeks. You still have to give them the information and educate them on it, but there are ways to do it gently, where you can say, like you’re thinking that it potentially could be quite serious. You’re not saying that it’s cancer, but, you’re a little bit worried. There are ways that you can do it. I actually tell people this story. So I was a registrar training in oral medicine.

Jaz’s Introduction:
It’s November, which means it’s oral medicine and oral pathology month. You know what? I actually really regret having these months. Like, to try and be organized enough, to have enough episodes or at least one episode to dedicate for that month. It’s been tough for me. So I think once we finish all the months, I’m probably not going to reintroduce this specific theme month because it’s just too much pressure on us as a team. But I do hope you’ve enjoyed the past months and having a little bit of focus.

Even if it was just one or two episodes that month, it’s been nice on the Protrusive Guidance Community app to have some like themed polls and themed questions. Thank you all for getting involved. Today’s episode is on white patches. It was going to be white patches and red patches, but it was so much to cover on white patches that our amazing guest Amanda and I decided that actually let’s just focus on white patches.

Why? Because white patches are so much more common than red patches. I know red patches are scarier, but you’ll see way more white patches day in and day out. Think about it, right? Lichen planus, lichenoid reactions, both of those get a huge amount of coverage in this episode, as well as smokers mouth and some lesions that you can get on the tongue.

The mission of this episode is to help you identify and get a differential diagnosis. And importantly, recognize which type of these lesions warrant a referral and which one of these referrals should be urgent. Stay tuned for a really educational episode.

Dental Pearl
Now, every PDP episode I give you a Protrusive Dental Pearl, and today’s pearl is the infographic that you’ll definitely want to grab for this episode. As per our previous infographics, it’s just an incredible summary of everything Amanda teaches us in this episode. We made it visual and easy to follow. It’s like a little cheat sheet, just like some of the other, like the antifungals one that we have or how to choose a ceramic one. And this one is available on Protrusive Guidance for free.

So if you want a copy of this one, you just have to click on this episode within Protrusive Guidance and you’ll be able to get it. Anyone can join for free on Protrusive Guidance. If you identify yourself to be a Protruserati, one of us, you’ll If you’re geeky and if you’re nice make a free account and if you want CPD or CE credits while you’re at it. Make a paid account.

We’d love to see you on there. And there’s so much education that we’re constantly adding. You’ve got pretty much 300 plus hours of CE credits available for you. But more powerful than that, is the power of community. It’s been so nice to be moved away from Facebook to our own app and how people have just engaged in the most wonderful way, in a helpful way.

The kind of toxicity you see on those other social media platforms, Facebook, you don’t get that on Protrusive Guidance. Because the kind of person that’d be listening to an episode on oral medicine. Yes, you know who you are, you’re so geeky. That’s the kind of person I want on our group. So to get that infographic, head on over to www. protrusive. app on your browser, make a free account, then you can download it on Android, iOS, and use those login credentials to access the platform. And then of course, you can make a community account or a CE account, or just keep it as a free account and access all the free parts of the podcast in the best way possible.

Now, while we’re talking about Protrusive Guidance, I want to introduce this new thing called Community Insight. Every now and then I post a poll and I’m just amazed about the variation of responses that we get from the Protruserati. So recently I put a poll up asking how do you guys manage a symptomatic, okay, so symptomatic cracked molar.

What is your most likely management assuming the crack is not a true vertical fracture, so basically it’s a restorable tooth, you think. And it’s symptomatic, so obviously the pulp is upset. The kind of pain when someone says, Oh yeah, when I bite together, when I chew something hard, I feel a pain right here. Or when you use a tooth sleuth, and they bite down, and they release, and they feel that sharp pain.

That’s the classic cracked tooth, right? Cracked tooth syndrome. How is everyone managing that? Well, let me tell you, 34% of you are going straight to a definitive custodial coverage restoration. So that could be Emax, Zirconia, Gold, whatever. You’re going straight to definitive. You guys are brave. I respect you.

18% are placing a long term provisional indirect restoration. I voted for this one. For me, it’s an approach I quite like to provisionalize it with a custodial coverage restoration. And this could be for many months, four months, six months, even up to a year. And I’ll be honest, it’s not just because I feel as though this is the best way to manage it, it’s kind of like diary management.

Sometimes my diary gets so crazy that I want to just give the patient a break until their next checkup and their problem is sorted, the pain is gone, they’ve got that temporary crown and we’ll upgrade it. It also gives us an opportunity to see if this tooth ends up needing a root canal treatment. Now, the most popular option you guys selected with 36% was a large cuspal coverage composite and then reassess that in the future.

Nowadays with a matrix system is available or something we’ve discussed previously on this podcast. It is much easier to do these large composites and with the material improvements we’ve had over the years, this is a really viable option. And lastly, with 9%, only 9% of you would place a composite core.

So basically remove the old restoration, clean out the crack a little bit, and just place a core without custom coverage. So sounds like probably that’s not the way to go if 91% of us are not doing that. And if you’d like to join this poll, please again, join us on Protrusive Guidance and engage.

There’s lots of interesting weekly polls. It’s just great to get insight from everyone. We can all certainly learn from each other. Anyway, enjoy Amanda’s energy. Enjoy her knowledge nuggets. I’ll catch you in the outro.

Main Episode:
Dr. Amanda Phoon Nguyen, welcome back to the Protrusive Dental Podcast. How are you?

[Amanda]
I’m great, and you?

[Jaz]
Yes, very well. Happy New Year to you and all the listeners. I’m not sure exactly when this episode is coming out, so it might be later in the year. We’re trying to go for like an all medicine month, which is why I’m so excited to have you back again. Your episode on antifungals was absolutely brilliant.

Like sometimes because I love restorative dentistry so much, Amanda, and no disrespect to any other specialty, right? And I just feel like, yeah, restorative is amazing. And then I look at other disciplines and all medicine. Sometimes for the general dentist, it’s not as sexy as veneers, right? It’s the same with occlusion and TMD that I like.

I know you like as well, basically. It’s not as sexy as onlays and veneers and stuff. However, how brilliantly engaging you made that and how digestively made that. So hats off to you. That’s have been the feedback from the Protruserati. So well done. And I imagine how you are with dentists and educating.

You’re fantastic, but I imagine you’re also brilliant with your patients. I know, you know how I know this because I saw your social media today and a patient made you a cake.

[Amanda]
She did. I was so happy. I was so excited. In case you couldn’t tell, I do have a bit of a sweet tooth and we were just chatting randomly about food and she was like, I make a really good cake. I’m going to make one for you. And I was like, Oh, thank you. And it was an orange chiffon cake. It was absolutely beautiful. Hats off to her.

[Jaz]
I think that the secret is whatever you want for your patient, start talking about it. So, with some of my patients, I talk about books and things I read. And so literally yesterday, a patient gifted me a really nice book about leadership that he wrote, actually, it’s like a university text.

