ESSENTIALS OF DIAGNOSIS
Leukoplakia: A white lesion that cannot be removed by rubbing the mucosal surface.
Erythroplakia: Similar to leukoplakia except that it has a definite erythematous component.
Oral Lichen Planus: Most commonly presents as lacy leukoplakia but may be erosive; definitive diagnosis requires biopsy.
Oral Cancer: Early lesions appear as leukoplakia or erythroplakia; more advanced lesions will be larger, with invasion into the tongue such that a mass lesion is palpable. Ulceration may be present.
Oropharyngeal Cancer: Unilateral throat masses, such as emanating from the tonsils or base of tongue, typically presenting with painful swallowing and weight loss.
Leukoplakic regions range from small to several centimeters in diameter (Figure 8–5). Histologically, they are often hyperkeratoses occurring in response to chronic irritation (eg, from dentures, tobacco, lichen planus); about 2–6%, however, represent either dysplasia or early invasive squamous cell carcinoma. Distinguishing between leukoplakia and erythroplakia is important because about 90% of cases of erythroplakia are either dysplasia or carcinoma. Squamous cell carcinoma accounts for 90% of oral cancer. Alcohol and tobacco use are the major epidemiologic risk factors.
Leukoplakia with moderate dysplasia on the lateral border of the tongue. (Used, with permission, from Ellen Eisenberg, DMD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed. McGraw-Hill, 2013.)
The differential diagnosis may include oral candidiasis, necrotizing sialometaplasia, pseudoepitheliomatous hyperplasia, median rhomboid glossitis, and vesiculoerosive inflammatory disease, such as erosive lichen planus. This should not be confused with the brown-black gingival melanin pigmentation—diffuse or speckled—common in non-Whites, blue-black embedded fragments of dental amalgam, or other systemic disorders associated with general pigmentation (neurofibromatosis, familial polyposis, Addison disease). Intraoral melanoma is extremely rare and carries a dismal prognosis.
Any area of erythroplakia, enlarging area of leukoplakia, or a lesion that has submucosal depth on palpation should have an incisional biopsy or an exfoliative cytologic examination. Ulcerative lesions are particularly suspicious and worrisome. Specialty referral should be sought early both for diagnosis and treatment. A systematic intraoral examination—including the lateral tongue, floor of the mouth, gingiva, buccal area, palate, and tonsillar fossae—and palpation of the neck for enlarged lymph nodes should be part of any general physical examination, especially in patients over the age of 45 who smoke tobacco or drink immoderately. Indirect or fiberoptic examination of the nasopharynx, oropharynx, hypopharynx, and larynx by an otolaryngologist, head and neck surgeon, or radiation oncologist should also be considered for such patients when there is unexplained or persistent throat or ear pain, oral or nasal bleeding, or oral erythroplakia. Fine-needle aspiration (FNA) biopsy may expedite the diagnosis if an enlarged lymph node is found.
To date, there remain no approved therapies for reversing or stabilizing leukoplakia or erythroplakia. Clinical trials have suggested a role for beta-carotene, celecoxib, ...