The Hidden Dangers of Leukoplakia: What Every Dentist Should Know

So there's no real scenario where you would not biopsy an area of leukoplakia then? Not one. There is not one exception I would make to it. You know, I've seen dysplasia in 13-year-old boys. So there's just no reason to watch it when you could biopsy it and then properly treat it. Welcome to the Phil Klein Dental Podcast. So we're taking off the rubber dam after doing a MOD on number 30, and we notice a white patch on the posterior side of the tongue. We asked the patient if he was aware of this white spot, and he says he thinks it's been there for years, but he's not really sure. It's never hurt him, and it's never bothered him before, so he never really told anybody about it. After taking a closer look, the white patch looks like the typical leukoplakia. Now the patient has no history of heavy smoking or drinking. So the question is, what should you do as this patient's general dentist? What risk does the patient face by not referring the patient to an oral surgeon or periodontist for a second opinion in a biopsy? Or perhaps ashyou should just do the biopsy yourself. To tell us about leukoplakia and what we should be doing as GPs is our guest, Dr. Ashley Clark. Dr. Clark is a dentist and board-certified oral pathologist currently serving as the vice president of CAMP Laboratory. She is on the professional board for oral cancer cause and digital dental notes. Dr. Clark has won several teaching awards, has provided over 100 continuing education courses, and has authored more than 40 publications and book chapters. She's also been a very active contributor to VivaLearning.com. We appreciate that. She can be reached at aclark@camplaboratory.com. We'll be getting to our guests in a second, but first, when it comes to digital workflow equipment, it's important to partner with companies that provide premium products with unparalleled service, all at an affordable price. That's why you should check out Shining 3D Dental, a company that offers a complete and integrated suite of high-quality and easy-to-use digital dental equipment. Their local offices are based in California and Florida, so you get in-time comprehensive support. In fact, Shining3D Dental can furnish your office with an entire suite of digital equipment for under $27,000. This includes their AoralScan3 wireless intraoral scanner, Metasmile 3D facial scanner, and the AccuFab 3D printer with its post-processing equipment. Plus, the Shining 3D Dental digital workflow solution includes cloud storage, synchronization, and software for consultation, analysis, and design. So whether you're taking your first step into digital dentistry or you're looking to add additional equipment, check out Shining 3D Dental's complete digital dental portfolio. To learn more, visit shining3ddental.com. Dr. Clark, thanks for joining us on our show. Yeah, thank you so much for having me. So this is certainly a very important topic, Dr. Clark. We know a lot about leukoplakia and what it can lead to. And we see leukoplakia clinically quite a bit. It's fairly prevalent in the mouth. To set the stage for this podcast, tell us what leukoplakia is in its simplest terms. Tell us how prevalent it is. And what are the most common areas in the mouth where we might see leukoplakia? Leukoplakia literally translates into white patch. But in the oral cavity, that is not what we mean by the term leukoplakia. Leukoplakia is a sharply demarcated white patch that we cannot call anything else. And the fact that it has very sharply demarcated borders, meaning you know exactly where the white ends and the normal begins, that's the best way to know if something is true leukoplakia. The prevalence of leukoplakia rapidly increases with age. In fact, about 10% of men. over the age of 70, will have leukoplakia somewhere. We're starting to see more and more leukoplakia of the gingiva that is being clinically misdiagnosed as lichen planus. And so the gingiva is a common area to find leukoplakia, but really the danger zones where the dysplastic epithelium is happening in the cancer, lateral tongue. ventral tongue, floor of mouth. Now you have to biopsy leukoplakia no matter where it is, but those are the most important areas. Lateral, ventral tongue, floor of mouth. What about the lip? Oh, that's a great point. So I was focusing on intraoral. So leukoplakia can be a part of actinic chylitis on the vermilion. So not the mucosa. And the way actinic chylitis works is it reads the book very well. It's a very common pre-malignant condition. This is something that if you start looking for it in your patients, you will absolutely see it, especially in Caucasian men over the age of 45. The first thing that happens is there is a blurring of the border, so sort of the opposite of leukoplakia in the mouth, where you can't see exactly