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Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017
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Image courtesy of Medscape.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A systematic evaluation of the oral hard and soft tissues can provide clinicians with much information regarding a patient's health. Although the primary objective of an oral examination is to distinguish between health and disease, a comprehensive oral examination—in conjunction with a thorough medical and dental history—can also provide valuable insight into a patient's overall health and well-being.[1,2] Can you can identify the causes of the oral cavity abnormalities in the following cases?
Image courtesy of Medscape.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A patient presents with exposed, necrotic bone in the left anterior maxilla. What is the most likely diagnosis?
Alveolar osteitis (dry socket)
Medication-related osteonecrosis of the jaws
Osteomyelitis
Osteosarcoma
Image courtesy of Medscape.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: B. Medication-related osteonecrosis of the jaws (MRONJ).
Shown is a case of stage 1 MRONJ of the right mylohyoid ridge area. The workup for cases of MRONJ includes exploring and excluding diagnoses of osteomyelitis and primary and metastatic bone neoplasms. In the case of recent tooth extraction, alveolar osteitis should also be considered. MRONJ can be seen in patients taking a range of medications, including anti-resorptive and anti-angiogenic agents, that are given for cancer therapy and osteoporosis. The most well-known class of causative drugs are bisphosphonates, particularly those given intravenously. These drugs inhibit osteoclast function and disturb bone remodelling. Patients usually present with exposed bone, halitosis, and pain. Pathologic fractures and infections can also be seen. Dental trauma, such as tooth extraction and dento-alveolar surgery are among the common risk factors for the development of MRONJ, although this condition may occur spontaneously. Treatment of MRONJ includes the use of topical and systemic antibacterials and antifungals. Nonvital bone sequestra may be removed surgically in patients with advanced MRONJ. Dental treatment is best limited to less invasive procedures.[3]
Image courtesy of Claudia C Cotca, DDS, MPH.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A patient presents with complaints of soreness that has lasted for several days or more and the inability to eat comfortably. The recent medical history of this patient includes cancer therapy, compromised dentition and other oral lesions.
What is the diagnosis of this lesion on the tongue that is approximately 7-8mm in the relaxed tongue position?
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: C. Radiation & chemotherapy induced oral ulcer lesion
One of the important diagnoses to be considered when a patient with a history of cancer presents with an ulcer on the lateral border of the tongue is squamous cell carcinoma. Initially, traumatic causes should be eliminated and the patient reviewed. However, in this particular case, there is a known history of cancer therapy (chemotherapy and/or radiation therapy) which is a well-known cause of chemotherapy- or radiation therapy-induced oral mucositis. Oral presentations of these changes may range from erosions or erythema to large, painful ulcers that make eating very difficult, and thus contribute to malnourishment, further exacerbating the patient's condition. These ulcers may also be accompanied by xerostomia and herpetic and candidal infections, which may be fatal in patients with immunosuppression. Current targeted treatment strategies include cryotherapy with ice chips, low-level laser therapy, anti-inflammatory and anti-microbial treatment in addition to growth factors, such as palifermin, to enhance the healing of oral mucosal lesions.[4]
Shown is an ulcerative oral mucositis lesion on the buccal mucosa.
Image courtesy of the US Centers for Disease Control and Prevention (CDC) | Susan Lindsley.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A 30-year-old female complains of "odd-looking teeth" (shown), which she has had for as long as she can remember. She does not have any pain or discomfort. On examination, her gingival health is normal, with little inflammation present. Percussion tests and pulp tests reveal that her teeth are vital.
What caused the appearance of these teeth?
Abrasion
Multiple carious lesions
Congenital syphilis
Trauma
Image courtesy of the CDC | Robert E. Sumpter.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: C. Congenital syphilis
An increase in the incidence of primary and secondary syphilis (19%) and congenital syphilis (6%) was reported in the U.S. from 2014 to 2015.[5] Patients with congenital syphilis have incisors with a straight-edge, screwdriver shape and a notch in the middle of the incisal surface (called Hutchinson's incisors). The molars have numerous globular projections, resulting in abnormal occlusal anatomy (called mulberry molars) with a narrow occlusal table. In addition, a short maxilla and a high-arched palate contribute to malocclusion.[2,6]
Image courtesy of Wikimedia Commons | James Heilman, MD.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
The gingiva of a 12-year-old patient presenting with pain appears erythematous (shown) at times with hypertrophic irregular collar pegs, and poor oral hygiene is noted. Multiple ulcers are present on the tongue and lips. The patient has a temperature of 103°F, and swollen cervical lymph nodes are present.
