Leukoplakia

The term leukoplakia originates from two Greek words:

Leuko means white

&

plakia means patch.

Definition by WHO: 

It is a whitish patch or plaque that cannot be characterized, clinically or pathologically, as any other disease and which is not associated with any other physical or chemical causative agent except the use of tobacco.

Classification 

•According to clinical description:

Homogenous:

 It is a completely whitish lesion.

Flat: It has smooth surface.

Corrugated: Like a beach at ebbing tide.

Pumice-like: With a pattern of fine lines (cristae).

Wrinkled: Like dry, cracked mud surface.

Non-homogeneous 

Nodular or speckled: Characterized by white specks or nodules on erythematous base.

Verrucous: Slow growing, papillary proliferation above the mucosal surface that may be heavily keratinized.

Extensive lesion of this type is known as oral florid papillomatosis.

Ulcerated: Lesion exhibits red area at the periphery of which white patches are present.

Erythroleukoplakia: Leukoplakia is present in association with erythroplakia.

•According to etiology:

Tobacco-induced

 Non-tobacco-induced.

•According to risk of future development of oral cancer:

High-risk 

Low-risk 

Intermediate group

•According to histology:

Dysplastic 

Non-dysplastic

•According to extent:

Localized
Diffuse

Etiopathogenesis:-

Tobacco: It refers to dried leaves of nicotina tobaccum.

Tobacco is used widely in two forms: Smokeless tobacco (chewable tobacco and oral use of snuff) and smoking tobacco (cigar, cigarette, bidi and pipe).

Smokeless tobacco: When tobacco is chewed, various materials leach out of it, such as tobacco tars and resins.

These are the extracts of tobacco, containing various chemical constituents such as nitrosonornicotine, nicotine, pyridine, and picoline and collidin. All these chemical constituents as well as the alkaline pH of snuff act as local irritants and are related to the alteration of mucosa. Smokeless tobacco is believed to result in chemical damage that produces sub-lethal cell injury within the deeper layers of oral epithelium. This, in turn, induces concomitant epithelial hyperplasia.

Smoking tobacco: Smoking tobacco is harmful as this smoke contains polycyclic hydrocarbons,beta-naphthylamine, nitrosamines, carbon monoxide nicotine, etc, which act as source of irritation. These produced by smoking tobacco also plays a major role Exposure to heat results in alteration of tissue. The initial signs of heat-induced alteration of tissue are increased reddening and stippling of mucosal surface. As the use of irritant continues with the exposure to heat, minute white and red striations are formed and the tissue surface may appear slightly swollen. The striations may be caused by increased capillary proliferation and keratin formation.

Alcohol: The prevalence of leukoplakia is higher among the regular and occasional drinkers than the non-drinkers. It causes irritation and burning sensation of oral mucosa when applied locally. Alcohol facilitates the entry of carcinogen into exposed cells and thus alters the oral epithelium and its metabolism.

Other factors are:-

Sanguinaria

Chronic irritation

Candidiasis

Galvanism

Regional and systemic factors:-

Syphilis

Vitamin deficiency

Nutritional deficiency

Xerostomia

Hormones

Drugs

Virus

Idiopathic

Clinical features:-

• Sex: Males are most frequently affected

• Age: 35 to 45 years 

• Common sites: it occurs anywhere on oral mucosa. Bucaal mucosa most commonly involved. Lip lesions and tongue lesions are also common. In edentulous pt., Alveloar ridge can be involved.

• Size: 2cm in triangular shape.

• Ebbing tide: some leukoplakia thay occur in the floor of the mouth are refferred as Ebbing tide.

• Extent: The extent of involvement may vary from small, well-localized, irregular patches to diffuse lesions involving considerable portion of oral mucosa. Multiple areas of involvement are not uncommon

• Color: Lesion may be white or yellowish white, but with heavy use of tobacco lesion, it may assume brownish color

• Surface: The surface of the lesion is often finely wrinkled or shriveled in appearance and may feel rough on palpation •Symptoms: Some patients may report a feeling of increased thickness of mucosa. Those with ulcerated and nodular type may complain of burning sensation. Enlarged cervical lymph nodes may be a single occurrence of metastasis.

Clinical types:-

1.) Pre leukoplakia

2.) Homogeneous leukoplakia

3.) Ulcerate leukoplakia

4.) Nodular leukoplakia

5.) Verrucous leukoplakia

6.) Proliferative verroucous leukoplakia

7.) Erythroleukoplakia

Diagnosis:

• Clinical diagnosis: Clinically any white patch with history of tobacco chewing which cannot be rubbed off is the diagnostic indicator for leukoplakia

• Laboratory diagnosis: In biopsy, hyperorthokeratosis, hyperparakeratosis, acanthosis of epithelium, epithelial dysplasia, liquefaction degeneration basal cell hyperplasia can be seen. Scanning electron microscopy will show epithelial dysplastic changes.

Malignant potential:-

Occurs in 0.3% to 10% of cases.

Differential Diagnosis:-

1.) Lichen planus

2.) Syphilitic mucus patches

3.) White sponge nevus

4.) Lupus erythematous

5.) Leukoedema

6.) Hairy leukoplakia

7.) Verruca vulgaris

8.) Verrucous carcinoma

9.) Electrogalvanic white lesion 

Management:-

• Elimination of etilogical factors:

• Prohibition of smoking

• Removal of chronic irritant 

• Conservative treatment:

• Vitamin therapy

• Antioxidant therapy

• Antimycotic preparation 

• Estrogen 

• Retinoids

• Surgical management:

 Conventional surgery 

 Cryosurgery 

 Fulguration 

• LASER

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