Common Oral Pathologies: Best Practices for Dental Professionals

Mucoepidermoid carcinomas are the number one malignant salivary gland tumor. If a mucoepidermoid carcinoma is going to be on the lip, it's going to be on the lower lip. And also mucoepidermoid carcinomas can be cystic, meaning they might burst and then refill exactly behaving like a mucocele does. So make sure it's not a mucoepidermoid carcinoma. Welcome to the Phil Klein Dental Podcast. So many of the listeners of this podcast program, and I'm honored to... to speak to you on a regular basis through this program are general dentists, specialists, dental hygienists, and assistants. For most of us, it's likely that we're going to encounter a variety of intraoral pathologies during our career, and this could happen fairly routinely. However, the reality is many of us have not received extensive training on identifying and managing some of these common lesions. The gap in knowledge can be particularly concerning when it comes to detecting early stage oral cancers and other potentially serious conditions. So in this episode, we're joined by Dr. Ashley Clark. She's a leading expert in the field of oral pathology. She's a board certified pathologist and a dentist, and she's going to guide us through the common pathologic entities that we might encounter in everyday practice. She'll break it down, what to look for during our typical oral exam. and she'll provide some insights on how to best manage these findings. So when we see something that's suspicious, the typical questions usually come to mind. Should we watch it? Should we monitor it for how long? Should we refer the patient to a specialist or take immediate action and perform a biopsy right then and there? So Dr. Clark is going to help clarify all that while she shares her practical tips and critical information. to help us all make informed decisions, ensuring our patients receive the best possible care. And by the way, I do want to say that Dr. Clark has provided over 100 continuing education courses. She has authored more than 40 publications and book chapters. And if you have any questions after this podcast, you can reach her at aclark@camplaboratory.com. And that email is listed in the description of this podcast episode. We'll be getting to our guest in a second, but first... With countless dental composites on the market today, choosing the right one can be overwhelming. Yet a few products rise above the rest, and VOCO composites lead the way. For over a decade, Grandioso's tooth-like physical properties have remained unmatched by any other restorative material. With its stunning aesthetics, exceptional durability, and superior handling, Grandioso stands out as the clear choice for all your composite needs. And if you're looking to simplify posterior restorations with a single-shade solution, check out Admira Fusion Extra. This omni-chromatic nano-hybrid covers all 16 Vita Classical shades with a single shade. It achieves this without compromising strength, handling, or radiopacity, providing fast, strong, and aesthetic Dr. Clark, thanks for joining us. Thank you so much for having me. We're very happy to have you on the show, Dr. Clark, and you've been a great contributor to Viva Learning over the years, both in webinars and podcasts, with your insights into how dentists and staff can help detect and identify early signs of some very dangerous pathology. So speaking of pathology, intraoral pathology, what are some of the most common pathologic entities that a dentist and a dental team typically would face? in a dental practice? So it depends on your patient population. In the pediatric population, you're going to run into a lot of dentigerous cysts and mucoceles are a big one. Mucoceles about 80% of the time occur on the lower lip in children and young adults. Another place you can get a mucocel that some people may have forgotten is the ventral tongue. And that one's important to remember because as you're doing the surgery, You can't just clip off the mucosilla at the base. You have to go in and grab the minor salivary gland or it'll come right back. And then that 10-year-old gets to have two biopsies. So those are the big ones in kids. As we get older, we start to see things like bumps on the gum, reactive lesions that tend to grow from the interdental papilla. So some people call these interdental proliferative masses. Let's just call them bumps on the gum. It seems easier. So that's pyogenic granuloma, peripheral ossifying fibroma, peripheral giant cell granuloma. Those are pretty common gingival lesions. Fibromas are exceedingly common. They're the most common mesenchymal tumor with which we deal. Odontomas are the most common odontogenic tumor. Some people don't think of odontomas as a tumor, but... this purpose, let's just say they are. Fibromas need to be biopsied and sent for histologic evaluation. It is quite literally impossible to diagnose a fibroma without a microscope. So that's one thing to point