Recognition of oral potentially malignant disorders and transformation to oral cancer.

Oral potentially malignant disorders refer to oral mucosal disorders with increased risk for malignant transformation, primarily to oral squamous cell carcinoma (SCC). Leukoplakia and erythroplakia are the most common of these disorders, but others have been identified. Transformation rates to oral cancer vary based on multiple factors. Healthcare providers should be aware of risk factors and clinical manifestations of these disorders and should intervene early to monitor and/or treat them to reduce the potential for malignant transformation.

Oral erythroplakia-What is it?

Oral erythroplakia is a rare type of lesion, and little is known about the origin of the lesion. It has traditionally been described as the red counterpart of oral leukoplakia, which implies that it is a red lesion that cannot be characterized clinically or pathologically as any other definable lesion. A definition by exclusion is less satisfactory than a positive description to define a lesion, and as erythroplakia probably is related to lichenoid lesions, a new approach to perceive the lesion is proposed based on the clinical features of a fiery red, sharply demarcated lesion situated at a slightly lower level than the surrounding mucosa. Such a definition would probably help clinicians distinguish erythroplakia from other red lesions of the oral mucosa. Although the course of such lesions varies, a significant proportion will develop malignancy, which is why they should be followed at short intervals.

Evidence for a possible anatomical subsite-mediated effect of tobacco in oral potentially malignant disorders and carcinoma.

PURPOSE: To test the hypothesis that cigarette smokers develop oral potentially malignant disorders or carcinomas in preferential anatomical subsites. METHODS: The association of smoking habit with the presence of oral lesions in specific anatomical subsites was assessed in 123 patients using the odds ratio analysis. RESULTS: When compared to all the other subsites, the relative frequency of smokers with lesions was higher in the buccal mucosa and in the floor of the mouth (FOM) (P=0.002 and P=0.005), while it was lower in the tongue (P<0.0005). Smokers were about 7 years younger than non-smokers (P=0.008). CONCLUSIONS: The association of smoking and age suggests that smoking may contribute to generate a field of injury that leads to lesions in shorter periods than other causes. The stronger relationship of smoking with lesions in the buccal mucosa and FOM than in the tongue suggests that tissue characteristics mediate the effects of tobacco.

Is workplace screening for potentially malignant oral disorders feasible in India?

BACKGROUND: Because of delays in diagnosis, oral cancer usually presents for therapy at a late stage. Patients are unaware of having lesions as they are mostly asymptomatic and physicians generally do not examine the mouth sufficiently. People in rural areas or are underserved may not frequently visit the dentist who can easily pick up these lesions early. Screening programs are useful in that regard. Such programs in general are conducted by either inviting people to come to a screening center or by health care workers visiting the individual households. However, those who work during the day may not visit screening centers or be at home during the day of the screening by a visiting health care worker. Workplace screening overcomes these challenges. METHODS: To assess the feasibility of a screening program to detect potentially pre-malignant oral disorders in a workplace in India, clinically visible mucosal lesions were compared with the clinical photographs of the same lesions assessed by an expert. Role of smoking, alcohol, and chewing betel quid and tobacco in the etiology of those lesions were assessed. RESULTS: Sixty-nine percent of the eligible subjects participated in the screening (n=1613). Prevalence of leukoplakia was 5%. Bidi (OR=35.6), and cigarette smoking (OR=22.8), alcohol (OR=17.6), and tobacco and areca nut chewing (OR=7.5), were significantly associated with leukoplakia and erythroplakia (all P< 0.05). CONCLUSIONS: Conduction of a screening program by valid visual inspection to detect potentially malignant oral disorders within a workplace is not only feasible but also effective.

Natural history of potentially malignant oral lesions and conditions: an overview of the literature.

At a workshop coordinated by the WHO Collaborating Centre for Oral Cancer and Pre-cancer in the UK issues related to potentially malignant disorders of the oral cavity were discussed by an expert group. The consensus views of the Working Group are presented in a series of papers. In this report we review the literature on the epidemiology and natural history of potentially malignant disorders (PMD), detailing those characteristics of the patients and lesions thought to be associated with future development of oral squamous cell carcinoma (OSCC). Older patients, particularly females are more at risk than younger patients; the duration of PMD may be important. Those who have never used tobacco seem at greater risk than smokers. OSCC is more likely with PMD on the lateral and ventral tongue, floor of mouth and retromolar/soft palate complex than with those elsewhere. The vast majority of PMD in which OSCC develop are non-homogenous although 5% of homogenous PMD will develop carcinoma. Large lesions covering several intraoral subsites also appear more at risk.

