DIAGNOSIS

OF
ORAL
MUCOSAL
LESIONS Dr. Damanpreet Isher
Professor & Head
DEPARTMENT OF ORAL MEDICINE &
RADIOLOGY
 “DIAGNOSIS IS NOT THE END, BUT THE BEGINNING OF
PRACTICE”
- MARTIN FISCHER

DIAGNOSIS IS THE ART OF IDENTIFYING THE DISEASE –

DEFECTS, DEFORMITY, DYSFUNCTION AND DIFFERENTIATE
FROM ONE ANOTHER BY SCIENTIFIC METHODS

IT FORMS THE BASIS OF ANY CLINICAL JUDGEMENT.

DIAGNOSIS OF DISEASE HAS ALWAYS BEEN THE CORNERSTONE

OF DENTAL PRACTICE.
 PROPER HISTORY TAKING IS AN
“THE ART OF CLINICAL INTEGRAL PART OF A DENTAL
DIAGNOSIS LIES IN THE TREATMENT PLAN AND FORMS THE
FOUNDATION OF A SUCCESSFUL
ABILITY TO ASK THE RIGHT DENTAL PRACTICE.
QUESTIONS”

A STELLAR DIAGNOSIS AND

AN APT TREATMENT PLAN
ARE WHAT MAKE YOU A
GOOD DENTIST, A RELIABLE
CLINICIAN AND A REPUTED
DOCTOR
 THE ADVENT OF MODERN CLINICAL
RESEARCH, PRECISE DIAGNOSTIC
TOOLS AND ADVANCED IMAGING
TECHNIQUES HAS STARTED A BRAND
NEW ERA IN DENTISTRY THEREBY
WIDENING ITS HORIZONS AND
CONTRIBUTING MEANINGFULLY TO
THE GROWTH OF DENTISTRY.
 THE SCOPE OF THIS FIELD IS VERY VAST,
CONSIDERING THE PLATFORM TODAY I
HOPE AND I SHALL TRY MY BEST TO
COVER ALL THE BASIC ASPECTS OF
COMMONLY ENCOUNTERED ORAL LESIONS
IN A DENTAL OFFICE WHICH SHALL
BENEFIT US ALL IN FUTURE, NOT
WITHSTANDING ANY SPECIALITIES
 ORAL ULCERS
• “Appears as a breach or break in the continuity
of the skin, mucous membrane or surface
epithelium due to molecular necrosis covered by
granulation tissue”
MALIGNANT ULCER

• THEY CAN BE CLASSIFIED AS:

- ACUTE OR CHRONIC

- SOLITARY OR MULTIPLE

- RECURRENT/ NON RECURRENT MAJOR RECURRENT APHTHAE

 RECURRENT APHTHOUS STOMATITIS /CANKER SORES
MINOR
• 80 % of cases
• AGE OF ONSET: 10-19 YRS
• NUMBER OF ULCERS: 1-5
• SIZE: <10MM
• DURATION: 7-14 DAYS
• HEAL WITHOUT SCARRING
MAJOR HERPETIFORM
• 5-10% of cases
• 10-15% of cases
• AGE OF ONSET: 20-29 YRS
• AGE OF ONSET: 10-19 YRS
• NUMBER OF ULCERS: 10-100
• NUMBER OF ULCERS: 1-10
• SIZE: 1-2 mm ( Multiple, recurrent crops,
• SIZE: >10MM
pin sized discrete, often coalesce)
• DURATION: >30 DAYS
• DURATION: 10-30 DAYS
• HEAL WITH SCARRING
• HEAL WITHOUT SCARRING
 HERPES SIMPLEX INFECTION

