Pathology Log of Literature

Heather Wilhelmi

Parashar, P. (2014). Proliferative Verrucous Leukoplakia: An elusive disorder.

The Journal of Evidence-Based Dental Practice, Annual Report Series, June,
147-153.

This article is meant to help bring higher awareness to a rare disorder

called proliferative verrucous leukoplakia in an attempt to help professionals
detect the disease early on. Proliferative Verrucous Leukoplakia (PVL) is a
disorder that can be very challenging to diagnose. It initially represents
hyperkeratosis. This plaque lesion develops into a verrucous hyperplasia,
wart-like, lesion. As it continues to develop it forms into squamous cell
carcinoma. This lesion is persistent, slow growing, and has a high tendency
to transform into a malignancy. It is critical to identify and treat it in the
early stages to help prevent or manage malignancies.
As a RDH it will be important to identify all lesions, as well as
distinguish between them. This article made me more aware of the
similarities this disorder has to other oral disorders as well as the differences.
Hygienists complete an intraoral examination during each visit making it a
prime time to identify pathologies and lesions. It is critical to have follow up
visits to monitor the lesion, assess and adjust treatment plans, and perform a
biopsy when needed.
I agree that this would be difficult to diagnose, since it initially can
appear as other disorders and usually is painless. I therefore, agree that as a
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RDH you must learn how to recognize this and start treatment as early as
possible to stop the formation of cancer and better outcomes for the patient.
I agree that multifocal white lesions should always be viewed as suspicious.
I learned that studies have found PVL is most commonly found in
females over 60 years old, but can affect men too. The precise etiology is
unknown. Studies have shown links to tobacco and alcohol use, gene
markers, weakened immune systems, HPV, and candida. There is no solid
evidence, however, showing that these links predispose a person to
developing PVL. HPV 16 has often been found in the biopsies of PVL, but not
always. Candida has also been found in biopsies. This could be because it
was a factor in the cause of PVL or it could be that the surface of the lesion is
a place that easily harbors candida.
I also learned that recognizing and distinguishing PVL may take time
from the initial identification of a lesion. First it appears as hyperkeratosis,
which is seldom multifocal and is usually benign. PVL grows into a multifocal
lesion that is usually malignant. Although it may take the appearance of
lichen planus, it only affects the oral mucosa. Lichen planus affects the skin
as well.
This relates to the pathologies we have learned so far in pathology
including the recognition and description of lesions of lichen planus,
hyperkeratosis, and leukoplakia. This article reinforces and builds on this
knowledge and the importance of distinguishing between pathologies. The

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pathology must be identified to form a treatment plan that gives our patient
the best outcome possible.

Bartold, P. Mark, DDSc, PhD (2014). Interrelationship between Rheumatoid

Arthritis and Periodontal Diseases. The Journal of Professional Excellence,
Dimensions of Dental Hygiene, November, 56-59.

This article brings to light the similarities and relationship of

rheumatoid arthritis and periodontal disease. Both of these are chronic
inflammatory diseases that cause the destruction of hard and soft tissues.
Rheumatoid arthritis affects 1-2% of the population and advanced
periodontal disease affects 5-15% of the population. Both of these are a
result of genetics and environmental triggers. Both may enter remission and
despite treatment may continue to progress. Cytokine cells in our immune
system play a large role in both diseases. The excessive production of
cytokines and low levels of inflammation inhibitors cause bone resorption.
This article will affect the way that I explain periodontal disease and its
destruction to patients. As an RDH I will be able to utilize this knowledge and
comparison to help better educate my patients in the importance of taking
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care of their oral cavity and explain that if not done how this very real
disease can develop and progress causing bone loss and eventually the loss
of teeth.
I agree that there are many similarities of how these diseases cause
our bodies to breakdown tissues. I also feel there is more to learn about the
relationship between these.
I did learn more about the different factors that can influence both of
these pathologies, which will help me explain to patients ways to help stop
progression. For example smoking and nutrition are risk factors. In fact,
studies have shown that Omega-3 fatty acids help influence the outcome of
rheumatoid arthritis and more studies are being conducted to determine if
this will also help lessen inflammation progression in periodontal disease.
Hormone disposition can play a role. For example, pregnancy hormones can
increase periodontal inflammation. Gender, age of onset, stress,
physiological health are also factors of both pathologies.
We have learned about our immune response and how it relates to
periodontal destruction through resorption. This article put this information
into a format that will help relate it to a persons overall health.

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Rada, Robert E., DDS (2015). Oral Effects of Kidney Disease. The Journal of
Professional Excellence, Dimensions of Dental Hygiene, January, 24-28.

This article explains the importance of detecting the oral effects of

kidney disease. Kidney disease leads to end-stage renal disease (ESRD)
within 10-20 years in which the kidneys fail requiring either dialysis or a
transplant. Cases have risen 600% from 1980 to 2009. Deaths rose from
10,000 in 1980 to over 90,000 in 2009. The most common causes of kidney
disease are diabetes and high blood pressure. Kidneys are critical to survival
due to the functions they perform, such as expelling wastes, producing red
blood cells, and regulating blood pressure. The patient normally does not

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notice symptoms until advanced stages. However, orally warning signs can
be detected allowing a physician to treat early and reduce the risk of ESRD.
This affects me as the hygienist. By thorough examination I will be
able to better detect the signs helping the patient seek medical attention. I
will also be able to better educate a patient who has ESRD and how they are
at an increased risk for oral disease along with ways to help prevent oral
disease. Recognizing the special precautions and preparing for the
complications that may be experienced by someone on dialysis is also
critical.
I agree that a RDH must be knowledgeable about kidney failure and
the oral effects to be able to properly and effectively treat patients. I also
feel that interdisciplinary collaboration is essential to appropriately managing
a patients oral treatment.
I learned 7 important signs that suggest advanced renal disease. One
is the pallor of the mucosa which is caused by anemia from the reduced
production of red blood cells. Another is the urea in saliva causing breath
malodor. Stomatitis due to the urea build up in blood possibly resulting in
red ulcers or thick gray exudate covering the mucosa. Xerostomia, dry
mouth, can be a cause of dialysis and medicines. Calculus formation
accelerates due to the altered levels of calcium and phosphates.
Radiographs may show well-circumscribed, unilocular, or multilocular