where the lip ends and the skin begins. Then the lip starts to get blotchy pale areas. Then the lip starts to get scaly areas. And the lesion really does read the book and develop in that fashion. So the next thing that happens is leukoplakia. And this is the first step in which you must biopsy. Those first three steps, you can catch them and tell the patient to wear sunscreen. So then there's leukoplakia. Again, it affects older white men who spend a lot of time outdoors and aren't using sunscreen. This is a UV sunlight driven lesion. By the time someone has a non-healing ulcer on their lower lip, that is indicative of cancer, of progression to cancer. So we really want to catch it in those early phases. But yes, lower lip. actinic chelitis more than doubles your chance of getting a lip cancer. Yeah. And I think they have creams, chemotherapeutic creams that they recommend for the lip. Yeah. You know, it depends on where you go. I just got an email about this today and I just had to, I didn't have to, I was able to talk to our tumor board about this on Wednesday because we had a 38 year old with a very severe actinic chelitis. And we were kind of debating, do we treat this topically? You know, what do we do? And dermatology prefers to treat topically. And I think if that's my lip, that's what I want. Surgeons prefer to cut. And that's acceptable treatment too. So you just sort of need to understand the risks and benefits of both. And, you know, if the topical therapy fails, then, of course, dermatology is going to cut. But there are topical therapies for that. Tell us more why it's important for dentists to manage leukoplakia. I mean, it's something that is so prevalent based on what you said just before, age group, sun related, could be, of course, if it's on the lip. So why is it, again, so important that we make sure that we identify it and manage it as promptly as possible? Absolutely. This is especially important for general dentists because they're the ones seeing the patient at the base level. Like we as specialists can't see the patients until the dentist has recognized the leukoplakia and then sent it to oral surgery or perio to do the biopsy. For every single oral cancer, you know, your tongue cancers and your floor of mouth cancers, for every single oral cancer that is not driven by HPV, 100% will have a spot there before the cancer happens. So if we can catch the spot and treat it, then we will prevent or we can prevent the cancer from happening. 85% of the time, that spot is leukoplakia. So if we want to lower oral cancer risks in the United States, the absolute... number one best way to do it is to reduce smoking, right, and vaccinate. But the best thing that we can do in our hands, you know, we can't stop the patient from smoking, but we can catch that leukoplakia and get it treated. So that's the most important thing that dentists can do to help lower the oral cancer rate that they can control. So 85% of the premalignant lesions in the mouth that are not related to HPV or white spot lesions. What about the other 15%? There are other potentially malignant disorders or precancers, as we call them, like red spots, erythroplakia is, you know, that's pretty rare, but that's one example. Oral submucous fibrosis, which is something that happens in people using a rake and nut products. So there's other types of precancerous spots, just none come even close to being. as prevalent as leukoplakia. It's sort of like when I say oral cancer, almost all of us are thinking squamous cell carcinoma because 80% of oral cancers are squamous cell carcinomas. So when I think potentially malignant disorder, pre-cancer, I think leukoplakia. Okay. So what are the chances of an undetected white spot, leukoplakia, to turn into cancer? Yeah, so any true leukoplakia, so not frictional keratosis, not tongue chewing, anything like that, but if it's truly a sharply demarcated white spot, it depends on the stage. We don't know how prevalent or what the risk is of it turning into cancer until we biopsy, but every single area of leukoplakia has the potential to turn into cancer. They don't all. And we don't know which ones will, but all of them have the potential to move into dysplasia and cancer. And if a patient tells the dentist in the area of the leukoplakia at one time there were ulcers, but then they healed, is that something to be concerned about or only the ones that obviously do not heal? So I'm not really concerned about healing ulcerations as far as cancer development because a cancerous ulcer wouldn't heal. But if the patient has an area of leukoplakia, no matter if they report ulcers in it or not, I'm going to biopsy it. But yeah, non-healing ulcers must be biopsied. The ones that heal don't bother me as much. Okay. So there's no real scenario where you would not biopsy an area of leukoplakia then? Not