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PATIENT STORY

A 57-year-old female smoker presents at the physician's clinic with a 7-month history of a nonpainful white patch below her tongue. She admits to drinking 2 to 3 beers in the evening and smoking 1 pack of cigarettes per day. Your examination reveals a painless white, thick lesion with fissuring below the tongue (Figure 44-1). A biopsy shows this to be premalignant and the patient is told that she must stop smoking and drinking. She is also referred to an oral surgeon for further evaluation of her dysplasia.

FIGURE 44-1

Homogenous leukoplakia on the lateral tongue presenting with a uniform surface plaque and surface cracks in a patient with a long smoking history. A 4-mm punch biopsy was performed and showed moderate dysplasia. (Reproduced with permission from Michaell Huber, DDS.)

INTRODUCTION

The World Health Organization defines leukoplakia as a clinical term used to recognize "white plaques of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer."1,2 For all types of leukoplakia (see "Clinical Features" below) the risk of malignant transformation is approximately 1%, with a much higher risk associated with leukoplakias manifesting a red and/or highly variable (e.g., nodular or verrucous) surface texture component.

The term erythroplakia is reserved for a purely red lesion, which is described as a "fiery red patch that cannot be characterized clinically or pathologically as any other definable disease."1,2 It may be flat or slightly depressed and exhibits a smooth or granular surface texture. The majority of erythroplakias will undergo malignant transformation.

SYNONYMS

Homogenous leukoplakia; nonhomogenous leukoplakia; speckled leukoplakia; nodular leukoplakia; verrucous leukoplakia; proliferative verrucous leukoplakia; erythroleukoplakia; erythroplakia; erythroplasia.

EPIDEMIOLOGY

  • Leukoplakia occurs in 0.5% to 2.0% of adults and is most frequently seen in middle-age and older men.1

  • Erythroplakia occurs in approximately 0.02% to 0.83% of adults and is most commonly observed in middle-age and elderly persons, with no gender distinction.1

ETIOLOGY AND PATHOPHYSIOLOGY

  • Both leukoplakia and erythroplakia likely represent clinical changes associated with the underlying multistep progression of alterations at the molecular level underlying the development of dysplasia and subsequent carcinoma.

  • For all types of leukoplakia, the risk of malignant transformation is approximately 1%, with a much higher risk associated with nonhomogenous leukoplakias or leukoplakias manifesting a red component.1

  • For erythroplakia, the risk of malignant transformation is extremely high, with approximately 90% of cases demonstrating either dysplasia or carcinoma at the time of biopsy.3

RISK FACTORS

  • Smoking, alcohol, and areca nut exposure are the most prominent risk factors for leukoplakia and erythroplakia, and create a synergistic effect when combined....

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