Case #9
A 55-year-old male visited a general dentist for an initial examination. During the appointment, an irregular mottling of the vermilion of the lower lip was noted.
Joen Iannucci Haring, DDS, MS
History
The patient was aware of the blotchy area on the lower lip and stated that it had been present for at least one year, perhaps longer. The lesion was described as painless and had no history of bleeding and crusting. When questioned about prolonged or chronic sun exposure, the patient stated that he had worked outdoors in construction for more than 25 years.
When questioned about his last medical visit, the patient stated that he last saw a physician several months earlier for treatment of viral pneumonia. The patient appeared to be in a good state of health and denied any history of serious illness, heart problems, or high blood pressure. A review of the medical history revealed an allergy to penicillin. At the time of the dental appointment, the patient was not taking medications of any kind.
Examination
The patient`s blood pressure, pulse rate, and temperature were all found to be within normal limits. No enlarged lymph nodes in the head and neck region were detected upon palpation. Physical examination of the head and neck region revealed an irregular mottling of the lower vermilion of the lip. Pale and blotchy areas, redness, and keratosis were noted (see photo). Further examination revealed no other lesions present.
Clinical diagnosis
Based on the clinical information presented, which of the following is the most likely clinical diagnosis?
* malignant melanoma
* basal cell carcinoma
* squamous cell carcinoma
* actinic cheilosis
* actinic keratosis
Diagnosis
actinic cheilosis
Discussion
Actinic cheilosis is a pre-malignant alteration of the vermilion of the lower lip caused by excessive sun exposure. The term actinic refers to sun exposure and the term cheilosis refers to the lip. People with outdoor occupations - farmers, sailors, or construction workers, for example - and outdoor sportsmen - golfers and fishermen, for example - are especially prone to developing actinic cheilosis.
In addition, individuals who lack pigmentation of the skin and have fair complexions are at greater risk to developing this lesion. People with light complexions who sunburn easily are most often affected. This condition is similar to actinic keratosis of the skin in both cause and behavior.
Clinical features
Actinic cheilosis is typically seen in individuals over age 45 and occurs more frequently in men than in women (10:1). This lesion develops slowly, and, consequently, most patients are unaware of its presence. The first changes that are seen include atrophy of the vermilion of the lower lip with a smooth surface and blotchy, pale areas.
A blurring of the mucocutaneous junction (junction between the skin and lip) also is noted. Rough, dry, and scaly areas may appear on the vermilion as the lesion progresses. Over time, actinic cheilosis also may include non-healing ulcerations that last for months. Such ulcerations suggest the progression to early squamous cell carcinoma of the lip.
Diagnosis and treatment
Squamous cell carcinoma of the lip should be included in the differential diagnosis of actinic cheilosis. Areas of leukoplakia and ulceration must be submitted for a biopsy to rule out such a malignancy. The definitive diagnosis of actinic cheilosis is made based on a biopsy and histologic examination of the lesion.
Treatment for severe cases of actinic cheilosis includes a procedure where the vermilion of the lower lip is removed. A portion of the labial mucosa is then pulled forward or the wound is permitted to heal via secondary intention.
Without treatment, careful long-term follow-up of the lesion is necessary. Patients should be encouraged to use a sunscreen to prevent further degeneration.
Squamous cell carcinoma is estimated to occur in 6 percent to 10 percent of actinic cheilosis cases. Because the lip area is a highly visible and accessible area, both the dentist and dental hygienist can play an important role in the detection of this type of cancer. If cancer is suspected, the patient must be referred promptly for a biopsy. The dental professional who recognizes cancer is providing a valuable service to the patients ? a service that patients will undoubtedly remember and appreciate.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.
