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1 2015 course one self-study course The Ohio State University College of Dentistry is a recognized provider for ADA CERP credit. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at The Ohio State University College of Dentistry is approved by the Ohio State Dental Board as a permanent sponsor of continuing dental education contact us phone toll free fax smsosu@osu.edu web dentistry.osu.edu/sms ABOUT this COURSE READ the MATERIALS. Read and review the course materials. COMPLETE the TEST. Answer the eight question test. A total of 6/8 questions must be answered correctly for credit. SUBMIT the ANSWER FORM ONLINE. You MUST submit your answers ONLINE at: RECORD or PRINT THE CONFIRMATION ID This unique ID is displayed upon successful submission of your answer form. ABOUT your FREE CE TWO CREDIT HOURS are issued for successful completion of this selfstudy course for the OSDB biennium totals. CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. ALLOW 2 WEEKS for processing and mailing of your certificate. The Ohio State University College of Dentistry is an American Dental Association (ADA) Continuing Education Recognized Provider (CERP). FREQUENTLY asked QUESTIONS Q: Who can earn FREE CE credits? A: EVERYONE - All dental professionals in your office may earn free CE credits. Each person must read the course materials and submit an online answer form independently. Q: What if I did not receive a confirmation ID? A: Once you have fully completed your answer form and click submit you will be directed to a page with a unique confirmation ID. Q: Where can I find my SMS number? A: Your SMS number can be found in the upper right hand corner of your monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for your office only, and is the same for everyone in the office. Q: How often are these courses available? A: FOUR TIMES PER YEAR (8 CE credits). Page 1

2 2015 course one PIGMENTED LESIONS OF THE ORAL MUCOSA This course will help dental professionals to familiarize themselves with common pigmented lesions of the oral mucosa and to derive a differential diagnosis for various pigmented lesions. written by neetha santosh, dds edited by rachel a. flad, bs karen k. daw, mba, cecm INTRODUCTION Pigmented lesions of the oral mucosa are one of the leading causes for which patients seek professional treatment. These lesions can have a wide spectrum of diagnoses and can be physiologic or pathologic in origin. A variety of discoloration, including brown, gray, black, blue, purple, and yellow, can occur on oral mucosa. Patient history, clinical presentation, and location can be very helpful in narrowing down the differential diagnosis of these various pigmented lesions. BROWN, GRAY, AND/OR BLACK LESIONS PHYSIOLOGIC PIGMENTATION Physiologic pigmentation usually occurs as diffuse discoloration of oral mucosa in dark-skinned individuals and it is considered a normal variation. The discoloration is usually seen on the gingiva, but can also involve the labial mucosa, buccal mucosa, and the tip of the fungiform papillae of the tongue. The color can range from light brown to black and is due to an increased melanin deposition in the basal layer of oral epithelium. Diagnosis is made by a typical clinical appearance. No treatment is necessary, unless for aesthetic reasons. POST-INFLAMMATORY PIGMENTATION Post-inflammatory pigmentation occurs on the oral mucosa which had previous injury or inflammation. Like physiologic pigmentation, post-inflammatory pigmentation is seen more often in dark-skinned individuals. The discoloration can be focal or diffuse and is commonly seen in patients with chronic mucosal conditions such as lichen planus, pemphigus, and mucous membrane pemphigoid. The pigmentation may resolve gradually, once the condition is treated. SMOKER S MELANOSIS Smoker s melanosis is a diffuse pigmentation of the oral mucosa seen among heavy smokers. Chemicals in tobacco smoke, such as nicotine, increases melanin production which causes the pigmentation. Smoker s melanosis is frequently seen in light-skinned individuals. Page 2