one. There is not one exception I would make to it. You know, I've seen dysplasia in 13-year-old boys. There's just no reason to watch it when you could biopsy it and then properly treat it. We'll be getting right back 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 of 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 radio opacity, providing fast, strong, and aesthetic posterior fillings. Join thousands of dentists who trust VOCO for proven performance, superior aesthetics, and lasting results. Explore VOCO's full range of composite materials and request a sample at voco.dental. We need to treat things by diagnosing them first, and that seems like such a simple thing. Diagnose it, then treat it. And if you don't biopsy these things, you don't have a diagnosis, and therefore you cannot be treating it with all the best information available. So before you treat it, and that might be monitoring it. But before you treat it, we really need to get a baseline diagnosis to determine how the treatment goes. If you do a biopsy of leukoplakia and it's hyperkeratosis, then the treatment is to monitor. But if you do a biopsy and it comes back as moderate dysplasia, then the treatment is to get rid of all that tissue. And you don't know which is going to be which until you biopsy it. So general dentists, obviously you're going to see many more patients than the oral surgeon. Right. Do you think for the most part that GPs feel more comfortable sending the patient to an oral surgeon for the biopsy rather than do it themselves, even though it could be a very routine biopsy, maybe simply for the purpose of having the oral surgeon visually see the lesion prior to the biopsy procedure? What's your feeling on that? So as a general dentist, if you don't know, refer it out. Isn't that the saying? When in doubt, refer it out. So if you're not sure, does this need a biopsy? Number one, you can send, is my email address going to be on here? Because if people want to send me pictures, they can send me pictures, right? If they work closely with a periodontist or an oral surgeon, they can send the specialist those photos to see if it needs a biopsy. Or the general dentist can biopsy it themselves. I know we don't really teach a lot of that in dental school, and I think that's... a shame because we are literally microsurgeons when we're performing uh dentistry you can cut a crown at six degrees you can certainly do a punch biopsy of the gingiva so all of those scenarios are appropriate and anything that is biopsied part of the word biopsy includes to send the tissue for histologic evaluation so if you're doing your own biopsies like even cutting off fibromas, you've got to send that tissue in for histologic evaluation. And I used to not say that, but I've come across a lot of folks on social media who are adamant that this isn't standard practice. So I want to emphasize that you have to submit any human tissue that you biopsy in for a diagnosis, even though that seems so understood, like that should be understood. And those biopsy kits are pretty simple, right? You have a laboratory that you can provide them at no charge, right? Absolutely. So our biopsy kits that we provide everyone for free, we pay for the shipping. We pay for the shipping back. We provide the formal and we provide all the paperwork. The only thing that the general dentist would need to do is have some sort of cutting device like a scalpel. I like to use a punch. sutures if you need it, something to help stop the bleeding. And it's really quite simple. Whenever people are filling out the biopsy forms, when I ask for a differential diagnosis or a clinical diagnosis, if you're doing your own biopsies, you do not need to put five or six things. It's preferable to just say one thing. That way I have the best picture of what it looked like clinically. So if you say, mild dysplasia is your guess, then I know this was a pretty thin area of leukoplakia that didn't look that bad. But if you say mild dysplasia, carcinoma in situ or cancer, then I don't really know what it looks like clinically. So one guess is best or the gold star is to send a clinical photograph. And what is your recommendation for taking the best photo of that lesion? Can they just use the one that's the camera that's mounted to the brackets table, the intraoral camera? Yeah, the intraoral wand photos take wonderful pictures of teeth. And I think they're essential for a general dentist to help with treatment planning. They take terrible biopsy photos. So the best way... to take a photo of a lesion is i shouldn't say they take terrible biopsy they take terrible pathology photos so the best way to capture a lesion is either you know drag out your fancy nikon or whatever brand you have or use the thousand dollar phone that's in everybody's pocket you can turn your smartphone camera