This document discusses potentially malignant oral disorders including leukoplakia, erythroplakia, oral submucous fibrosis, actinic cheilitis, and lichen planus. It describes the clinical presentation and risk factors for each condition. Biopsy is recommended for lesions to determine the level of dysplasia and guide treatment, which may include surgical excision depending on the diagnosis and severity of dysplasia. While not all premalignant lesions will transform into cancer, some like erythroplakia have a high risk of already representing severe dysplasia or early cancer.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine
Al-Azhar University. Oral biopsy; why, when, and how? Biopsy is the removal of the tissue from the living organism for the purpose of microscopic examination and diagnosis. Looking for a definitive diagnosis is the aim of biopsy. Types of Biopsy include incisional, excisional, drill, fine needle and frozen section biopsy.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine
Al-Azhar University. Oral biopsy; why, when, and how? Biopsy is the removal of the tissue from the living organism for the purpose of microscopic examination and diagnosis. Looking for a definitive diagnosis is the aim of biopsy. Types of Biopsy include incisional, excisional, drill, fine needle and frozen section biopsy.
ORN is an inflammatory condition of bone that occurs after the bone has been exposed to therapeutic doses of radiation usually given for a malignancies.
A cyst is an epithelium-lined sac containing fluid or semisolid material. In the formation of a cyst, the epithelial cells first proliferate and later undergo degeneration and liquefaction. The liquefied material exerts equal pressure on the walls of the cyst from within. Cysts grow by expansion and thus displace the adjacent teeth by pressure. May can produce expansion of the cortical bone. On a radiograph, the radiolucency of a cyst is usually bordered by a radiopaque periphery of dense sclerotic bone. The radiolucency may be unilocular or multilocular. Odontogenic cysts are those which arise from the epithelium associated with the development of teeth. The source of epithelium is from the enamel organ, the reduced enamel epithelium, the cell rests of Malassez or the remnants of the dental lamina.
Cancer of the oral cavity accounts for approximately 3% of all malignancies diagnosed annually in 270,000 patients world-wide. Oral cancer is the 12th most common cancer in women and the 6th in men. Many oral squamous cell carcinomas develop from potentially malignant disorders (PMDs). Lack of awareness about the signs and symptoms of oral PMDs in the general population and even healthcare providers is believed to be responsible for the diagnostic delay of these entities.
ORN is an inflammatory condition of bone that occurs after the bone has been exposed to therapeutic doses of radiation usually given for a malignancies.
A cyst is an epithelium-lined sac containing fluid or semisolid material. In the formation of a cyst, the epithelial cells first proliferate and later undergo degeneration and liquefaction. The liquefied material exerts equal pressure on the walls of the cyst from within. Cysts grow by expansion and thus displace the adjacent teeth by pressure. May can produce expansion of the cortical bone. On a radiograph, the radiolucency of a cyst is usually bordered by a radiopaque periphery of dense sclerotic bone. The radiolucency may be unilocular or multilocular. Odontogenic cysts are those which arise from the epithelium associated with the development of teeth. The source of epithelium is from the enamel organ, the reduced enamel epithelium, the cell rests of Malassez or the remnants of the dental lamina.
Cancer of the oral cavity accounts for approximately 3% of all malignancies diagnosed annually in 270,000 patients world-wide. Oral cancer is the 12th most common cancer in women and the 6th in men. Many oral squamous cell carcinomas develop from potentially malignant disorders (PMDs). Lack of awareness about the signs and symptoms of oral PMDs in the general population and even healthcare providers is believed to be responsible for the diagnostic delay of these entities.
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2. Various oral mucosal lesions, particularly red lesions
(erythroplasias) and some white lesions (leukoplakias), have
a potential for malignant change
In general, the most common white lesions have the lowest
risk of malignant transformation. Practitioners will see many
oral white lesions, but few carcinomas
The term "premalignant" conveys the idea that all the
lesions subsumed under this heading will, necessarily,
transform into malignancy, which is not true.
7. Clinical examination
Careful and thorough inspection of the mucosal
surfaces by a trained clinician in a good light remains
the standard method for identifying suspicious oral
lesions. Any detected lesion should be palpated by a
gloved finger to determine its texture. Leukoplakic
lesions should be wiped away by careful use of a damp
swab, in which case the diagnosis may well be that of
an acute pseudomembranous candidiasis. All findings
must be recorded, clinical photographs of the lesions
may be helpful during follow up visits.
