Premalignant conditions of oral cavity

ENT oral cavity

1. PREMALIGNANT CONDITIONS OF ORAL CAVITY Presentation By Devasuriya.K Roll Number 31

2. ANATOMY OF ORAL CAVITY Extension of Oral Cavity From the skin-Vermilion border of lips ANTERIORLY to the junction of hard and soft palate SUPERIORLY and the line of the Circumvallate papillae POSTERIORLY . Most common site for oral cavity cancer : 1) Floor of the mouth 2) Lateral Border of Anterior Tongue 3) Buccal Sulcus 4) Retromolar Trigone

3. LIST OF PREMALIGNANT CONDITIONS OF ORAL CAVITY LEUKOPLAKIA ERYTHROPLAKIA MELANOSIS AND MUCOSAL HYPERPIGMENTATION CHRONIC HYPERPLASTIC CANDIDIASIS ORAL SUBMUCOSAL FIBROSIS SYPHILITIC GLOSSITIS SIDEROPENIC DYSPHAGIA ORAL LICHEN PLANUS DISCOID LUPUS ERYTHEMATOSUS DYSKERATOSIS CONGENITA

4. CONDITIONS ASSOCIATED WITH MALIGNANT TRANSFORMATION HIGH RISK LESIONS Erythroplakia ( Homogenous/Speckled) Proliferative Verrucous Leukoplakia Chronic Hyperplastic Candidiasis MEDIUM RISK LESIONS Oral Submucous Fibrosis Syphilitic glossitis LOW RISK LESIONS Oral Lichen planus Discoid LUPUS Erythematosus Discoid Keratosis Congenita

5. LEUKOPLAKIA DEFINITION : It is a clinical term used to describe any white patch or plaque that cannot be rubbed off or characterized clinically or pathologically as another disease. Most Common Sites involved: 1. BUCCAL MUCOSA 2 . ORAL COMMISURES Other sites involved are Tongue,Gingivobuccal Sulcus,Mucosal Surface of Lip,Floor of Mouth.

6. LEUKOPLAKIA CHEEK AND SPECKLED LEUKOPLAKIA ON LATERAL BORDER OF TONGUE

7. ETIOLOGY SMOKING TOBACCO CHEWING BOTH ALCOHOL AND SMOKING Other White lesion of Oral Mucosa like LICHEN PLANUS,DISCOID LUPUS ERYTHEMATOSUS,CANDIDIASIS should be excluded before confirming a condition of Leukoplakia. Leukoplakia is a hyperkeratotic,irreversible patch which is most common premalignant lesion of Oral cavity. Leukoplakia is a persistent and adherent patch

8. TYPES OF LEUKOPLAKIA HOMOGENOUS VARIETY They are uniform white patches with less malignant potential . This is the MOST COMMON TYPE and prevalent in BUCCAL MUCOSA.

9. NODULAR (SPECKLED) This is a variation of Leukoplakia arising on ERYTHEMATOUS BASE and has the highest rate of malignant transformation.

10. EROSIVE (ERYTHROLEUKOPLAKIA) Leukoplakia is interspersed with Erythroplakia and has Erosions and Fissures. Leukoplakia can be associated with 1) Submucous Fibrosis 2) Hyperplastic Candidiasis 3)Plummer Vinson Syndrome. Most commonly seen around 40years of age. Male : Female = 3 : 1 PAINLESS AND NON TENDER.

11. HISTOLOGY OF LEUKOPLAKIA 25% of Leukoplakia show some form of Epithelial Dysplasia. Higher the grade of dysplasia more are the chances of its going into malignant change.

12. Leukoplakia presents as spectrum of epithelial changes ranging from hyperkeratosis overlying a thickened,acanthotic but orderly mucosal Epithelium to lesions with markedly dysplastic changes sometimes merging into carcinoma in situ (PARAKERATOSIS WITH WIDENING OF RETE PEGS) Histology picture shows SEVRERE DYSPLASIA with NUCLEAR AND CELLULAR PLEOMORPHISM,NUMEROUS MITOTIC FIGURES AND LOSS OF NORMAL MATURATION.

13. HAIRY LEUKOPLAKIA Hairy leukoplakia is a distinctive oral lesion on the lateral border of the tongue that is usually seen in IMMUNOCOMPROMISED PATIENTS and is Caused by EPSTEIN BARR VIRUS (EBV). Seen in patients infected with HIV and may portend the development of AIDS. Hairy leukoplakia takes the form of WHITE,CONFLUENT PATCHES OF FLUFFY (HAIRY) HYPERKERATOTIC THICKENINGS,ALMOST ALWAYS SITUATED ON LATERAL BORDER OF TONGUE. Microscopic appearance : HYPERKERATOSIS and ACANTHOSIS with “ BALLOON CELLS” in the UPPER SPINOUS LAYER.