What disease pathology does this patient have?
Hand-foot-and-mouth disease
Herpangina
Aphthous stomatitis
Herpetic gingivostomatitis
Image courtesy of Sheldon Mintz, DDS.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: D. Herpetic gingivostomatitis
Typical signs of herpetic gingivostomatitis are small vesicles that rupture easily and form shallow, punctate ulcers (shown). As these lesions develop, they will form a central area of shallow ulceration with yellow fibrin in the middle. This is accompanied by fever, malaise, and lymphadenopathy. Unlike patients with herpangina or hand-foot-and-mouth disease, those with herpetic gingivostomatitis may present with lesions on the lips, buccal mucosa, tongue, and hard palate. In recurrent herpes simplex infections, the keratinized mucosa is usually affected. It is unusual for healthy individuals with sound immune systems to have recurrent herpetic gingivostomatitis. Instead, local trauma may predispose to reactivation and the development of localized crops of ulcers in the affected mucosa. The lesions usually resolve within 1 week.[7]
Image courtesy of Wikimedia Commons | James Heilman, MD.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A 14-year-old patient presents with a severe sore throat, fever, and fatigue. Clinical examination reveals tonsillitis with surface exudate (shown), as well as numerous petechiae on the soft palate.
Which virus does this patient have?
Herpes simplex virus 1
Coxsackievirus
Epstein-Barr virus
Varicella zoster virus
Image courtesy of the CDC | Emory University, Dr Sellers.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: C. Epstein-Barr virus
The majority of the population have asymptomatic subclinical infection of Epstein-Barr virus. Patients present with prolonged fatigue, malaise, and sore throat. On examination, patients infected with Epstein-Barr virus commonly have prominent lymphadenopathy, along with pharyngitis, palatine petechiae (shown), and lingual tonsillar enlargement, and less commonly but more specifically, edema of the uvula. On occasion, surface exudate is present on the tonsils. Rare complications include hyperplastic circumvallate papillae, which can compromise the airway. Petechiae on the hard or soft palate can be present. Airways should be monitored in patients with severe enlargement of the tonsils. Many of these signs/symptoms last 4-6 weeks.[8]
Image courtesy of Wikimedia Commons | Dr. David J. Midgley.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A 5-year-old boy presents with multiple vesicles around his lips (shown), fever, and a slight sore throat.
Which virus does this patient have?
Herpes simplex virus 1
Coxsackievirus
Epstein-Barr virus
Varicella zoster virus
Image courtesy of Wikimedia Commons | Shawn C.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: B. Coxsackievirus
Coxsackievirus A16 is the most common cause of hand-foot-and-mouth disease. The most commonly involved oral sites are the tongue, palate, buccal mucosa, and labial mucosa. Signs/symptoms include sore throat, dysphagia, and low-grade fever. The lesions start as erythematous macules that develop into small vesicles that later ulcerate. Although oral vesicles do not typically appear in the oropharyngeal area and are generally confined to the anterior region of the mouth, ulcerous lesions can appear on the soft palate and oropharynx (shown in a different patient). In herpangina, on the other hand, the vesicles and ulcers are confined to the oropharyngeal sites.[9] The size of the oral lesions in hand-foot-and-mouth disease can range from 2-7 mm, although they can be as large as 1 cm. The disease is self-limited, lasting 1-2 weeks; no treatment is necessary.[10]
Image courtesy of the CDC | Sol Silverman, Jr, DDS.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A 48-year-old man presents to the doctor's office because bumps are appearing all over his body. He also thinks that he has a bruise in his mouth. He was recently tested for sexually transmitted diseases, but the results are still pending. On examination, a dark purple patch is present on the hard palate without ulceration.