ACUTE HERPETIC GINGIVO-STOMATITIS/ HERPES LABIALIS/ FEVER BLISTER/ COLD SORE/ INFECTIOUS STOMATITIS

• CHRONIC CLUSTERS OF EROSIVE/VESICULAR LESIONS ON KERATINIZED SURFACE, WITHOUT AN

ERYTHEMATOUS PERIPHERY
• SUDDEN ONSET OF MULTIPLE PAINFUL VESICULAR LESIONS ON AN ERYTHEMATOUS BASE
• GENERALLY LASTS FOR 10—14 DAYS, CONTAGIOUS
• PRODROMAL SYMPTOMS PRECEDE WHICH INCLUDE FEVER, CHILLS, MALAISE . ALSO ASSOCIATED
WITH BURNING, TINGLING, IRRITABILITY, PAIN UPON SWALLOWING AND REGIONAL
LYMPHADENOPATHY IN THE LOCALZED AREA
 TRAUMATIC ULCER
• APPEARANCE: MOVABLE BASE, WELL CIRCUMSCRIBED,
ROLLED, EVERTED, WHITE HYPERKERATOTIC BORDERS
COVERED WITH PSEUDOMEMBRANE.
• PERIPHERY: WHITISH AND HYPERKERATINIZED IN CONTRAST
TO ERYTHEMATOUS PERIPHERY OF MINOR APHTAHE
• CAUSATIVE FACTORS: CHEEK BITING, SHARP CUSPS,
BROKEN RESTORATIONS ETC.
• NO SPECIFIC SIZE AND SHAPE
• APPEARS AS A SINGLE ENTITY

IF THE ULCER REMAINS UNHEALED

FOR OVER A MONTH, GO FOR BIOPSY ULCER DUE TO SHARP
MARGIN
 TRAUMATIC ULCER APHTHOUS STOMATITIS

• SITE: ANYWHERE • SITE: NON-KERATINZED MUCOSA

• SIZE: NON SPECIFIC • SIZE: <1CM
• SHAPE: NON SPECIFIC • SHAPE: ROUND/ OVAL
• NUMBER: SINGLE ENTITY • NUMBER: MULTIPLE
• PERIPHERY: WHITISH AND HYPERKERATINIZED • PERIPHERY: ERYTHEMATOUS WITH A YELLOWISH
CENTRE
 MALIGNANT ULCER

CHRONIC ULCER LEADING TO SQUAMOUS CELL CARCINOMA

• INDURATED BASE FIXED TO THE UNDERLYING TISSUE

• SPREADS LOCALLY AND THEN TO REGIONAL LYMPH NODES
• BIOPSY IS CONFIRMATORY
 MANAGEMENT
1) PALLIATIVE
• TOPICAL ANAESTHETICS: - BENZOCAINE GEL – ORABASE GEL, MUCOPAIN GEL (TWICE DAILY FOR 7 DAYS)
- DICLOFENAC SODIUM - 1% DICOGEL (TWICE DAILY FOR 7 DAYS)

• ANTISEPTIC MOUTH RINSES: 0.2% CHX MOUTHWASH (TWICE DAILY FOR 7 DAYS)

• TETRACYCLINE RINSE (250mg CAPSULE IN 50ml WATER QID * 5 DAYS) IN RECURRENT ULCERS AND TO DECREASE SEVERITY

TOPICAL CORTICOSTEROIDS:

• TRIAMCINOLONE ACETONIDE 0.1% IN ORABASE PASTE, eg: KENACORT, KENALOG OINTMENT (TWICE DAILY FOR 7-10 DAYS)

• FLUOCINONIDE 0.05% GEL - SUPRICOL, LIDEX GEL (HIGH POTENCY) (TWICE DAILY FOR 7-10 DAYS)

• CLOBETASOL 0.05% - TENOVATE CREAM (SUPER HIGH POTENCY) (TWICE DAILY FOR 7-10 DAYS)

• BETAMETHASONE 0.5 mg - TABLETS AS MOUTHWASH – (4 TIMES A DAY FOR A WEEK) - BETNESOL RINSES

IMMUNOMODULATORS:

• AMLEXANOX 5% ORAL PASTE “WONDER DRUG” (ANTI-INFLAMMATORY ANTI-ALLERGIC IMMUNOMODULATOR)- VERY EFFECTIVE
IN PRODROME PHASE; IS BENEFICIAL IN PREVENTING IT’S OCCURRENCE (4 TIMES DAILY* 10 DAYS) - LEXANOX ORAL PASTE,
APTHASOL ORAL PASTE

• REBAPIMIDE AMINO ACID DERIVATIVE MUCOPROTECTIVE AGENT FOR SCAVENGING FREE RADICALS
(100MG TID * 7 DAYS) –TAB REBAGEN
• LEVAMISOLE (ANTI-HELMINTHIC IMMUNE POTENTIATING DRUG- RESTORES DEFICIT PHAGOCYTIC
FUNCTION AND IS USED IN RECURRENT CASES TO POSTPONE THE EPISODES (150mg OD * 1WEEK) – TAB
ERGAMISOLE, TAB LEVOMOL, TAB VERMISOLE

