3. Introduction
• Precancerous lesion
• “Morphologically altered tissue in which cancer is more
likely to occur, than in its apparently normal
counterpart”
• Precancerous condition
• “Generalized state of the body, which is associated with a
significantly increased risk of cancer”
6. Leukoplakia
• The term LEUKOPLAKIA was first coined by a Hungarian
Dermatologist SCHWIMMER in 1877
• Originates from Greek words – “leucos” - white and “plakia” -
patch
• WHO 1978
• “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”
7. Epidemiology
1. Prevalence
• Represents 85% of all oral precancers
2. Incidence
3 – 4 % of adult population
3. Age
Usually in the 4th – 6th decades of life
4. Sex
Males have the highest incidence, with the trend changing gradually
8. Classification of leukoplakia
(Axell & Pindborg et al 1983)
• Based on CLINICAL TYPE:
Homogenous
Non homogenous
• Based on ETIOLOGY:
Tobacco associated
Idiopathic
• Based on EXTENT:
Localized
Diffuse
9. • Based on risk of MALIGNANT TRANSFORMATION
High risk sites
Floor of mouth
Lateral/ventral surface of tongue
Soft palate
Low risk sites
Dorsum of tongue
Hard palate
• Based on HISTOLOGY:
Dysplastic
Non dysplastic
10. Sharp’s staging of leukoplakia
• Stage I- Earliest lesion-non palpable, faintly translucent,
white discoloration
• Stage II- Localized or diffuse, slightly elevated plaque of
irregular outline. It is opaque white & may have a fine
granular texture
• Stage III- Thickened white lesion showing induration and
fissuring
12. • Most studies have reported mortality ratios for smokers
versus never smokers of about 5:1, with several reporting
ratios in excess of 10:1. Furthermore, the risk for death
from oral cancer is consumption related
• Male cigarette smokers had a relative risk for oral cancer
27.7 times greater than that of a male never smoker
• These studies have found that after 3 to 5 years of smoking
abstinence, oral cancer risk decreased by about 50%
13. Clinical presentation
• Any mucosal surface, solitary or multiple,
“White patches”
• Varies from a non-palpable faintly
translucent white area to a thick fissured,
papillomatous or indurated lesion
• Colour varies from white, grey or yellowish
white, sometimes brownish-yellow
• 70% in buccal mucosa, commissural areas, followed by lower lip,
floor of the mouth, palate & gingiva
14. SYMPTOMS
• Patients may report with a feeling of increased thickness of
mucosa
• Those with ulcerated or nodular type may complain of
burning sensation
• Enlarged cervical lymph nodes may signal occurrence of
metastasis
15. Clinical variants of leukoplakia
Homogeneous/ Leukoplakia Simplex Speckled/Nodular
Ulcerative
16. Histopathological features
• Keratinization pattern
• Thickness of epithelium
• Changes in underlying
connective tissue
• Waldron & Shafer (1975)
80% lesions show benign hyperkeratosis with/without acanthosis &
17% represent CIS
Dysplastic changes typically begin in basal & parabasal zones of
epithelium
17. • Five clinical criteria for high risk of malignant change
– The nodular type
– Erosion or ulceration within lesion
– Presence of a nodule indicates malignant potential
– A lesion that is hard in its periphery
– Lesion of anterior floor of mouth & undersurface of tongue
• In all cases, relative risk of malignant potential is determined
by presence of epithelial dysplasia upon histological
examination
19. Conservative management
• Elimination of etiological factor
• Restraining from smoking or chewing tobacco
• To remove sharp broken down teeth
• Correction & replacement of overhanging or faulty metal
restorations with a metal bridge
21. • Surgical Excision: entire lesion excised if it is >1cm in size,
following modalities used:
a) Scalpel – surgical stripping
b) Cryosurgery – with liquid nitrogen
c) Electrocautery
d) Laser ablation
22. Erythroplakia
WHO DEFINITION:
“Any lesion of the oral mucosa that presents as a
bright red velvety patch or plaque, which cannot be
characterized clinically or pathologically as any other
recognizable condition”
Reported by Querat in 1911
23. CLASSIFICATION
• Clinical variants
1. Homogenous erythroplakia
2. Erythroplakia interspersed with patches of leukoplakia
3. Granular or Speckled erythroplakia
24. • Etiology : Same as oral leukoplakia
• Age : Mainly middle age, peak 65-74 years