So top tips, if you want to start getting presents, start telling your patients what you like, and they might start getting you things, which is interesting. Now, for those who have not yet heard the antifungals episode, I’m going to encourage them to go back to it. Before we delve deep into the world of white patches, essentially answering the question of when should we refer? What are the common diagnoses we make? Just for the new listeners who haven’t seen you or come across you, just tell us about yourself and your position in oral medicine.

[Amanda]
Yeah, so I’m an oral medicine specialist in Perth, Western Australia. I mostly work in private practice, although I am a unit coordinator and senior lecturer at Curtin University, adjunct senior lecturer in oral medicine at the University of Western Australia.

I’m also part of the committee of the Oral Medicine Academy of Australasia. And I’m part of the expert committee for a head and neck cancer Australia. So I do a bunch of things on the side, but mostly oral medicine related, which is good because that’s what I like.

[Jaz]
Amazing. So let’s delve deep into this in terms of segmenting it. I’m going to have a white patches episode with you and a red patches. Thought it’d be nice to just, instead of mixing them together and encouraging or introducing confusions, let’s make it really tangible. Let’s go into white patches as an overarching thing. I was taught in school that white patches can be scary, but generally they’re going to be okay.

Red patches, a little bit scarier and you’re more likely to refer red patches than white patches. So before we delve deeper into those two, what would you say about this comment that I’ve made? Do you believe in that as well?

[Amanda]
I do kind of, however, when we started to talk about recording this episode together, I thought it was a really big topic and I was wondering how to actually make it easy and digestible to understand. And I think maybe the easiest way to start off first is to classify it into normal white patches, non pathological white patches, or red and white patches that part of the normal spectrum and don’t necessarily need any sort of referral. And then what we would classify as the oral potentially malignant disorders, because occasionally I do get variants of normal anatomy that are referred in, and those are the ones that I don’t think are necessarily require referral. So a classic example of this would be-

[Jaz]
Should we pivot actually, so Amanda, should we perhaps pivot then? And if we make this episode as normal stuff, don’t panic guys. This is all normal kind of stuff that we see that might be red, might be white, but these are not worth worrying about. And then in the second episode, we look, go further into the red and white patches that maybe are a worthy referral. What do you think?

[Amanda]
Yeah, no, I think that works really well. So in terms of the things that I will classify as variants of normal anatomy that don’t necessarily need referral, is actually surprisingly geographic tongue. So I do get referrals occasionally for geographic tongue. Sometimes the dentist is quite sure what it is, but the patient needs the reassurance.

Sometimes the dentist is actually unsure. So geographic tongue is pretty common. About three percent of the population have it. It’s usually associated with a fissured tongue. If the patient has geographic tongue and it’s asymptomatic, it doesn’t necessarily need any treatment. And the diagnosis of geographic tongue is usually clinical, so it doesn’t usually need a biopsy.

So if you’re seeing something and you’re pretty confident that it’s geographic tongue and you’re keeping an eye on it, I think that that is fine. So geographic tongue, the name geographic, I think, comes because the little areas of erythema, or red patches, actually look like islands. They look like islands on a map and they can move around as well.

So if you’re reviewing the patient and you see that these red patches move, they’re not necessarily worrying. So geographically-

[Jaz]
Just to clarify for the younger colleagues that they’re not actually moving when the patient sticks out their tongue, as in like when you see them every few months. They’ll change position. They’re not actually moving. I can imagine them floating like tectonic plates on the tongue.

[Amanda]
That would be amazing. But no, very slow. So it’s not usually something that you would see at the same appointment. That’s absolutely correct and very good to clarify. But the map light areas of erythema on the tongue are usually surrounded by a yellow white serpiginous border.

So there’s usually a little white border around it. Now most people would be familiar with how geographic tongue looks on the dorsal tongue, which is what we’ve just described. However, you can get other areas that look a little bit depopulated, a little bit smoother on the ventral or the lateral tongue as well. And these can sometimes catch people out if they’re not sure what it looks like. So if it looks like an area-

[Jaz]
You have it just on the ventral and then not on the dorsal. Could that happen? Okay. I can see, I can see why that would catch people out then. Yeah.

[Amanda]
And the other thing is, well, and this one, I think sometimes if you’re not sure, if in doubt, you can refer, but you can get geographic tongue, which is called erythema migrans. You can actually get erythema migraines on other parts of the mouth. So you can get it on the palate, on the gingiva, on the buccal mucosa as well. So if you see something that looks a lot like geographic tongue on the oral soft tissues, not necessarily the tongue, just because it’s not on the tongue doesn’t mean that it is an erythema migrans.

So that is probably an example of a variant of normal anatomy that doesn’t need referral. Now if it’s causing the patient significant discomfort, then that might be a reason to refer because sometimes they can be managed with things like topical steroids or sometimes maybe the patient just needs reassurance, but by and large, that is pretty uneventful. Keratosis is-

[Jaz]
Before we go to keratosis, I think that’s really good. ‘Cause I’ve learned something already, right? I thought I knew. Yes. Geographic tongue. When it comes away, I know to reassure the patient, but I didn’t appreciate that you can get it on the gingiva. I didn’t appreciate that. You can get it on the ventral, the floor of mouth, kind of a part of the tongue, so that, I definitely learned something there. I heard that sometimes these patients may not be able to tolerate spicy foods as well as others. Is there any truth in that?

[Amanda]
Yeah, because the areas of the tongue are de-papillated, there can actually be more sensitivity to certain foods. Spicy foods is one of them, and interestingly, chocolate as well can sometimes cause pain in patients with geographic tongue.

[Jaz]
Is there any way I can induce geographic tongue to my wife?

[Amanda]
I don’t know, but if you know a way, let me know, because I love chocolate.

[Jaz]
Excellent. Okay, great. You can move to keratosis, which I’m sure is going to be a huge one, I guess.

[Amanda]
It is because keratosis is difficult sometimes to tell apart clinically from leukoplakia. So the definition of a leukoplakia is a white patch of unknown significance. Keratosis is basically where there’s some sort of trauma or friction in the oral cavity and the oral mucosa has then developed a thicker area of keratosis. So it’s usually seen, for example, in edentulous ridges, that’s a pretty common place to find them.

Now, it can be difficult to tell keratosis and leukoplakia apart. So my top tips is if you’re suspecting someone of developing or having keratosis, is to look for the traumatic source. See why the patient may be developing white patches in the area. A good thing to appreciate as well is if the white patch is localized or well defined or poorly defined.

So a classic example, and everyone I think would have seen this at some stage or they will see it at some stage. Where a patient is a condition called Morsicatio , which is a fancy term to basically describe mucosal biting. So you get a white patch usually on the lower lip or on the buccal mucosa around where the linea alba is and it looks like a corrugated white patch.

It looks exactly like the patient has been chewing on the area. The surface texture is irregular and they get, you know, white patches. So if you see something like that, say if you see a poorly defined white patch on the lower labial mucosa. And as you’re talking to the patient, you see the patient chewing their lower lip. That is more than likely an area of keratosis because you’ve identified a traumatic source.

