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Introduction

Erythroplakia , leukoplakia,
keratosis

Most mouth carcinomas appear to arise in

apparently normal mucosa, but some are
preceded by potentially malignant (sometimes
termed premalignant ) clinically obvious lesions ,
especially :
Erythroplakia
Leukoplakia ,some particularly : speckled leukoplakia ,
verrucous leukoplakia .

Conditions that may predispose to

malignancy include :

Non-reticular lichen planus

Lupus erthematosus
Syphilitic glossitis
Submucous fibrosis
Actinic cheilites
Previous oral malignancy
Immunosuppression

Habits that may predispose to malignancy include:

Tobacco use
Alcohol use
Sunlight exposure

Most potentially malignant lesions show dysplasia on biopsy, and

this appears to be the most predictive marker in current use for
malignant potential .
Mild atypia is the term used where few of the features of dysplasia are
present and the epithelium is reasonably well organised .

Severe dysplasia is the term used if organisation is disrupted and many

cellular abnormalities present.

Factors predictive of future malignant transformation may include :

Dysplasia
History of cancer in the upper aerodigestive tract
P53 tumour suppressor expression
Loss of heterozygosity involving chromosomes 3p or 9p.
Chromosomal polysome

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Erthroplakia
Erthroplasia is a rare condition defined as any lesion of the oral
mucosa that presents as bright red velvety plaques which cannot be
characterised clinically or pathologically as any other recognisable
condition ( WHO,1978) .
Erythroplastic lesions are well defined velvety red plaques which are
usually ( at least 85%)severely dysplastic or frankly malignant .
Erthroplasia is the oral lesion with the most severe dysplasia and
greatest predilection to develop to carcinoma .

Uncommon: mainly seen in elderly men .it is much less common than leukoplakia .

Age :
Occure in the middle aged and the elderly .

Sex:

Eryrthoplasis contains areas of dysplasia , carcinoma in situ or invasive

carcinoma in virtually every case.
Carcinomas are seen 17 timer more frequently in erythroplakia than in
leukoplakia and these are therefor the most potentially malignant of
oral mucosal lisions , but erythroplasia is far less common than
leukoplakia.

Occurs mostly in men .

Geographic:
It has no known geographic incidence.

Unknown, but tobacco and alcohol use are probably involved.

Red velvety patch of variable configuration , commonly on :

soft palate
floor of mouth
buccal mucosa .
- Some erythoplakias are assosiated with patches and are then terned speckled
leukoplakia .

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Diagnosis
A biopsy should be done to examine for epithelial dysplasia and carcinoma and
the lesion should be diflammatory and atrophic lesions (e.g. Deficiency
anaemias , geographic tongue , lichen planus).

Patient information is an important aspect in management . Any causal factor such as

tobacco use should be stopped and lesions removed .there is no hard evidence as
to the ideal frequency of follow-up , but it has been suggested that patients with
mucosal potential malignant lesions be reexamined:
Within 1 month
At 3 months
At 6 months
At 12 months
Annually thereafter

Classification of leukoplakia and

erythroplakia
Leukoplakia
Leukoplakia : homogeneous
flat
corrugated
pumic-like
wrinkled

Erythroplakia
uniformly red
red with white nodules

Leukoplakia : non - homogeneous

Verrucous
Proliferative and verrucous
Nodular
Erythroleukoplakia (speckled)

Leukoplakias are clinical white patches that cannot be wiped off the mucosa and
cannot be classifically or microscopically as another specific disease entity ( such
as lichen planus).
Leukoplakia is thus a clinical diagnosis only and can only be made by exclusion.
Leukoplakia can be totally benign or sometimes can be precancerous or a marker
for cancer elsewhere in the upper areodigestive tract.

Iccidence :
Occure in about 0.1 % of the population

Age :
Occurs predominantly in the middle aged and elderly .

Sex:
Occurs more in men than women .

Geographic :
It has no known geographic incidence.

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Malignant potential
These are habits such as :
Tobacco use
Betel use
Alcohol use
Use of sanguinarine

The malignant potential depends on the appearance , site and some aetiological factors .