What disease does this patient have?
Pyogenic granuloma
Hematoma
Kaposi sarcoma
Non-Hodgkin lymphoma
Image courtesy of the CDC | Sol Silverman, Jr, DDS.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: C. Kaposi sarcoma
Kaposi sarcoma lesions (shown) are typically located on the hard and soft palates; occasionally, they may occur on the maxillary gingiva. They are reddish to blue-purple, nodular or macular lesions that are found bilaterally.[11] While these lesions were seen in an immunocompromised patient's systemic profile, in the early 1990s, when the acquired immunodeficiency syndrome (AIDS) epidemic was at its peak, patients with the human immunodeficiency virus (HIV) had a 1 in 2 chance of developing Kaposi sarcoma. With currently available HIV treatment, however, only six patients with HIV per million in the United States will ever develop Kaposi sarcoma.[12] However, Kaposi sarcoma is still strongly associated with AIDS and in some cases it might be the first clinical sign of the disease. The treatment for HIV-related Kaposi sarcoma is antiretroviral therapy (ART).[13] The patient in this image is HIV positive and has candidiasis overlying the intraoral Kaposi sarcoma lesion (arrow).
Image courtesy of Medscape.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
During a routine physical examination, a 53-year-old man is curious about the painless discoloration on his gums. He states that it has been present all of his life. Several cutaneous pigmentations can also be seen on the attached gingiva, buccal mucosa, and perioral regions.
What is the cause of the pigmentation?
Hematoma
Peutz-Jeghers syndrome
Amalgam tattoo
Gingival pigmentation
Image courtesy of Medscape.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: B. Peutz-Jeghers syndrome
The oral lesions of Peutz-Jeghers syndrome (shown) usually develop in early childhood and are often mistaken for freckles. Intraoral pigmented lesions primarily affect the buccal mucosa and tongue. In addition, the pigmentation spots can cross the vermilion border of the lips (shown in a different patient) and extend into the perioral regions. Patients with Peutz-Jeghers syndrome should be monitored for intestinal tumors, polyps, and intussusception, as they are 15 times more likely to develop intestinal cancer than the general population.[14,15]
Image courtesy of the CDC | Drs. J. Lieberman and Freideen Farzin.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A 65-year-old man is experiencing soreness in his mouth, and he has a sore spot on his inner cheek (shown) that has been slowly enlarging. On examination, an erythematous, denuded surface is noted on the buccal mucosa.
What disease does this patient have?
Pemphigus vulgaris
Erosive lichen planus
Pemphigoid
Erythema multiforme
Image courtesy of the CDC | Drs. J. Lieberman and Freideen Farzin.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: A. Pemphigus vulgaris
Oral lesions are present in 50-70% of patients with pemphigus vulgaris. Superficial, ragged erosions with ulcerations occur on the oral mucosa (shown), the buccal and labial mucosae, soft palate, and gingivae being common sites. Areas exposed to chronic abrasion during teeth brushing and constant frictional activity can cause more symptomatic erosive lesions. A majority of patients will exhibit oral mucosal lesions prior to cutaneous lesions. The blisters formed in pemphigus vulgaris are associated with the binding of immunoglobulin G (IgG) to keratinocyte adhesion molecules desmoglein 1 and 3, resulting in loss of cell-to-cell adhesion. At times, mucosal lesions may be the only clinical manifestation of pemphigus vulgaris. The mortality rates are 5-10%.[16]
Image courtesy of Medscape.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A 44-year-old female is concerned about a white streak on her lower inner cheek (shown). She is unsure when it first appeared. It does not hurt or cause any discomfort. On examination, the streak does not wipe off, and it does not disappear when the mucosa is stretched.
What is the cause of white streaks on the oral mucosa?