out. One of the most common epithelial tumor is something called a squamous papilloma, oral squamous papilloma. Squamous papillomas in different parts of the body behave differently. But in the oral cavity, the oral squamous papilloma, one in 250 of your patients will have this. It's incredibly common. It's the number one tumor that affects the soft palate. They like to live there in the uvula, gingiva, tongue. And the thing to know about squamous papillomas are they are not sexually transmitted. and they have nothing to do with HPV-driven cancer. I think that's very important for the entire dental team to know because they are such common lesions that your patient population, definitely you will see a papilloma. So you have to be able to answer those questions when the patient Googles and figures out. You know, they hear HPV and they think sexually transmitted and they think cancer. And you have to be able to confidently tell your patient no for both of those things. So in the last few minutes or so, you've mentioned quite a few names of pathologic entities that GPs might encounter. It seems to me that many of us, with all the things we have on our plate, with running a practice and keeping up with all the new materials and methods and techniques and equipment, for us to stay on top of all the pathologic knowledge that's required to identify these lesions is a big task. And I know we had to know many of the important lesions for the boards, but once you're out for a couple of years, there's no question the memory starts to go. So what do you suggest GPs do? To maintain a satisfactory level of knowledge when it comes to understanding the common pathologic entities in the mouth and identifying them as best they can and making the decisions to either refer out or biopsy. Yeah. First, the general dentist will forget. It's just, it will happen. I placed amalgams and resins every single day in third and fourth year dental school. I haven't been in dental school in quite a while now. I promise you, I do not remember how to place a resin, even though it's something I did so often and it's such a simple procedure in dentistry. So I don't think beating ourselves up about forgetting things is the solution. So there are a couple of things we can do. Number one, if... ever want to place a resin again, I would go to a continuing education course on how to do it. So that's one good idea of how you can stay up to date on pathology is take continuing education courses. There's a lot of... for people to stay up to date or be refreshed i like to talk about common oral pathology things that the real world dentist is going to see you'll never get a lecture about vitamin d resistant rickets from me right um and then In dental school, you will, but not as a practicing clinician. We have so little time with dentists taking our courses. We want to pack them with as much powerful information as possible. The next thing you can do is get yourself a community to help you. If I had to place a resin, I know four or five dentists that I could call right now and say, walk me through this. Remind me how to do this. I could send a picture and say, what do you see? And that's the same thing you can do with pathology. You can email me, your former teacher, whomever taught you pathology. I promise you he or she gets pathologic pictures sent to them all the time. They're happy to help. Oral surgeons are typically well-trained in oral pathology. So rely on your community of experts to help you. If you ever see anything that doesn't look normal, because certainly you know what normal looks like, snap a picture and ask somebody for help. But don't forget to do your pathology screenings. We call them oral cancer screenings, but we're really looking for any pathology. Every patient, every time. Just take a quick look. It takes 10 seconds. Do it every patient, every time. So if you were a GP and didn't obviously have the knowledge that you have, and you saw something that kind of looked like a fibroma, but it could have been any one of those things you just mentioned that are benign, what questions would you ask the patient to get a better idea of that tissue condition? We'll be getting right back to our guest in a second. 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But in my opinion, and it's not an opinion, in my viewpoint, you can bite your cheek and then a fibroma is created or a tumor pops up and then you start biting it and you didn't notice it until you bit it. So it's really hard to differentiate that. So you can ask how long it's been there. For example, if it is a fibroma and the patient is absolutely certain it's been there for 20, 30 years. Would I argue with them about biopsying that? Absolutely not. But if they're not sure, then I'd argue with them. You can ask them if there's any pain, keeping in mind that dysplastic lesions, pre-cancers, and early cancers are not painful. So is it painful when they say yes and it's just an... sort of a come and go ulcer