Oral Oral premalignancypremalignancy

Prepared by Saman W. Boskany

Oral Premalignancy are groups of Oral Premalignancy are groups of disorders or conditions that associated disorders or conditions that associated with increase risk for developing oral with increase risk for developing oral cancer and it can be divided to :cancer and it can be divided to :

OralOral premalignancypremalignancy

PremalignantPremalignant lesionlesion Premalignant conditionPremalignant condition

Premalignant lesionsPremalignant lesionsAre those lesions in which carcinoma Are those lesions in which carcinoma

may develop may develop

OR OR

Morphologically altered tissue in which Morphologically altered tissue in which cancer is more likely to occur than its cancer is more likely to occur than its apparent normal counterpart apparent normal counterpart

Is the abnormalities in Is the abnormalities in PROLIFERATION ,

PROLIFERATION , MATURATION or DIFFERENTIATION

MATURATION or DIFFERENTIATION of of the epithelium and these include:

the epithelium and these include: 1- nuclear hyperchromatism

1- nuclear hyperchromatism 2- nuclear pleomorphism

2- nuclear pleomorphism 3- incresed nuclear/cytoplasm ratio

3- incresed nuclear/cytoplasm ratio 4- abnormal mitosis 4- abnormal mitosis 5- Subsurface keratinazation

5- Subsurface keratinazation

In these lesions histopathological examination In these lesions histopathological examination demonstrate demonstrate epithelialepithelial dysplasiadysplasia or growth or growth abnormality abnormality

mild moderate severmild moderate sever

Grading of dysplasia Grading of dysplasia

Premalignant lesion Premalignant lesion

leukoplakialeukoplakia

ChronicChronic hyperplastichyperplastic candidiasiscandidiasis

ErythroplakiaErythroplakia

leukoplakia leukoplakia It’s a white patch or plaque that can not be It’s a white patch or plaque that can not be

diagnosed clinically or pathologically as any diagnosed clinically or pathologically as any other disease & other disease & will not rub offwill not rub off “WHO” “WHO”

Types Types

Thin leukoplakia Thin leukoplakia Thick or homogenous leukoplakia Thick or homogenous leukoplakia Granular or nodular leukoplakia Granular or nodular leukoplakia Verruciform leukoplakiaVerruciform leukoplakiaProliferative verruciform leukoplakia Proliferative verruciform leukoplakia Erythroleukoplakia or speckled leukoplakia Erythroleukoplakia or speckled leukoplakia

Clinical features :Clinical features :1- mostly above 40 years1- mostly above 40 years2- Strong male predilection 70%2- Strong male predilection 70%3- variable size (small to very wide lesion )3- variable size (small to very wide lesion )4- variable surface character (homogenous , 4- variable surface character (homogenous ,

nodular , erosive or speckled )nodular , erosive or speckled )5- may be soft or thick and fixed to the 5- may be soft or thick and fixed to the

underlying tissue underlying tissue 6- Its commonest Premalignant lesion it 6- Its commonest Premalignant lesion it

forms 85% of such lesions forms 85% of such lesions 7- low risk of malignant transformation 5%7- low risk of malignant transformation 5%

EtiologyEtiology

However its unknown but may be :However its unknown but may be :1- tobacco ;more than 80% are smokers 1- tobacco ;more than 80% are smokers 2- alcohol2- alcohol3- sanguinaria ‘toothpaste containing herbal3- sanguinaria ‘toothpaste containing herbal4- ultraviolet Lower lip vermilion 4- ultraviolet Lower lip vermilion 5- microorganism ,like treponema pallidum , 5- microorganism ,like treponema pallidum ,

candida albicans , human papilomavirus candida albicans , human papilomavirus 6- trauma 6- trauma

TreatmentTreatment Stop the causative habitStop the causative habitBiopsy is mandatory Biopsy is mandatory If dysplasia is mild 6 monthly follow up If dysplasia is mild 6 monthly follow up If moderate to sever dysplasia complete If moderate to sever dysplasia complete

removal is recommended either by surgical removal is recommended either by surgical excision , laser ablation , electrocautery and excision , laser ablation , electrocautery and cryosurgery cryosurgery

Chemo-preventive is experimental Chemo-preventive is experimental

Erythroplakia Erythroplakia

It’s a bright red plaque which can not be It’s a bright red plaque which can not be characterized clinically or pathologically as characterized clinically or pathologically as any other condition or disease any other condition or disease

Clinical feature Clinical feature 1- It’s the disease of old age 1- It’s the disease of old age

2- usually asymptomatic 2- usually asymptomatic

3- usually irregular in outline ,typically not plaque 3- usually irregular in outline ,typically not plaque instead its a flat or depressed , red color is due instead its a flat or depressed , red color is due to atrophied mucosal lining to atrophied mucosal lining