3 Females are more likely to be affected due to the influence of female sex hormones along with smoking. The anterior facial gingiva is the most common location and presents as diffuse, light brown pigmentation. History of smoking, along with clinical presentation, is usually sufficient to make a diagnosis. Smoker s melanosis will resolve gradually once the person quits smoking. A biopsy of the area may be required if pigmentation is in an unusual area, such as the hard palate, or if there are any sudden changes in clinical presentation. DRUG-INDUCED PIGMENTATION A variety of medications such as antimalarial agents (chloroquine, hydroxychloroquine, and quinidine), tranquilizers (chlorpromazine), chemotherapeutic agents, minocycline, estrogen, or medications to treat AIDS can cause druginduced pigmentation of the oral mucosa. The pigmentation can be due to drug-induced melanin production or by the deposition of drug metabolites. Drug-induced pigmentation can cause the skin and mucosal surfaces to have a diffuse or specific pattern of pigmentation depending on the medication. Females are more prone to be affected due to the interaction with sex hormones. Minocycline can cause blue-gray discoloration of the bone and developing teeth. It usually affects the hard palate and the facial surface of the alveolar bone and can also cause rare pigmentation of soft tissues such as the lips, tongue, eyes, and skin. Antimalarial drugs and tranquilizers can cause blue-black discoloration of the hard palate. Estrogen, chemotherapeutic agents, and medications to treat AIDS can cause diffuse brown pigmentation of the skin and oral mucosa. Diagnosis can be made by the history of onset of the pigmentation shortly after drug usage. Gradual fading of the pigmentation is seen once the offending drug is discontinued. HAIRY TONGUE Hairy tongue is described as a hair-like appearance due to the elongation and keratin accumulation on the filiform papillae of the dorsal tongue. It can be due to an increase in keratin production or a decrease in keratin removal from the dorsal surface of the tongue. Hairy tongue is mostly seen in heavy smokers or people with poor oral hygiene. The midline of the tongue, anterior to the circumvallate papillae, is the most frequent location. Brown, yellow, or black discoloration of elongated filiform papillae is due to stains from tobacco and food or pigment-producing bacteria. Hairy tongue is diagnosed by its characteristic clinical appearance. Scraping the tongue and improving oral hygiene are the recommended treatments. AMALGAM TATTOO An amalgam tattoo is the pigmentation of the oral mucosa due to the implantation of amalgam. Amalgam particles can be embedded into the oral mucosa during restoration or removal of an amalgam filling, or during the extraction of an amalgam-filled tooth. An amalgam tattoo usually appears as a black, blue, or gray macule and commonly occurs on the gingiva, alveolar mucosa, and buccal mucosa. Usually an amalgam-filled tooth can be seen in the vicinity of the lesion, unless the tooth has been extracted. Amalgam material, which has been embedded in the alveolar ridge, can be seen as radiopaque fragments in radiographs of the area. Page 3

4 Diagnosis is usually made by the clinical appearance of the lesion and can be confirmed by the presence of radiopaque amalgam fragments in radiographs. If a clinical correlation cannot be made or metallic fragments are not detected in a radiograph, a biopsy of the lesion is recommended to rule out melanocytic lesions. No treatment is necessary unless there are aesthetic reasons. NON-AMALGAM TATTOO Graphite tattoos and intentional tattoos are some types of intraoral exogenous pigmentations. Graphite tattoos are commonly seen on the palate and occur from the accidental embedding of graphite particles from a pencil. The hard palate is the most common site of graphite tattoos and an isolated grayish macule of mucosa (similar to an amalgam tattoo) is seen. Intentional tattoos can be cultural tattoos seen on the maxillary facial gingiva or amateur tattoos on the lower labial mucosa. No treatment is usually necessary. Corticosteroids and laser therapy may be used to remove intentional tattoos. ORAL MELANOTIC MACULE Oral melanotic macules are the most common melanocytic lesion affecting the oral cavity. It appears as a flat, uniformly pigmented, welldemarcated brown macule. Oral melanotic macules can affect people of all ages, but females are more frequently affected. The vermillion zone of the lower lips is the most common site of occurrence, and it can also affect the buccal mucosa, gingiva, and palate. It occurs due to an increase in brown melanin deposition in the basal layer of the oral epithelium. Diagnosis is typically made by the characteristic clinical presentation of a flat, well-demarcated brown macule. No treatment is necessary unless for aesthetic reasons. If there is any change in size or appearance of the lesion, surgical excision is the treatment of choice. Excised tissue must be submitted for histopathological