Leukoedema
Lichen planus
Leukoplakia
Candidiasis
Image courtesy of Medscape.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: B. Lichen planus
Lichen planus is a chronic immune-mediated inflammatory disease in which the antigen is a self-peptide. The most common pattern of oral lichen planus is the reticular form which consists of interlacing raised, thin, white lines known as Wickham's Striae (shown on the previous slide). Variations in these lesions include appearance as papules or plaques (shown), and in erosive lichen planus they often manifest as painful lesions. Oral lichen planus is typically symmetrical and occurs primarily on the buccal mucosa, buccal vestibule, tongue, and gingiva.[17] Clinically identical lesions include lichenoid drug eruptions, which may be unilateral. Certain cases with the clinical appearance of erosive lichen planus can be resistant to treatment. In such instances, a diagnosis of chronic ulcerative stomatitis should be considered.[18] Malignant transformation of oral lichen planus can be seen in approximately 1% of cases, particularly those with the erosive type.[19]
Image courtesy of Medscape.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A 25-year-old man who was recently hospitalized for epileptic seizures states that his teeth (shown) are "shrinking." He admits that he has not been able to afford to go to the dentist for a regular checkup, but he has never experienced anything like this before. On examination, generalized gingival hyperplasia with calculus deposits is noted.
How do you treat this patient?
Refer to the dentist for a cleaning and checkup.
Refer to the primary physician for the possibility of altering the patient's medications.
Refer to a rheumatologist for a possible autoimmune disorder.
Order a biopsy, and refer the patient to an oncologist
Image courtesy of Medscape.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: B. Refer to the primary physician for the possibility of altering his medications.
In drug-induced gingival hyperplasia, disruption of normal gingival collagen degradation results in enlargement of the gingiva. The gingival enlargement typically begins in the interdental area and continues until the crown is obscured (shown in a different patient). Painful erythematous edges can manifest depending on the medically compromised state of the patient. The main culprits in drug-induced gingival hyperplasia are anticonvulsant agents (eg, carbamazepine, phenobarbital, phenytoin), calcium channel blockers (eg, nicardipine, nifedipine, verapamil), and immunosuppressants in transplant protocols such as cyclosporine, oral contraceptives, and erythromycin. The patient's speech and mastication may be affected. In general, changing the medication regimen may resolve the gingival hyperplasia, however, laser or conventional scalpel gingivectomy/ gingivoplasty surgical treatment is often necessary if the enlargement is not resolved after medication is reduced, proper oral hygiene is maintained, or after a short regimen of antibiotics.[20] Increased risk for decay and periodontal advancement remains a concern, however, while routine oral hygiene and plaque control improve the prognosis, additional treatments may be necessary to address the implications of the patient's compromised systemic profile.
Image courtesy of Wikimedia Commons | Dozenist.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A 27-year-old woman complains of dental sensitivity. On examination, several of her teeth exhibit severe facial and interproximal decay (shown).
What is the cause of the tooth decay?
Bulimia
Gastroesophageal reflux disease (GERD)
Abrasion of teeth
Methamphetamine use
Image courtesy of Wikimedia Commons | Dozenist.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: D. Methamphetamine use
Methamphetamine use can cause carious lesions (shown), which initially affect the facial smooth and interproximal regions of the tooth (arrows) and eventually lead to destruction of the entire crown. The severity of the tooth decay is most likely a result of both psychological and physiologic changes. Stimulation of the central nervous system can cause extreme xerostomia and result in patients consuming great quantities of sugary and acidic drinks. Periodontal disease and tooth loss can be seen at higher rates in methamphetamine users compared to non-users. In patients with bulimia or GERD, the dental damage is primarily from the palatal side rather than the facial surface. If the patient is receptive to treatment, recommend topical fluorides and encourage consumption of water rather than sugary, carbonated drinks.[21]
Image courtesy of the CDC | Sol Silverman, Jr, DDS.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
A 47-year-old man noticed a white patch in his mouth (shown) a few weeks ago. He is able to wipe the patch off, but it comes back. The patient is also experiencing a burning sensation in his mouth, and there is an unpleasant taste as well.
What could be the cause of this white plaque formation?
HIV infection
Use of systemic steroids
Chronic xerostomia
All of the above
Image courtesy of Wikimedia Commons | James Heilman, MD.
Clues in the Oral Cavity: Are You Missing the Diagnosis?
