Management of leukoplakia

Leukoplakia is a pre-cancerous lesion of the oral cavity

1. Management of Leukoplakia Shashank Trivedi (110301192)

2. 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%.

3. Extrinsic: - Smoking -Tobacco -Spirit -Sepsis(HPV/Candidiasis) -Sunlight -Sharp Teeth -Spices Etiological factors Intrinsic: -Genetics -Old Age(>45 years) -Nutrition -Immunosuppression

4. 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.

5. INVESTIGATIONS

6. 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.

7. Speckled leukoplakia after Toluidine Blue staining

8. 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.

9. 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.

10. Incisional Biopsy Histological appearance: Hyperkeratosis and basal cell hyperplasia

11. TREATMENT

12. 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.

13. Medical Management ( Chemoprevention) Carotenoid and Retinoid: Eg : β -Carotene Vitamin E Selenium Canthaxanthin Astaxanthin phytoene

14. Vitamin A 75000-300000 IU/day for 3-18 months 13-cis retinoic acid 1.5mg/Kg per day for 3 months Followed by 0.5mg/Kg per day for 9 months β Carotene 30mg daily for 3-6 months

15. 4. Fenretinide -Synthetic retinoid -200mg/day -Reduces the relapse and appearance of new leukoplakias 5. Vitamin E 800 IU/day

16. 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

17. 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.

18. 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.

19. 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.

20. 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.

21. Conclusion There 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.

22. Bibliography Textbook of Oral Medicine and Radiology- Dr.Ravikiran Ongole Textbook of Oral Medicine- Burkitt Textbook of Oral Pathology- Shafer’s

23. Thank You