management of Oral leukoplakia by cryotherapy

oral leukoplakia management by cryotherpy

1. MANAGEMENT OF ORAL LEUKOPLAKIA BY CRYOTHERAPY - A CASE REPORT Presented by Dr. Y ogesh L odelliwar 1 st yr PG Guided by P rof.Dr M ahendra P atait Dr. kedar saraf

2. INTRODUCTION The term leukoplakia originates from Greek word leuko =white, plakia =patch. The term leukoplakia refers to a clinical entity defined by the World Health Organization (WHO) as “a white patch or plaque that cannot be characterized clinically or histologically as any other disease . The term leukoplakia was first used by S chwimmer in 1877 to a white lesion of tongue, which probably represented a syphilitic glossitis.

3. He proposed the term leukoplakia for diffuse patch on the dorsum of tongue. Since then it was evolved as a clinicopathological concept over many years; sometimes representing an innocent hyperkeratosis and sometimes dysplastic features. Leukoplakia is the most common premalignant lesion of the oral mucosa. The dysplastic epithelium or frank invasive carcinoma is, in fact found only in 5% to 25% of biopsy samples of leukoplakia.

4. PREVALANCE The prevalence of leukoplakia in India varies from 0.2% to 4.9% 2 . Men's are affected more frequently than woman and vast majority of leukoplakia occurs in the age range of 35-45 years 3 . Oral leukoplakia may affects any part of the mouth, but usually seen on the buccal mucosa tongue and gingiva. The research has shown that oral leukoplakia on the ventral surface of the tongue, floor of mouth and soft palate are more likely to become precancerous/dysplastic.

5. The exact cause of oral leukoplakia is still unknown, although certain risk factors have been identified. More than 80% of patient with oral leukoplakia have a history of tobacco use and the condition is six times more common among smoker's than non-smokers. The frequency of dysplastic or malignant alteration in oral leukoplakia has ranged from 15.6 to 39.2 percentages in several studies 1 .

6. CASE REPORT: A 20 year male patient presented to the Department of Oral Medicine and Radiology of SMBT Dental College & Hospital, Sangamner with a chief complaint of dirty deposits in the upper and lower teeth of the jaw since 2 yrs years. H/O Present Illness : Patient was apparently alright 2 years ago when he noticed dirty deposits in upper and lower teeth of jaw . Initially patient had least deposits over teeth, later on it is progressed and covers the all teeth.

7. Medical History : No relevant history of any systemic illness, medications, drug allergies. Dental History: N o relevant history Family History: No relevant family history. Personal History: Patient cleans his teeth with toothbrush and toothpaste2 times daily - Habit of gutkha chewing 4-5 sachets per day since 3-4 yrs

8. Intraoral Examination : Inspection : A diffuse white lesion is seen on right buccal mucosa extending roughly between 46, 47, 48 region. it is about 3cm in dimension superio -inferiorly and 1.5 -2 cm dimension in antero -posteriorly. It has diffuse border and rough surface. it is non- scrapable , non – inflammatory, non tender and not raised from the surface. Hard Tissue Examination: Teeth present: all teeth present Dental caries: Occlusal caries with 46

9. INVESTIGATIONS: Toluidine blue test was performed which showed positive results

10. Provisional diagnosis: Oral leukoplakia

11. Differential diagnosis Lichen planus Leukoedema Cheek biting lesion Smokeless tobacco lesion White sponge nevus

12. Lichen planus The presence of wickham’s striae on buccal mucosa helps in differentiating lichen planus from leukoplakia. Leukoplakia more often affects men whereas lichen planus occurs more frequently in women Lichen planus mostly seen bilaterally on buccal mucosa. If chronic irritant can not be identified and area of characteristic of Wickham straie is discovered, the lesion is probably lichen planus . Lichen planus is chronic mucocutaneous disease of unknown etiology , may be immunological disturbances either local or general and perhaps of autoimmune character.

13. leukoedema It is easily differentiated from leukoplakia because it classically occurs on the buccal mucosa, frequently covers most of the surface characteristics with faint milky opalescence. The characteristic folded and more prominent wrinkled pattern that can be eliminated by stretching buccal mucosa.

14. Cheek biting lesion The lesion on buccal mucosa takes roughen white cast because of increased thickness of epithelium and keratin. The lesion on buccal mucosa can be evaluated by checking occlusal interference during bite. Careful follow up reveals regression of the erosion when the habit is modified or eliminated.

