oral leukoplakia management by cryotherpy

2.  The term leukoplakia originates from Greek
word leuko=white, plakia=patch.
 The term leukoplakia refers to a clinical entity
defined by the World Health Organization
(WHO) as “a white patch or plaque that cannot
be characterized clinically or histologically as
any other disease.
 The term leukoplakia was first used by
Schwimmer in 1877 to a white lesion of tongue,
which probably represented a syphilitic glossitis.

3.  He proposed the term leukoplakia for diffuse
patch on the dorsum of tongue. Since then it
was evolved as a clinicopathological concept
over many years; sometimes representing an
innocent hyperkeratosis and sometimes
dysplastic features.
 Leukoplakia is the most common premalignant
lesion of the oral mucosa.
 The dysplastic epithelium or frank invasive
carcinoma is, in fact found only in 5% to 25% of
biopsy samples of leukoplakia.

4.  The prevalence of leukoplakia in India varies
from 0.2% to 4.9%2.
 Men's are affected more frequently than woman
and vast majority of leukoplakia occurs in the
age range of 35-45 years3.
 Oral leukoplakia may affects any part of the
mouth, but usually seen on the buccal mucosa
tongue and gingiva.
 The research has shown that oral leukoplakia on
the ventral surface of the tongue, floor of mouth
and soft palate are more likely to become
precancerous/dysplastic.

5.  The exact cause of oral leukoplakia is still
unknown, although certain risk factors have
been identified.
 More than 80% of patient with oral leukoplakia
have a history of tobacco use and the condition
is six times more common among smoker's than
non-smokers.
 The frequency of dysplastic or malignant
alteration in oral leukoplakia has ranged from
15.6 to 39.2 percentages in several studies1.

6.  A 20 year male patient
presented to the Department of
Oral Medicine and Radiology of
SMBT Dental College &
Hospital, Sangamner with a
chief complaint of dirty deposits
in the upper and lower teeth of
the jaw since 2 yrs years.
 H/O Present Illness: Patient was
apparently alright 2 years ago
when he noticed dirty deposits
in upper and lower teeth of jaw.
Initially patient had least
deposits over teeth, later on it is
progressed and covers the all
teeth.

7.  Medical History: No relevant history of any
systemic illness, medications, drug allergies.
 Dental History: No relevant history
 Family History: No relevant family history.
 Personal History: Patient cleans his teeth with
toothbrush and toothpaste2 times daily
- Habit of gutkha chewing 4-5 sachets per day
since 3-4 yrs

8. Intraoral Examination:
 Inspection:A diffuse white lesion is seen
on right buccal mucosa extending roughly
between 46, 47, 48 region. it is about 3cm
in dimension superio-inferiorly and 1.5 -2
cm dimension in antero-posteriorly. It has
diffuse border and rough surface.
 it is non-scrapable, non – inflammatory,
non tender and not raised from the
surface.
 HardTissue Examination:
Teeth present: all teeth present
Dental caries: Occlusal caries with 46

9.  Toluidine blue test was performed which
showed positive results

10.  Oral leukoplakia

11.  Lichen planus
 Leukoedema
 Cheek biting lesion
 Smokeless tobacco lesion
 White sponge nevus

12.  The presence of wickham’s striae on buccal mucosa
helps in differentiating lichen planus from leukoplakia.
 Leukoplakia more often affects men whereas lichen
planus occurs more frequently in women
 Lichen planus mostly seen bilaterally on buccal mucosa.
 If chronic irritant can not be identified and area of
characteristic ofWickham straie is discovered, the lesion
is probably lichen planus.
 Lichen planus is chronic mucocutaneous disease of
unknown etiology, may be immunological disturbances
either local or general and perhaps of autoimmune
character.

13.  It is easily differentiated from leukoplakia
because it classically occurs on the buccal
mucosa, frequently covers most of the surface
characteristics with faint milky opalescence.
 The characteristic folded and more prominent
wrinkled pattern that can be eliminated by
stretching buccal mucosa.

14.  The lesion on buccal mucosa takes roughen
white cast because of increased thickness of
epithelium and keratin.
 The lesion on buccal mucosa can be evaluated
by checking occlusal interference during bite.
 Careful follow up reveals regression of the
erosion when the habit is modified or
eliminated.

15.  It resembles leukoplakia, but it often has a
wrinkled pattern and is easily identified by it
location in the vestibule and history of
smokeless tobacco use.