[Jaz]
And these can look really nasty. I’ve seen a lot of my patients with this where cheek nibblers, I like to call them, and it looks really, sometimes it goes to the bottom because it really looks quite diffuse and the skin is flaking away. Yeah, it’s really, really nasty actually.

[Amanda]
Now, the good thing about this condition is that it’s not inherently serious. Most times, patients are aware that they’re doing it. I usually try to counsel patients to stop if they can, but would I biopsy an area that is clearly cheek biting? I wouldn’t, as well.

And that’s not something that necessarily I would follow up. I think it’s always the patient’s aware. I’m pretty happy to leave that as is. Another classic example of keratosis would be a patient that has a broken tooth filling or a fractured cusp, I’ve had some patients referred in for ulcers or red and white patches on the sides of your buccal mucosa.

And it is immediately adjacent to a broken tooth or a broken filling, something like that should be addressed first and see if the white patch goes away. In most cases, if you have identified the traumatic cause, it will.

[Jaz]
So in that case, let’s put a little dilemma into it. You see a patient with some sort of white patch, you suspect frictional keratosis or traumatic keratosis because it’s next to a broken tooth.

So rather than thinking, Hmm, this could be a leukoplakia, let me refer this. It’s a good thing to put the GIC or smooth, soflex disc just remove the source of trauma and reassess. And is that like a two week thing? One week thing? What do you recommend?

[Amanda]
I recommend two weeks. So if you see something, so whether it’s an ulcer, red patch, white patch. Look for a cause of trauma. If you can identify the cause of trauma, eliminate the source of trauma. Review the patient in about two weeks and see if the area is still there, if it has improved or if it’s unchanged or getting worse. If the area is still persistent, if it looks about the same intensity, is not really fading, that’s when I would recommend speaking to the patient about a referral.

[Jaz]
Excellent. And how about retromolar pad areas? Is that something on your list? I often see white patches or thickening. I feel as though from the wisdom tooth at the top or a cusp that is just getting low or food trauma where there’s a tooth at the top, there’s no tooth at the bottom, like you said, edentulous area and the food is being sort of like the mucosa is being used as a tooth, for example. Is that a common one that we see? And is that something that gets referred to you?

[Amanda]
It does. And those ones can be tricky. So I would like to caveat by saying that even doubt, please refer, like if you’re not sure it is safer to refer. However, a good tip that I would have for this sort of situation, say the retromolar pad, or, a patient has had a bilateral mandibular wisdom teeth removed is to have a look at the contralateral side as well.

If they look fairly similar on the left and the right side, then I’m sort of less worried. However, if there’s a unilateral area that’s significantly worse or anything like that, then I think that that would be a reason to consider referral.

[Jaz]
Okay, great. Any other white patches of keratosis that we need to worry about? Any sort of presentations?

[Amanda]
Just keep in mind that even with Leukoplakia, even though the definition of Leukoplakia is that it’s a white patch of unknown significance, when you biopsy a Leukoplakia, the results would come back as no dysplasia, mild, moderate, or severe dysplasia, usually, right? And dysplasia is where there are precancerous or potentially precancerous changes that they see on histopathology.

However, you can get keratosis of unknown significance even when you biopsy a leukoplakia. So what I mean by that is that sometimes you get some people who do biopsies of white patches and it comes back with the result with no dysplasia but with keratosis. And they think it’s fine, it’s not a leukoplakia, and then they don’t review the patient.

Just because it’s come back as keratosis with no dysplasia doesn’t mean that it’s not a leukoplakia. Yeah, yeah. Sorry, I know sometimes that that can be confusing, but if the clinical suspicion is of a leukoplakia and there is no dysplasia on biopsy, clinically it is still a leukoplakia and it should be followed up.

So the first thing you want to do is actually to see if there is a cause for the white patch or not. If not, then it is clinically a leukoplakia. And then you need to decide histopathologically, what it is and what you’re gonna do.

[Jaz]
So to clarify that, when you refer and they look at the biopsy and they find that there is no dysphasia, but they find keratosis, we cannot then say, oh, it’s just keratosis. We still call it a leukoplakia because we haven’t found the source of the trauma, and therefore we keep reviewing and keep an eye on it, but we label it still in our mind as a leukoplakia.

[Amanda]
That’s it. And there are different types and grades of leukoplakia as well. So a condition that I did want to discuss today is something that’s called proliferative verrucous leukoplakia and it basically looks like white plaques and patches in the mouth and they can be quite florid.

So the patient can get these generalized white patches on the gingiva, tongue, buccal mucosa, things like that. Now proliferative verrucous leukoplakia is a oral potentially malignant disorder that has quite a high malignant transformation rate. So the malignant transformation rate for a proliferative verrucous leukoplakia is between 50% to about 90%, usually about 50%.

So this is a patient that is very likely to develop a oral squamous cell carcinoma. Now initially with proliferative verrucous leukoplakias, it can just look like a leukoplakia. It can just look like a area of keratosis. And when you biopsy proliferative verrucous leukoplakia, it can sometimes just come as keratosis.

So, we always have to go with our clinical impression. So, if I followed up a patient with a leukoplakia for some time and I’m quite happy that it’s low risk, nothing’s really changing, I would refer back to the general dentist. And what I think is important for general dentists to know is how to work with an oral medicine specialist.

So usually we would review our patients, but we review our patients also keeping in mind that we are referring them back to the general dentist for their ongoing dental examinations as well. So if a general dentist knows that the patient has any of these oral potentially malignant disorders, they should still be doing their comprehensive head and neck examinations, review examinations and contacting the specialist if there’s any changes. So that’s something that I would recommend.

[Jaz]
Yeah, you can’t just rely then on the Oral-Med specialist who sees them twice a year, once a year, to then do the submandibular lymph nodes exam, ask for weight loss. You still gotta do your due diligence, oral cancer exam, don’t think that someone’s taking care of it.

And I think photos, as a general dentist, we take photos of our work anyway and that can really help you as a specialist, especially when we’re sending a referral or when they’re monitoring and together if we’re looking for changes. So that’s a good sign to pick up the camera, don’t you think?

[Amanda]
A hundred percent. So if there is one thing that I would like the Protruserati to learn or to do, if they’re not already doing-

[Jaz]
Well done.

[Amanda]
Please send clinical photographs with your oral medicine referrals, because it makes a big difference when we’re in triaging. Because one of the things that I think is a common-ish question is, how urgent is referral?

You see a white patch, you’ve eliminated any source of trauma, it’s still there. How urgently does this need to be seen by an oral medicine specialist? Now, generally on the whole, the malignant transformation rate for a oral potentially malignant disorder is about 8%. So it’s not, so I mean, it’s going to turn into a canvas.

[Jaz]
And that’s 8% annual, is it? Is that how it’s measured, right? Like 8% per year. Okay.

