MANAGEMENT OF LEUKOPLAKIA

Shashank Trivedi

(110301192)

WHAT IS LEUKOPLAKIA

Leukoplakia is defined as “A

predominantly white lesion of the oral

mucosa that cannot be characterized as any

other definable lesion”.

It is the most common pre-malignant

lesion of the oral mucosa with a malignant

potential of 15.6 to 39.2%.

Extrinsic:

-Smoking

-Tobacco

-Spirit

-Sepsis(HPV/Candidiasis)

-Sunlight

-Sharp Teeth

-Spices

ETIOLOGICAL FACTORS

Intrinsic:

-Genetics

-Old Age(>45 years)

-Nutrition

-

Immunosuppression

CLINICAL PRESENTATION

Leukoplakia can be either solitary or

multiple.

Leukoplakia may appear on any site of the

oral cavity, the most common sites being:

buccal mucosa, alveolar mucosa, floor of the

mouth, tongue, lips and palate.

Classically two clinical types of

leukoplakia are recognised: homogeneous

and non-homogeneous, which can co-exist.

INVESTIGATIONS

TOLUIDINE BLUE STAINING

Toluidine blue clinically stains malignant lesions,but not

normal mucosa.The dye is taken up by the nuclei of

malignant cells manifesting increased DNA sysnthesis.

It serves as a guide to biopsy by localizing tumor cells

within the area of the lesion.

It uses 1% aq.solution of the dye that is decolorized with 1%

acetic acid

The dye binds to dysplastic and malignant epithelial cells

with a high degree of accuracy.

Speckled leukoplakia after Toluidine Blue staining

CYTOBRUSH TECHNIQUE

This technique is more accurate than any

other cytologic technique used in the oral

cavity.

This technique uses a brush with firm

bristles that obtains individual cells from the

full thickness of the epithelium.

BIOPSY

When the suspicious lesion is

identified,an incisional biopsy using a

scalpel or a biopsy forceps is

recommended.

When the lesion is very small,Excisional

biopsy is performed as an investigative

procedure and as a treatment modality.

Incisional Biopsy

Histological appearance:

Hyperkeratosis and basal cell hyperplasia

TREATMENT

GENERAL CONSIDERATIONS

All possible agents leading to white keratotic lesions should

be eliminated(such as sharp teeth/Candidal infection) so as to

rule out other definable lesions.

In persisting lesions/absence of possible causative factor:

Biopsy should be taken to exclude histologically the presence

of a definable lesion and to establish the degree of epithelial

dysplasia.

Up to 60% of leukoplakias regress or totally disappear if

tobacco use is stopped.

MEDICAL MANAGEMENT( C H E M O P R E V E N T I O N )

Carotenoid and Retinoid:Eg:β-Carotene

Vitamin E

Selenium

Canthaxanthin

Astaxanthin

phytoene

1. Vitamin A75000-300000 IU/day for 3-18 months

2. 13-cis retinoic acid1.5mg/Kg per day for 3 months Followed by0.5mg/Kg per day for 9 months

3. β Carotene30mg daily for 3-6 months

4. Fenretinide -Synthetic retinoid -200mg/day -Reduces the relapse and appearance of new leukoplakias

5. Vitamin E 800 IU/day

PHOTODYNAMIC THERAPY(PDT)

PDT involves using specific wavelength of laser

light to activate a photosensitizing drug which is

administered systemically and is retained selectively

in the lesion.

This triggers a cold photochemical reaction

resulting in the generation of reactive products such

as singlet oxygen that damages tissue

Advantages:Inactivation of clinically subtle/undetectable alteration.Sparing of normal tissue.Minimal morbidity.

Disadvantage:Cutaneous photosensitivity which can persist for several months after administration of the photosensitizer which can be a major problem in the Indian Subcontinent,where oral cancer is most common.

TOPICAL CHEMOTHERAPY

Involves the use of Podophyllin solution or

Bleomycin.

According to the studies conducted by

Kovacs et al,1962 and Hammersley el

al,1985:These drugs have induced some

regression or even total resolution of

dysplasia and of clinical lesions.

OTHER ALTERNATIVE MODALITIES OF

TREATMENT

Green Tea

It has an anti-inflammatory action,antioxidant

action and Anticancer action.

Oral Lycopene

in the dose of 8 mg/day is beneficial in the

treatment of oral leukoplakia.

SURGICAL LINE OF TREATMENT

If the lesion is very small,it should be excised as a

part of investigation and as a treatment option.

Complete surgical removal (leaving free-lesion

borders) is recommended in cases with epithelial

dysplasia.

Even if the lesion is completely removed, long term

review is still usually indicated since leukoplakia can

recur.

CONCLUSIONThere is no known therapy to prevent development of oral

leukoplakia and there is no known therapy to prevent oral

squamous cell carcinoma developing from oral leukoplakia.

It has been demonstrated that a healthy life style and the

abstinence of tobacco are the best way to prevent both. Fresh

fruits and vegetables may have a protective effect in the primary

prevention of oral cancer and precancer.

Early diagnosis and treatment of leukoplakia, can reduce the

high rates of oral cancer morbidity and mortality in many

countries.

BIBLIOGRAPHY

Textbook of Oral Medicine and Radiology- Dr.Ravikiran Ongole

Textbook of Oral Medicine- Burkitt

Textbook of Oral Pathology- Shafer’s

Thank You