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 



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