15. Smokeless tobacco lesion It resembles leukoplakia, but it often has a wrinkled pattern and is easily identified by it location in the vestibule and history of smokeless tobacco use.

16. White sponge naevus It occurs soon after birth or at least by puberty and is usually widely distributed over oral mucous membrane. In contrast, leukoplakia is seen in patient over 40 years of age and usually is not disseminated throughout the oral cavity. It shows familial pattern not so characteristics of leukoplakia.

17. Final diagnosis oral leukoplakia

18. Treatment Patient was advised for cryotherapy after screening . The whole procedure was explained to patient before the treatment started. cotton swab with diameters of 4 -6 mm in dimension were used for the therapy depending on the size of the lesion. the lesion site was air-dried before treatment to prevent the cotton swab from sticking to the oral mucosa. The cotton swab was dipped into liquid nitrogen for at least 5 seconds and applied to the lesion with pressure for 20 seconds to form an ice ball and then allowed to thaw for another 20 seconds . Four consecutive freeze-thaw cycles were performed on the same area of the lesion . Patient was recalled for follow up after 10 days.

19. Second visit after 10 days The lesion showed 40% reduction after first application. Patient had no history of pain and burning sensation after cryotherapy. Patient stopped his habit completely. Patient was recalled to continue the treatment .

20. Third visit for 2 nd treatment The same procedure was performed on lesion located on right side of buccal mucosa. The cotton swab with liquid nitrogen was placed on remaining site of lesion. The patient was recalled for follow up.

21. Fourth visit for follow up The lesion over buccal mucosa showed gross changes of 5-10% after second application. The lesion showed no recurrence. On palpation ,the lesion had smooth surface and had no burning sensation. Patient is kept on follow up and recalled after 1 month

22. Discussion There are different treatments for leukoplakia, which have shown different results. Treatment of oral leukoplakia includes surgical and non surgical methods. Non surgical treatments includes antioxidants, retinoids and photodynamic therapy. Surgical treatment of leukoplakia can be done through conventional surgery, laser surgery, electro surgery or cryosurgery .

23. Leukoplakia located on the floor of the mouth, soft palate and tongue are considered lesions of high risk for malignant transformation while in other areas, such as the gingiva, hard palate and the buccal mucosa are considered to represent a low risk of malignancy . Conventional surgery may frequently used, but may cause scars and loss of tissue and there is high time of work in relation to the cryosurgery . Moreover recurrence has been reported in 10%to35% of the cases. Cryosurgery is the deliberate destruction of tissue by application of extreme cold and has been used in oral medicine and pathology for over30 years.

24. It is carried out with either an ‘‘open’’ or a ‘‘closed’’ system. Open-system cryotherapy involves directly applying the cryogen to the lesion with a cotton swab or using open spray. Closed-system cryotherapy offers a greater degree of control with a more-complex and -delicate apparatus. The mechanism for cell destruction after cryosurgery are complex involving a combination of direct and indirect effects. Direct effects consist of ice crystals that form in extracellular and intracellular fluid ,cellular dehydration ,toxic intracellular electrolyte concentration, Inhibition of enzymes, protein damage, thawing effect causes the cell to vacuolate , swell and rupture and thermal shock injury to cells. Indirect effects include vascular changes that lead to ischemic necrosis of the treated tissue and immunological responses that cause cell damage through a cytotoxic immune mechanism .

25. Cryosurgery is well accepted by patient due to relative lack of discomfort, absence of bleeding and minimal to no scarring. Relatively no need of antibiotics and analgesics after cryotherapy, rarely It required . Disadvantages are a lack of control over the temperature achieved within the cell and lack of precision with depth and area of freezing. Numerous application is required on the lesion due to rapid evaporation of liquid nitrogen from cotton swab. The patient had received 2 cycles of cryosurgery and the lesion showed the regression of 60% without scar formation and patient is kept on follow up. This indicate that multiple cycles of cryosurgery is necessary for effective treatment of large lesions.

26. Conclusion Cryosurgical treatment has certain advantages over conventional surgery and these includes bloodless treatment, very low incident of secondary infection and a relatively lack of scarring and pain. Hence cryosurgery which is not much used in dentistry has got a key role when used properly in treatment of oral leukoplakia which is resistant to all other conventional treatments. It is very safe ,inexpensive and easy performing technique for the treatment of various oral lesion particularly oral leukoplakia.

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