4- sometime there is coexisting area of leukoplakia 4- sometime there is coexisting area of leukoplakia

5- risk of malignant transformation is very high 5- risk of malignant transformation is very high (may reach 100%) , and often already malignant (may reach 100%) , and often already malignant on first biopsyon first biopsy

TreatmentTreatment

Biopsy is mandatory Biopsy is mandatory Removal regarding to degree of dysplasia Removal regarding to degree of dysplasia

as recommended for leukoplakia as recommended for leukoplakia

Chronic hyperplastic candidiasis Chronic hyperplastic candidiasis

Chronic candidial infection cause white Chronic candidial infection cause white plaque or lesion that can not be removed plaque or lesion that can not be removed by scraping , specially it affects oral by scraping , specially it affects oral commissures also the immunological commissures also the immunological condition of the patient may be affected to condition of the patient may be affected to cause candidial infection cause candidial infection

Its least common form of candidasis Its least common form of candidasis Such lesions have increased frequency of Such lesions have increased frequency of

epithelial dysplasia epithelial dysplasia

Treatment Treatment

Polyene agent (nystatin , amphotericin B)Polyene agent (nystatin , amphotericin B) Imidazole agent (clotrimazole and ketoconazoleImidazole agent (clotrimazole and ketoconazoleTriazole (fluconazole , itraconazole )Triazole (fluconazole , itraconazole )

Premalignant conditions Premalignant conditions Are generalized state or condition Are generalized state or condition

associated with significantly increase risk associated with significantly increase risk for cancer development for cancer development

OROR Are groups of conditions which affect Are groups of conditions which affect

epithelium of oral mucosa makes it epithelium of oral mucosa makes it atrophied and more susceptible to atrophied and more susceptible to environmental carcinogens environmental carcinogens

PremalignantPremalignant conditionsconditions

OralOral submucoussubmucous fibrosisfibrosis

ErosiveErosive lichenlichen planusplanus

SyphiliticSyphilitic glossitisglossitis

SideropenicSideropenic dysphagiadysphagia

Actinic chelitisActinic chelitis

PreviousPrevious oraloral malignancymalignancy

ImmuneImmune suppressionsuppression

OralOral submucoussubmucous fibrosisfibrosis * * Is a chronic ,progressive scaring Is a chronic ,progressive scaring In which there is In which there is

a fibrous band formation beneath the epithelium a fibrous band formation beneath the epithelium and it will cause limitation of mouth opening and and it will cause limitation of mouth opening and tongue movement tongue movement

**Its mostly confined to Indians and south east Asia it Its mostly confined to Indians and south east Asia it may be due to hypersensitivity to chili , release of may be due to hypersensitivity to chili , release of enzymes from betel nut or vitamin deficiency enzymes from betel nut or vitamin deficiency

**it has 5% risk for oral carcinoma development it has 5% risk for oral carcinoma development

** Female are more susceptible than male Female are more susceptible than male

** 19 times more liable to get carcinoma than normal 19 times more liable to get carcinoma than normal person person

TreatmentTreatment

Not regress by habit cessationNot regress by habit cessation In mild type may be treated by intra-lesional In mild type may be treated by intra-lesional

corticosteroid injection corticosteroid injection In late stages by splitting or excision of In late stages by splitting or excision of

fibrous bands to improve opening fibrous bands to improve opening Recent study show intralesional injection of Recent study show intralesional injection of

interferon gamma for full improvement interferon gamma for full improvement Frequent evaluation Frequent evaluation

Actinic cheilitis Actinic cheilitis It’s a common Premalignant alteration of It’s a common Premalignant alteration of

lower lip vermilion that results from lower lip vermilion that results from continuous or over extended exposure to continuous or over extended exposure to ultraviolet light of sun ultraviolet light of sun

Most common in outdoor occupation Most common in outdoor occupation farmer’s lip or sailor’s lipfarmer’s lip or sailor’s lip

Clinical features Clinical features

Mostly above age of 45Mostly above age of 45Male to female ratio is 10:1Male to female ratio is 10:1Very slow progressionVery slow progressionAtrophy ,Smooth and blotchy area then Atrophy ,Smooth and blotchy area then

rough , dry and scaly area then chronic rough , dry and scaly area then chronic focal ulceration then sq. cell carcinomafocal ulceration then sq. cell carcinoma

Treatment Treatment Most of the changes are irreversible Most of the changes are irreversible Use of sunscreen Use of sunscreen Biopsy should be submitted to rule out Biopsy should be submitted to rule out

carcinoma carcinoma If not carcinoma do shaving of lip If not carcinoma do shaving of lip

vermilionectomyvermilionectomy Alternatively CO2 laser ablation or Alternatively CO2 laser ablation or

electrodesiccation electrodesiccation Long term follow upLong term follow up If sq cell carcinoma identified treat accordinglyIf sq cell carcinoma identified treat accordingly