examination since the differential diagnosis of an oral melanotic macule includes the oral melanocytic nevus, amalgam tattoo, and melanoma. ORAL MELANOCYTIC NEVUS The melanocytic nevus, also known as the common mole, is a benign proliferation of nevus cells. They can be congenital or acquired, depending on the time of occurrence. An intraoral melanocytic nevus is much less common compared to its cutaneous counterparts. The oral melanocytic nevus is more commonly seen in females and is a well-demarcated macule. The color can range from brown to black, although it can sometimes present as a nonpigmented macule. Most of them are seen on the palate, mucobuccal fold, and the gingiva. A congenital melanocytic nevus is larger in size compared to an acquired nevus. Generally, no treatment is required for oral melanocytic nevus except for aesthetic reasons. Since the early stages of melanoma can mimic a melanocytic nevus, histopathological examination of a surgically excised nevus is mandatory. ORAL MELANOACANTHOMA Oral melanoacanthoma is a benign, rapidly enlarging melanocytic lesion in the oral cavity. Some studies have shown association of trauma with these lesions. Cutaneous melanoacanthoma is not related to oral melanoacanthoma, which is a pigmented seborrheic keratosis seen in older Caucasians. Page 4

5 Oral melanoacanthoma almost always occurs in African-Americans, with females more commonly affected than males, and usually occurs during their 30s and 40s. Although the buccal mucosa is the most common site of oral melanoacanthoma, any oral mucosal site can be affected. It appears as an asymptomatic, smooth, dark-brown to black colored macule which rapidly grows in size over the duration of a few weeks. radiolucent defects on a radiograph. Sometimes, oral melanomas develop with little or no pigmentation. These are called amelanotic melanomas and are difficult to diagnose clinically, as they may mimic a pyogenic granuloma. A biopsy is usually performed to rule out a differential diagnosis of early melanoma. There is no need for subsequent treatment after confirming the diagnosis of oral melanoacanthoma, as most of the lesions will gradually resolve on their own. MELANOMA Melanoma is a malignant neoplasm of melanocytes. Most of the melanomas are cutaneous lesions, but can occur at any location in the body where melanocytes are present. Cutaneous melanoma is the third most common type of skin cancer, after basal cell carcinoma and cutaneous squamous cell carcinoma. Acute damage by UV radiation is the most common etiologic factor for cutaneous lesions. The risk factors also include familial history of melanoma, personal history of melanoma, congenital nevus or dysplastic nevus, fair skin, light hair and eye color, and higher frequency of sunburn. Oral melanomas are comparatively rare and are less than one percent of all melanomas; however, they act more aggressively than cutaneous melanomas. Melanomas are usually seen in older adults, with the average age being 40 to 70 years old. They are more common in Caucasians and have a male predilection. The maxillary gingiva and the hard palate are the most common sites of occurrence in the oral cavity. Oral melanomas usually start as irregular, brown- to black-colored macules. With time, they increase in size and become exophytic in appearance. Often, these exophytic masses can get ulcerated and become painful. It can destroy the underlying bone and can produce irregular Oral Melanoma Any suspicious pigmented lesion on the hard palate and maxillary gingiva should be biopsied. Oral melanomas are usually treated by surgical excision with wide margins. Sometimes a hemimaxillectomy is performed on patients whose maxillary bone is also involved. Once the diagnosis of oral melanoma is established, depth of invasion of the lesion is measured, as oral melanomas deeper than 0.5 mm have a poor prognosis. The prognosis of oral melanomas are very poor, due to difficulty in obtaining a clear surgical margin during the initial treatment and early chances of distant metastasis. Old age, male gender, and amelanotic melanomas are other factors contributing to a bad prognosis. Periodic follow-up of melanoma patients are very important as they have higher chances of recurrence. PEUTZ-JEGHERS SYNDROME Dr. Carl Allen, The Ohio State University College of Dentistry Peutz-Jeghers syndrome is an autosomal dominant inherited condition and is manifested by multiple freckle-like lesions of the hand, periorificial skin (mouth, nose, anus, and genital skin) and the oral mucosa, and multiple polyps of the intestine. Patients with this syndrome are more susceptible to develop cancer. Page 5