16.  It occurs soon after birth or at least by
puberty and is usually widely distributed over
oral mucous membrane.
 In contrast, leukoplakia is seen in patient over
40 years of age and usually is not
disseminated throughout the oral cavity.
 It shows familial pattern not so characteristics
of leukoplakia.

17.  oral leukoplakia

18.  Patient was advised for cryotherapy after
screening .
 The whole procedure was explained to
patient before the treatment started.
 cotton swab with diameters of 4-6 mm in
dimension were used for the therapy
depending on the size of the lesion.
 the lesion site was air-dried before
treatment to prevent the cotton swab
from sticking to the oral mucosa.
 The cotton swab was dipped into liquid
nitrogen for at least 5 seconds and applied
to the lesion with pressure for 20 seconds
to form an ice ball and then allowed to
thaw for another 20 seconds.
 Four consecutive freeze-thaw cycles were
performed on the same area of the lesion.
 Patient was recalled for follow up after 10
days.

19.  The lesion showed 40%
reduction after first
application.
 Patient had no history of
pain and burning sensation
after cryotherapy.
 Patient stopped his habit
completely.
 Patient was recalled to
continue the treatment .

20.  The same procedure
was performed on
lesion located on right
side of buccal mucosa.
 The cotton swab with
liquid nitrogen was
placed on remaining
site of lesion.
 The patient was
recalled for follow up.

21.  The lesion over buccal
mucosa showed gross
changes of 5-10% after
second application.
 The lesion showed no
recurrence.
 On palpation ,the
lesion had smooth
surface and had no
burning sensation.
 Patient is kept on
follow up and recalled
after 1 month

22.  There are different treatments for leukoplakia, which have
shown different results.
 Treatment of oral leukoplakia includes surgical and non
surgical methods.
 Non surgical treatments includes antioxidants, retinoids and
photodynamic therapy.
 Surgical treatment of leukoplakia can be done through
conventional surgery, laser surgery, electro surgery or
cryosurgery.

23.  Leukoplakia located on the floor of the mouth, soft palate
and tongue are considered lesions of high risk for malignant
transformation while in other areas, such as the gingiva, hard
palate and the buccal mucosa are considered to represent a
low risk of malignancy.
 Conventional surgery may frequently used, but may cause
scars and loss of tissue and there is high time of work in
relation to the cryosurgery.
 Moreover recurrence has been reported in 10%to35% of the
cases.
 Cryosurgery is the deliberate destruction of tissue by
application of extreme cold and has been used in oral
medicine and pathology for over30 years.

24.  It is carried out with either an ‘‘open’’ or a ‘‘closed’’ system.
 Open-system cryotherapy involves directly applying the
cryogen to the lesion with a cotton swab or using open spray.
 Closed-system cryotherapy offers a greater degree of control
with a more-complex and -delicate apparatus.
 The mechanism for cell destruction after cryosurgery are
complex involving a combination of direct and indirect
effects.
 Direct effects consist of ice crystals that form in extracellular
and intracellular fluid ,cellular dehydration ,toxic intracellular
electrolyte concentration, Inhibition of enzymes, protein
damage, thawing effect causes the cell to vacuolate, swell
and rupture and thermal shock injury to cells.
 Indirect effects include vascular changes that lead to ischemic
necrosis of the treated tissue and immunological responses
that cause cell damage through a cytotoxic immune
mechanism.

25.  Cryosurgery is well accepted by patient due to relative lack of
discomfort, absence of bleeding and minimal to no scarring.
 Relatively no need of antibiotics and analgesics after
cryotherapy, rarely It required.
 Disadvantages are a lack of control over the temperature
achieved within the cell and lack of precision with depth and
area of freezing.
 Numerous application is required on the lesion due to rapid
evaporation of liquid nitrogen from cotton swab.
 The patient had received 2 cycles of cryosurgery and the
lesion showed the regression of 60% without scar formation
and patient is kept on follow up.
 This indicate that multiple cycles of cryosurgery is necessary
for effective treatment of large lesions.

26.  Cryosurgical treatment has certain advantages
over conventional surgery and these includes
bloodless treatment, very low incident of
secondary infection and a relatively lack of
scarring and pain. Hence cryosurgery which is
not much used in dentistry has got a key role
when used properly in treatment of oral
leukoplakia which is resistant to all other
conventional treatments.
 It is very safe ,inexpensive and easy performing
technique for the treatment of various oral
lesion particularly oral leukoplakia.

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