• THALIDOMIDE - ANTINEOPLASTICS, FOR REFRACTORY, RECURRENT ULCERS IN IMMUNOCOMPROMISED

CASES (100mg OD * 15 DAYS) – CAP THAANGIO, CAP THALIMAX, CAP THALOMID

2) VITAMIN AND MINERAL SUPPLEMENTS

• VIT C – TAB. LIMCEE 500mg OD*15 DAYS
• IRON AND FOLIC ACID - TAB. LIVOGEN OD*15 DAYS
• VIT B12 – TAB. NEUROBION , TAB. MECOBALAMIN 12 OD*15 DAYS
•

3) FOR VIRAL ETIOLOGY

• AVOID ANY PERSONAL CONTACT WITH OTHERS TO LIMIT THE DISEASE
• FOLLOWING A SOFT, BLAND DIET WITH ADEQUATE HYDRATION IS IMPORTANT
• PRESCRIBE SUNSCREEN TO AVOID UV RAYS

• ANTIVIRALS
• TOPICAL : 5% ACYCLOVIR 5 TIMES A DAY * 4 DAYS – ZOVIRAX OINTMENT
: 1% PENCYCLOVIR EVERY 2 HOURS FOR 4 DAYS – DENAVIR OINTMENT
(BETTER ABSORPTION AT VERMILLION BORDERS THAN ACYCLOVIR)
 LEUKOPLAKIA
“A white patch or plaque in the oral cavity which cannot be scrapped off or stripped off easily & more over, which cannot
be characterized clinically or pathologically as any other disease”

Homogeneous-asymptomatic Proliferative verrucous leukoplakia

Speckled Leukoplakia Verrucous leukoplakia
CRACKED MUD APPEARANCE (PVL)
ETIOLOGY
1. SMOKING – 80% OF THE CASES. CRONIC IRRITATION FROM TOBACCO
- Unilateral
2. ULTRAVIOLET RADIATION - LEUKOPLAKIA OF THE LOWER LIP VERMILION. - Habit oriented
- Non- scrapable
3. MICROORGANISMS - CANDIDA ALBICANS , HPV-16 AND HPV -18.
- Extends from the
4. VITAMIN DEFICIENCY - DEFICIENCY OF VITAMIN A PRODUCES METAPLASIA AND anterior part of the
KERATINIZATION OF CERTAIN EPITHELIAL STRUCTURES. PATIENTS WITH LEUKOPLAKIA SHOW LOWER mouth towards the
SERUM LEVELS OF VITAMIN A posterior end 14

5. SANGUINARIA - RINSES CONTAINING THE HERBAL EXTRACT SANGUINARIA

A BIOPSY IS INDICATED IF:
- THE FLOOR OF THE MOUTH, LATERAL
BORDER OR THE TONGUE, VENTRAL
SURFACE OF THE TONGUE, SOFT PALATE
- FEMALE PATIENT
- NON-SMOKER
- NON-HOMOGENOUS
- RESISTANT LESIONS

POTENTIALLY MALIGNANT
MALIGNANT TRANSFORMATION RATE IS 8.9 to 17.5%

PREVALENCE:
- PREVALENCE RATE VARIES FROM 0.2 TO 5.2% IN
INDIA.
- MALE PREDILECTION
 MANAGEMENT
- REMOVE THE IRRITANT, STOP THE ADVERSE HABITS

CONSERVATIVE TREATMENT
a) Retinoids - High doses of Vitamin A is known to cause complete remission of Leukoplakia. (Increased Bioavailability)

- Acitretin 0.25 - 1 mg per kg body weight

b) Lycopene (most efficient biological anti-oxidant agent)

c) Beta Carotene (anti-oxidizing action) – Antoxid capsule 30 mg

d) Vitamin C and E - Tab. TISSOT OD*15 DAYS

NON- CONSERVATIVE TREATMENT

- Surgical (Knife) excision
- Excision by Laser
- Excision by Cryosurgery
 LEUKOEDEMA
NORMAL VARIATION OF THE MUCOSA