[Oral erythroplakia and erythroleukoplakia: red and red-white dysplastic lesions of the oral mucosa--part 1: epidemiology, etiology, histopathology and differential diagnosis]. / Erythroplakie und Erythroleukoplakie: Rote und rot-weisse Risikoläsionen der Mundhöhlenschleimhaut. Teil 1: Epidemiologie, Atiologie, Histopathologie und Differenzialdiagnose.

Oral erythroplakia (OE) and oral erythroleukoplakia (OEL; synonym: speckled leukoplakia) are working diagnoses for red and red-white lesions of the oral mucosa after exclusion of all other possible diagnoses for lesions with a similar clinical appearance. A good knowledge of oral medicine and possible differential diagnoses of oral mucosal pathologies is mandatory to correctly detect OE and OEL on this exclusion basis. In the present review article in a series of two, epidemiologic data, etiologic factors, possible differential diagnoses, and the histopathologic characteristics of OE and OEL will be presented and discussed regarding the current literature. A thorough histopathologic examination of these epithelial precursor lesions is mandatory to recognise the presence and the severity of epithelial dysplasia, which is a decisive factor for the subsequent treatment planning.

Long-term treatment outcome of oral premalignant lesions.

The purpose of the present retrospective study was to learn the long-term outcome of oral premalignant lesions, leukoplakia and erythroplakia, with or without surgical intervention and to relate the outcome to factors supposed to be significant for malignant development including clinical type, demarcation, size, site, presence of epithelial dysplasia, smoking and surgery. A total of 269 lesions in 236 patients were included. Ninety-four lesions were surgically removed, 39 lesions (41%) being homogenous and 46 (49%) non-homogenous leukoplakias whereas nine (5%) were erythroplakias. Seventy-three percent of the lesions were associated with tobacco habits. The mean size of the lesions was 486 mm(2), and 71% of the lesions showed a degree of epithelial dysplasia. After excision the defects were closed primarily by transposition of mucosal flaps or they were covered by free mucosal or skin grafts. A few defects were left for secondary healing. After surgical treatment the patients were followed (mean 6.8 yrs, range 1.5-18.6 yrs), and new biopsies taken in case of recurrences. One hundred and seventy five lesions had no surgical intervention, 149 lesions (85%) being homogenous and 20 (11%) non-homogenous leukoplakias, and 6 (3%) erythroplakias. Eighty-one percent of the lesions were associated with smoking. The mean size of the lesions was 503 mm(2) and 21 of the lesions (12%) exhibited epithelial dysplasia. Sixty-five lesions were not biopsied. These patients were also followed (mean 5.5 yrs, range 1.1-20.2 yrs), and biopsies taken in case of changes indicative of malignant development. All patients were encouraged to quit smoking and candidal infections were treated. The possible role of different variables for malignant development was estimated by means of logistic regression analysis. Following surgical treatment 11 lesions (12%) developed carcinoma after a mean follow-up period of 7.5 yrs. Non-homogenous leukoplakia accounted for the highest frequency of malignant development, i.e. 20%, whereas 3% of the homogenous leukoplakias developed carcinomas. Surgically treated lesions with slight, moderate, severe and no epithelial dysplasia developed carcinoma with similar frequencies, i.e. 9-11%. Without surgical intervention 16% of the 175 lesions disappeared whereas seven lesions (4%) developed carcinoma after a mean observation period of 6.6 yrs. The highest frequency of malignant development (15%) was seen for non-homogenous leukoplakias, this figure being 3% for homogenous leukoplakias. Fourteen percent of lesions with slight epithelial dysplasia developed malignancy and 2% of lesions with no dysplasia showed malignant transformation. Logistic regression analysis showed a seven times increased risk (OR = 7.0) of non-homogenous leukoplakia for malignant development as compared with homogenous leukoplakia and a 5.4 times increased risk for malignant development for lesions with a size exceeding 200 mm(2). No other examined variables including presence of any degree of epithelial dysplasia, site, demarcation, smoking and surgical intervention were statistically significant factors for malignant development.

Oral erythroplakia--a review.