6 Multiple dark freckle-like lesions on perioral skin is the most characteristic presentation of this syndrome. Even though they resemble freckles, intensity of these lesions does not change with sun exposure. Similarly, bluish-gray macules are also seen on the vermilion zone of the lips, the labial and buccal mucosa, and the tongue. Since patients with Peutz-Jeghers syndrome have higher chances of developing cancer, they should be referred to a gastroenterologist to monitor for the development of intestinal intussusception and cancer. ADDISON S DISEASE (HYPOADRENOCORTICISM) Addison s disease is a condition characterized by decreased production of adrenal corticosteroid hormones due to damage of the adrenal cortex. Autoimmune diseases, infections (such as tuberculosis and deep fungal infections), and metastatic tumors are some of the etiologic factors for adrenal cortex destruction. BLUE AND/OR PURPLE LESIONS MUCOCELE Mucocele is a dome-shaped lesion of the oral mucosa which forms due to damage of the salivary gland duct and the release of mucin into the surrounding soft tissues. Trauma is the most common etiologic factor of a mucocele. A mucocele is usually seen in children and young adults, as they are more prone to biting the oral mucosa. Mucoceles have a bluish hue due to the spilled mucin content within the lesion. A mucocele is most often located on the lower lips, but can also be seen on the buccal mucosa, the floor of the mouth, the anterior ventral tongue, the palate, and the retromolar pad. Patients often report a history of periodic rupturing and reformation of the mucocele. Gradual development of weakness, fatigue, depression, and hypotension are a few of the symptoms seen with Addison s disease. Hyperpigmentation of the skin, known as bronzing, is one of the characteristic presentations. In the oral cavity, diffuse or patchy brown pigmentation may be seen. Oral pigmentation can be one of the first signs of Addison s disease. History of recent appearance of oral pigmentation should raise the suspicion for Addison s disease and the patient should be referred to his/her general physician for a complete physical work-up and laboratory studies of serum cortisol and ACTH. Addison s disease is typically treated by corticosteroid replacement therapy. In an event of a lengthy surgical procedure, the dose of corticosteroids should be increased to meet the body s high stress level. Mucocele The majority of mucoceles break and heal by themselves. Some long-standing lesions may require surgical excision. Care should be taken to remove the offending salivary gland along with the mucocele to avoid chances of recurrence. The surgically removed lesion should be submitted for microscopic examination to rule out a salivary gland tumor. SALIVARY GLAND TUMORS Dr. Neetha Santosh, The Ohio State University College of Dentistry Salivary gland tumors can be benign or malignant lesions. They can affect either the major salivary Page 6

7 glands (parotid, submandibular, and sublingual salivary glands) or the minor salivary glands seen in the oral cavity on the soft palate, tongue, labial mucosa, buccal mucosa or the retromolar pad area. Salivary gland tumors are seen in middle aged or older adults with females having a higher chance of developing them. Inside the oral cavity, the palate is the most common location to develop salivary gland tumors, followed by the lip, buccal mucosa, tongue, and retromolarpad area. They usually present as a slow-growing, painless, fluctuant mass. Most of them have a bluish discoloration and can be ulcerated due to trauma. A biopsy of any bluish pigmented mass should be done to achieve the correct diagnosis, as certain salivary gland tumors can mimic a mucocele clinically. Treatment of salivary gland tumors varies based on diagnosis of a benign or malignant condition. GINGIVAL CYSTS OF THE ADULT Gingival cysts of the adult is a developmental cyst on the gingiva, arising from the remnants of dental lamina. It represents the soft tissue counterpart of lateral periodontal cysts, which have the same clinical and microscopic features, but occurs within the jaw. the facial gingiva of the mandibular canine and premolar. Clinically, they appear as a domeshaped, painless, bluish or blue-gray swelling. The lesions are usually less than 1 cm in diameter. The diagnosis is usually confirmed by a histopathologic examination and an absence of jaw involvement. Gingival cysts of the adult are usually treated by surgical excision and have an excellent