Appearance :

Leukoplakias vary in size : some are small and focal ,othersmore

widespread occasionally involving very large areas of the oral mucosa
and in other patients several discrete separate areas of leukoplakia can be
seen . Leukoplakia has a wide range of clinical presentations , from
homogeneous white plaques , which can be faintly white or very thick and
opaque to nodular white lesions or lesions admixed with red lesions .

Homogeneous leukoplakias : the most common type , are uniformly white plaques
common in the buccal (cheek) mucosa and usually of low premalignant potential.
sometimes lesions are widespread , suggesting there are widespread molecular
changes in the mucosa.
Non - homogeneous or heterogeneous leukoplakias : nodular , verrucous and speckled
leukoplakias which consists of white patches or nodulees in a red , often eroded , area
of mucosa have a high risk of malignant transformation and therefore are far more
serious .

Site :
High risk sites for malignant transformation include the soft palate complex and
ventrolateral tongue and floor of the mouth .

DIGNOSIS

Malignant potential
Aetiological factors :

Proliferative verrucous leukoplakia is a diffuse white and \or papillary lesion

seen in elderly patients , often associated with humman papilloma viruses ,
which has inexorably slow progression over one or two decades , to verrucous
or squamous cell carcinoma .
Candidal leukoplakias may be associated with an increased risk of malignant
change .
Syphilitic leukoplakia , especially of the dorsum of the tongue , is a feature of
tertiary syphilis rarely seen now .
Hairy leukoplakia is causes by Epstein Barr virus (EBV).

There are no clinical signs or symptoms which reliably predict whether a

leukoplakia will undergo malignant change and thus there must be use of
microscopy to detect dysplasia .
Biopsy is therefore generally indicated and is mandatory for those leukoplakias
which are :

In patients with previous or concurrent head and neck cancer

Non homogeneous ,i.e. :

1.
2.
3.

Have red areas

Are verrucous
Are indurated

In a high risk site such as the floor of the mouth or the tongue
Focal
With symptoms
Without obvious aetiological factors

In the event of biopsy not being available or the patient refusing scalpel biopsy
,the oral brush biopsy may be helpful

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Management
Some patients have spomtaneous remission of leukopllakia, but
the lesion may be potentially malignant and thus both
behaviour(lifestyle) modification and active treatment of the
lesion are indicated.
The prevalence of malignant transformation in leukopllakias is 235 % over 10 years and is highest in lesions with severe
dysplasia.
Patient information is an important aspect in management.
Removal of known risk factors (tobacco,alcohol and trauma) is
a mandatory first step. Success is difficult to achieve .
The patient should be re-examined 3 months after instituting
this . If the lesion presists, it should be removed .

Surgery
Surgery is an obvious option for the management of leukoplakia,
certainly for patients with predisposition to malignant
transformation, such as leukopllakias that are:
1.
2.
3.
4.
5.
6.

Speckled
Verrucous
Form high-risk sites,including the floor of the mouth/ventrum of the tongue
or soft palate/ fauces
In a patient with previous cancer in the upper aerodigestive tract dysplastic
Polysomic (aneuploidy or tetraploidy)
Tested positive for genetic markers such as mutated tumour suppressor
factor p53 or loss of heterozygosity on chromosomes 3p or 9p .

Medical therapies

Resection with a scalpel or laser is probably the most effective and safe means
of removing pathologic tissue since-unlike the case with cryosurgery,
coagulation or laser vaporisation a specimen for pathologic evaluation (of
histology and margins) is produced and the pain and postoperative scarring are
less with these techniques than with coagulation .
Finally , laser excision (usually with the carbon dioxide laser) seems to have
advantage over the use of a scalpel as intraoperative bleeding and the need for
mucosal or dermoepidermal flaps are reduced .
Follow-up : patients should be regularly checked at 3,6 and 12 months and
then annually for any :

Size change
Appearance of red lesions
Ulceration
Recurrences
New lesions

Up to 30% of leukoplakias can markedly improve or even resolve

when aetiological factors are removed and medical therapies
(anti-inflammatory and antimycotic therapy) used .
Up to 60% of leukoplakias regress or totally disappear if tobacco use
is stopped.
Some candidal leukoplakias respond to antifungal drugs (smoking
should also be stopped ) and dysplasia may regress.
Since leukoplakias are only potentially cancerous , it is generally
accepted that radiotherapy or systemic chemotherapy are
inappropriate treatment.

