PathologyLeukoplakia—A Diagnostic and Management Algorithm
Section snippets
White Lesions in Genetic Diseases and Genodermatoses
These are extremely uncommon and all have specific and distinctive histopathologic features. Cannon white sponge nevus presents as diffuse bilateral white plaques of the oral mucosa and particularly the buccal mucosa and tongue and could involve esophageal and genital mucosa, but not the skin.5, 6 Similarly, hereditary benign intraepithelial dyskeratosis presents as bilateral thick white plaques of the oral mucosa and as gelatinous plaques of the conjunctiva without involvement of the skin.7, 8
White Lesions Caused by Local Injury
Lesions in this category include leukoedema, frictional keratoses, and contact injury, such as keeping mildly caustic substances for long periods at 1 site (eg, smokeless tobacco or chewing gum).
Leukoedema occurs in up to 90% of the population and can occur after exposure to mildly irritating substances (eg, mouthwash, toothpaste, and tobacco or marijuana smoke).11, 12 It presents as delicate gray-white lacy lines on the buccal mucosa or ventral tongue that disappear with stretching of the
White Lesions Caused by Infections
Oral candidiasis is the most common opportunistic fungal infection; it is usually caused by C albicans, a commensal present in 20 to 30% of patients.16 Oral lesions occur when the normal flora is altered (as in patients with hyposalivation, who wear dentures, who smoke, or who are on immunosuppressive agents). Additional contributing factors include anemia, diabetes mellitus, endocrine dysfunction, immunosuppression (eg, acquired immunodeficiency syndrome or human immunodeficiency virus [HIV]),
Immune-Mediated Keratotic Lesions
Oral lichen planus (OLP) is an immuno-mediated chronic condition present in 1 to 2% of the population, usually middle-age women.33 Of note, 10 to 15% of patients with OLP have cutaneous lesions. OLP can be idiopathic or secondary to local or systemic conditions and in particular to ingestion of medications such as antihypertensive and hypoglycemic agents.
Oral lesions are typically symmetric and bilateral and there is controversy regarding the clinical types. Although 6 distinct forms, namely
Leukoplakia
Leukoplakia is a potentially malignant lesion defined as a “white plaque of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer” (eg, frictional keratoses).3 Leukoplakia is a clinical term only; its definition is usually modified after a histopathologic evaluation. For example, a clinical impression of leukoplakia at biopsy examination might show candidiasis, bite keratosis, or lichen planus.
Management
White lesions with a histopathologic diagnosis of dysplasia or carcinoma in situ should be excised with clear margins, especially for cases of moderate or severe epithelial dysplasia93 (Fig 12). Of note, some cases of dysplasia (particularly mild dysplasia) have been reported to regress over time. However, it has been shown that several cases of mild dysplasia in reality could represent reactive epithelial atypia from trauma and therefore regression and recurrence would be expected.37
Reported
Conclusions and Future Directions
- 1)
Oral white lesions are common, but true leukoplakia has substantial potential to develop into cancer.
- 2)
Clinical features of leukoplakia, including partial demarcation, fissuring, and large size, and demographic information and social history guide the clinician in recognizing high-risk lesions; this is particularly true for PVL.
- 3)
Histopathologic examination is vitally important for the management of leukoplakia. Dysplastic lesions or carcinoma in situ should be excised with clear margins.
- 4)
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Conflict of Interest Disclosures: None of the authors have any relevant financial relationship(s) with a commercial interest.