The document reports on a case study of a 65-year-old male patient who presented with diffuse erythematous patches on the hard palate and grooves that bled upon probing, and was diagnosed with oral erythroplasia based on a positive toluidine blue staining test and histological examination showing epithelial atrophy and mild dysplasia. Oral erythroplasia is a potentially malignant disorder strongly associated with tobacco and alcohol use that requires surgical excision due to its high risk of transforming into carcinoma.

1. By
ASWANTH.E.P

2. Introduction
Erythroplasia describes precancerous red colour
that develop on the penis .(Queyrat 1911)
Oral erythroplakia defined as any lesion of oral
mucosa that presents as bright red velvety plaques
which cannot be characterized clinically or
pathologically as any other recognizable
condition(WHO)

3. Case report
A 65 yrs old male patient complaints about loose
teeth in upper right back region of the jaw since 2
month due to which he experienced difficulty in
chewing food
Past medical history- NRH
Past dental history- NRH
Habits – tobacco chewing 4-5 times a day since 35-
38 yrs and bidi smoking 2-3 bidies per day since 50
yrs

5. Clinical
examination
Diffused
erythematous
patches was seen
on the hard palate
which extend into
anterior part of the
soft palate

6. Diffused vertical grooves on the palate
Palate was soft and tender on palpation
Bleeding on probing was seen from the
grooves
Depapillated areas are present on the
dorsum of the tongue along with whitish
coating which can be scrapable
Saliva was found to be thick and ropy in

7. Toluidine test procedure
Step 1 : rinsing with water twice for 20 sec each after
rinsing ,patient was asked to rinse with 1% acetic acid
Step 2: drying of area with gauze. Care was taken to not
abrade the tissue while drying
Step 3: application of toluidine blue solution (1%) with
cotton swab on the lesion . Swab was kept over the
lesion for 15-20 sec
Step 4: rinsing with acetic acid followed by gargled with
water
Step 5 : positive staining of palate suggestive of
dysplastic changes
Dorsum of tongue give a false positive test as the stain
was mechanically retained

9. • Incisional biopsy
• Blood investigations
• Histological slide examination- to confirm
erythoplasia

10. • Surface of keratinize layer was seen to
be thin
• Epithelial atrophy with mild dysplasia

11. Discussion
Erythroplasia may appear as smooth
velvety granular or nodular lesion with
well defined margins
• Red lesions may sometimes associated
with white spots or small plaques
(erythroleucoplakia)
Etiology
Alcohol consumption
Tobacco use

12. • A)Clinical variants
• -Homogeneous erythroplakia
• -Erythroplakia interspersed with patches of
leukoplakia
• -Granular leukoplakia
• B)Inflammatory
• -Candida albicans infections
• -Tuberculosis
• -Histoplasmosis

13. Erythroplakia Early SCC
Valvety red or granular red macule Red lesion on gingive
Lesion has no apparent cause Lesion has apparent cause
Gingival lesion does not respond to
periodontaal therapeuticaal
measures
Gingival lesion respond to
periodontaal therapeuticaal
measures
Age -50-70 yrs Mostly occurs in older men
Differential diagnosis

14. Erythroplakia Erythematous candidiasis
Valvety red or granular red
macule
Erythematous lesion
Borders of lesion are sharp &
well demarcated
Borders are diffuse
Site : Floor of mouth Site : Tongue,Palate
Age : 50 – 70 years At any age
Histologically thin epithelium
,dysplasia
Candida albicans can be seen

15. Erythroplakia Erythema multiforme
Age :50-70 yrs In young adults
Valvety red or granular red
macule
Sloughing of oral mucosa with
diffuse redness
Red macule with white centre
Site : Floor of mouth Buccaal mucosa,lips

16. Erythroplakia Leukoplakia
Valvety red or granular red
macule
Whitish lesion
Smooth margins Rough margins
Age :50-70 yrs 35-40 yrs
Site -Floor of tongue Buccal mucosa,tongue
Thin epithelium Thick epithelium

17. Provisional diagnosis
Oral erythroplasia
Investigations
Toluidine blue staining was carried out adjunct
prior to incision biopsy
With toluidine blue an acidophilic meta chromatic
nuclear stain , will stain a dysplastic area due to its
affinity for mitotic cells whereas normal mucosa will
not retain the stain

18. Vital stainig with toluidine blue reveals the
otherwise unapparent cytological details which
was 1st used by Richart in 1963 to stain uterine
cervical carcinoma insitu
Its application for detection of oral premalignant
and malignant lesions was 1st reported by Neibel
and Chomet in 1964
It is basic meta chromatic dye that stains the
acidic cellular components
since cancer cells contains quantitatively more
DNA and RNA than normal epithelial cells ,
toluidine blue has greater affinity for these cells

19. Malignant epithelium contains wider intra cellular
canals which facilitate the greater penetration of
the dye
It is a simple fast and inexpensive technique
Chance of false positive result due to mechanical
retention in areas of inflammation ulceration and
fissures can be reduced by restaining after 2
weeks
Palate is stained positive suggestive of positive
dysplastic changes
Diagnosis of erythroplakia was confirmed by
histological examination

20. • Erythroplakia considered as one among the most
severe of all oral premalignant lesions
• Incidence of severe dysplasia or carcinoma in
this lesion is very high – 80-90%
• Histopathologically erythroplakia of homogenous
type , 51% transform into invasive carcinoma, 40
% carcinoma insitu and 9% mild or moderate
dysplasia
• It may associated with tobacco consumption and
use of alcohol

21. • In India betalnut pan and tobacco chewing is highy
prevalent
• Oral Erythroplakia prevalence in India is about
0.2%
• Patient advised to stop tobacco or alcohol habits
and encouraged to take diet rich in vegetables and
fruits ( antioxidants )
• Biopsy mandatory
• Treatment is surgical excision including laser
• Recurrence and development of malignancy at the
sate site is very high

22. Reference
1)Oral Erythroplakia –a case report from
International journal of applied dental
sciences
2)Differential diagnosis of oral & maxillofacial
lesions by by Norman K Wood & Paul W
Goaz