prognosis. ERUPTION CYST (ERUPTION HEMATOMA) An eruption cyst is a cyst that forms in the soft tissue that lies above an erupting crown. It represents the soft tissue counterpart of dentigerous cysts. Eruption cysts usually occur in children under 10 years of age. Deciduous central incisors and permanent first molars are the most prone to acquiring an eruption cyst. Clinically, the cyst appears as a soft, clear swelling on the gingiva of erupting teeth. Eruption cysts are prone to trauma, which gives them a blue or purple color due to blood in the cystic fluid. No treatment is usually required, as eruption cysts normally break by themselves once the tooth erupts. Resilient cysts can be treated by excising the superficial portion of the cyst. Gingival Cyst Dr. Carl Allen, The Ohio State University College of Dentistry VARICOSITIES (VARICES) Varices are abnormally dilated veins with a tortuous course. They are considered to arise due to age-related degeneration of connective tissue that surrounds the blood vessels. Gingival cysts of the adult usually affect adults over 40 years of age. The cysts are commonly found on Varices are commonly seen in adults 60 years of age or older. A sublingual varix is the most common of the oral varices. They are most often seen as multiple, painless, bluish-purple elevated Page 7

8 blebs on the lateral border and ventral surface of the tongue. They can also be seen as single lesions on the labial and buccal mucosa. No treatment is usually required for sublingual varices. Isolated lesions on the labial and buccal mucosa can be surgically excised for aesthetic reasons. SUBMUCOSAL HEMORRHAGE A submucosal hemorrhage occurs in the oral cavity due to trauma, which results in bleeding and extravasation of blood within the mucosa. Based on the size of the hemorrhage, it can be referred to as a petechiae, purpura, ecchymosis, or a hematoma. Petechiae are tiny pinpoint hemorrhages smaller than 3 mm in diameter. Purpuras are slightly larger than petechiae, often between 3 mm and 1 cm in diameter. Ecchymosis is a submucosal hemorrhage greater than 2 cm. When a hemorrhage produces a mass, it is then called a hematoma. A submucosal hemorrhage presents as a reddishpurple, flat or elevated lesion, mostly on the labial or buccal mucosa. Blunt trauma, cheek biting, violent coughing, upper respiratory infections, anticoagulant medication usage, and coagulation disorders are some of the common causes of a submucosal hemorrhage. A diagnosis is made by the correlation of trauma history or medication usage and clinical presentation. If a diascopy is performed, these lesions should not blanch, as blood is entrapped within the mucosa and not within the blood vessel. Usually, treatment is not required for a submucosal hemorrhage and lesions should completely resolve within two weeks. If they do not heal within two weeks, a coagulation disorder or other systemic disease should be ruled out by laboratory investigations. HEMANGIOMA Hemangiomas are benign developmental vascular neoplasms. They are the most common tumors seen in infants and children. Hemangiomas are more common in females. Caucasians are more prone to develop this lesion. The head and neck area manifests 60% of all hemangiomas occurring in the body. Intraorally, the tongue is the most common site of occurrence and usually presents as a red or blue-purple mass. Hemangiomas can be of two types depending on the time of occurrence, namely congenital and infantile hemangiomas. Congenital hemangiomas are formed completely at the time of birth, while infantile hemangiomas usually develop in the first few weeks after birth. 50% of the hemangiomas resolve by themselves by age 5 and 90% will be resolved by age 9. Occasionally, intraosseous hemangiomas can be diagnosed in the jaws. The mandible is more commonly affected than the maxilla and a radiographic examination shows a multilocular radiolucent defect. Hemangiomas are diagnosed by the clinical history of the presence of the lesion and by clinical appearance. A diascopy can be performed to see if the red or purple lesion is caused by either blood within the blood vessels or leaked blood. A diascopy is performed by firmly pressing a glass slide against the lesion and if the lesion is caused by blood within the blood vessels, as in hemangioma, the lesion will blanch. Hemorrhagic lesions such as petechial, purpura, or ecchymosis will not blanch, since those are caused by leaked or extravasated blood. Hemangiomas usually require no treatment, since the majority will resolve by themselves. Sclerotherapy, with ethanol or corticosteroids, can be used to decrease the size of the lesion and the remaining lesion can be removed by surgical excision or cryotherapy. Any surgically excised tissue should be submitted for histopathologic examination to confirm the diagnosis. Page 8