[Amanda]
And it’s not something that’s overly urgent. So it’s not like you’ve already spotted a cancer. So I don’t think it has to be triaged as extremely urgent. So sometimes they may be awake for a couple of months to get in to be seen, but it is important that I think, put it into context. Like how urgent does it have to be? You should refer the patient, but the patient doesn’t have to be seen within the same week.

[Jaz]
Got it. And now just go through this real world chat here. It’s not really patches, but I had a gentleman on Monday, like we’re a Wednesday on Monday who had a wisdom tooth extraction. In October, end of October, right? And we’re in January now, so three months ago. He came in nine weeks later with pain and swelling around the wisdom tooth area, which is a strange time. So, so long after the wisdom tooth extraction, he was given some antibiotics by a colleague. Again, several weeks later, he’s now got a firm lump in that area, right?

And the wisdom tooth area is completely healed. And the OPG shows that there’s no bony loss there, and we can clearly see the soft tissue mass there. I did not like the look of it. And also, we also have to talk about other things like, have you ever been having any night sweats and weight loss, that kind of stuff?

And he said yes for night sweats. So, I’m thinking, okay, I’m on the phone here to MaxFax saying, okay, I’ve got someone. Can you please see them right now? I think that might be appropriate kind of thing. Like if you’re really concerned about someone’s wellbeing. And they said, okay, we can’t see it right now, but because it’s a busy public hospital, it’s strained.

So they said, okay, send it urgently with it, within what we have in the UK, we have a two week wait pathway. So they will be seen within two weeks. I think it’s good to use your judgment and also ask those other questions and feel the lymph nodes. So on that topic, like before we could delve deeper into different types of patches and stuff, I think it might be good to just recap. What are the other bits of information you’d like in that referral letter, which will help you to triage that patient because, for me, the presence of that night sweats is quite concerning to me.

[Amanda]
Yeah. So I think first of all, just putting myself in the shoes of a general dentist, you see a patient come in and they have a lesion of some sort in their mouth. What would make them at a riskier category are some of the things that you would already be picking up in the medical history. So if the patient has a history of cancer themselves, if they have a family history of cancer, if they smoke, if they drink, if they chew areca nut, if they use alcohol containing mouthwashes, if they vape.

These are some of the questions that I would recommend that people start incorporating into their medical history. Because don’t forget, with family history of cancer, we know some of these things do have a genetic component. We do know that different types of cancers can metastasize to the oral cavity as well.

So we do want to make sure that if the patient is at a slightly higher risk category, that we are considering that appropriately. So you’ve done your medical history, you’ve picked out some of these red flags, now, when you do the extra oral examination, just in the context of head and neck cancer, the lymphadenopathy is very important, which is what you talked about, feeling the lymph nodes, knowing where you’re feeling, checking for any sort of tenderness, enlargement, or fixation.

If you do note fixation of any lymph nodes, any unilateral enlargement, that should definitely be noted in the referral. Now, one of the red and white patches that we’re going to be talking about later is actinic cheilitis, which is where there are pre cancerous changes, usually to the lower lip.

This is unexposed. The etiology of this is chronic sun exposure and it can turn into skin cancer. So if you do note any sort of funny lesions on the lip or in the mouth, you’ll be wanting to note all of this down in the referral and sending a photograph with it. Now, what the red flags are for oral cancers that are important to note into the referral is how long the lesion has been there?

That is usually the number one question when it comes to an ulcer when it comes to a red patch with a white patch. Is it a chronic problem? Is it a recurrent problem or is it acute and generally it’s not acute by the time it actually gets into us. So you want to know when it started ideally if you can put this in who they have seen and what they have tried. Because sometimes what we would do is that if we receive a referral and the patient has had multiple interventions before we actually try to get some of the patient’s correspondence and history and reports in with us for the appointment.

Then you can go on to the lesion characteristics. Some people do get bogged down in how they actually describe the lesion. I’m quite practical. I mean, I don’t really care if you call it a plaque or a patch or a nodule or a papule, like if there’s a photograph and I know roughly what it looks like, that is actually, I would much rather have a clinical photograph.

[Jaz]
This is like me sweating, writing these letters, thinking, hey, wait, like even antibiotics, is it a capsule? Is it tablet? Like little things that start me sweating. And what’s his maxfax? So what’s his medicine specialist going to think of me using these wrong terms? Was it a papula? Nodule? It’s so right.

[Amanda]
Honestly, I’m speaking for myself, but I’m sure others will say, don’t care. Yeah. If there’s a photograph that will help me so much more. So yes.

[Jaz]
A hundred percent echo.

[Amanda]
And then we go to lesion characteristics. So persistence is one of them. Sight is very important because tongue and floor mouth are high risk sites in the oral cavity. So we want to know if it’s any of those high risk sites. And then we want to know if the area is fixed or indurated. It is an ulcer, it has a raw margin. Now, fixation and induration, technically we can’t tell from the photograph. So, one of the general principles when doing a hidden examination is that whatever you see, you must feel.

So, it’s important that if you see an ulcer, red patch, white patch, whatever in the mouth, obviously don’t do it in something that’s frankly infectious like a cold sore or anything, but if you see like a swelling like what you had before, you need to feel it. You need to tell the person that you’re referring to whether it’s firm, whether it’s fixed.

And usually you can tell because if you think about what it feels like to palpate scar tissue, you know, it’s not soft, it’s not mobile, you can’t move it around. That’s basically induration and then fixation as well. Now, if something is indurated or fixed.

[Jaz]
So what’s the distinction between fixed and induration is that firmness, right?

[Amanda]
And fixed means it can’t move.

[Jaz]
So something can still be hard but you can move it around and therefore they’re not quite the same obviously, they’re not always going to be fixed and indurated.

[Amanda]
But when we’re talking about oral cancer, red flags, they do usually come together. Yeah, but you can definitely get something that’s indurated, you can definitely get something that’s hard, that’s not fixed.

[Jaz]
Understood.

[Amanda]
So what we want to do, so we’ve covered persistence, we’ve covered sight, induration, fixation, and then all of the other systemic characteristics that you’ve talked about is very important as well. Has the patient had unintentional weight loss, fever? Malaise, you know, is there a lot of pain, do they have difficulty moving their tongue, you know, any of this sort of stuff, difficulty swallowing, you would be wanting to include all of that, because the more information you put for these types of symptoms, the better the receiving party can triage them.

And the other thing that I would recommend, and this is what I like my referrers to do. If you have a case that ticks multiple of these red flags to actually call me and let me know that this patient is on their way. You don’t necessarily have-

[Jaz]
If that one I described, for example, if you were my local specialist, would you be happy to, and I think that would that be appropriate to have that kind of phone call, right?

[Amanda]
And sometimes if you can’t get hold with the specialist at the very least leave a message with their reception. So they know, because it just really helps us with triaging the patients and knowing what the expectations are and giving the patient an appropriate appointment and letting you know when that appointment is as well. So it all forms part of the record.