flash on and the overhead light off and those take wonderful pictures of the oral cavity in fact almost all of my photos that i show in my ce courses are taken with a smartphone so they just take really nice photos if you have a nikon or a nice camera of course that's preferable but it's it takes more time to do that it's more expensive so just use your smartphone yeah so overhead overhead light off flash on Overhead light off, smartphone flash on. Okay, good. And then they would email you that photo. Now it has to be done through HIPAA actually. So how's the transfer of that photo? You can email it to me through a secured site. If you want to tell me the name of the patient, et cetera, then that's really how it has to be done. If you're not giving me any of the protected health information, you can email me a photo or text me a photo. I get texts of photos all the time. and say, hey, does this need a biopsy? Because the patient's pathology inside the mouth is not a personal identifier. So that's okay to send. You just can't send the name or date of birth without doing it through secure email. Okay. So what about if they are sending you a biopsy and they also want to text you a photo? How do they match up that photo with the biopsy specimen? Yeah. So there's one of two ways you can do that. You can email me through secure website. or secure email the photo. Or you can call me and say, hey, I'm about to send you a picture of this guy and then or this patient. And then you can send me the photo via text message. So it's I give my cell phone to all of my contributors, my cell phone number. So it's really easy. I try to make it as easy as possible to communicate, to help with patient care. No, that's great. So if a patient doesn't have any risk factors, they don't smoke, they never drank, they don't drink now. Does that mean the patient isn't in danger of their leukoplakia being dysplastic? So that's an excellent question. And this is probably one of the worst understood areas. I get emails all the time. Here's this leukoplakia, but my patient doesn't smoke or drink. Do I need to biopsy this? And you would think that because they're not engaging in socially risky behaviors. that their chances of cancer are lower. And overall they are. But once they have the leukoplakia, I am much more worried about the patient that doesn't smoke or drink than I am about the patient that does. Because if two people have leukoplakia, one is smoking and one isn't, only one of those two humans... can do something to lower their risk of cancer and it's the one who's smoking that if they stop smoking that will lower their cancer risk because the cells are turning over and they go back to normal after a certain period of time the one who doesn't smoke they can't do anything it's genetic so that's a common misconception that if you don't drink or don't smoke then your leukoplakia is allowed to live there it's not it's got to be biopsied yeah and so many skin cancers are caused by uv damage But in the mouth, there's no UV activity. So the etiology for these, they don't really understand why some patients, let's take that patient population where they don't smoke or drink. I don't think the medical community really understands why some people get leukoplakia and the red speckled erythroplakia versus those patients that don't, you know, that absolutely have no history of getting that leukoplakia. There's really no known reason other than genetics, right? Yeah, we don't consider heredity a major risk factor in oral cancer development, but this is one where I would make an exception. We consider oral cancer 95% of the time an environmental cancer, just like skin cancers are environmental cancers, preventable by not going in the sun. If they don't smoke or drink, it must be genetic. There's no other or a random mutation. Most of these patients have a mutated P53 gene. So there is some sort of genetic component there. Yeah, except if it's on the lip, if it's on. If it's on the lip, that's UV. Yeah, right. So lower lip, upper lip, we're not so sure. Right. And that's the border between the lip and the skin. But there's also a. border between the exposed lip and the mucosa. And that's also a spot where leukoplakia can be present. Yeah, you can get leukoplakia there too. Like I said, especially older white men are the ones who are most prevalent, actually for all leukoplakias, but especially the lower lip ones. And that's just from the UV exposure, most likely. Yeah. So there's a 10 to 1 male to female ratio for actinic chelitis of the lower lip. And the only thing that they can hypothesize as to why it would be such a big gender difference i mean i go outside too but they hypothesize women don't women you didn't know women didn't go outside oh you go outside wow i thought women never went outside okay that's good to know yeah farmer's