type of thing, that makes me feel better if it's painful. So you have to know why you're asking that. You can ask, do you drink, do you smoke? That's more information gathering on how that tissue will behave. But I don't know any other scenario other than the 20-year fibroma. in which I would make my decision whether or not to biopsy based on asking the patient questions. I'm trying to think if there are any other exceptions, but I don't think so. So in the case of a fibroma, which is very common, if it's small, isn't it just easier for the dentist to remove the whole fibroma, take it off? Yeah. So you should do an excisional biopsy with fibromas, especially if they're less than 1.25 centimeters, I think is the... the dental code for the biopsy you would code. So quick question before you go on, Dr. Clark, about excisional biopsy of fibromas. Some of us use scalpel blades and some of us prefer to use a laser. Talk to us about using a laser when it comes to doing a biopsy. If you're a practice that has a laser and remove a fibroma, yes, a fibroma or a laser causes thermal artifact. But in the base of a fibroma, it doesn't affect the diagnosis. If you are a practice that uses lasers to do biopsies, you should never do an initial biopsy of a white lesion with a laser because it just fries too much of the tissue and you don't get a good diagnosis. But a papilloma, a fibroma, use your laser. That doesn't bother me at all. Okay, so for patients... Yeah. So if a patient is complaining about the fibroma, saying this kind of bothers me, it's in a spot where I'm always playing with it with my tongue and I'm chewing on it and the dentist removes it, they could use a laser in the case of a fibroma, but they should absolutely send it for histologic evaluation, correct? That is correct. This isn't something that I thought needed to be emphasized. I thought people would just intuitively know that any human tissue you take out of the body you have to send that for histologic evaluation. It is quite literally impossible to diagnose a fibroma with your eyes. But I've seen prominent dentists online not send their tissue in, and it's very concerning to me. So that is something I want to emphasize. Just, I think it was two months ago, it was this year, there was a patient who had a fibroma, and the treatment for fibroma is to excise it and send it for histologic evaluation. The treatment is not to watch it. Now, are there exceptions to that rule? Of course, if the patient knows it's been there for 20 years, that's different. But in general, the standard of care is to biopsy it and send for histologic evaluation. But anyway, so this year I had... fibroma they finally after about a year decided to get it biopsied because it had started to bother them now it should have been biopsied even before it was bothering them but just they were biting it like you were saying when the dentist did the excisional biopsy there was a mucoepidermoid carcinoma up the tissue which is why it looked like a fibroma there was quite literally a cancer that looked exactly like any other fibroma I've ever seen because it was the cancer that was pushing up the tissue. And that is incredibly rare. I'm not suggesting that's something that happens commonly, but you can't be the one that misses it. So you have to always turn in your tissue for histologic evaluation. My lab takes medical insurance. I don't charge that much for my biopsies. So just send it in. It's not going to make or break the patient. Yeah. I'm wondering, does it, you think it helps being a dentist and a pathologist like you are where you have your own laboratory do you think that helps you put things in perspective at all or is it just a tissue is tissue a histologic section is a histologic section i think doing what i do and understanding the microscopy helps me do better biopsies so for example um leukoplakia if i get a shallow biopsy of a flat white lesion if the person doesn't get deep enough into the tissue, I'm not going to give them a good result. And I only know that because I see the tissue under the microscope. So it helps me understand how to do a better biopsy. So if there are any dental students listening to this that are wanting to go into oral surgery or perio, I highly recommend you go sit with your school's pathologist and look at slides with him or her. The next thing is... don't think if I was a general dentist, and if I'm being quite honest with myself, I don't think I would know the rules of when to biopsy what. For example, if you have a flat pigmented lesion, which again, very common oral pathology, an isolated flat pigmented lesion. I'm not talking physiologic pigmentation. That's everywhere. Just one spot. The rule is you should take a radiograph. If you can't find amalgam on the radiograph and the soft tissues, you must biopsy that lesion. And if I'm being honest with myself, I don't know that I would have practiced dentistry that way. I probably would have assumed a lot of things were amalgam