White plaques of questionable risk, diagnosed when other known diseases or disorders that carry no risk for oral cancer have been excluded.
Multiple clinical forms exist: homogeneous, speckled, nodular, and verrucous.
May be idiopathic, but is commonly seen in heavy tobacco users and consumers of alcohol or betel.
The majority are histologically benign with a wide range of histological characteristics within this category of lesions.
Certain leukoplakias, particularly non-homogeneous leukoplakias, such as speckled leukoplakia and verrucous leukoplakia, have a significant risk of malignant transformation and require frequent and careful follow-up, often with biopsy confirmation or definition of the biological nature of the leukoplakia over time.
Oral leukoplakia, as traditionally defined by the World Health Organization (WHO), is a predominantly white lesion of the oral mucosa that cannot be characterised as any other definable lesion. Leukoplakia is often associated with tobacco smoking, although idiopathic forms are not rare. An international working group has amended the earlier WHO definition as follows: "The term leukoplakia should be used to recognise white plaques of questionable risk having excluded (other) known diseases or disorders that carry no risk for cancer".
Leukoplakias are commonly homogeneous and most are benign. Non-homogeneous leukoplakia, or so-called speckled leukoplakia or nodular leukoplakia - a predominantly white or white and red lesion (erythroleukoplakia) with an irregular texture that may be flat, nodular, exophytic, or papillary/verrucous - is more likely to be potentially malignant. Histological features of both forms of leukoplakia are variable and may include orthokeratosis or parakeratosis of various degrees, mild inflammation, and variable degrees of epithelial dysplasia. However, although criteria for dysplasia have been defined by the WHO, it is difficult to make an objective categorisation of dysplasia owing to a high inter-observer and intra-observer variation in assessment.
History and exam
Key diagnostic factors
- presence of risk factors
- homogeneous white plaques
- other causes for white lesions excluded
- non-homogeneous appearance
Other diagnostic factors
- male sex
- age >40 years
- tobacco use
- alcohol use
- betel use
- chronic candidiasis
- genetic predisposition
- Fanconi's anaemia
- sunlight exposure
- HPV infection
- Treponema pallidum infection (syphilis)
1st investigations to order
- incisional biopsy
Investigations to consider
- brush biopsy
- autoantibodies for ANA, double-stranded DNA, and Smith antigen
- Treponema pallidum serology
- chemiluminescent spectroscopy
- molecular and chromosomal markers
James Sciubba, DMD, PhD
Milton J. Dance Jr. Head and Neck Cancer Center
Greater Baltimore Medical Center
JS declares that he has no competing interests.
We would like to gratefully acknowledge the late Dr Crispian Scully for his contribution to this topic.
Finn Praetorius, DDS
Department of Oral Pathology
School of Dentistry
University of Copenhagen
FP declares that he has no competing interests.
Isaac Van der Waal, DDS, PhD
Professor and Head
Department of Oral and Maxillofacial Surgery/Oral Pathology
Vrije Universiteit Medical Center
IVdW declares that he has no competing interests.
Michaell Huber, DDS
Division of Oral Medicine
Department of Dental Diagnostic Science
University of Texas Health Science Center
MH declares that he has no competing interests.
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