Willard J. Peng, DDS MS; Claudia Camelia Cotca, DDS, MPH | September 13, 2017 | Contributor Information
Answer: D. All of the above
Candida albicans causes pseudomembranous candidiasis (thrush) when normal host immunity or normal host flora is disturbed. A superficial layer of white curds will appear on various intraoral sites, including the tongue (shown); the white coating/patches can be easily removed with a tongue depressor or a piece of gauze, and the underlying mucosa may appear normal or erythematous. An impaired or altered immune system, as from chemotherapy or conditions such as Sjögren syndrome, HIV infection (see earlier slide on Kaposi sarcoma), or diabetes mellitus, may induce the formation of thrush. In addition, the use of broad-spectrum antibiotics can eliminate competing bacteria, thereby allowing overgrowth of C albicans.[22]
Cutaneous Clues to Accurately Diagnosing Rheumatologic Disease
Rheumatologic diseases have a wide variety of cutaneous manifestations that can be difficult to identify. Are you able to recognize these skin presentations in your patients?Slideshows, May 2016
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Contributor Information
Authors
Willard J. Peng, DDS, MS
Dentist
Scripps Poway Dental Care
San Diego, CA
Disclosure: Willard J. Peng, DDS, MS, has disclosed no relevant financial relationships.
Claudia Camelia Cotca, DDS, MPH @dclaserdentist
Washington Institute For Dentistry & Laser Surgery
Chevy Chase, MD
Disclosure: Claudia C. Cotca, DDS, MPH, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
Clinical Associate
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Muhammed Yakin, BDS MMedSci DClinDent
Senior lecturer in oral pathology
School of Dentistry and Health Sciences
Charles Sturt University
New South Wales
Australia
Disclosure: Muhammed Yakin, BDS MMedSci DClinDent, has disclosed no relevant financial relationships.
Neville BW, Damm DD, Allen CM, Chi AC. Oral and Maxillofacial Pathology. 4th ed. St. Louis, Mo: Elsevier 2016.
Blanchaert RH. Bisphosphonate-Related Osteonecrosis of the Jaw Treatment & Management. Medscape Drugs & Diseases. Updated March 8, 2017. Available at: http://emedicine.medscape.com/article/1447355-overview. Accessed August 20, 2017.
Lalla RV, Saunders DP, Peterson DE. Chemotherapy or radiation-induced oral mucositis. Dent Clin North Am. 2014;58:341-9. PMID: 24655526
US Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2015. Atlanta: U.S. Department of Health and Human Services; 2016. https://www.cdc.gov/std/stats15/default.htm Accessed August 17, 2017.
Gompf SG. Herpangina. Dermatologic Manifestations of Hand-Foot-and-Mouth Disease. Medscape Drugs & Diseases. Updated June 16, 2017. Available at http://emedicine.medscape.com/article/218502-overview. Accessed August 17, 2017.
World Health Organization. Guidelines on the Treatment of Skin and Oral HIV-Associated Conditions in Children and Adults. 2014. Available at: http://www.ncbi.nlm.nih.gov/pubmed/26203484. Accessed August 17, 2017.
Gondak RO, da Silva-Jorge R, Jorge J, Lopes MA, Vargas PA. Oral pigmented lesions: clinicopathologic features and review of the literature. Med Oral Patol Oral Cir Bucal. Nov 1, 2012;17(6):e919-24. PMID: 22549672
McMillan R, Taylor J, Shephard M, et al. World Workshop on Oral Medicine VI: a systematic review of the treatment of mucocutaneous pemphigus vulgaris. Oral Surg Oral Med Oral Pathol Oral Radiol. Aug 2015;120(2):132-142.e61. PMID: 25934414
Qari H, Villasante C, Richert J, Rees T, Kessler H. The diagnostic challenges of separating chronic ulcerative stomatitis from oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;120:622-7. PMID: 26337216
Laudenbach JM. Malignant Potential of Oral Lichen Planus/Lichenoid Lesions. Medscape News and Perspectives. Published May 31, 2017. Available at http://www.medscape.com/viewarticle/880491. Accessed August 17, 2017.
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