Untitled Quiz

Potentially Malignant Lesions

• Potentially malignant lesions (PML) are tissues where cancer is more likely to develop than in normal tissue.
• Key learning objectives include identifying PML based on history and clinical findings, selecting appropriate investigations, and listing topical medications for dysplastic lesions.
• Epidemiology: PML lesions occur in about 1.5% to 4.5% of the global population. Men are disproportionately affected. These lesions account for 17%-35% of new oral cavity cancers and transform into malignant cancers between 0.7% and 2.9% annually.

Premalignant Lesion

• A premalignant lesion is a morphologically altered tissue where malignancy is more likely to develop compared to its normal counterparts.

PML Types

• Leukoplakia: A white patch or plaque that cannot be clinically or histologically diagnosed as another disease; predominantly found on the oral mucosa.
• Erythroplakia: Bright red, velvety plaques; high risk of malignant transformation. Common sites include the floor of the mouth, tongue, buccal mucosa, retromolar pad, and soft palate.
• Chronic Hyperplastic Candidosis (candidal leukoplakia): Firm, white, leathery plaques, often found on the buccal mucosa near the mouth corners, palate and tongue.
• Speckled leukoplakia: Characterized by white nodules on an erythematous background, a combination of leukoplakia and erythroplakia. More likely to exhibit dysplasia than pure white lesions.
• Syphilitic leukoplakia: Found on the tongue's dorsal surface. Tertiary syphilis manifestation; rarely seen now. High premalignant potential.
• Snuff dipper's lesion: White plaque in the buccal or labial vestibule (where tobacco is held). Keratotic.
• Dyskeratosis congenita: Classic triad of nail dystrophy, reticular skin pigmentation, and oral leukoplakia. Increased malignant transformation potential.

Leukoplakia

• Clinically and histologically cannot be categorized as another disease.
• Predominantly a white lesion on the oral mucosa.
• Incidence: 0.2% to 4% of males, common in older age groups.
• Sites: Buccal mucosa, floor of the mouth, retrocommissural areas, ventral tongue, alveolar ridge, palate.
• Etiology: Idiopathic leukoplakia, cigarette/tobacco smoking, alcohol exposure, betel nut chewing, candidiasis, Human papillomavirus (HPV), HIV, HEP C.
• Classification: Homogenous (uniform appearance), Non-homogenous (distinct features, such as nodular or proliferative verrucous appearance)

Erythroplakia

• Bright red, velvety plaques that cannot be classified as other lesions.
• High risk of malignant transformation.

Speckled Leukoplakia

• White nodules on an erythematous background.
• Combination of leukoplakia and erythroplakia features.
• Higher risk of dysplasia than pure white lesions.

Proliferative Verrucous Leukoplakia

• Multifocal white patches or plaques with rough surface projections.
• Most common in older women and non-smokers..
• Very high risk of transformation.

Candidal Leukoplakia

• Firm, white, leathery plaques, mostly affecting buccal mucosa around the mouth corners, palate and tongue.
• Doesn't slough off.

Syphilitic Leukoplakia

• A manifestation of tertiary syphilis, often found on the dorsal surface of the tongue.
• Rare now.
• High premalignant potential.

Snuff Dipper's Lesion

• Characterized by a keratotic, white plaque in the buccal or labial vestibule (where snuff is held).

Dyskeratosis Congenita

• Classic triad: Nail dystrophy, reticular skin pigmentation, oral leukoplakia.
• Increased potential for malignant transformation.

Evaluation

• Early identification is key to management.
• Factors include: length of time, evolution of lesion, pain, recent dental trauma, bleeding, history of smoking or alcohol abuse, associated symptoms like dysphagia, trismus (difficulty opening mouth) and weight loss.
• Special attention should be paid to a patient's medical history, such as autoimmune disorders or organ transplants.

Treatment & Management

• Low-risk lesions: Cessation of risk factors (alcohol, tobacco, betel nut) and close observation.
• High-risk lesions: Surgical excision with appropriate margins, laser excision, laser vaporization, photodynamic therapy, and long-term follow-up.
• Management (general):
  • Stop associated habits
  • Dietary intervention
  • Treat candidiasis or iron deficiency if present
  • Biopsy for dysplasia assessment
  • Assess risk of transformation based on clinical and histological findings
  • Consider ablation of individual lesions
  • Maintain observation for malignant changes