tattoos. But as a pathologist, you just you can never, ever break that rule. The rule is if you can't prove it's an amalgam with a radiograph, you must biopsy it. And I know that you can never break that rule because I have seen far too many melanomas. that look exactly like melanotic macules and if you watch that even for six months the patient's chance of survival It dramatically decreases. So we've got to biopsy those isolated pigmented lesions. But again, I'm not trying to be hard on people because I think if I'm being honest with myself, I probably would have practiced that way too. But since I do see the rare stuff and the common stuff, it helps me to solidify like, yes, these are the rules and they're there for a reason. So with amalgam hardly being used anymore, and I know it's still being used in some parts of the country in some clinics. it's used internationally of course in some countries but generally speaking it's material of the past you would think that most dentists wouldn't consider a pigmented lesion in the oral mucosa or anywhere else in the mouth being sourced to an amalgam When you see an isolated pigmented lesion, it's almost always a melanotic macule or an amalgam tattoo. And more and more and more in my practice, it's been getting away from amalgam tattoo and almost all the flat pigmented lesions are melanotic macules. You know, I've had a patient where they had three amalgam fillings right in a row, develop a grayish, it looked gray, spot on the hard palate. And it was just assumed this was an amalgam tattoo. And the patient was dead in about 18 months because no one ever did a biopsy until it was too late to get them diagnosed with their melanoma. It's just a rule. I will break the fibroma rule. If the patient's confident it's been there for 20 years, I won't biopsy the fibroma if they want to keep it. But the isolated pigmented rule, I just would. I would never break that rule. I would biopsy every area of an isolated pigmented lesion if you can't prove it's an amalgam with a radiograph. No question. We can't sit back and assume that a dark lesion in the mouth is a... is an amalgam tattoo for sure. Yeah. I mean, I don't mean to worry anyone like the, if you're listening to this and you're thinking, wow, I've got 10 patients or I've been watching their amalgam tattoos. It's probably fine. You know, I don't want to worry you, but especially if you've been watching them, but your next new patient that comes in now, you know, don't do that anymore. Now let's get a biopsy and make sure we know what we're dealing with. So let's pivot back to the common pathologic entity, the mucoseal commonly found in the lower lip. What is your recommendation for managing what we suspect to be a mucoseal? So there are rules for mucoseals too. And the rule is if you have a mucoseal, not a superficial mucoseal, mind you, superficial mucoseals that occur on like the palate, they can burst and go away on their own and never come back. So I'm talking true lower lip mucoseal. The rule is to biopsy it and submit it for histologic evaluation. The number one reason why we do that is because these lesions will never go away unless we biopsy them. So mostly it's because the lesion is chronic. Let's just get rid of it. But number two, mucoepidermoid carcinomas are the number one malignant salivary gland tumor. If a mucoepidermoid carcinoma is going to be on the lip, it's going to be on the lower lip. It prefers the lower lip to the upper lip. And also mucoepidermal carcinomas can be cystic, meaning they might burst and then refill exactly behaving like a mucosal does. So we also want to make sure it's not a mucoepidermal carcinoma. Now, so that's the rule as we biopsy these. I would make exceptions to this. You know, if my five-year -old had a mucosal, I would wait until he was old enough to handle the anesthesia before I biopsied it. He's a child. It's on the lower lip. I'm willing to roll the dice there, you know, considering the risks of biopsy include him. He would have to go under some sort of anesthesia, et cetera. But any adult, like if you're 50 and you've got a lower lip mucosal, you get that thing cut out and make sure it's not cancer. So because these are typically in young people, I would not break that rule for an adult. And doing an excisional biopsy. if it's small enough would be preferred when the dentist is doing that biopsy, right? Do an excisional biopsy, but the most important thing is to pluck out the minor salivary glands that are causing the lesion. So you want to excise it. In a vertical line, the sac of mucin will usually just sort of pop out. And then you want to grab anything that looks like a minor salivary gland. Minor salivary glands look like little lobules of fat to me. They're like little whitish, yellowish lobules. So you want to grab those. The other thing I want to say about a mucocele is if you ever see a mucocele on the retromolar pad, that's cancer until proven otherwise. And that is a rule. If my five-year-old