14. Extensive Leukoplakia on Dorsum of Tongue with carcinoma on lateral margin

15. DIAGNOSIS AND TREATMENT BIOPSY confirms the diagnosis as well as rules out CARCINOMA. Elimination of associated ETIOLOGICAL FACTORS (PAN CHEWING AND ALCOHOL) is the initial basis of management. All erythroplakia and Speckled Leucoplakia should undergo incisional biopsy. Severe epithelial dysplasia and Carcinoma in situ should be Ablated by surgical excision. REGULAR FOLLOW UP IS MANDATORY. LASER VAPORISATION can be done.

16. Severe Dysplasia on Lateral border of tongue and Laser Vaporisation.

17. PROLIFERATIVE VERRUCOUS LEUKOPLAKIA It is a rare progressive exophytic variant of leukoplakia which is frequently multifocal and carries higher risk of malignant transformation. Arises in the absence of traditional risk factors for oral premalignancy. Common in elderly women not associated with tobacco use.

18. KEY POINTS ON LEUKOPLAKIA

19. ERYTHROPLAKIA Definition: It is defined as the lesion of Oral Mucosa that presents as a Bright red velvety plaque that cannot be characterized clinically or pathologically as any other recognizable condition. Red colour is due to decreased keratin causing shining and prominence Of Submucosal Red vascularised Connective tissue. Most Common Sites involved: 1) LOWER ALVEOLAR MUCOSA 2)GINGIVOBUCCAL SULCUS 3) FLOOR OF MOUTH

20. Features of Erythroplakia Males and Females equally affected (No sex predilection) 3 varieties are 1. HOMOGENOUS 2. SPECKLED/GRANULAR 3. ERYTHROPLAKIA INTERSPERSED WITH LEUKOPLAKIA Malignant potential is 17 times higher than Leukoplakia. Histological Feature : PARAKERATOSIS WITH SEVERE EPITHELIAL DYSPLASIA is the typical feature.

21. Lesion of Maxillary Gingiva and Mandibular Alveolar Ridge

22. Diagnosis and Treatment For diagnosis, BIOPSY is done For treatment, SURGICAL ABLATION is necessary Lesions of Erythroplakia shows Severe Dysplasia,Carcinoma In situ So BIOPSY is must to rule out CARCINOMA. ERYTHROPLAKIA OF CHEEK

23. MELANOSIS AND MUCOSAL HYPERPIGMENTATION Benign pigmented lesions of Oral Mucosa may transform into malignant melanomas. Incidence of conversion from benign to malignant is UNKNOWN. But,Biopsy is Mandatory. 25% of mucosal melanomas resemble benign lesion.

24. CHRONIC HYPERPLASTIC CANDIDIASIS It produces dense plaques of leukoplakia particularly around the commisures of mouth. Higher incidence of Malignant transformation and is associated with Candida albicans Management includes Prolonged Topical Antifungal Treatment for 6 weeks or Systemic Antifungal Treatment for 2 weeks. If medical management fails,consider Surgical Excision.

25. Chronic Hyperplastic Candidiasis involving LEFT BUCCAL MUCOSA

26. ORAL SUBMUCOSAL FIBROSIS It is a progressive fibrosis deep to the Mucosa of Oral Cavity which causes Trismus and Ankyloglossia. ETIOLOGY: Beetlenut,Tobacco and Vitamin Deficiency. 5-8% of them can convert into malignancy Management includes Avoiding precipitating factors and maintaining oral hygiene. Local injection of Dexamethasone with hyalase biweekly with vitamin and iron supplements Surgical excision of lesion with coverage of raw area using skin graft or tongue flap.

27. Oral submucosal fibrosis of right buccal Mucosa and soft palate

28. Risk of premalignant condition to malignant condition

29. LICHEN PLANUS 6P’s : PRURITIC,PURPLE,POLYGONAL,PLANAR,PAPULES,PLAQUES. Papules are highlighted by white dots called WICKHAM STRIAE. Lichen planus is characterized histologically by dense,Continous infiltrate of lymphocytes along dermoepidermal junction (example of interface dermatitis ) Anucleate ,necrotic basal cells gets incorporated into inflammed papillary dermis called as COLLOID or CIVATTE BODIES

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