9 KAPOSI S SARCOMA Kaposi s sarcoma is a malignant vascular neoplasm. Human herpes virus 8 (HHV-8) is the causative factor for Kaposi s sarcoma. Kaposi s sarcoma usually has four different clinical presentations: classic, endemic, iatrogenic (transplantation associated), and AIDS-related. The classic form of Kaposi s sarcoma usually affects elderly men on the lower extremities. The endemic form of Kaposi s sarcoma is seen in young children living in Equatorial Africa and affects various lymph nodes in the body. The iatrogenic form is seen in renal transplant patients and arises due to the loss of immunity caused by immunosuppressive drugs taken following renal transplantation. AIDS-related Kaposi s sarcoma is seen in the end stages of HIV infection and its incidence is decreasing due to anti-aids therapy. Oral lesions are seen in almost 50% of AIDS-related Kaposi s sarcoma. In the oral cavity, Kaposi s sarcoma commonly affects the hard palate, gingiva, and the tongue. It usually starts as a purple patch, evolves into a plaque stage, and finally develops into purple nodular masses. The diagnosis of Kaposi s sarcoma is achieved by examining the tissue under a microscope. The HHV-8 virus can be identified by immunohistochemical staining. The treatment of Kaposi s sarcoma depends on the clinical presentation. Surgical excision, systemic or intralesional chemotherapy, and radiation therapy are various choices of treatment for Kaposi s sarcoma. BLUE NEVUS Blue nevus is a benign proliferation of nevus cells deep within the tissue. Blue nevus gets its name from the blue color of the lesion due to the Tyndall effect. Since the nevus is located deep within the tissue, when the light is reflected back, colors with longer wavelengths, such as red and yellow, will be absorbed by the tissue and colors with shorter wavelengths, such as blue, will be reflected back. Blue Nevus Blue nevus is commonly seen in children and young adults. Females are more prone to develop this nevus. It is usually seen on the hard palate as a small, blue or bluish-black macule. A biopsy is usually performed to rule out a differential diagnosis of an early melanoma, because of the similar clinical location and appearance. Once the blue nevus is surgically removed, chance of recurrence is rare. FORDYCE GRANULES YELLOW LESIONS Fordyce granules are ectopic sebaceous glands seen on the oral mucosa. Fordyce granules are more commonly seen in adults. They present as multiple yellow papules on the buccal mucosa or vermilion zone of the lip. The lesions are normally asymptomatic. Dr. Carl Allen, The Ohio State University College of Dentistry The diagnosis of Fordyce granules is made by typical clinical location and presentation. No treatment is required for Fordyce granules. Page 9

10 PARULIS Parulis (gum boil) is a focal collection of pus on alveolar or palatal mucosa, formed due to a sinus tract draining dental abscess. Parulis usually presents as small, yellow-red nodules on the alveolar or palatal mucosa of a the non-vital tooth. The lesion periodically ruptures and discharges a foul-tasting pus. It can be asymptomatic or painful, depending on the amount of pus accumulated within the alveolar bone. Pulp testing or radiographic evaluation following insertion of a gutta-percha point into sinus tract can help in determining the responsible non-vital tooth. Parulis will be completely resolved following endodontic therapy or extraction of the responsible non-vital tooth. ORAL LYMPHOEPITHELIAL CYST Oral lymphoepithelial cysts are developmental cysts that arise in oral lymphoid tissue. Oral lymphoepithelial cysts are common in young adults. The floor of the mouth, ventral surface and lateral border of the tongue, the soft palate, and the area of the palatine tonsil are the most common locations to develop this cyst. Clinically, it presents as small, yellow-white nodules on the oral mucosa. Oral lymphoepithelial cysts are usually treated by surgical removal and they do not recur. LIPOMA Lipoma is a benign neoplasm of adipose tissue. Lipoma is the most common soft tissue neoplasm in the body, but its occurrence in the oral cavity is not as common. Although this lesion is seen more in obese individuals, a decrease in calorie consumption does not decrease the size of lipoma. Lipoma is commonly seen in adults over 40 years