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Topical anticancer drugs or retinoids can cause regression and are

generally well tolerated and effective, but their efficacy is only
temporary , and perhaps their best indication is when the
location or extent of the lesion reder surgical removal fifficult .
Topical treatment of leukoplakia with podophyllin solution or
bleomycin has induced some regression or even total resolution
of dysplasia and clinical lesions and lesions reccur more slowly
that after surgery .
Treatment with photodynamic therapy in which a light-sensitising
dye is given to the patients and light shone on the lesion to
activate the dye and cause necrosis of the pathological tissue ,is
still in its infancy .

Incidence
Actinic cheilitis (actinic keratosis of lip,solar keratosis , solar
cheilosis) is common in sun exposed individuals .

Age
Occures mainly in adults

Sex
Most prevalent in men

Geographic
Mainly seen in persons from the tropics and less in black people

Actinic cheilitis

Predisposing factors
Sun damage is most common in :
Hot , dry regions.
Outdoor workers
Fair-skinned people

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Clinical features
Actinic cheilitis is a chronic premalignant keratosis of
the lip caused by long exposure to solar irradiation .
Most is therefore seen :
On the lower lip,with sparing of the oral
commissures .
In fair skinned men
In the fourth to eight decade of life
Particularly in those who have prolonged exposure to
sunlight (e.g. Fishermen ).

In the early stages there may be redness and oedema,

but later the lip becomes dry and scaly and wrinkled
with grey to white changes in pigmentation. Lesions
may appear as a smooth or scaly , friable patch or
can involve the entier lip . Later, the epithelium
becomes palpably thickened with small greyish white
plaques. Eventurally , warty nodules may form.

Diagnosis

Management

A careful history and a biopsy are

often indicated.

Prevention is advised, especially in high risk individuals .

particular care to protect the vermilion of the lips with
adequate sunscreens is needed in patients with
photosensitivity disorders, and in those whose exposur
to ultraviolet light (especially UVB)is high, such as
mountaineers and skiers.

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Stomatitis nicotina
Management of established actinic chilitis is required
both to relieve symptoms and to prevent
development of squamous cell carcinoma.
This is best achieved by the removal of the
premalignant epithelium by topical chemoexfoliants
and surgery .
Following management, prevention of recurrence by
the regular use of a UVA and UVB protective
sunscreen is advisable.

Stomatitis nicotina known as smokers

palate, smokers keratosis, nicotinic stomatitis,
stomatitis palatini, leukokeratosis nicotina
palati is a diffuse white lesion covering
most of the hare palate, typically related to
pipe or cigar smoking .

Incidence

Predisposing factors

It is uncommon.

Age

Smokers keratosis is seen usually among heavy , long-term

pipe smokers and some cigar smokers or reverse
cigarette smoking, rarely in cigarette smokers.

It occurs in middle- aged or elderly adults.

Sex
It occurs in more men than women.

Geographic
It is seen worldwide.

Presumably the hyperkeratosis is related to tobacco products

and /or heat .

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Clinical features
The appearances of smokers keratosis are distinctive in that the
palate is affected, but any part protected by a denture is
spared.
The teeth are often stained from the tobacco exposure.
The lesion has two components, namely :
White thickening of the palatal mucosa due to hyperkeratosis.
Inflammatory swelling of minor mucous glands, which show
as red spots against the white hyperkeratosis, as small
umbilicated swellings with red centres.

Management

Patient information is an important aspect in

management .
Few patients have spontaneous remission and the
patient should be stop the causative habit .

Diagnosis

The clinical appearances and history are so distinctive that biopsy

should not normally be necessary .
The condition is not known to be potentially malignant, but the
patient may develop premalignant changes at other sites in the
upper aerodigestive tract.