lip or sailor's lip and i am certainly not a farmer or a sailor and i think those are historically more male jobs so that could be why that's funny yeah so and um The other hypothesis is that women are using lip protecting balms, which my husband owns ChapStick, but I don't. So I don't know that I buy any of those, but there's something to it. It's a 10 to one male to female ratio. Yeah. And that kind of leukoplakia, if it's visible on the lip, is that something a dentist should tell the patient about and refer to a dermatologist or should they be biopsying that as well? You can do either one. If you see leukoplakia or non-healing ulceration, those are the scenario or any, you know, sort of in duration or things like that. But those are the two main scenarios in which you need to catch it. And you have those two options. You can refer to dermatology or oral surgery. Some benefits for dermatology is that in general, more dermatologists will accept medical insurance compared to oral surgery. Now, that's not true universally. I mean, dermatologists have an exceedingly long wait list in some areas, but oral surgeons have long wait lists in some areas. So all of those things sort of go into account, but either one is appropriate. Plastic surgery is another option, but I would prefer derm or oral surgery to plastic surgery. So the most common spot, if you would just tell our audience in the mouth, not including the lip, where would GPs most commonly find leukoplakia in the mouth? Posterior lateral tongue. And it will be right on the bite line. So please don't confuse that with frictional keratosis. If it is sharply demarcated, it is not frictional keratosis. So if the GP wants to biopsy that, they could do a simple punch biopsy, send it out to a lab like yourself. And we'll leave your email in the description of this podcast. And if they don't want to do anything themselves, but they are suspicious of that white patch, who should they send it to? Oral surgeon or... Periodontist? Oral surgery or a periodontist. Okay. Both of them can do appropriate biopsies. I usually send gingival biopsies to perio and other biopsies to oral surgery. But I've got a periodontist in Texas who does all sorts of biopsies. So perio does biopsies too. Even fewer of them work with medical insurance. So again, there are some considerations. But both of those are an option. I also want to say one more quick thing about leukoplakia. And I'm going to say, of course, there are exceptions to this, but I'm just going to say, if you're a general dentist, if you're a hygienist and assistant, as a rule, if there is a white patch that's non-removable on the attached gingiva, it is leukoplakia. Sharply demarcated white lesion, not coming and going. It's never frictional. It's never frictional. on the attached gingiva. So last question as we wrap up this podcast, and it's been very good, Dr. Clark, that you've talked all about this. You have so much experience with this. Out of all the leukoplakia biopsies that you receive, how many come back as dysplastic? In general, so I won't give like my lab's number because I don't know it. But in general, 80% of leukoplakias are totally benign. They're just hyperkeratosis. And I remember learning that in school and just sort of spitting out that statistic. But upon reflection, I think the important thing to emphasize about that statistic is that if you're a general dentist or a hygienist or an assistant, you're going to see a lot of these leukoplakias over the next two, three years after you've listened to this podcast, and you're going to biopsy all of them. And you're going to keep getting an influx of benign hyperkeratosis, benign hyperkeratosis. So don't let your brain trick you. into thinking you don't need to biopsy the next one. You have to biopsy all of them. Like your brain will start to think, I'm experienced now. I've seen this before. It's probably hyperkeratosis. You never know. So you've got to biopsy them all. Yeah, but 20% that are not. 21 and 5 are dysplastic. That's pretty high. Yeah. So to me, you know, I'm not practicing dentistry right now, but that wouldn't persuade me not to take every single. leukoplakia seriously, because 20%, I mean, that's a big number. I mean, people that get melanoma, they have a one in nine chance of getting another dark spot diagnosed as melanoma. They have a one in nine chance, which is, you know, that's more than 10%. And that seems really high to me. But 20% is two out of 10 people are on their way to getting cancer that have leukoplakia. That's very high. Yeah. So I can't imagine a GP taking that lightly. Very, very important information. We will, again, hear more from Dr. Clark in the future. She's been a great contributor to Viva Learning. So we thank you very much. Thank you very much and have a great evening, Dr. Clark. Thanks for having me.