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August 27, 2007

by Nancy Burkhart, RDH, EdD

Presentation: Mr. Spengos is your patient, and he is a 57-year-old male in good health. The patient occasionally uses antihistamines for seasonal allergies and omeprazole for esophageal reflux (GERD). His primary occupation is that of an engineer with a lot of on-site work for new developments of large buildings. He is an avid sailor and has made many long distance cruises on his 35-foot Beneteau sailboat. Mr. Spengos appears healthy with a rustic, tanned complexion. The patient has been a one-pack a day smoker for more than 30 years and consumes alcohol on a daily basis.

Clinical Impressions: After checking all external surfaces and lymph nodes of the head and neck, you focus on the perioral tissues. You notice that Mr. Spengos has a rather crusted, stretched appearance to his lips and especially the lower lip (see Figure 1). The line of definition in the lower lip is poorly defined and the vermillion border appears to blend into the tissue joining the lip with a bulbous appearance. You also notice that there is pigmentation of the lower lip and an ulcerated area to the left of the midline. White striated areas are seen throughout the lower lip. You question Mr. Spengos about his use of a lip sunblock or any skin sunblock. He replies that he does not use any type of SPF protection. Additionally, he informs you that he has had major sunburns throughout life and spends the weekends on his sailboat when possible.

Diagnosis: Actinic cheilitis

Etiology and pathogenesis: Actinic cheilitis is a premalignant condition affecting the lower lip and caused by excessive sun exposure. Long-term exposure to ultraviolet radiation (UVR) leads to freckling, loss of elasticity, telangiectasia, and actinic cheilitis (Huber, 2005).

Diagnosed more frequently in males and in individuals over 50 years of age, squamous cell carcinoma is often found in the late stages and has the potential to spread throughout the body. The typical patient diagnosed with actinic cheilitis is someone who is Caucasian with a history of tobacco use. Studies (Markopoulous et al., 2004) have found a correlation of tobacco and outdoor occupations in a study group of 65 patients diagnosed with actinic cheilitis. Most of the patients worked as construction workers, fishermen, and farmers with an average age of 50-plus years and a 12:1 male to female ratio. Reported lesions were on the right side of the lip in 46.1 percent of the cases because of the preference to hold their cigarette on the right side as opposed to the mid-line or the left side. Interestingly, the patients in this study reported the lesions to be present for 2.6 years before diagnosis.

Additionally, 72.3 had moderate dysplasia to invasive squamous cell carcinoma at the time of biopsy, with the remaining patients diagnosed as having mild epithelial dysplasia (27.7 percent). Damage from the sun is known to cause basal cell carcinoma, squamous cell carcinoma, acantholytic dermatosis (Barabino et al., 2003), melanoma, and actinic keratosis or solar keratosis (Huber, 2005).

Method of transmission: Actinic cheilitis is not transmitted from one individual to another.

Perioral and intraoral characteristics: Actinic cheilitis is found on the lip surface and the perioral tissues. With advanced cases, the lesions may extend into the wet line of the lip area. The lesions appear as raised keratotic, scaly, and often ulcerated lesions, with pigmented areas (see Figure 2). Actinic cheilitis features mixed red and white lesions on the lower lip with or without ulcerations.

Extraoral characteristics: The lip appears crusted, with white-opalescent appearing areas, and loss of the normal definition of the vermilion border of the lip (see Figure 3).

In the normal lip tissues, small fine lines are visible, but most are lost when sun damage causes destruction of the tissues. One study (Menta Simonsen et al., 2007) reported that lesions presenting with poorly demarcated borders were diagnosed with the most severe histopathological changes.

Distinguishing characteristics: A non-healing ulcerated area with scaling or white patches on the lower lip is characteristic of actinic cheilitis. The lower lip may appear bulbous or swollen with no vermilion border and may become indurated as the actinic cheilitis progresses. Most commonly affected are fair skinned, white individuals who have had significant sun exposure.

Significant microscopic features: The epithelial surface shows a thickened layer of parakeratin.  There is irregular thickening of the spinous cell regions resulting in elongation of the rete ridges.  The rete ridges have a bulbous architecture in some areas and the epithelium shows dysplastic changes with disruption of the normal maturation pattern.  The light blue staining areas in the connective tissue indicate solar elastosis as a result of damage to the collagen by the long duration of sun exposure (see Figure 4).