• Gender : Predilection for men
• Location/size
- Soft palate, floor of the mouth & buccal mucosa & tongue
- Typical lesion < 1.5 cm in diameter but >4cm also
observed
25. - Smooth and granular/nodular, well defined
- May have an irregular, red granular surface interspersed
with white or yellow foci
- Soft on palpation
26. • Highest risk for malignant transformation - 14-50%
• Based on the fact that on histology 80-90% of cases
present as-
- Carcinoma In Situ
- Severe epithelial dysplasia
- Microinvasive carcinoma
27. Management
• Biopsy should be performed
• Treatment guided by histopathologic diagnosis
• Recurrence , multifocality common
• Careful long term follow up
28. Intraepthelial carcinoma (Ca in Situ)
• Arises frequently on the skin, but also on mucous membranes,
including oral cavity
• Most severe stage of epithelial dysplasia
• Striking feature – dysplastic epithelial cells donot invade into
connective tissue
• Common among elderly, with a male prdiliction
• Present as white plaques or ulcerated, & reddened areas
• Site – floor of the mouth, tongue, lips
• Has combined features of leuko & erythroplakia
29. • Histopathology
• Keratin may or may not be present on the surface, but if present it
is usually parakeratin
• Individual cell keratinization or keratin pearl formation are rare
• Consistent finding – loss of orientation & normal polarity of cells
• Treatment
• No accepted treatment
• Surgical excision, irradiation & cauterization
31. Oral lichen planus
• Named by E Wilson ( British physician) 1896
Lichen – latin for primitive plants (symbiotic algae & fungi)
Planus – latin for flat
• Definition
• “A common chronic immunologic inflammatory mucocutaneous
disorder that varies in appearance from keratotic (reticular or plaque
like) to erythematous and ulcerative, affecting the stratified squamous
epithelium”
32. • Affects 0.5% to 1% of world's population
• Approx half patients with cutaneous LP have oral
involvement
• Mucosal involvement, sole manifestation in up to 25%
cases
• Peak incidence - middle age, F:M- 2:1
• Characteristically associated with persistent clinical
course & resistance to most conventional treatments
34. Etiology & pathogenesis
• Both antigen-specific & non-specific mechanisms may be involved
in pathogenesis of OLP
• Antigen-specific mechanisms:
– antigen presentation by basal keratinocytes and
– antigen-specific keratinocyte killing by CD8+ cytotoxic T-cells
• Non-specific mechanisms:
– mast cell degranulation and
– matrix metalloproteinase (MMP) activation
35. • These mechanisms may combine to cause
T-cell accumulation in superficial lamina propria
Basement membrane disruption
Intra-epithelial T-cell migration &
Keratinocyte apoptosis
38. Clinical features
Asymptomatic
• Reticular – Wickham’s striae + discrete erythematous border
• Plaque-like – Resemble leukoplakia, common in smokers
Symptomatic
• Atrophic – Diffuse red patch, peripheral radiating white striae
• Erosive – Irregular erosion covered with a pseudomembrane
• Bullous – Small bullae / vesicles that may rupture easily
39. Histology
Shklar -3 classic microscopic
features of OLP
• Overlying hyperkeratinization
• A bandlike layer of chronic
inflammatory cells within
underlying connective tissue
• Liquefaction degeneration of basal
cell zone
40. Diagnosis
• The characteristic clinical aspects of OLP - sufficient for
correct diagnosis
• An oral biopsy - to confirm clinical diagnosis
(exclude dysplasia & malignancy)
• Gingival LP more difficult to diagnose, direct
immunofluorescence of perilesional mucosa for diagnosis
42. Management
• Reticular type is asymptomatic & treatment often
unnecessary
• Erosive type presents significant management problems
• All patients should optimize oral hygiene
• Oral candidiasis should be excluded/treated
• Cortico steroids, is the treatment of choice eg – Fluocinonide
or Clobetasol gel for 2 weeks, with 3mnths follow-up
43. • In symptomatic patients with apparent contact dental
factor, patch test with replacement of amalgam
• In those with no apparent contact factor, topical or
intralesional steroid - first line treatment. A short course
of systemic steroid for more rapid control
44. Lichenoid reaction
• The oral lichenoid eruption is a less specific entity compared with
LP of the skin.
