LEUKOPLAKIA - oral medicine notes

 LEUKOPLAKIA 

POTENTIALLY MALIGNANT DISORDER :

•  Risk of malignancy being present in a lesion or condition either during the time of initial diagnosis or at future date 

PRECANCEROUS LESION : 

Benign morphological altered tissue in which cancer is more likely to develop than its normal counterpart :

• leukoplakia 
• Erythroplakia 
• Tobacco pouch keratosis 
• Palatal lesion in reverse smokers 

PRECANCEROUS CONDITION : 

Generalized state or a disease which can be associated with greater than normal risk of cancer development 

• OSMF
• Lichen planus 
• Epidermolysis bullosa 

LEUKOPLAKIA : 

• White plaque of questionable risk having excluded (other)known disease or disorder that carry no risk for cancer 

PLAQUE- 

• Raised lesion that are greater than 1 cm in diameter ,they are essentially large papules 

PAPULE: 

• Lesion raised above skin or mucosal surface that are smaller than 1 cm in diameter 

WHO DEFINITION :

• Non scrapable white patch or plaque that cannot be characterized clinically or pathologically as any other disease

WHY WHITE LESION APPEAR WHITE?

1) Due to increased production of keratin 

2)Acanthosis ( abnormal ,benign thickening of stratum spinosum)

3)Intra and extra cellular accumulation of fluid in the epithelium 

4)Microbe : fungi that produce whitish pseudo membrane and contain sloughed epithelial cells,fungal mycelium,neutrophils loosely attached to  the oral mucosa .

ETIOLOGY :

• Smoking 
• Syphilis
• Sharp tooth
• Spicy food
• Sepsis
• Sunlight 
• Sanguinaria 
• Vitamin A and B deficiency 
• galvanism 

SITES :

• Buccal mucosa and commisures- commonly involved 
• Alveolar mucosa
• Lip
• Tongue
• Hard and soft palate 
• Floor of the mouth 
• Gingiva 

• Tongue+Gingiva -Common site for malignant changes 

CLINICAL FEATURES :

• Gender: male predilection 
• Large white verrucous area to small nodular structure 
• If surface texture appear homogenous but it contain verrucous ,papillary ,exophytic its considered NON HOMOGENOUS 
• Verrucous leukoplakia : aggressive proliferation pattern ,high recurrence rate - proliferative verrucous leukoplakia 

-Women >men 

-Site : lower gingiva 

-Malignant potential high 

TYPES :

HOMOGENOUS 

• Uniform ,white patch ,well demarcated plaque with identical reaction pattern
• Surface texture : smooth,thin,leathery (cracked mud) 
• Malignant transformation : 1- 7%

NON-HOMOGENOUS :

A) Speckled :

mixed white and white areas ,advanced dysplasia in biopsy 

high malignant transformation 

B) Nodular

C) Verrucous 

D) Proliferative verrucous 

INVESTIGATION ;

• Based on clinical observation ,that is not explained by definable cause such as trauma 
• If healing does not occur in two weeks tissue biopsy is essential to rule out malignancy 
• Conventional clinical diagnostic tools: toluidine blue dye ,oral rush biopsy kits ,salivary diagnostics and optical imaging system 
• Gold standard diagnosis : biopsy ,small lesion- excisional biopsy ,large lesion- incisional biopsy 
• Dysplastic changes : drop shaped rete ridge,basal cell hyperplasia,acanthosis,mitotic activity ,keratin pearl formation

DIFFERENTIAL DIAGNOSIS:

• Lichen planus ( plaque type)
• Lichenoid reaction
• White sponge nevus
• Frictional keratosis 
• Acute pesudomembraneous candidiasis 
• Leukoedema

MANGEMENT ;

VAN DER WAL :MANGEMENT OF ORAL LEUKOPLAKIA /ERYTHROPLAKIA :

                                   PROVISIONAL  CLINICAL DIAGNOSIS 

Elimination of                                                                 No possible cause 

                                                                                    (definitive 

                                                                                    clinical diagnosis )

possible causes 

( 2-4 weeks observation )

Good response        No response                                Biopsy 

Definable lesion                                             no definable lesion                                                       definable lesion 

management accordingly                                dysplasia                                             management accordingly 

                                                                       no dysplasia               

                                                              Treatment /Observation 

                                                             Follow up 

• Measures should be taken to influence the patient to discontinue such habits 
• Evidence based treatment - field cancerisation ,in absence of evidence based treatment - surgery 

A) CHEMOPREVENTION; 

• L- ASCORBIC ACID 
• ALPHA TOCOPHEROL 
• RETINOIC ACID 
• VITAMIN A derivative 
• Beta carotene 1,50,000 intranational units twice per week for 6 months 
• Bleomycin -topical ,0.5%/day for 12 to 15 days 

B) Surgical 

PROGNOSIS ; 

• Based on duration of lesion,gender,site,clinical appearance ,habit association,degree of dysplasia