Differential diagnosis: The clinician should consider squamous cell carcinoma as the primary diagnosis. The clinical appearance and histologic aggressiveness cannot be evaluated clinically (Manganaro et al., 1997) and the clinician must rely on histological examination of the tissues for a correct diagnosis. Actinic cheilitis often affects the center of the lip, and pemphigus vulgaris may also appear in this location (see Oral Exams, RDH, April 2007). Other considerations less ominous would be dermatitis, acantholytic dermatosis of the lip, actinic keratosis (solar keratosis), and allergy related lesions.

Treatment: AC is irreversible, and vermilionectomy or lip shave is often performed over the entire lip area. However, the newer Mohs micrographic surgery has been reported with excellent results. Other treatment modalities for actinic cheilitis include laser surgery, cryosurgery, 5-FU of 1.0 to 5.0 percent, chemical peels (producing poorer results), electrodesiccation, and curettage.

Patients should be referred to a dermatologist or an oral surgeon when actinic cheilitis is suspected since early detection is necessary for a successful outcome. Early detection also results in less extensive treatment for the patient.

Patients who smoke, such as the case study patient, should be directed to a smoking cessation program either in the dental office or at a local facility that offers smoking cessation programs.

Additionally, all patients who spend time in the sun should be encouraged to use a sunscreen, wide-brimmed hats, and to wear protective lip balm. Many offices make lip balm a standard part of the products that they send home with the patient after a routine dental maintenance appointment. Dental offices can order lip balms from various companies in attractive colors and designs, with their office logo displayed. The extraoral exam is part CHX, two parts water to one part CHX, and one part water to one part CHX), essential oils, and bleach (0.5 percent). Since I’ve never had a patient agree to use bleach (and I don’t blame them one bit), I suggest a variety of antimicrobials that taste good and appeal to the patient. For example, my cost-conscious patients like the idea of adding a low-cost antimicrobial like an essential oil. My patients who are dedicated to naturopathic approaches to wellness prefer mouthrinses with “natural” ingredients like herbs and essential oils. For patients with spontaneous bleeding, I like to recommend CHX, but I may also have them rinse with 0.12 percent CHX. The important point to remember about the addition of an antimicrobial agent to a water bath is that these antimicrobials don’t penetrate biofilm.

The Pik Pocket^® subgingival irrigation tip penetrates 90 percent of the depth of pockets that range from 1 mm to 6 mm in depth, and 64 percent in pockets that are 7 mm or greater in depth.⁶

As the wellness movement continues to grow, clinicians will discover that patients are desirous of any and all products that keep them healthier and more attractive. Like “Snog Me Senseless” breath fresheners and mouthrinses with “natural” ingredients, powerbrushes, interdental piks and brushes, and dental water jets are available for patients who take the message of oral biofilms seriously. If you’re one of those clinicians who is in a finger flossing, manual toothbrushing rut, remember that the sky’s the limit when you customize oral hygiene care. Move beyond the finger flossing/manual toothbrushing days of yesteryear and get patients excited about new approaches to oral biofilm control.

References

1. Cobban SJ. Evidence-based practice and the professionalization of dental hygiene. Int J Dent Hygiene 2004; 2:152-160.

2. American Academy of Periodontology: The role of supra and subgingival irrigation in the treatment of periodontal diseases. J Periodontol 2005; 76:2015-2027.

3. Cunningham AB, Ross RJ. Biofilms: the hypertextbook. Montana State University http://www.erc.montana.edu/biofilmbook.

4. Barnes CM. Comparison of irrigation to floss as an adjunct to toothbrushing: effect on bleeding, gingivitis, and supragingival plaque. J of Clin Dent 2005; 16(3):71-76.

5. O’Hehir TE. Hygienists’ opinions about oral irrigation. Hygienetown 2007; 3(4):8-9.

6. Braun RE, Ciancio SG. Subgingival delivery of an oral irrigation device. J Periodontol 1992; 63:469.

About the Author

Nancy Burkhart, RDH, EdD, is an adjunct associate professor in the Department of Periodontics at Baylor College of Dentistry and Texas A & M Health Science Center in Dallas. Nancy is also a co-host of the International Oral Lichen Planus Support Group through Baylor (www.bcd.tamhsc.edu/lichen). She is the co-author of General and Oral Pathology for Dental Hygienists, published by Lippincott Williams & Wilkins in Baltimore, which will be released in October 2007. She can be contacted at nburkhart@bcd.tamhsc.edu.

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