[Jaz]
Brilliant. Well, this detour is important because this is like the real world decision making that we have to do in practice. So if in doubt, definitely consider a referral, but reaching out by phone call is a great option if you’re so lucky to have a local specialist like yourself.

With the theme again, going back to perhaps the non worrisome lesions, the more daily lesions, obviously, all the fungal stuff we’ve covered already really, you’ve done a brilliant job of that. So let’s not go there, but I know you covered, maybe did you cover a type of lichen planus maybe, but is it worth talking about lichen planus as a common white patch that we would see? Was that on your list?

[Amanda]
Before we do lichen planus, maybe we’ll finish finish leukoplakia, because there was something that I wanted to say about the leukoplakia. So when you see the white patch, I think maybe the easiest thing to do is to consider whether there is a cause that you can identify for it or whether there isn’t.

If there isn’t a cause that you can identify for it, then you would probably be considering it to be a leukoplakia. Now within the realms of leukoplakia, there are actually homogenous and non homogenous leukoplakia. Now, what I mean by homogenous is that imagine you have this white patch in front of you and whether you look at the anterior or the posterior portion, it all looks the same.

So you can get these sort of white plots or patches that are very uniform. Now a homogenous leukoplakia is fairly low risk. So that is something that I don’t think needs as a general referral. Now you can get the non homogenous leukoplakias where it starts to look a little bit thicker in one side, for example. So when you look at the lesion and you select the spot and then you select another spot on it, they look different.

[Jaz]
That’s a great way to describe it because I always thought that maybe homogenous was like, it’s either white or it’s white with some red specks or it’s a bit patchy, but you’re right in terms of the the quality, the thickness, the contour of it as well can be non homogenous. It all might be the same color, but there might be some thicker bits, some thinner bits. That’s a good way to think about it.

[Amanda]
So when you have the non homogenous leukoplakias, you can think, you can get things like verrucous leukoplakia, where they look like craggy little white bits. You can get nodular leukoplakia. Where you get like little lumpy bits within the leukoplakia, they’re all non homogenous leukoplakias. Now non homogenous leukoplakias do have a higher malignant transformation risk. So that one there, I would class that like a little bit higher basically.

Now, before we move on to leukoplakia, I’m just going to, we’ve talked about proliferative verrucous leukoplakia. Now, proliferative verrucous leukoplakia, that will probably be diagnosed by the oral medicine specialist. So, the relevance that I would like your listeners to take away from that is that if you have a patient with PVL, they’re generally on close recall with oral medicine, but they will also be seeing, you, the dentist, for their regular checkups.

A patient with proliferative verrucous leukoplakia needs lifelong regular checkups, so this is not a patient that should fall off the books. If you have a patient with PVL who doesn’t want to go back to the oral medicine specialist, you should counsel them appropriately because their risk is really high, basically, of turning into an oral squamous cell carcinoma.

[Jaz]
Have you already described what these ones look like?

[Amanda]
So they are usually white plaques, and they’re in multiple areas of the mouth, and they can be non homogenous. So they can look like diffuse, thick white plaques, or thin white plaques, they can be craggy, they can be pretty flat, but proliferative verrucous leukoplakia at its early stages can just look like a white patch.

[Jaz]
Can the differential diagnosis of that also be lichen planus?

[Amanda]
Can be flat tiped lichen planus. And we will move into lichen planus. So I think sometimes for clarity’s sake, if you see a white patch and you don’t think that there is any sort of cause that you can identify, sometimes it might just be easier to refer it and then get the diagnosis and review the patient together with the oral medicine specialist appropriately, because it can be confusing.

So we’ve covered leukoplakia, we’ve covered proliferative verrucous leukoplakia, now we’re going to talk about erythroplakia before I go on to oral lichen planus. Now erythroplakia-

[Jaz]
Sure, now before you go into erythroplakia, it’s worth saying like, there are different referral systems in different countries. In the UK, what we have is a pathway whereby we choose, you know, is it urgent or non urgent, so you have to make that decision, right? But then we are required to send an image, which I think is really good. And so I always say, if in doubt if you select urgent, but you apply an image, they do triage it, right?

And they will then downgrade it themselves because they’re so busy, right? They have to pick and choose who they can see within the two week wait pathway. And so if there’s elements of being non homogeneous and perhaps you can’t find the cause and you’ve got to add in all the other information as well. If you’re really stuck on the fence, is it fair to say, do it urgent, send a photo, but it will get triaged by the country.

[Amanda]
I’ll constantly speak for the UK, because I’m not familiar with that system, but in Australia, yes. yeah, if you’re in doubt, I would rather you tick urgent. And send me the referral, the photograph, I’ll have a look. Even if I see the patient and it turns out to be a non urgent case, I would never blame the general dentist because the general dentist is doing the best they can to give the patient the best information they can. I would much rather that happen then what commonly happens the other way around.

So there is actually an art and a skill with referring patients with these types of lesions because as dentists, we’re naturally very caring. We don’t want our patients to be upset. So sometimes people shy away from actually letting the patients know that they think that it could be something that’s potentially serious.

So I’ve had a patient that didn’t come in for an appointment for a year and a half. His case ended up being an oil screamer cell carcinoma, but he didn’t end up coming in for a year and a half because although he was referred, he thought the dentist didn’t look that worried about it, so he thought that was probably going to be okay.

So I think I would much rather if you’re going to have to pick between the two options, you err on the side of caution and take urge and let the patient know that you think it’s serious because that’s a much better outcome than the other way around.

[Jaz]
Well before we go on to erythroplakia, one more thing then, because I think it’s wonderful what you’re mentioning all this real world stuff. But when we do this pathway in the UK and in any country, you tick certain things like if you think it’s urgent or not. And then one of the things that we have to tick if you do urgent is have you explained to the patient that this could be cancer? You have to tick it right and probably for that reason that if you downplay it and underplay it they may not go to that appointment.

So I think it makes sense there, but then I love the word serious I like the word serious. The C word is difficult to say sometimes. What is your personal opinion on general dentists using the C word, Cancer, or is it okay thinking this could be something sinister or serious? I sometimes say sometimes I have been shying away from the C word and I’ve chosen to use other words. What’s your advice?

[Amanda]
So I think it depends on the patient. So you have to read the patient a little bit. Because you may have some patients that haven’t been to see the dentist in a long time, they’re fairly cavalier, they don’t think it’s going to be anything serious, they will go see the oral medicine specialist when they get some time off work or when it suits them.

Those are the patients that you probably have to sit down and actually have a conversation with them, tell them that you’re worried that it’s cancerous, they’ve got these risk factors, it is much better than it gets picked up early. Sometimes you get patients that are very anxious. And as soon as you use the, see what that’s all they’re going to see, that’s all they’re going to hear, they can’t sleep for two weeks.

You still have to give them the information and educate them on it, but there are ways to do it gently where you can say, like, you’re thinking that it potentially could be quite serious. You’re not saying that it’s cancer, but you’re a little bit worried. There are ways that you can do it.