ErosiveErosive lichenlichen planusplanus its not as common as reticular type but is more its not as common as reticular type but is more

significant for patient as its symptomaticsignificant for patient as its symptomatic Lesion is atrophic , erthymatos with central necrosis Lesion is atrophic , erthymatos with central necrosis

and at the periphery there is border of fine white and at the periphery there is border of fine white radiating striae or some time may be at the gingival radiating striae or some time may be at the gingival margin produce a reaction called desquamative margin produce a reaction called desquamative gingivitis gingivitis

Some data shown that there is an association between Some data shown that there is an association between erosive or atrophic lichen planus and oral erosive or atrophic lichen planus and oral squamous cell carcinoma cell carcinoma

Treatment Treatment Biopsy is recommended Biopsy is recommended Corticosteroid is recommended sp. TopicalCorticosteroid is recommended sp. TopicalBe aware of candidacies development Be aware of candidacies development Topical retinoid and cyclosporine Topical retinoid and cyclosporine

occasionally is advocated occasionally is advocated Re evaluation at 3 months intervals Re evaluation at 3 months intervals

SideropenicSideropenic dysphagiadysphagia

Also its called plummer-vinson syndrome Also its called plummer-vinson syndrome those patient suffer from iron deficiency those patient suffer from iron deficiency anemia which cause atrophy of oral anemia which cause atrophy of oral mucosa and difficulty in swallowing mucosa and difficulty in swallowing because iron is an essential requirement because iron is an essential requirement for growth of oral epithelium , mostly it for growth of oral epithelium , mostly it leads to esophageal carcinoma also may leads to esophageal carcinoma also may leads to oral carcinoma leads to oral carcinoma

Angular cheilitis

Papillary atrophy

Clinical featuresClinical features Most of the pt. are north European backgroundMost of the pt. are north European background Mostly women 30-50 years Mostly women 30-50 years They are typically complain from burning mouth They are typically complain from burning mouth

syndrome syndrome Angular cheilitis is often present Angular cheilitis is often present Red , smooth tongue Red , smooth tongue Difficult swallowing (esophageal web )Difficult swallowing (esophageal web ) Spoon-shaped nail (koilonychia )Spoon-shaped nail (koilonychia ) Sign and symptom of anemia Sign and symptom of anemia

TreatmentTreatment

Treat anemia by dietary iron supplement Treat anemia by dietary iron supplement Occasionally esophageal dilatation Occasionally esophageal dilatation Regular follow up (5% to 50% risk of Regular follow up (5% to 50% risk of

carcinoma)carcinoma)

SyphiliticSyphilitic glossitisglossitis

In Tertiary syphilis the tongue In Tertiary syphilis the tongue may involve diffusely with may involve diffusely with GummaGumma and appear large , and appear large , lobulated and irrigular shape lobulated and irrigular shape this lobulated form is termed this lobulated form is termed interstitial glossitis ,and diffuse interstitial glossitis ,and diffuse atrophy and loss of dorsal atrophy and loss of dorsal tongue papillae produce a tongue papillae produce a condition called Luetic condition called Luetic Glossitis which makes it more Glossitis which makes it more susceptible to environmental susceptible to environmental carcinogens carcinogens

TreatmentTreatment

Penicillin Penicillin Erythromycin or tetracycline for penicillin Erythromycin or tetracycline for penicillin

sensitive pt.sensitive pt.For neurosyphilis pt. may not get total cure For neurosyphilis pt. may not get total cure

from such medication from such medication

Factors for malignant transformationFactors for malignant transformation

1- habit like tobacco , betel nud 1- habit like tobacco , betel nud

2- Clinical conditions of the patient ex. 2- Clinical conditions of the patient ex. Immunity and nutrition Immunity and nutrition

3- Female has high risk 3- Female has high risk

4- Age of the patient 4- Age of the patient

5- Size of the lesion 5- Size of the lesion

6- Period or duration of the disease6- Period or duration of the disease

7- Degree of dysplasia (sever dysplasia has 7- Degree of dysplasia (sever dysplasia has high risk )high risk )

8-Area affect there is some area have higher 8-Area affect there is some area have higher risk risk

A- floor of mouth A- floor of mouth

B- posteriolateral side of tongue B- posteriolateral side of tongue

C- retromolar area C- retromolar area

D- D- anterior pillar of fauces

9- If the lesion ulcerated fissured or nodulate9- If the lesion ulcerated fissured or nodulate

In which In which very highvery high means more than 25% means more than 25% after 5 become malignant and after 5 become malignant and lowlow means if means if

2-3% during 5 years become malignant2-3% during 5 years become malignant