of age. The buccal mucosa and the buccal vestibule are the most common sites for occurrence, followed by the tongue, the floor of the mouth, and the lips. Clinically, it presents as a painless, soft, yellow nodular mass which is usually less than 3 cm in size. Conservative surgical excision is the treatment of choice and the chance of recurrence is very rare. JAUNDICE (ICTERUS) Jaundice is a condition characterized by yellowish pigmentation of skin and mucosa, due to increased bilirubin in the blood. The increase can be due by the rapid break down of red blood cells in disorders such as autoimmune hemolytic anemia, or due to decreased processing of bilirubin by the liver in conditions such as viral infections and alcohol induced hepatotoxicity. Jaundice can also be seen in newborn babies or individuals having gall stones or cancer. Jaundice is characterized by diffuse, yellowish pigmentation of the skin and mucosa, with the severity depending on the blood bilirubin count. Tissues with a higher amount of elastin, like sclera, the soft palate, and the lingual frenulum will have greater yellow pigmentation, since elastin fibers have a higher tendency to bind with bilirubin. Treatment of jaundice depends on the underlying cause of hyperbilirubinemia. Patients with jaundice should be referred to their general physician for a complete physical work-up and laboratory investigations to determine the exact cause. Page 10

11 CONCLUSION Pigmented lesions can have various clinical presentations ranging from physiologic pigmentation to malignant conditions such as melanoma. A correct diagnosis of a pigmented lesion is very important as it can change previous treatment plans. A biopsy of the lesion and submission of the tissue for histopathological examination is mandatory if clinical diagnosis is in doubt. REFERENCES 1) Neville B, Damm D, Allen C, Bouqot J. Oral & Maxillofacial Pathology. 3rd ed. Philadelphia, PA: Saunders Company; ) Greenberg M, Glick M, Ship J. Burket s Oral Medicine. 11 th ed. Hamilton, Ontario: BC Decker Inc.; ABOUT THE AUTHOR NEETHA SANTOSH NEETHA SANTOSH GRADUATED SUMMA CUM LAUDE FROM CHRISTIAN DENTAL COLLEGE, INDIA, WHERE SHE FURTHER COMPLETED HER GENERAL PRACTICE RESIDENCY. SHE THEN PURSUED A POSTDOCTORAL FELLOWSHIP IN ORAL BIOLOGY AT INDIANA UNIVERSITY SCHOOL OF DENTISTRY. CURRENTLY, SHE IS DOING HER RESIDENCY IN ORAL AND MAXILLOFACIAL PATHOLOGY AT THE OHIO STATE UNIVERSITY. HER RESEARCH AT OSU PRIMARILY FOCUSES ON IDENTIFYING BIOMARKERS THAT CAN PREDICT THE PROGRESSION OF ORAL PREMALIGNANT LESIONS TO SQUAMOUS CELL CARCINOMA. HER FUTURE CAREER PLAN IS TO JOIN ACADEMICS WHERE SHE CAN TEACH AND PRACTICE ORAL AND MAXILLOFACIAL PATHOLOGY. NEETHA SANTOSH CAN BE CONTACTED AT SANTOSH.2@OSU.EDU. CE COURSES AVAILABLE FOR PURCHASE Need additional Continuing Education credits before you renew your license? Realized that you missed an SMS CE course? All of our CE courses are available once the due date has passed for only $25 per course. Courses Available for Purchase: 2013 Course 1 Workplace Violence Course 2 Human Immunodeficiency Virus Course 3 GI Disease and Oral Lesions Course 4 Human Papillomavirus 2014 Course 1 Orofacial Pain Course 2 Gingival Pathology Course 3 Panoramic Radiography and Radiolucencies of the Jaws Course 4 White Lesions of the Oral Cavity Please contact the SMS office if you are interested in purchasing any of these courses (toll-free) smsosu@osu.edu Page 11

12 post-test instructions - answer each question ONLINE - press submit - record your confirmation id - deadline is February 15, 2015 The most common site of occurrence of oral melanomas are the hard palate and the maxillary gingiva. 1 T F SUBMIT 2 T F Hemangiomas are most commonly seen in adults. 3 ONLINE T F 4 T F Eruption cysts typically occur in children over 10 years of age. Pigmented lesions of the oral mucosa are one of the leading causes for which patients seek professional treatment. SUBMIT 5 T F lipoma. ONLINE 6 T F 7 T F 8 T F Patients with Peutz-Jeghers syndrome have higher chances of developing gastrointestinal cancer. Although lipomas are most commonly seen in obese individuals, a decrease in caloric consumption will not decrease the size of the Estrogen, chemotherapeutic agents, and medications to treat AIDS can cause diffuse brown pigmentation of the skin and oral mucosa. Fordyce granules are melanocytic lesions and always require treatment. d i r e c t o r john r. kalmar, dmd, phd kalmar.7@osu.edu a s s i s t a n t d i r e c t o r karen k. daw, mba, cecm daw.37@osu.edu channel coordinator rachel a. flad, bs flad.4@osu.edu Page 12