had a mucocele on the retromolar pad, I would put him under general anesthesia to get that thing biopsied. So that's a rule I never break. Retromolar pad mucoceles get biopsies unless they burst and go away on their own. So your point, Dr. Clark, is that a mucocele on the retromolar pad is highly likely to be malignant. The mucoepidermoid carcinomas like to live on the retromolar pad. So we've just got to make sure. Mucoceles are allowed to live there too, but it's such a high degree that it could be a cancer, a salivary gland cancer, that you can't risk watching it. This year, I've had two people with mucoepidermic carcinomas that their dentist watched. The first one, she was in her 80s, and the dentist said, hey, you have this mucoceal on the lower lip. I'll pop it for you. And he didn't biopsy it. He popped it. And, you know, a year later, that cancer had wrapped around the nerve. You know, this is an 80-something-year-old. That's incredibly uncommon for a person her age to get a mucocele. And the treatment is not to lance it, right? And then the next one was a person who told their patient she had a mucocele of the retromolar pad, watched it for over three years before it was biopsied. And these things progressed. and get bigger and then the surgery becomes huge. So it's just, you don't want to do that to your patients. So if it's an adult or on the retro water pad, we've got to biopsy those mucoceles. So when it comes to the common mucocele, Dr. Clark, is it common for the mucocele to kind of subside, kind of go away and then reemerge? And that's something that the patient might tell us, which would give us a clue that it is a true mucocel? True mucoceles can pop and then sort of refill. Yes, but they will never completely go away unless you biopsy them and take out the affected minor salivary gland. Okay, and that kind of excisional biopsy sounds like to me should be done by an oral surgeon, maybe a periodontist, right? I mean, somebody with a little bit more training. These are more difficult biopsies than just a fibroma or even leukoplakia because of... way you should conservatively remove it. You know, you don't want to do a wide excision. You want to cut like a slit in the tissue. And I use a Kolesian clamp when I'm doing these things. So I think this is best sent to oral surgery. So when I asked you the most common pathologic entity, fibroma was kind of number one on your list, but you didn't really mention leukoplakia. Is that also one of the most common pathologic entities? So leukoplakia, I'm sorry, I thought I mentioned that. So leukoplakia is also, as we get into adulthood, especially around age 40, is when we really start to see the prevalence of leukoplakias pick up. So now anyone's allowed to have leukoplakia. I've seen 13-year-olds with leukoplakia, but age 40 is when they really start to ramp up. And in fact, 10% of male patients over the age of 70 will have leukoplakia somewhere. Common areas where leukoplakia is going to be dysplastic, meaning it needs to be removed completely, are the lateral tongue, ventral tongue, floor of mouth, and lower lip. But you never know which ones are going to be dysplastic until you biopsy it. So you must biopsy all areas of leukoplakia. So how fast does a leukoplakia progress if it is going to be dysplastic from the time it first appears? Assuming you were able to identify, Within a month's period, leukoplakia has now appeared on the side of the tongue, and it's going to be dysplastic and turn into cancer. How long is that process? So if leukoplakia eventually does turn into cancer, the average time it takes is between two and four years. I think we're used to conventional wisdom of if you see something, you call the patient back in two weeks, and if it's still there, you biopsy. And that's not really true. I don't know where we all collectively decided we came up with this two-week rule, right? But where that came from, actually, the science behind it is an ulcer. So if you have someone with an ulcer, meaning a discontinuation of epithelium, that patient you can call back in two weeks to make sure that that ulcer has healed. If not, we can biopsy it. But if it's not an ulcer... which takes 10 days to re-epithelialize. That's why we wait two weeks. If it's not an ulcer, we don't want to wait two weeks anymore. We want to refer the patient that day for biopsy or do the biopsy that day. This is especially true of leukoplakia. There's no need to call the patient back in two weeks. Nothing will happen. Go ahead and get it biopsied. And before we wrap up this podcast, Dr. Clark, you have a full-service pathology lab. Tell us about that. We provide the formalin. The mailing, we pay for getting you the materials and sending it back to us. Paperwork, we provide all of that. But you'll need the instruments to do the biopsy itself. And you can find information about her lab at camplaboratory.com. Dr. Clark, really appreciate the insight. Fantastic discussion. Thank you so much. Thank you.