• Best considered as a reaction pattern of oral mucosa to a variety of
insults, including
– OLP itself
– Contact allergy
– Trauma and
– Other inflammatory dermatoses (e.g. oral lupus erythematosus
may look very lichenoid)
45. Oral submucous fibrosis
DEFINITION -
“It is a slowly progressing chronic fibrotic disease of the
oral cavity & oropharynx, characterized by fibroelastic
change and inflammation leading to a progressive
inability to open the mouth, swallow or speak”
46. Clinical features
Age
• Range wide & regional; even prevalent among teenagers in India
Ranges from 11-60 years
Sex
• From 0.2 - 2.3% in males to 1.2 - 4.5% in females in Indian
communities
Race
• South-East Asian countries, in Indian immigrants to other
countries
47. Mortality/morbidity
• High rate of morbidity - progressive
inability to open mouth, resulting in
difficulty eating & consequent
nutritional deficiencies
• Significant mortality rate - can
transform into oral cancer, particularly
Squamous cell carcinoma 7.6%
48. Etiology
• Initially classified as idiopathic, now
• Betel quid & it’s components (Arecoline, an active
alkaloid found in betel nuts, stimulates fibroblasts to
increase production of collagen by 150%)
• Capsaicin – Chillies (hypersensitivity reaction)
• Nutritional factors
• Immunological factors
49. Clinical presentation
• Common site – buccal mucosa, retromolar area, uvula,
palate, etc
• Initially, pain and a burning sensation upon
consumption of hot & spicy foods
• Vesicle & ulcers
• Excessive or reduced salivation & defective gustation
• Hearing loss
50. • Depapillation & atrophy of tongue and uvula
• Depigmented & loss of stippling over gingiva
• Nasal tone in the voice
• Difficulty in deglutition
• Impaired mouth movements (eg, eating, whistling,
blowing, sucking)
51. Clinical stages
Three stages (Pindborg, 1989) based on physical findings:
• Stage 1: Stomatitis includes erythematous mucosa, vesicles,
mucosal ulcers, melanotic mucosal pigmentation & mucosal
petechiae
• Stage 2: Fibrosis occurs in ruptured vesicles & ulcers when
they heal, hallmark of this stage
52. • Stage 3: Sequelae of OSF
– Leukoplakia is found in more than 25% of
individuals with OSF
– Speech and hearing deficits may occur because of
involvement of the tongue and the eustachian tubes
53. RANGANATHAN K (2001)
• Group I : Only Symptoms, No mouth opening
• Group II : Mouth opening > 20mm
• Group III : Mouth opening < 20mm
• Group IV: Limited mouth opening, precancerous
& cancerous changes throughout mucosa
54. Histopathology
• Hyperkeratinized, atrophic epithelium with flattening
& shortening of rete pegs
• Nuclear pleomorphism & severe inter-cellular edema
• Finely fibrilar collagen & increased fibroblastic activity
in early stage showing dilated & congested blood vessels
with areas of hemorrhage
55. • Advanced stage shows “homogenization” and
“hyalinization” of collagen fibers (important feature)
• Degeneration of muscle fibers and chronic inflammatory
cell infiltration in the connective tissue
56. Management
1. Behavioral therapy
- Patient counseling, stoppage of habit
2. Medicinal therapy
-Hyaluronidase: Topically, shown to improve symptoms more
quickly than steroids alone
- Mild cases – intralesional inj Dexamethasone 4 mg to reduce
symptoms & surgical splitting / excision of fibrous bands
- Recent study – intralesional inj of gamma interferon 3 times a
week, improves mouth opening significantly
57. References
1. Burket’s oral medicine diagnosis & treatment – 10th edition
2. Textbook of oral pathology –shafer 5th edition
3. Neville’s Oral and Maxillofacial Pathology - 2nd edition
4. Emedicine – Diseases of oral mucosa, Oral submucous fibrosis,
Jan 26, 2007
5. Oral leukoplakia related to malignant transformation, Oral
Science International 2006;45-55
WHY WHITE LESIONS APPEAR WHITE?
Increased thickness of the epithelium
Increased and abnormal production of surface keratin
Imbibition of fluid by surface layer
Coagulation of surface tissue leading to necrosis
Reduced vascularity in underlying lamina propria
Sub mucosal deposit of ectopic sebaceous tissue
Hairy Leukoplakia
Definition Hairy leukoplakia is one of the most common and characteristic
lesions of human immunodeficiency virus (HIV) infection. Rarely,
it can also appear in immunosuppressed patients after organ transplantation.
Etiology Epstein–Barr virus seems to play an important role in the
pathogenesis.
Clinical features Hairy leukoplakia presents as a white asymptomatic,
often elevated and unremovable patch. The lesion is almost always
found bilaterally on the lateral margins of the tongue, and may spread
to the dorsumand the ventral surface (Fig. 3). Characteristically, the
surface of the lesion is corrugated with a vertical orientation. However,
smooth and flat lesions may also be seen. The lesion is not precancerous.
Laboratory tests Histological examination, in situ hybridization, polymerase
chain reaction (PCR) and electron microscopy.
Differential diagnosis Chronic biting, lichen planus, frictional keratosis,
cinnamon contact stomatitis, uremic stomatitis, candidiasis.
Treatment Not required; however, in some cases aciclovir or valaciclovir
can be used with success
Size varies from a small, well localized patch measuring from a few mm in dia to a diffuse large lesion, covering a wide mucosal surface
Retinoids
They decrease cohesiveness of abnormal hyperproliferative keratinocytes & may reduce potential for malignant degeneration. They modulate keratinocyte differentiation.
Nystatin therapy- it is given in candidal leukoplakia 500,000 IU twice daily plus mouth rinses with chlorhexidine solution
Vitamin B complex- it is given as a supplement in cases of commissural and lingual lesions
High risk factors for malignant transformation
smoking,
excessive alcohol intake,
atrophic, ulcerative or erosive clinical types,
presence of erythroplakic lesions and
Sites involving the tongue, gingiva or buccal mucosa
Specific findings of stage 2 include the following:
Reduction of the mouth opening (trismus)
Stiff and small tongue
Blanched and leathery floor of the mouth
Fibrotic and depigmented gingiva
Rubbery soft palate with decreased mobility
Blanched and atrophic tonsils
Shrunken budlike uvula
Sinking of the cheeks, not commensurate with age or nutritional status