- Faint milky appearance with

folded and wrinkled pattern as
compared definite whiteness of
leukoplakia.
- Lesions do not rub off.
- Bilateral
Diffuse white Whiteness
TREATMENT : disappears when
- No treatment indicated. appearance of the
- No malignant change has been buccal mucosa the cheek is
reported. stretched17
 CHEEK BITING (MORSICATIO BUCCARUM)
- Generally one cheek is worse than the
other
- Once the habit is detected, the diagnosis is
made
- Produces a rough, scrapable, corrugated,
thickened, shredded, white area with
tissue tags which may be combined with
intervening zones of erythema, erosion,
or focal traumatic ulceration at the level MANAGEMENT
Discontinuation of habit
of occlusal plane
- A higher prevalence has been found in Morsicatio = Bite
Buccal mucosa = morsicatio buccarum
people who are under stress or who exhibit
Labial mucosa = morsicatio labiorum
psychologic conditions. Lateral border of the tongue = morsicatio linguarum
 FRICTIONAL KERATOSIS
(FOCAL HYPERKERATOSIS)

• NON-SCRAPABLE, WHITE IRREGULAR PLAQUES

• ASSOCIATED WITH HYPERKERATOSIS, WHICH IS
BODY’S RESPONSE TO CHRONIC IRRITATION
• ETIOLOGY: CHRONIC MECHANICAL IRRITATION
CAUSED BY SHARP EDGES OF TEETH OR
RESTORATIONS, DENTAL PROSTHESIS, ABRASIVE
FOODS, VIGOROUS TOOTH BRUSHING
• SITE: BUCCAL MUCOSA (ALONG THE OCCLUSAL
LINE), LIPS, LATERAL MARGINS OF THE TONGUE,
AND EDENTULOUS ALVEOLAR RIDGES.

TREATMENT: REMOVAL OF THE CAUSATIVE FACTOR

SMOKELESS TOBACCO–INDUCED KERATOSIS
(SNUFF POUCH/ SNUFF DIPPER'S LESION/ TOBACCO POUCH KERATOSIS)

• IT OCCURS IN MUCOSAL SURFACE, WHERE THE QUID IS

HABITUALLY PLACED AND APPEARS AS WHITE
THICKENED AND CORRUGATED, BECOMES MORE
LEATHERY AS THE LESION PROGRESSES
• UNILATERAL, HABIT ORIENTED
• ASSOCIATED WITH CERVICAL ABRASIONS, GINGIVAL
RECESSION
• POTENTIALLY MALIGNANT LESION

MANAGEMENT
Stoppage of habit — maximum lesion
20
regresses following the cessation of habit.
 GEOGRAPHIC TONGUE
(ERYTHEMA MIGRANS/ BENIGN MIGRATORY GLOSSITIS/ WANDERING RASH)
• First described by RAYER IN 1831
• FEMALES > MALES, 1-2% POPULATION
• TENDS TO RUN IN FAMILIES
• ASSOCIATED WITH:
• PSORIASIS , REITER’S SYNDROME , FISSURED
TONGUE ATOPY ALLERGIES , CHRONIC
INFLAMMATORY BOWEL DISEASE, CELIAC
DISEASE,LICHEN PLANUS , HIV , LUPUS
ERYTHEMATOSUS,DIABETES MELLITUS AND
ORAL CONTRACEPTIVES.
• VIT. D , B6 , B12, FOLIC ACID , IRON AND ZINC
DEFICIENCY.
• IT IS ASSOCIATED WITH HORMONAL
DISTURBANCES, EMOTIONAL STRESS AND Appears as serpenginous white lines which are due to
ANAEMIA depapillation of filiform papillae on dorsal or lateral
• ASYMPTOMATIC, ASSOCIATED WITH HALITOSIS, surface of tongue, only to appear in another site in a few
DUE TO ENTRAPMENT OF FOOD days
MANAGEMENT –
 AVOID HOT, SPICY, ACIDIC FOODS , TOBACCO , WHITENING AGENTS, TOOTH PASTE WITH ADDITIVES
 ANTI-INFLAMMATORY
 TOPICAL ANESTHETICS, ANTI-HISTAMINICS, TOPICAL TACROLIMUS ,STEROIDAL RINSES AND
OINTMENTS
 ZINC SUPPLEMENTATION
 VIT. B SUPPLEMENT