I actually tell people this story. So I was a registrar training in oral medicine and I had a patient who came in and it was, it looked to me like he had a cancer on his floor of mouth. And for, I can’t remember what the exact reason was, but for a good reason, the biopsy couldn’t be done that day.

I think he had to go or he didn’t have someone with him. So I rebooked him for the next week. The patient never showed up and I never knew what happened to this patient after. And I was really worried about it. We tried to send him letters and all of these things. In the end, he never came in and I never knew what happened to him, but I always wondered what would have happened if I had actually told him that I thought that he had cancer.

And we actually had an oral medicine consultant visiting from the UK at the time, who was a visiting consultant. And I had a chat with him, lovely man. And he was like, look, I actually tell patients when I think it is cancer, because it’s important that they know how serious I think it is. So they don’t miss appointments or they don’t put things off and only come in when they feel like it.

So I do think that you do have to read the patients. You can’t tell everyone that they’ve got cancer because some people are just not going to be able to take that, but the message still has to be delivered in a appropriate manner.

[Jaz]
It’s individualized, customized, and I love that actually, I really like this approach to read your patient. And we all know, you can all think, we can all imagine in our mind that really stressy worrier patient, that’s the worst thing. I mean, if you just tell them that it might not even be serious, they’ll still be there at the appointment several hours early, they still won’t get any sleep anyway. So you don’t want to over egg it on that kind of patient. So I do like that very real world advice actually.

[Amanda]
And maybe there’s a tip and I’m not sure this is what’s in the UK, but this is what I recommend my colleagues in Australia do. Sometimes you can impart the seriousness of what you think it is by the actions that you take. So what I mean by that is that you can go, look, I’m a little bit concerned about this.

I would like you to see the oral medicine specialist. My receptionist Jasmine here is going to call the oral medicine specialist now and we’re going to get you the next available appointment. So the patient already knows because this is not normal action that you take for anyone. And they kind of get it.

So that could be something that you could do as well, if that’s a feasible thing, depending on where your listeners are, to actually call for the patient, get the appointment, let the patient know you don’t want them to miss the appointment because you are concerned. And that sometimes gets the message across.

[Jaz]
Yeah, you’re really taking ownership of you. You’re holding their hand, you’re leading them to the right place where we’re in their best interest. I like that as well. So on that topic of slightly more serious things, maybe erythroplakias.

[Amanda]
Erythroplakias are actually quite rare. So not every red patch that you see in the mouth is going to be an erythroplakia. An erythroplakia is a red patch, again, of unknown cause. The malignant transformation rate for a true erythroplakia is actually about 35%. So it’s actually quite high. It is a fiery red patch. It is usually painless, however, sometimes it can be a little bit tender. And it does tend to have like a velvety granular type of texture. So this is not necessarily one that people are going to see all the time, but if you see an erythroplakia I think that should be an urgent ish referral.

[Jaz]
What about something that looks like a white patch with red dots on it? Would you still classify that as a as a leukoplakia or is that an erythroplakia because it’s got red and white?

[Amanda]
Not really. So it depends on what it looks like. It can be a non homogeneous leukoplakia. You can get erythroleukoplakias, which are red and white, but an erythroplakia is red only.

[Jaz]
Understood. Fine. And in terms of the common diagnoses that are made once you see this and how we should manage it in practice, I mean, if you see this, is it still the same, i. e. look for a potential cause or here there would be no traumatic cause, therefore it would be an urgent referral?

[Amanda]
I think maybe in someone who is not familiar with looking at lesions, just as a general rule, always try to look for a cause, because you might be confusing an area of erythema, for example, where there’s a trauma in the area.

Sometimes they can look erythematous, they can look a little bit red. You might not know how that looks like in comparison to a true erythroplakia. But if you see something that is velvety, granular, well defined red patch, that’s, to be honest, pretty good for an erythroplakia.

[Jaz] A
nd therefore refer urgently .

[Amanda]
Now, let’s talk about lichen planus. Now, lichen planus is something that I think most people will see because lichen planus is actually quite, quite, common or I feel like it’s quite common because I see a few cases every day. Now-

[Jaz]
100% very common. I think in general practice, most of the colleagues when we speak about it, yeah, it is lichen planus and sometimes I’m there scratching my head. A lot of the patients have had actually a official diagnosis and have had biopsies because I see a lot of an elderly patient base. And so they’ve always had an approved biopsy already. And then we’re just monitoring for changes. But I do sometimes look at a patch and I think, hmm, this kind of looks like a lichen planus, like classic lichen planus, but they’ve never had an official diagnosis.

So one thing I’m looking to gain from you is insight into how important is it for this individual to actually get a lichen planus, or is it appropriate to go with this looks like a textbook lichen planus and therefore we should just monitor and brand them with that diagnosis or something?

[Amanda]
Yeah, this is actually controversial, by the way. So you’re gonna, if you put 10 oral medicine specialists in the room, you’re probably going to get half disagree with the other half. Now, generally for me, if possible, ideally, I would like clinical histopathological correlation. So, biopsy, that’s because you can get things that mimic each other in the oral cavity.

All of these things that we’re talking about sometimes you can get lupus for example, vesicular bullous conditions, they can look like lichen planus, however, if the burden of the biopsy is too high, so for example, medically speaking, the patient’s a lot of medications, the patient was dental phobic, needle phobic. If the burden of the biopsy is too high, in select cases, I’m happy to treat them as clinical oral lichen planus. But where possible, I do like to have the histopathological correlation.

[Jaz]
That’s a very fair guideline, I think, to go by. And I think if it’s specific to that individual, like, for example, it could be someone who’s very elderly, but finds it very difficult to get to appointments. And you look at the notes and you think, oh, this patient has had it for 15 years and there’s some photos and it’s looked the same and you feel as though it is lichen planus in that case, the burden might be too much to then send this patient as a new patient to get a biopsy. Would you agree with that example?

[Amanda]
If the patient is symptomatic. Or if there’s any sort of unusual features, then I think that will probably then shift the balance to them needing to be seen or biopsied. But, in cases where it’s very mild, very classical, no issues, patient finds it really hard, all of that sort of stuff, I’m quite a practical person, so I sort of think sometimes it’s fine as long as they’re going to get regularly looked over, I’m happy with that.

But ideally, gold standard, I would like a biopsy. Because we are talking now about classical lichen planus classic, the Wickham striae, the white striae. There are six different types of oral lichen planus, though. So you can get bullous lichen planus, where they look like blisters in the mouth.

You can get erosions or atrophy, where there’s ulcers or really red tissues. You can get the plaque type, which is the type that we’re talking that can look a lot like leukoplakia, although the main difference between the two is that our lichen planus, ideally, in an ideal world, would be bilateral.

So if you see bilateral plaques everywhere, or you see the taro with plaques on both sides, generally quite happy with plaque type lichen planus for those. And then you can get papula lichen planus where you get these little white bumps. The other thing about the striae as well that I forgot to say is that sometimes in a melanated patient, the wickham striae will actually be brown.