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radiolucencies, brown tumors and bone disease loss of lamina dura. Healing
after extractions is usually delayed as well.
As we learned in past courses sometimes pre-medication is required. If
a patient is under hemodialysis they must take a pre-antibiotic due to an
arteriovenous shunt.
This is a situation where it is critical to review the health history very
thoroughly and plan the treatment accordingly. Due to excessive bleeding
there may be a need to have many short appointments to reduce the
bleeding. Tetracycline and nonsteroidal anti-inflammatory drugs should not
be prescribed, since these can aggravate the ESRD. All oral manifestations
should be reported to the physician to help manage the patients overall
health.

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Barnes, C.M., RDH, MS (2014). Dental Hygiene Intervention to Prevent

Nosocomial Pneumonias. The Journal of Evidence-Based Dental Practice,
Annual Report Series, 103-114.

This article presents studies on how oral care can affect the
development of pneumonia in the critically ill or long term care residents.
Aspiration pneumonia is the leading cause of death in nursing homes and
some hospitalized patients. Oropharyngeal secretions aspirate into the lungs
and cause an infection. Gram negative organisms from dental biofilm have
been found in the respiratory systems of patients with aspiration pneumonia.
Many factors play a role in the biofilm build-up from poor oral hygiene to
medications causing xerostomia. Control trials show strong evidence that
providing mechanical oral hygiene from brushing to scaling may prevent
pneumonia.
As a dental hygienists I would be very interested in working with
the elderly. It is motivating to know that working along with other health
care providers to share expertise could make such a huge impact in a
persons quality of life and longevity. It would be a great opportunity to help
lessen the impact of this disease.
I agree that dental hygienists play a critical role in the prevention of
aspiration pneumonia. As a dental hygienist I would be interested in working
with the elderly and health compromised population to share expertise and
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educate the patients along with the rest of their healthcare team improving
the outcome of their care.
We have learned how the bacteria in the oral cavity causes systemic
concerns. It seems obvious that the bacteria would travel throughout a
persons body, especially their lungs. This article put it into perspective as to
how often this affects the overall health of the population. Most people think
of the mouth and body separate. Meaning that if they have a cavity from
too much pop that this wouldnt hurt their lungs. It is critical to educate
each patient not only how to care for themselves, but how it does affect the
whole body and health.
It also seems like a given that the elderly or people already
compromised would have difficulties in keeping good oral hygiene. We have
also learned about many tools people can use at home to assist in their oral
hygiene care. Coupling this knowledge with our ability to educate the
patient would help influence the best homecare possible. Extending this
education to other health care providers that are caring for them is a huge
step in advancing their care. With nosocomial pneumonias being a major
cause of morbidity and mortality among vulnerable patients it is critical to
not only improve their home or hospital care, but to do a thorough job with
their exam and scaling as well.

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.
Mishler, O.P., RDH, MS and Shiau, H.J., DDS, DMSc (2014). Management of
Peri-Implant Disease: A Current Appraisal. The Journal of Evidence-Based
Dental Practice, Annual Report Series, June, 53-59.

In todays dental practices implants are commonly used in place of

missing teeth. The implant structures are made with titanium posts that are
surgically placed into the alveolar bone. These collect biofilm just like
natural teeth and are susceptible to complications and disease as well. Good
home care and regular maintenance appointments are key to managing the
health of these implants and the surrounding tissues. Initially the implants
may cause some inflammation during the healing process. Biofilm
containing gram negative organisms, similar to those found in chronic
periodontitis, can adhere to the implants. If not regularly removed the
biofilm colonizes and causes peri-mucositis, similar to gingivitis. If this
continues to advance it will progress into peri-implantitis, similar to
periodontitis.
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I agree that the clinician plays a key role in assessing the health of the
implant sites. This is done by checking for BOP, probing depths, suppuration,
recession, and bone loss utilizing radiographs. Routine checks are critical for
early detection and management.
The role I will play as an RDH will not be to only scale and educate the
patient on oral hygiene. I will also need to help change the incorrect
perception that implants are not vulnerable to disease.
We have learned that an implant is scaled in the same way as a natural
tooth. The difference is that you should use a tip that is less hard than the
titanium of the implant. A clinician will probe and scale using the same
technique and angulation that we have been practicing. We should direct
the patient toward using a dentifrice that contains triclosan, such as Colgate
Total toothpaste Triclosan will help to reduce inflammation and the number
of gram negative organisms on the implant site.
Implants are surgically placed into the alveolar bone. This means that
there is a lack of strength due to no natural attachment. If there is bone loss
the implant will be mobile. I found it interesting that the mucosa actually
forms an extra seal after surgery that gives an additional protection from
bacteria.
If peri-mucositis progresses into peri-implantitis then a microbial, such
as minocycline, may be beneficial in treatment also. Yet, if the bone loss
persists surgical intervention will be necessary to create an elevated gingival
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flap for better access and cleaning. The surface of the implant can be
smoothed so that it retains less plaque. Regenerative approaches can also
help by filling in bone loss with grafting.
The main focus should be to keep the oral cavity of these patients
healthy, as with all patients, and to fully educate them about bacteria and
the development of biofilm. If inflammation and disease begin then
detection, management, and treatments are crucial.

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