WHITE LESIONS: Leukoplakia

Leukoplakia is a clinical term without any histologic significance. It is defined as a white patch or plaque that cannot be scrapped off and cannot be characterized, clinically and histologically, as any other disease entity. Leukoplakia is the most common potentially malignant disorder (precancerous lesion) and is characterized by biological heterogenicity.

Etiology: The exact etiology remains unknown. Smoking and alcohol consumption are the main environmental causative factors, followed by human papillomavirus (HPV) types 16 and 18, Candida species, chronic local friction, etc. 

Clinical features: Based on the clinical criteria, leukoplakia is classified into two main groups: 

(1) homogeneous (common-low risk) and 

(2) nonhomogeneous, which is subdivided into speckled or nodular (less common-high risk) and verrucous (rare-high risk) forms. 

Clinically, homogeneous form is characterized by a thin, flat uniform white plaque. The speckled form is characterized by a red surface with multiple, small, white macules or nodules. Verrucous form presents as an exophytic, irregular, wrinkled or corrugated white plaque.

Proliferative verrucous leukoplakia is a subtype of verrucous form, which is characterized by multifocal location, tendency to recur, is usually HPV positive, and has a high rate of malignant transformation. 

The total risk of malignant transformation of leukoplakia varies between 3 and 6% independent of the form. The buccal mucosa and commissures, tongue, floor of the mouth, gingiva, and lower lip are more frequently affected. 

The lateral border of the tongue and the floor of the mouth represent areas of high risk for malignant transformation. 

Laboratory tests: Biopsy and histopathologic examination must be done to determine the risk of malignant transformation of oral leukoplakia. 

The oral clinicians should remember that the histologic results represent exclusively the site of biopsy taken in a specific time frame and do not have a long-term value. 

Differential diagnosis: Lichen planus, lichenoid reaction, hairy leukoplakia, cinnamon contact stomatitis, nicotinic stomatitis, candidiasis, chronic biting, chemical burn, leukoedema, uremic stomatitis, lupus erythematosus, white sponge nevus, dyskeratosis congenita, pachyonychia congenita, skin, and mucosal grafts. 

Treatment: The treatment of choice is surgical excision and smoking cessation. Electrosurgery and laser may also be used as alternative procedures. A followup program every 6 months for 3 to 5 years is recommended.

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