Just so people are aware that, that still can be a type of lichen planus. So if it’s not classical lichen planus, so if it’s ulcerated, or if there are bullous lesions that then burst after a little while, any of these sort of things that are a little bit unusual, I would also push for a biopsy for those.

[Jaz]
And for these patients, in terms of symptomatic relief, while they’re waiting for their appointment, are things like benzydamine, like Difflam, kind of thing, is that appropriate?

[Amanda]
So what I would usually prefer in a patient that has mild symptomatic oral lichen planus, to use things like topical lignocaine, benzydamine, saltwater rinses, toothpaste change, avoid any sort of triggering foods like acidic, spicy, or even very textured foods like toast and things like that.

To hold off until they can see the oral medicine specialist. That does depend on where you’re listening from as to how practical that is, how long they have to wait. Because starting the patient on a potent topical corticosteroid or systemic corticosteroid can sometimes change the presentation before we see them.

In some cases, they can even change the biopsy result. So if the patient’s mild, they can wait. These simple things that we just talked about the topical pain relief, saltwater rinses, toothpaste change, diet change, should be enough for them to get to wait till they can get an appointment, get the biopsy, get the result.

Now, if the patient is more symptomatic and they’re finding it quite difficult, you can do a mild corticosteroid, like something like Kenalog In Orabase which is Triamcinolone, 0.1% ointment. I think patients can use that in the meantime, but as a general dentist, I wouldn’t recommend starting them on anything stronger until they’ve been diagnosed.

And then usually once the patient has been diagnosed and they have some sort of management regime, that will be communicated with the general dentist. And then you can do things like make sure the patient’s on their regime, renew scripts immediate, things like that.

[Jaz]
With the erosive version of lichen planus, am I right in that of the six, that is the one that’s most affiliated with a dysplastic change or pre cancerous?

[Amanda]
Yeah. And that’s also usually the one that is most symptomatic. So usually if I see someone with erosive lichen planus, I would like a biopsy because sometimes you can get dysplastic changes on the background of lichen planus as well. So usually I would do those cases and those cases almost invariably need some sort of symptomatic management because it’s painful.

[Jaz]
I’m just trying to think for a lot of my colleagues who have to sometimes again make decisions of urgent or non urgent. So as a guideline, if you see something that looks classic and has been there for a little while and you feel as though the burden is not too much for them to get a biopsy, maybe send it again, send a photo and let the triage team figure out in terms of the burden of your patients to prioritize that to do it.

But if you see a more of a erosive, not quite classic, you see these more lumpy or plaque like and it’s worrisome to do it as urgent, but again, send the photos because the oral medicine specialists will be able to get an idea. Okay. I think it’s this, but I think we will see them. So as a guideline, is that a fair statement?

[Amanda]
I think so. So generally the things that I would triage as higher would be red flags. So we’ve talked about those, the fixation, induration, sites, patient factors, systemic signs, and pain. So those are usually the two that I would give the patient, or 3HM is higher for a sooner appointment. So even if the patient, for example, has what doesn’t look like very painful areas to you, but if they’re in significant amounts of pain, I would probably mark that as urgent because we-

[Jaz]
Got it. Now with one diagnosis, I remember. So, are we okay to move away from like a plaintiff? Is there anything else they want to cover there? Okay. One diagnosis I remember seeing when I was one year out of dental school, my first year at dental school and I got a little bit worried and I remember bringing my trainer in at the time and for to have a look and he kind of reassured me, but it was a enlarged taste bud.

So at the very back is the foliate ones that can be quite enlarged sometimes if I got that right. And so this looked like a red lump at the back of the tongue, but when the patient stuck a tongue, it was bilateral and it was exact spot where these taste buds usually live. Can you tell us if this is something that you’ve had as a referral before, is it something that you see any advice on this?

[Amanda]
Yep. So I do get patients get referred in for a circumbionic papilla. So generally as a good rule of thumb, I would ask you to look at the other side as well, see if it’s bilateral. Bilateral, things are usually less worrying. The other one that I get sent in quite commonly is actually the lymphoid tissue at the posterior lateral tongue.

So if someone’s not familiar at looking at the posterior lateral tongue for the first time, it looks a little bit lumpy, it looks a little bit red, they can be a little bit worried that it could be a carcinoma or something like that. However, you can get your tonsillar tissue, you can get your foliate papilla on the side of your tongue as well.

So what I would usually recommend is have a bit of gauze, apply some traction to the tongue, look at the posterior lateral tongue, and the left and the right should look very similar. And if that’s the case, then I’m quite happy to leave those as well.

[Jaz]
Great. Well, as we’re coming to the end, are there any other notes that you made in terms of red and white patches that all general dentists so generally no, obviously there’s a whole textbook on all the different red and white patches and I’m not expecting anyone to, exactly right.

But do you think we’ve covered all the key ones? The only one I have in my mind that perhaps we haven’t covered is something that you might see in smokers, right? Smoker’s mouth. That’s something maybe worth covering, but any others that you think we should be aware of?

[Amanda]
So there is a distinction between oral lichenoid lesions and oral lichen planus. So, oral lichen planus, we sort of covered the different types of lichen planus. Now, you can get oral lichenoid lesions that sometimes can be triggered by different dental restorative materials, different medications. Now, oral lichenoid lesions actually have a higher malignant transformation rate than oral lichen planus.

And I’ve been asked before if there is a simple way that people can tell oral lichen planus and oral lichenoid lesions apart. You can’t. Even sometimes on histopathology, it’s actually very difficult. What I would usually go by is the patient’s history. Have they started any new medications? Antihypertensive sometimes can trigger these sort of changes.

And if they’ve got any new dental restorations placed. Now, if I see a patient with what looks like erosive oral lichen planus, but it’s only unilaterally, it’s only unilateral, it’s only on one side, and say it’s right next to a gold crown, or it’s right next to an amalgam, I might then consider an oral lichenoid lesion more.

The important thing, I think, or the relevance for the listeners of this is that an oral lichenoid lesion sometimes can respond to a change in dental material. But I don’t want anyone to misinterpret me and think that, okay, Amanda has said we’re going to change out all of these nasty amalgams and we’re going to give everyone a full month rehab.

That is not what I’m saying. However, in some cases with the oral lichenoid lesion, A change of dental material can sometimes cause improvement in a lesion. The easiest difference is that oral lacunate lesion does tend to be unilateral. Does this help you when the patient has full mouth amalgam?

Sometimes not, sometimes you can’t tell, but that is one of the clues that you can use. And the other thing as well to know is that there’s been a couple of papers that show, because amalgam is the one that has the bad rep, right? People are like, oh, amalgams cause oral lichenoid lesions. Actually, all dental materials can.

They have been found in congestion recomposites, even gold crowns, which are traditionally going to be more inert. So you do have to be careful that if you are going down that route of changing one filling for another, the other one is not going to cause the same problem. So in some of these cases in select patients, things like allergy patch testing with the dental series. Maybe something to consider if they start to have all of these areas and you’re doing a lot of complex rehab. So that’s probably one that I would think it’s important to consider.