* MANY DRUGS CAN ALSO CAUSE THIS CONDITION LIKE ANTI-DEPRESSANTS, PHENOTHIAZINES
AND DIURETICS
 CANDIDIASIS

PSEUDOMENBRANOUS CHRONIC HYPERPLASTIC ERYTHEMATOUS CANDIDIASIS/

CANDIDIASIS/ ORAL THRUSH
• COTTAGE CHEESE OR
CURDLED MILK
APPEARANCE
• Associated with bad taste,
Burning sensation
• HIV INFECTION, DIABETES
MELLITUS
CANDIDIASIS/ CANDIDAL
LEUKOPLAKIA
• Firm white leathery plaques
which are difficult to scrape off.
• POTENTIALLY MALIGNANT-
6.5%
ATROPHIC ORAL CANDIDIASIS
• Diffuse border, which helps
distinguish it from erythroplakia,
which has a sharper
demarcation.
• Associated with prolonged use of
antibiotics 23
 DENTURE STOMATITIS ANGULAR CHEILITIS MEDIAN RHOMBOID GLOSSITIS

CHRONIC ERYTHEMATOUS ANGULAR STOMATITIS/ GLOSSAL CENTRAL

CANDIDOSIS PERLÈCHE PAPILLARY ATROPHY
• VERY COMMON, WITH OVER 50%
OF DENTURE WEARERS AFFECTED • ASSOCIATED WITH • MORE IN ASTHAMATICS
IN SOME POPULATIONS AND SMOKERS
DECREASED VERTICAL
• PREDISPOSING FACTORS: POOR
DIMENSION, DIABETES • FORM OF
ORAL HYGIENE, POORLY FITTING
DENTURES, DIABETES MELLITUS, MELLITUS AND ERYTHEMATOUS
XEROSTOMIA NUTRITIONAL DEFICIENCIES CANDIDOSIS
• MALE> FEMALE • STAPHYLOCOCCUS AND • ASSOCIATED WITH
• GENTIAN VIOLET (UNPLEASANT STREPTOCOCCUS DIABETES MELLITUS
TASTE AND CONSPICOUS INFECTION AND HIV
STAINING OF MUCOSA, AND • VIT B2 AND Fe DEFICIENCY 24
MUCOSAL BURN WITH
SUPERFICIAL NECROSIS)
 MANAGEMENT
• ANTI-FUNGALS

• FLUCONAZOLE (as first line agent in non-neutropenic patients) – 150mg OD* 3 WEEKS – DIFLUCAN,
CANESTEN

* CLOTRIMAZOLE - TOPICAL – GEL 1% 3 TIMES A DAY, CANDID MOUTH PAINT, MYCILEX TROCHES,
- TABLET10 mg 5 TIMES A DAY

• NYSTATIN - TABLET 500000 UNITS, 4-6 ml IN ADULTS 4-6 TIMES A DAY OR ORAL SUSPENSION,
DISSOLVED SLOWLY IN MOUTH, BITTER TASTE
- 6 HOURLY (4 TABLETS DAILY FOR 2-4 WEEKS)
- NYSTATIN OINTMENT- 100000 UNITS PER ml – MYCOSTATIN SUSPENSION, NYLSTAT, NYSTEX DROPS

• AMPHOTERICIN B - FUNGILIN LOZENGES 10 mg, BETTER TASTE, 4 TIMES A DAY (4 LOZENGES DAILY FOR 2 WEEKS)
- FUNGILIN OITMENT (APPLIED TO DENTURE BASE AFTER MEALS IN DENTURE STOMATITIS)
- FUNGILIN CRÈME – DIRECT APPLICATION TO CORNERS OF THE MOUTH IN ANGULAR STOMATITIS

• MICONAZOLE - ORAL GEL , EVERY 6TH HOURLY

- TAB MICONAZOLE – 50 mg MUCOADHESIVE BUCCAL TABLET OD - ORAVIG

• ITRACONAZOLE – 100mg OD* 3 WEEKS – SPORANOX (ONLY GIVEN IF FLUCONAZOLE IS RESISTANT)

 MANAGEMENT

TOPICAL SYSTEMIC
NYSTATIN (1,00,000 UNITS)
 MANAGEMENT
CHLORHEXIDENE MOUTHWASH

VITAMINS
VIT B COMPLEX
VIT C

PROBIOTICS:
INSTAMELT POWDER (SACHET BD* UPTO 2 WEEKS)
BIFILAC LOZENGES (BD* UPTO 2 WEEKS)
ENTEROGERMINA AMPULES
PROBIOTIC YOGURT