Oral erythroplakia (OE) is considered a rare potentially malignant lesion of the oral mucosa. Reports entirely devoted to OE are very few, and only two reviews none of which are of recent date have been published. Only the true, velvety, red homogeneous OE has been clearly defined while the terminology for mixed red and white lesions is complex, ill-defined and confusing. A recent case control study of OE from India reported a prevalence of 0.2%. A range of prevalences between 0.02% and 0.83% from different geographical areas has been documented. OE is predominantly seen in the middle aged and elderly. One study from India showed a female:male ratio of 1:1.04. The soft palate, the floor of the mouth and the buccal mucosa is commonly affected. A specific type of OE occurs in chutta smokers in India. Lesions of OE are typically less than 1.5 cm in diameter. The etiology of OE reveals a strong association with tobacco consumption and the use of alcohol. Histopathologically, it has been documented that in OE of the homogenous type, 51% showed invasive carcinoma, 40% carcinoma in situ and 9% mild or moderate dysplasia. Recently, genomic aberrations with DNA aneuploidy has been demonstrated. p53 mutations with different degrees of dysplasia may play a role in some cases of OE. Transformation rates are considered to be the highest among all precancerous oral lesions and conditions. Surgical excision is the treatment of choice. Data on laser excision are not available. Recurrence rates seem to be high, reliable data are, however, missing. More studies on OE are strongly needed to evaluate a number of so far unanswered questions. The natural history of OE is unknown. Do OEs develop de novo or are they developing from oral leukoplakia through several intermediate stages of white/red lesions? The possible role of fungal infection (Candida micro-organisms) is not clear as is the possible role of HPV co-infection in the development of OE. More data on incidence and prevalence, biological behaviour and adequate treatment are urgently needed.

Oral medicine--update for the dental practitioner: red and pigmented lesions.

This series provides an overview of current thinking in the more relevant areas of oral medicine for primary care practitioners, written by the authors while they were holding the Presidencies of the European Association for Oral Medicine and the British Society for Oral Medicine, respectively. A book containing additional material will be published. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders, or discussion of disorders affecting the hard tissues. Approaching the subject mainly by the symptomatic approach--as it largely relates to the presenting complaint--was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made. Guidance on management and when to refer is also provided, along with relevant websites which offer further detail.

Chewing tobacco, alcohol, and the risk of erythroplakia.

Although chewing tobacco, smoking, and alcohol drinking have been suggested as risk factors for oral cancer, no study has examined the relationship between those factors and the risk of erythroplakia, an uncommon but severe oral premalignant lesion. In this study, we have analyzed the effects of chewing tobacco, smoking, alcohol drinking, body mass index, and vegetable, fruit, and vitamin/iron intake on the risk of erythroplakia and explored potential interactions between those factors in an Indian population. A case-control study including 100 erythroplakia cases and 47,773 controls was conducted, as part of an on-going randomized oral cancer screening trial in Kerala, India. The analysis was based on the data from the baseline screening for the intervention group, where the diagnostic information was available. The information on epidemiological risk factors was collected with interviews conducted by trained health workers. The erythroplakia cases were identified by health workers with oral visual inspections, and then confirmed by dentists and oncologists who made the final diagnosis. The odds ratios (OR) and their 95% confidence intervals (CIs) were calculated by the logistic regression model using SAS software. The adjusted OR for erythroplakia was 19.8 (95% CI, 9.8-40.0) for individuals who had ever chewed tobacco, after controlling for age, sex, education, body mass index, smoking, and drinking. The adjusted OR for ever-alcohol-drinkers was 3.0 (95% CI, 1.6-5.7) after controlling for age, sex, education, body mass index, chewing tobacco, and smoking. For ever-smokers, the adjusted OR was 1.6 (95% CI, 0.9-2.9). A more than additive interaction on the risk of erythroplakia was suggested between tobacco chewing and low vegetable intake, whereas a more than multiplicative interaction was indicated between alcohol drinking and low vegetable intake, and between drinking and low fruit intake. We concluded that tobacco chewing and alcohol drinking are strong risk factors for erythroplakia in the Indian population. Because the CIs of interaction terms were wide and overlapping with those of the main effects, only potential interactions are suggested.

Erythroplakic lesions in relation to oral lichen planus.

In a cohort of 740 referred patients with oral lichen planus eight patients were found with a sharply demarcated slightly depressed erythroplakic area. The histological examination of the biopsies from the erythroplakic lesion of the 8 patients showed seven with epithelial dysplasia. In addition, two of the lesions revealed a squamous cell carcinoma. In the erythroplakic lesion without dysplasia the histological picture was found to be characteristic of lichen planus. All eight patients were seen at later follow-up examinations (median observation period: 3.6 years) and in one patient a squamous cell carcinoma arose in the erythroplakic lesion during the control period. It is concluded that the reported erythroplakic lesions in relation to oral lichen planus seem to be premalignant and they should be followed and/or treated like oral erythroplakias.

Oral precancerous and malignant lesions associated with graft-versus-host disease: report of 2 cases.

The development of secondary malignancies has been recognized as a potential iatrogenic complication in patients who have graft-versus-host disease secondary to bone marrow transplantation. Lymphohematopoietic cancer is most frequent, although solid malignancies have also been reported. We describe 2 patients with graft-versus-host disease who developed oral precancerous and malignant lesions. The first patient, a 24-year-old white man, had erythroplakia of the buccal mucosa that proved to be carcinoma in situ histopathologically. The second patient, a 14-year-old Hispanic boy, developed synchronous cutaneous and lingual squamous cell carcinomas. The current cases and similar sporadic case reports found in the literature highlight the susceptibility of patients with graft-versus-host disease to the development of oral cancer. Therefore, it is recommended that thorough evaluation of the oral mucosa and close follow-up be offered to all patients treated with bone marrow transplantation and particularly to those who develop graft-versus-host disease.

