Dermatologic Manifestations of Oral Leukoplakia Clinical Presentation

Updated: Mar 10, 2022
  • Author: James J Sciubba, DMD, PhD; Chief Editor: William D James, MD  more...
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Presentation

Physical Examination

Most leukoplakias are smooth, white plaques (homogeneous leukoplakias), as shown in the image below.

Homogeneous leukoplakia. Homogeneous leukoplakia.

Most leukoplakias occur on the lip, the buccal mucosae, or the gingivae.

Some leukoplakias are white and warty (verrucous leukoplakia), as shown in the image below.

Verrucous or nodular leukoplakia. Verrucous or nodular leukoplakia.

Some leukoplakias are mixed white and red lesions (erythroleukoplakias or speckled leukoplakias), as shown in the image below.

Erythroleukoplakia. Erythroleukoplakia.

Proliferative verrucous leukoplakia (PVL), the least common form of leukoplakia, is characterized by verruciform keratosis that are progressive and multifocal, exhibiting a high rate of recurrence and progression to carcinoma.

Dysplastic lesions do not have any specific clinical appearance; however, where erythroplasia is present, dysplasia, carcinoma in situ, and frank carcinomas are more likely to be seen. The site of the lesion is relevant; leukoplakias on the floor of the mouth or on the ventrum of the tongue and the lip are sinister. The size of the lesion appears to be irrelevant. Even small dysplastic lesions may lead to multiple carcinomas and a fatal outcome. Note the image below.

Carcinoma referred to as a leukoplakia. Carcinoma referred to as a leukoplakia.

A practical clinical tool for evaluating oral mucosal lesions has recently been developed. This tool is based on the grading of general clinical observations on a color scheme that reflects an increasing spectrum of concerns (green to red, or no concern to serious concern). [12, 13] This tool is summarized in the table below, with the headers representing the green spectrum being “No Serious Concern”, the yellow being “Concern”, and the red being “Serious Concern”.

Table. Practical Clinical Tool for Evaluating Oral Mucosal Lesions (Open Table in a new window)

Issue

 

No Serious Concern

Concern: Consider Referral to Specialist if Clinician or Patient Concerned, Especially if Multiple Issues Apply

Serious Concern: Referral to a Specialist

Historical Features

Size

No change

No reduction in size, even after eliminating trauma to lesion after 10-14 days

Increasing size, even after eliminating trauma to lesion after 10-14 days

 

Chronology

Lesion heals

No resolution over brief observation period

Rapid symptom onset

Solitary lesion or change in one area of lesion

Lesion persisting 3 weeks or longer

Persistent ulceration

Persistent swelling

Loosening of a tooth

Nonhealing tooth extraction socket

 

Neurological

None

Lack of pain

Pain

Dysphagia

Odynophagia

Otalgia

Numbness/paresthesia

Speech or voice change

 

Weight

Normal

No weight loss

Weight loss

History

Lifestyle Habits

None

Tobacco consumption mild/moderate

Betel quid or khat consumption mild/moderate

Marijuana consumption mild/moderate

UV light exposure mild/moderate (lip surface exposure

Late-onset sexual debut

Few or moderate numbers of lifetime sexual partners

Tobacco consumption high

Betel quid or khat consumption high

Alcohol consumption high

Marijuana consumption mild/moderate

UV light exposure high

Early sexual debut

Numerous lifetime sexual partners

 

Medical History

Clear

Deficiencies of iron or vitamins A, C, or E

Diabetes

Discoid lupus erythematosus

Dyskeratosis congenita

Epidermolysis bullosa

Fanconi anemia

High-risk human papillomavirus infection Immune defects, including HIV/AIDS or chronic candidosis

Medications: Immunosuppressants, antihypertensives

Periodontitis, poor hygiene

Plummer-Vinson syndrome

Scleroderma

Xeroderma pigmentosum

Deficiencies of iron or vitamins A, C, or E

Diabetes

Discoid lupus erythematosus

Dyskeratosis congenita

Epidermolysis bullosa

Fanconi anemia

High-risk human papillomavirus infection

Immune defects, including HIV/AIDS or chronic candidosis

Medications: Immunosuppressants, antihypertensives

Periodontitis, poor hygiene

Plummer-Vinson syndrome

Scleroderma

Xeroderma pigmentosum

Examination and Imaging

Potentially Malignant Disorder

None

Leukoplakia

Lichen planus/lichenoid mucositis

Oral submucous fibrosis

Erythroplakia

Leukoplakia; speckled or verrucous

Lichen planus/lichenoid mucositis; unilateral

 

Lesion Features

Equivocal

White patch (leukoplakia)

Lichen/lichenoid

Oral submucous fibrosis

Red patch (erythroplakia)

Mixed red and white patch (erythroleukoplakia/speckled leukoplakia)

Granular surface

Rolled, elevated margins

Ulceration

Induration

 

Cervical Lymph Nodes

No enlargement

Possible enlargement

Enlarged, firm, fixed, nontender, asymmetric

 

Imaging

No abnormality

Any bone density change

Poorly defined, uncorticated, irregular radiolucency

Lamina dura loss

Teeth displaced and/or resorbed

Pathological fracture

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Causes

No etiologic factor can be identified for most persistent oral leukoplakias (idiopathic leukoplakia). Known causes of leukoplakia include the following:

  • Trauma (eg, chronic trauma from a sharp or broken tooth or from mastication may cause keratosis)
  • Tobacco use: This includes smoked (including reverse smoking—lit end retained within the mouth) and smokeless (use of snuff and chewing tobacco); chewing tobacco likely contributes to oral leukoplakia more than smoking. [14]
  • Alcohol
  • Use of areca (betel) nut preparations, khat (qat), and similar products [15, 16]
  • Infections (eg, candidosis, syphilis, Epstein-Barr virus infection): Epstein-Barr virus infection causes a separate and distinct non–premalignant lesion termed oral hairy leukoplakia.
  • Chemicals (eg, sanguinaria) [17, 18]
  • Ultraviolet radiation (eg, actinic cheilitis)
  • Immune defects: Leukoplakias appear to be more common in transplant patients.

In cases of proliferative verrucous leukoplakia, the above risk factors are frequently absent; high-frequency allelic loss and high-risk allelic profiles noted in such lesions probably account for high-risk progression to dysplasia and malignancy. [19]

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Complications

Some leukoplakias are potentially malignant. Dysplasia currently appears to be the best predictor of malignant potential. As many as 25% of leukoplakias are dysplastic at the first visit. DNA ploidy and loss of heterozygosity (LOH) studies may help predict outcomes. [20, 21, 22] Malignant change appears to be more frequent among nonsmokers than among smokers.

A poorer prognosis is noted in the following [22, 23, 24] :

  • Nonsmokers
  • Females
  • Nonhomogenous appearance
  • Size larger than 200 mm
  • Moderate or severe epithelial dysplasia
  • LOH at 9p/3p and further increased risk if additional LOH at 4q and 17p
  • Lesions in high-risk sites, such as the floor of the mouth/tongue/soft palate
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