MISCELLANEOUS
Salt water gargles.
Solution of water and baking soda/ lemon juice / apple cider vinegar
 LICHEN PLANUS

RETICULAR ANNULAR (MOST COMMON) EROSIVE

ATROPHIC BULLOUS HYPERPLASTIC

LEUKOPLAKIA LICHEN PLANUS
 MANAGEMENT
• CORTICOSTEROIDS
a. TOPICAL
• TRIAMCINOLONE ACETONIDE (0.1%) – KENACORT [MID-POTENCY] (3 TIMES/DAY FOR 2 WEEKS)
• CLOBETASOL (0.05%) – TENOVATE [SUPERPOTENT HALOGENATED CORTICOSTEROID] (TWICE DAILY FOR 2 WKS)
• BETAMETHASONE VALEARATE (0.1%) – MICROEMULSION (3 TIMES A DAY FOR 1 MONTH)

b. INTRALESIONAL
• TRIAMCINOLONE ACETONIDE (10 mg/dl) (0.5ml* ONCE A WEEK)– INJ. KENACORT

c. SYSTEMIC
• PREDNISONE TABLETS – 1MG/KG UPTO 50 KGS*10 DAYS – TAB. WYSOLONE

• IMMUNOMODULATORS
• DAPSONE (ANTI-LEPROTIC AND ANTI-INFLAMMATORY, FOR EROSIVE AND ATROPHIC VARIANTS) (100MG OD * 1-3
MONTHS) – TAB ACZONE, TAB DAPSON
• TACROLIMUS OINTMENT 0.03% OR 0.1% W/W - (MACROLIDE IMMUNEMODULATOR)
–(CAN BE GIVEN PACKCED IN NON-EUGENOL PERIODONTAL PACK FOR >3 DAYS)
TACROZ FORTE ORAL GEL – TACVIDO FORTE (0.1% W/W)
• LEVAMISOLE (ANTI-HELMINTHIC IMMUNE POTENTIATING DRUG - RESTORES DEFICIT
PHAGOCYTIC FUNTION AND IS USED IN RECURRENT CASES TO POSTPONE THE
EPISODES (150mg OD * 1 WEEK) – TAB ERGAMISOLE, TAB LEVOMOL, TAB VERMISOLE
• HYDOXYCHLOROQUINE – (ANTIMALARIAL DRUG) -100mg OD * 8 WEEKS

• MICRO-PULSE THERAPY
• 20 mg BETAMETHASONE TABLETS ON WEEKENDS WITH TOPICAL APPLICATION OF
CORTICOSTEROIDS AND IMMUNOMODULATORS ON WEEKDAYS - BD

• FOR EROSIVE AND ATROPHIC LP VARIANTS PRESENTING ON THE GINGIVA

• SOFT BRISTLED BABY TOOTH BRUSH TO BE USED ON THE OCCLUSAL SURFACE OF TEETH,
DORSAL SURFACE OF TONGUE
• WATER JETS
• CARBONBATED SODA – GULP, GARGLE AND SPIT
• AVOID BRISTLES ON BUCCAL/LINGUAL/PALATAL SURFACES
 “A CORRECT DIAGNOSIS IS THREE-
FOURTH THE REMEDY”

• A MISDIAGNOSIS LEADS TO A STALL IN THE PATIENT’S

TREATMENT PLAN AND JEAOPARDISES THE OVERALL
PROGNOSIS.

• BREAKING THE CHAIN OF SEQUELAE OF THE

PROGRESSION OF THE LESION BY INTERCEPTING THEM
IN THE VERY INITIAL PHASE PROLONGS THE
LONGEVITY OF THE PATIENT
Baking soda – inhibitory action against Streptococcus mutans
maintains good ph level in the mouth by neutrilizing acids.
Baking soda prevents gingivitis as it helps to break up bio-film that irritates the gums and useful
for removing superficial stains.
• DIAGNOSIS AND CLINICAL YOU MAKE THE FIELD GREAT BY

ASSESMENT IS THE ESSENCE CHOOSING TO BE GREAT AND

AND PROVIDES A HEADSTART EXCELLENT AT WHAT YOU CHOOSE

FOR FORMULATING AND TO DO, EACH DAY, EACH YEAR,

LAYING THE FOUNDATION OF EACH DECADE.

AN IDEAL TREATMENT PLAN

THANK YOU!