Erythroplastic lesion on the mandibular marginal gingiva.

Carcinoma of the gingiva is a significant risk to patients because the asymptomatic characteristics of erythroplastic lesions are not always readily identified. This case report shows the similarity in clinical appearance of squamous cell carcinoma of the gingiva to the common inflammatory changes associated with periodontal disease. A similar clinical presentation might be seen in any lesion with increased vascularity, including Kaposi's sarcoma associated with human immunodeficiency virus infection. Any erythroplastic change involving the oral mucosa should be viewed with suspicion and, if not resolved after removal of local sources of irritation, must be biopsied to establish a definitive diagnosis.

Oral mucosal lesions found in smokeless tobacco users.

The risk for oral mucosal lesions associated with use of smokeless tobacco among 1,109 professional baseball players during spring training in 1988 was investigated. Leukoplakia was very strongly associated with use of smokeless tobacco in this population of healthy young men. Of the 423 current smokeless tobacco users, 196 had leukoplakia compared to seven of the 493 nonusers (OR = 60.0, 95% CI = 40.5-88.8). The amount of smokeless tobacco used (in hours per day that smokeless tobacco was held in the mouth), recency of smokeless tobacco use (hours since last use), type (snuff versus chewing tobacco), and brand of snuff used were significantly associated with risk for leukoplakic lesions among smokeless tobacco users. Ninety-eight leukoplakic areas in 92 subjects were biopsied and examined microscopically. All lesions were benign, but one specimen had mild epithelial dysplasia. The long-term significance of leukoplakia in smokeless tobacco users and their relation to oral cancer is not clear.

[A case of erythroplakia of the palate, tongue and gingiva].

A case of a 58-year-old man with erythroplakia, which occurred in the palate, tongue and gingiva, is reported. The histological diagnosis of a biopsy specimen was carcinoma in situ. The patient was treated with irradiation (60Co, 5060 cGy) and chemotherapy (5-FU, arterial infusion, 6400 mg). The erythema completely disappeared following a 6-week therapy, and no atypical cells were histologically recognized. There were no signs suggesting recurrence or metastasis during the follow-up period of 5 months.

[Environmental pathology and dentistry. III. Carcinogenic process of the soft tissues of the oral cavity]. / Patologia ambientale ed odontoiatria. Nota III. I processi cancerosi dei tessuti mobili della cavità orale.

The context in which a relationship between environmental pathologies and dentistry is most easily distinguished is with reference to the carcinogenic processes of soft tissues in the oral cavity. In this study, a distinction is made between potentially cancerous lesions and true carcinomas, and the relationship between tumour pathology of the oral cavity and the surrounding environment is analysed. Clinical aspects are also illustrated.

How carcinogens cause cancer.

Several concepts have been formed regarding the origin of primary malignancies, but only recently has a theory on second primary cancers evolved. The aim of this report is to review the literature regarding current concepts associated with carcinogenesis, tobacco and alcohol, oral premalignancy, field cancerization and cancer prevention.

Oral leukoplakia and erythroplakia: a review and update.

Soft tissue health in the oral cavity is essential for overall dental and medical health and a successful maintenance of any restoration. This article reviews the clinical, etiologic, and prognostic features of oral leukoplakia, the most common of all chronic mucosal lesions, affecting 3% of all adults. The newest definitions for leukoplakia, erythroplakia, and smokeless tobacco keratosis are offered, along with a rationale for predicting malignant transformation and for treatment planning of these most important precancers. The learning objective of this article is to update the information for the clinician for early diagnosis and treatment of these lesions.

Erythroplakia: the dangerous red mucosa.

Erythroplakia is an uncommon and subtly innocuous change of the oral mucosa, but it has very specific and identifiable clinical characteristics, therapies, and prognostic features. It is the most dangerous of all the oral cancer precursor lesions, and a search for erythroplakia should be a part of every oral soft tissue examination in persons aged 35 years and older. No erythroplakia lesions should ever be left untreated. Much has been written about the malignant potential of oral leukoplakia, but too often the dental profession has ignored the more dangerous discoloration, erythroplakia, which carries a much greater cancer risk than the white lesions. A clear understanding of this lesion may save lives by identifying oral cancers prior to invasion or at an early stage, thereby avoiding extensive surgery and spread of the disease to other parts of the body. The learning objective of this article is to review and familiarize the reader with the terminology, diagnosis, etiology, treatment, and the prognosis of this disease.