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Diagnosis and treatment for Breakthrough Clinical oral pathology case: No. 22

Jan. 30, 2017
Dr. Stacey Simmons, editorial director of Breakthrough Clinical, shares some reader responses to last month’s oral pathology case of a healthy 27-year-old male who presented with a “toothache.” She explains her treatment recommendations for this patient and tackles the problem of patients who won’t accept necessary treatment.
Stacey L. Simmons, DDS, Editorial Director of DE's Breakthrough Clinical e-newsletter
This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.

Last month I presented a pathology case that, if you are performing frequent head, neck, and oral cancer screenings, is an all-too-common finding. In this particular case, a 27-year-old male came in for a toothache; it was the first time he had been seen in my office. His abscess was addressed, but the fact that he chewed one can of tobacco per day and had rough, corrugated-cardboard-like tissue in the lower left vestibule was an additional concern.

What are the effects of smokeless tobacco? Why should we as practitioners be concerned? What should we tell our patients, and how can we help them?

Smokeless tobacco produces many harmful effects in the mouth, including dental conditions (tooth abrasion, dentinal hypersensitivity, staining of the teeth, etc.), gingival conditions (gingivitis, periodontal disease, recession, etc.), mucosal conditions (premalignant lesions, oral and pharyngeal cancer, etc.), halitosis, diminishing of taste, and severe systemic effects. (1, 2)

“The oral lesions seen in smokeless tobacco use may be white lesions, red and white plaques, or raised red or white lesions. These may be precancerous, in situ carcinomas, squamous cell carcinomas, or verrucous carcinomas, predominantly occurring at the mucosal location where the quid is placed.” (2)

Cessation of tobacco use will typically see a resolution of the lesion within a week; (1) however, “a thorough history is important in establishing the correct diagnosis. A biopsy may be required to rule out carcinoma or precancerous changes, especially if the lesion is associated with induration, ulceration, erythema, and nonresolution within two weeks of stopping tobacco use.” (1)

Modalities to examine such areas include “oral cavity examination, supravital staining, oral cytology, and optical technologies.” (3) Early diagnosis and considerations for such include: (3)

  • Symptomatic and/or nonsymptomatic nonhealing lesions of the oral mucosa
  • History of smoking, chewing tobacco, alcohol consumption, oral HPV infection, drug use, long-term exposure to sunlight
  • Advanced age
  • Presence of immunodeficiency
  • Presence of genetic disease
  • Poor oral hygiene

When this case was presented, I requested that you post your recommendations for care and treatment. Here are some of the responses:

  • No biopsy indicated. This is hyperkeratosis.
  • Yes, send to oral surgery for evaluation and biopsy; let pathology dictate follow-up.
  • For sure, get a biopsy.
  • Needs a biopsy.
  • VELscope tests.
  • We encourage them to cease the habit or move the product for two weeks and return for a follow-up. If the tissue has not returned to normal, we refer to oral surgery.

For this patient, I recommended tobacco cessation or—if that was not practical for him (because cessation is difficult)—to move the snuff to another location. He came in a few days later for an extraction, and I requested that he return for a tissue assessment in two weeks. Unfortunately, he did not comply, and his status is currently unknown.

From one standpoint, the patient loses out, because it could potentially be something that warrants further care. However, at the very least, a lengthy discussion was held at his initial visit and extraction appointment, and—hopefully—he will ruminate over those conversations and at some point take my advice and recommendation into consideration.


1. Mirbod SM, Ahing SI. Tobacco-associated lesions of the oral cavity: Part I. Nonmalignant lesions. J Can Dent Assoc. 2000;66(5)252-256.
2. Wood NK, Goaz PW. Differential Diagnosis of Oral and Maxillofacial Lesions. 5th ed. St. Louis, MO: Mosby Publishing; 1997:588-589.
3. Yardimci G, Kutlubay Z, Engin B, Tuzun Y. Precancerous lesions of the oral mucosa. World J Clin Cases. 2014;2(12):866-872. doi: 10.12998/wjcc.v2.i12.866.

This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.

For more pathology cases, click here.

Stacey L. Simmons, DDS, is in private practice in Hamilton, Montana. She is a graduate of Marquette University School of Dentistry. Dr. Simmons is a guest lecturer at the University of Montana in the Anatomy and Physiology Department. She is the editorial director of PennWell’s clinical dental specialties newsletter, DE’s Breakthrough Clinical with Stacey Simmons, DDS, and a contributing author for DentistryIQ, Perio-Implant Advisory, and Dental Economics. Dr. Simmons can be reached at [email protected].

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