[Jaz]
A little bit more on a lichenoid than just try and get my head round it. Clinically, it’s difficult to say is it I mean obviously the unilateral bilateral helps. But if I showed you a photo it might be difficult to say it’s lichenoid or it’s lichen planus But once you biopsy it Is it clear from a biopsy, which of the two, okay, it isn’t.

So fine. Understood. Therefore, it could be like a experimental thing that, okay, in this case, we might consider seeing as a unilateral, let’s replace this very obvious, you know, amalgam that’s in that exact area. For example, that seems reasonable. I think, after having that discussion with all medicine specialists, for example, do you think the amalgam needs to be like a buccal component to it.

So for example, if it’s an occlusal and the mucosa is not actually rarely contacting that amalgam, can it still give the lichenoid reaction or does it have to have a buccal extension so it’s always in contact with the mucosa?

[Amanda]
It doesn’t always have to be in contact with the mucosa. So an occlusal filling care, but you are absolutely right because it is such a fine line, so you don’t really want anyone replacing all of these restorations willy nilly, which is why it’s not a recommendation for, to manage oral lichenoid lesions to routinely change out dental restorations, but in some cases it can be helpful.

So I think if the suspicion that it’s an oral lacunate lesion is high. If there is an adjacent filling, ideally it’s an adjacent filling that’s broken and needs replacement anyway, then in those types of cases, then I think it can be justified to change it out. But I wouldn’t recommend doing it routinely, definitely, because I think that that would be overtrading. But yeah.

[Jaz]
It is treating us very fair. And just to finish off on this, a smoker’s mouth, is there anything I remember seeing in textbooks that made something that we might see?

[Amanda]
So according to the WHO, so they actually have a 2020 classification of oral potentially malignant disorders. Reverse smoking is considered an oral potentially malignant disorder. Now, I didn’t actually have patients that reverse smoke where I am, but reverse smoking is actually where instead of putting the cigarette in with the filter. They actually put the lid end of the cigarette in their mouth.

Now, if you have any patients that are doing those changes in the oral cavity need to, I think, be reviewed by an oral medicine specialist. However, you can get another thing that’s called smoker’s keratosis. So this is not from reverse smoking. This is just from normal smoking. And to be honest, I think you can consider that very similarly to keratosis because there’s a traumatic cause that is causing these changes in the oral cavity. Ideally, we try to counsel the patients to reduce smoking.

Smokers keratosis does tend to be in areas where the smoke can gather, so it does tend to be the heart palate. You can get the white patches on the palate. You can get the inflammation of the minor salivary glands. In those cases, I don’t think it’s a leukoplakia because we do have a cause for it. And so in those cases, we would review them. They don’t always need a biopsy.

[Jaz]
Yeah. And with those diffuse areas, sometimes it might be difficult to pick, okay, where to actually biopsy and stuff, which makes total sense. So Amanda, we’ve covered a fair few lesions there. I think the main ones that I see as a general dentist have been covered. Is there any last one that you should, we should cover before we go to public?

[Amanda]
Yeah. So I would like to discuss oral subnucleus fibrosis, which is a oral potentially malignant disorder. Now, this is not something that everyone’s going to see all the time. However, it is not actually that uncommon areca nut chewing.

So betel quid chewing is quite common among certain populations, Taiwanese, Indian, Indigenous populations. And by chewing on the areca nut or the betel quid, it can produce this chemical called arecoline and it can actually cause cancerous changes in the mouth. Now what oral submucous fibrosis looks like are these thick fibrous bands, or it eventually becomes thick fibrous bands, usually in the buccal mucosa.

Patients have trismus, they can’t open their mouth very wide, they get these white patches, sometimes they get staining as well from the betel quid that they’re chewing. I would suggest that if you do see patients with these sort of symptoms, they should be referred to an oral medicine specialist as well.

I think oral submucous fibrosis does need to be regularly reviewed. The malignant transformation rate for that is about 5%. The best way to actually stop oral submucous fibrosis is to counsel patients to stop, because I’ve had patients that have mouth openings of five centimeters just because their submucous fibrosis is so bad.

[Jaz]
I think, yeah, I’ve seen this before a long time ago, but it felt like a really tight band and it felt like a piece of meat or something that was just really firm. I remember seeing that. Just out of pure curiosity, if it was a final question, what is the number one diagnosis you make as an oral medicine specialist week by week?

In fact, if you had to tally it all up basically, week or annual when you do your review, what’s the number one diagnosis you make on patients referred to you from general dentists?

[Amanda]
Gosh, that’s a difficult one. Lichen planus is definitely up there. And probably leukoplakia. Mm hmm.

[Jaz]
Yeah. Okay, great. Well, we’ve covered those here in terms of referrals. That’s been brilliant. Amanda, thanks so much for coming on again and doing a really great job of giving real world guidance and entwining with good lessons on how to approach these scenarios, the thought process, as well as a great revision of oral medicine for all dentists and also dental students who are learning this often tricky field.

You’re making it more exciting and more tangible, so thank you. How can we learn more from you? How can we follow you in the socials?

[Amanda]
So I do have Instagram and it’s called Oral Medicine, Oral Pathology, and I post cases. So if some of the things that we’ve talked about today, you want to know what they actually look like. I do have clinical photographs that my patients have kindly agreed for me to put on. On Facebook, it’s called A Spoonful of Oral Medicine, but it’s basically the same content.

Jaz’s Outro:
Amazing. Well, I think everyone should follow Amanda. I think she’s doing wonderful things in terms of trying to make our daily lives easier as dentists with oral medicine, but also doing right by our patients. We can’t just always be learning about veneers and onlays. It’s important to learn about these things because our patients will exhibit it and we want to be there for them to help them out. So Amanda, thanks for helping with that mission.

Well, there we have it guys. Thank you so much for listening all the way to the end. Once again, you are such a geek. Oral medicine, Really? You made it all the way to the end of oral medicine. I’m proud of you. Now you’re more confident with white patches, especially with that shiny new infographic that we have on Protrusive Guidance. And of course, while you’re there, why don’t you answer a few questions and get your CE credits.

Whether it’s CPD you’re after or CE credits, we got you fully covered. We are a PACE approved provider. Our quizzes are awesome and all your reflections that you provide, they end up going on your certificate and Mari, our CPD queen, will email you every quarter with an update of all your certificates.

It’s a great way to accumulate CE credits over the year, but also just validate your learning, cement your learning to reflect on everything that you’re learning from this podcast. Thanks to the wonderful guests that we have.

If you’re gaining value from this podcast, please do rate it. Give it a five star rating. This could be on Spotify, YouTube, Apple, wherever. We’d really appreciate that. And once again, thanks to team Protrusive without them, none of this would be possible. Thanks to all the people on Protrusive Guidance. You guys are the reason we do what we do. Thank you again. I’ll catch you same time, same place next week. Bye for now.