In an appearance-conscious world, patients today are increasingly concerned about their outward appearance. Various media have heightened public awareness of appearance, making patients very aware of any variations in what is deemed “normal.” The mouth and lips are so prominent that when there are abnormalities, patients want our help—both to fix their appearance and address concerns about cancer and other abnormal disease states. That is why chronic lip peeling, lip scaling, and ulcerative lesions of the lip will bring patients into a dental practice searching for answers.
Abnormalities of the lips and their various causes include the following:
• lip injuries
• exfoliative cheilitis
• basal cell and squamous cell carcinoma
• angular cheilitis
• parafunctional causes, such as lip smacking, lip biting, and chronic lip licking
• circumoral dermatitis
• chronic chapped lips
• mouth breathing resulting in lip fissures
• allergy-type reactions from lip products, toothpaste, and dental products
• metal allergy reactions
• food sensitivity
• damage from sun exposure
• contact dermatitis and skin diseases such as lichen planus, scleroderma, and pemphigus/pemphigoid
An abnormal outward appearance of the lips usually demands an etiology for the patient. Hygienists can begin by asking questions to narrow the prospect of the offending product or disease state.
Figure 1: Exfoliative cheilitis
Photo courtesy of Dr. Nathaniel S. Treister.
Exfoliative cheilitis, or EC, is caused by excessive production of keratin in the lip tissues (figure 1). Cracking of the vermilion border with dryness and scaling are clinical characteristics of exfoliative cheilitis. The production of keratin may follow a lip/mouth injury, a chronic factitial injury, or trauma, such as lip sucking. Exfoliative cheilitis may develop when chronic parafunctional habits, such as lip smacking, occur over time (figure 2).
Figure 2: Severe irritation of lip tissues from constant sucking and licking of lip tissue
Photo courtesy of Dr. Elena Barbería
Neville et al. reported that over time, the vermilion border can exhibit a thick, yellowish, hyperkeratotic appearance that may crust, fissure, and be hemorrhagic.1 Neville et al. also stated that the idiopathic form of exfoliative cheilitis presents the most problematic situation for the patient and the clinician.1 Sometimes, rendering a diagnosis can be a lengthy process and produce anxiety for the patient and frustration for the clinician.
When caused by an injury, the term factitious cheilitis is used. Other factors may be involved, such as personality disturbances and psychological issues. The condition is usually found in individuals under 30. When found in children, parents’ roles play an extremely important part in the process of limiting and eliminating parafunctional habits (see sidebar for more information).
Almazrooa et al. conducted a retrospective study of 15 patients with exfoliative cheilitis.2 The authors characterized the clinical features, management, and outcomes of patients having at least a two-month history of the condition. The median age of the patients was 59 and there was a female to male ratio of 2:1. Findings included patients who performed the parafunctional habit of lip licking (53%). Forty percent of the group had diagnosed psychiatric disorders. The clinical features reported by participants included peeling, crusting, scaling, and erythema. Calcineurin inhibitors and moisturizing agents were the frequent method of treatment.
With a lack of studies and clinical evidence related to exfoliative cheilitis, Almazrooa et al. stated that strong clinical evidence was not sufficient to fully guide clinicians in treatment modality, and that further studies were still needed with follow-up of patients.
As always, listen to your patients and continue to ask good questions!
Barbería E, Lucavechi T, Cardenas D, Maroto M. An atypical lingual lesion resulting from the unhealthy habit of sucking the lower lip: clinical case study. J Clin Pediatr Dent. 2006;30(4):280-282.
Burkhart NW. Morsicatio buccarum, labiorum, and linguarum. RDH. 2011;31(12):78-79,95.
1. Neville BW, Damm DD, Allen CM, Chi AC. Oral and Maxillofacial Pathology. 4th edition. 2016. Elsevier, St. Louis MO.
2. Almazrooa SA, Sook-Bin Woo, Mawardi H, Treister N. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116:e485-e489.
3. Burkhart NW. Lip damage of child from sucking on tissue. RDH. 2012;32(11):82-83.
Guidance for assisting clinicians in diagnosing and extinguishing behaviors associated with lip sucking3
Lip sucking occurs primarily among children, though all ages can be affected. The following guidelines focus on advice for addressing the problem with children and their parents.
• Explain to the child and parents the cause of the injury and inform them of the importance of discontinuing any habit.
• Careful evaluation of all patients with regard to occlusion, speech, swallowing patterns, and any deviations from normal should be addressed. Current or future oral habits may be identified and corrected.
• If the child is older, explain the esthetic importance that discontinuance of the behavior will have for him/her. Adolescents and older children are especially concerned with their appearance, and this approach may be all that is needed. The child must want to make the behavior change and be of an age that he/she can understand the concept. Additionally, trust with the clinician must be established.
• Determine when the habit is typically performed and teach self-management techniques that work for the individual. For example, does it occur at night, during the day, or during stressful daily activity?
• For the younger child (under 8 years old), it is very difficult to understand the importance of eliminating the habit. Parental involvement is very important, but the clinician must know the family. If parental involvement is sought, will it be beneficial? Or might it actually make the situation worse for the child (e.g., draw harsh punishment)?
• In some cases, the habit is an unconscious mechanism of the child to get attention from parents. If parents call attention to the habit, the child increases frequency and this reinforces the habit. The problem could become worse, and parents need to understand this concept if they are involved.
• If the problem is minor, a “watch and see” approach may be best, since calling attention to the issue may actually reinforce the behavior. Careful documentation and follow-up is needed.
• In some cases psychological support may be needed, depending on the individual circumstances and the severity of the problem.
• At any age, apply creams or treatment for skin lesions to keep the tissue from getting infected and abraded.
• Extraoral images are encouraged, since progress over time may be documented, evaluated, and actually decrease the anxiety of the parent who is concerned about progress.
Nancy W. Burkhart, EdD, BSDH, AFAAOM, is an adjunct associate professor in the Department of Periodontics-Stomatology at the Texas A&M University College of Dentistry in Dallas, Texas. Dr. Burkhart is founder and cohost of the International Oral Lichen Planus Support Group and coauthor of General and Oral Pathology for the Dental Hygienist. She was given the Dental Professional of the Year award in 2017 through the International Pemphigus and Pemphigoid Foundation and is a 2017 Sunstar/RDH Award of Distinction recipient. She can be contacted at [email protected].