9. Investigations
The best predictor of the potential for malignant
transformation is the degree of dysplasia seen
histologically. For this reason, and because a few
lesions will already be malignant, biopsy of red and
white patches is mandatory
The term dysplasia (literally, abnormal growth} is
given to the cytological abnormalities seen in both
malignant and premalignant cells
11. Diagnostic aids for clinical detection of
premalignant lesions: Vital tissue staining
12. Diagnostic aids for clinical detection of
oral premalignant lesions: Brush biopsy
and exfoliative cytology
13. Diagnostic aids for clinical detection of
oral premalignant lesions: Brush biopsy
and exfoliative cytology
14. Premalignant lesions vs Premalignant
conditions
Premalignant lesions were defined as morphologically
altered tissue in which cancer is more likely to occur than its
apparently normal counterpart. Examples: leukoplakia;
erythroplakia; Palatal changes associated with reverse
smoking
Premalignant conditions were defined as generalized state
or condition associated with significantly increased risk for
cancer development. Examples: oral submucous fibrosis;
lichen planus; discoid lupus erythematosus; actinic keratosis
15. Leukoplakia
It is defined as a white patch or plaque which cannot be
wiped off and cannot be characterized clinically or
pathologically as any other disease. This definition is,
therefore, a diagnosis of exclusion and only a clinical
descriptive term and has no diagnostic or prognostic
implication.
It is significantly more common in males (between 5th
and 7th decade of life)
It is six times more common among smokers
the most common sites include buccal mucosa, gingiva,
alveolar mucosa, and lower lip.
21. Malignant transformation
The site of leukoplakia; leukoplakia of the floor of mouth
had the highest risk of malignant transformation
Type of leukoplakia; speckled leukoplakia has the highest
malignant potential
Thickness of leukoplakia; the probability of dysplasia or
malignancy increases as the lesion increases in thickness
Long duration of leukoplakia.
Leukoplakia in non-smokers.
Female patients.
Presence of Candida albicans within the lesion.
26. Diagnosis
Elimination of other white lesions (differential
diagnosis).
Biopsy; regardless of the subtype or location, all
leukoplakias should be considered at risk for
malignant transformation and biopsy should be
obtained
Following biopsy, if no other disorder is
confirmed, the lesion is further characterized as
leukoplakia with or without dysplasia
27. Treatment
Observation This is reserved for mild lesions with no
dysplasia, any possible cause should be removed and
patients are instructed to discontinue detrimental habits.
(no or mild dysplasia)
Surgical excision Using a scalpel, this may or may not
involve removing clinically uninvolved margins. It is the
traditional method of treatment indicated for smaller,
localized lesions. (sever dysplasia and Carcinoma in situ)
30. Erythroplakia
It is defined as a red patch that cannot be characterized clinically
or pathologically as any other definable disease.
It is uncommon lesion It occurs in middle-aged or older adults
The floor of mouth, buccal mucosa, soft palate and tongue are the
most commonly involved sites
The lesions appear as well-demarcated, erythematous patches or
plaques with soft, velvety texture
90% of erythroplakic lesions histopathologically represent severe
epithelial dysplasia, carcinoma in situ, or superficially invasive
squamous cell carcinoma. Malignant transformation rate ranges
from 14% to 50%.
33. Diagnosis and Treatment
Any source of irritation identified is removed, if the
lesion does not regress after 2 weeks then biopsy is
indicated and subsequent treatment is guided by the
histopathological diagnosis
Because of the high incidence of significant epithelial
dysplasia, carcinoma in situ, or early invasive
squamous cell carcinoma at diagnosis, surgical
intervention is necessary
34. Oral submucous fibrosis
It is a chronic disorder characterized by fibrosis of the
lining mucosa of the upper digestive tract involving the
oral cavity, oropharynx and frequently the upper third of
the esophagus.
The etiology is linked to chewing of betel quid
Oral submucous fibrosis does not regress with habit
cessation, and treatment depends on the severity of the
condition
Treatment ranged from nutritional support to sutgical
excision in moderate to sever cases
36. Actinic cheilitis
It is a common potentially malignant alteration of the lower lip
vermilion that results from long term or excessive exposure to
the ultraviolet component of sunlight
There is a similar cutaneous condition termed actinic keratosis.
clinical changes include atrophy of the lower lip vermilion
border, blurring of margin between the vermilion zone and
cutaneous portion of lip is seen. As the lesion progresses,
rough scaly areas develop on the vermilion
Malignant transformation to sec occurs in 6%-10% of actinic
cheilitis cases.
39. Lichen planus
It is a chronic mucocutaneous disease that can affect the
skin or mucosa. The cause is suggested to be an
immunologically induced degeneration of the basal cell
layer of the mucosa is the cause
It occurs in middle-aged adults with female predilection.
Buccal mucosa, gingiva, and lateral tongue are the most
commonly involved sites.
Two main types of oral lichen planus have been
described; reticular and erosive, but other types of oral
lichen planus were described in the literature; papular,
plaque-like, atrophic (erythematous), and bullous
41. Malignant transformation
Although it is considered to be a controversial issue,
the malignant transformation rate has been reported
range from 0.3% to 3%.
Treatment
Topical or systemic corticosteroid therapy is the
mainstay in management of symptomatic oral lichen
planus.
42. DYSKERATOSIS CONGENITA
It is a rare heritable recessive or dominant trait.
The main features are dysplastic white or red
lesions of the oral mucosa, cutaneous
pigmentation, dystrophies of the nails and
haematological abnormalities