Oral and Maxillofacial Pathology
Management update of potentially premalignant oral epithelial lesions

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The term oral potentially malignant disorders, proposed at the World Health Organization workshop in 2005, has now been renamed potentially premalignant oral epithelial lesions (PPOELs). It is important to differentiate among PPOELs, which is a broad term to define a wide variety of clinical lesions, and oral epithelial dysplasia, which should be reserved specifically for lesions with biopsy-proven foci of dysplasia. PPOELs encompass lesions that include leukoplakia, erythroplakia, erythroleukoplakia, lichen planus, and oral submucous fibrosis. The primary goal of management of dysplasia includes prevention, early detection, and treatment before malignant transformation. The aim of this article is to inform the clinician about management of PPOELs.

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Background

Over the last 30 years, there has been a marginal improvement in the 5-year survival rate of patients with oral cancer treated with multimodality contemporary therapy. Current survival rates for all stages range from 50% to 55%.1 The emphasis on early detection, diagnosis, and treatment of premalignant lesions is to prevent their transformation to oral squamous cell carcinoma (OSCC). Early detection is pivotal to increasing the 5-year survival rate because it is directly correlated with stage

Detection and Diagnosis

To date, there have been no reliable and validated in vivo chairside adjuncts that have sufficient sensitivity and specificity to be more superior than clinical examination and tissue biopsy.9 Adjunctive aids include, but are not limited to, photodynamic detection, including autofluorescence, vital staining (toluidine blue, Lugol's iodine), and brush cytology. These techniques are minimally invasive and have virtually no morbidity, but they do carry considerable false-positive and

Treatment

PPOELs can be managed conservatively by observation alone. In theory, medical interventions, such as chemoprevention, are also available, considering the lack of medical therapies approved by the U.S. Food and Drug Administration. Surgical excision is the invasive management of choice for this group of lesions. Factors that influence the type of therapy include patient risk factors for malignancy (age, gender, and habits) and lesion risk factors (classification, size, morphology, malignant

Oral Leukoplakia

OL is defined by the WHO as a white patch that cannot be scraped or wiped off and is not attributable to any pathophysiology or disease process. It is essential to rule out other processes that OL can clinically mimic, such as candidiasis, lichen planus, nicotinic stomatitis, leukoedema, healing aphthous ulcers, white sponge nevus, and frictional keratosis. It is important to keep in mind that OL is a clinical diagnosis and not a histologic one. Various forms of OL have been distinguished in

Oral Erythroplakia

Oral erythroplakia (OE) is morphologically defined as a red, velvety plaque or patch that cannot be attributed to any other pathophysiologic process and is also a diagnosis of exclusion. OE can stand alone or be associated with OL. In the latter case, it is classified as an erythroleukoplakia (Figure 3). The incidence and prevalence of OE is much less than that of OL. However, OE has one of the higher MTRs (up to 50%) of all the PPOELs.26 The histologic study of biopsied homogeneous OE showed

Oral Submucous Fibrosis

OSF is a progressive fibrotic disease of the aerodigestive tract, but mainly affecting the oral cavity. Deranged collagen metabolism is the underlying pathophysiologic process.32, 33 This disease predominantly affects individuals living in the South East Asian countries, has equal gender predilection, and is seen in the second to third decades of life.32 Multiple etiologic factors have been linked to this disease and include nutritional deficiencies, such as those of vitamins, iron, and zinc;

Oral Lichen Planus

Lichen planus is a systemic mucocutaneous disease that commonly affects the oral mucosa but can also affect skin, nails, the scalp, and the vaginal mucosa. It usually manifests at the third to seventh decades of life.34 The disease has a strong female predilection. Intraorally, the buccal mucosa, tongue, and gingiva are the most common sites; lesions are usually bilateral and symmetric.35 The pathophysiology is currently understood as a T cell–mediated autoimmune destruction of the basal cells

Oral Epithelial Dysplasia

It is known that oral epithelial dysplasia (OED) is often the precursor to OSCC. Oral dysplasia is diagnosed histologically and defined by the WHO as a precancerous lesion of stratified squamous epithelium characterized by cellular atypia and loss of normal maturation and stratification short of carcinoma in situ.3, 23, 39 The presence and the grade of dysplasia contribute to the malignant transformation potential for all the above PPOELs.3, 9, 14, 19 OLP, OSF, OL, and OED are the gross

Human Papillomavirus and Dysplasia

Human papillomavirus (HPV) has been identified as a risk factor for the development of oropharyngeal squamous cell carcinoma (OPSCC). Of the several subtypes, HPV-16 and HPV-18 are deemed to pose a high risk for the development of OPSCC.45, 46 Two viral oncoproteins, E6 and E7, derived from the HPV gene, have been isolated, and their presence is necessary for malignant transformation to SCC. These oncoproteins exert their repressive effects on p53 and Rb tumor suppressor activity, respectively.

Prevention and Maintenance

Primary prevention is ideally the best and the first method in the management of premalignancy. Ultimately, the goal is to prevent premalignancy and its progression to malignancy. It is prudent to risk-stratify a patient and provide appropriate counseling and screening for higher-risk individuals. One systematic review study estimated that the population attributable risk for developing SCC was 25% for smoking alone, 18% for alcohol alone, and 40% for combined use of both.49 Both these risk

Conclusions

The management of premalignant lesions is complex, and the current literature regarding the ideal treatment modality is conflicting. The transition from normal mucosa to premalignant or dysplastic mucosa and to finally malignant change is a complex interplay between the environment and the host. Host factors include genetics and immune system function. Environmental factors include exposure to carcinogens, including betel liquid, tobacco, alcohol, and HPV. It is imperative that clinicians

References (51)

  • P. Holmstrup et al.

    Long-term treatment outcome of oral premalignant lesions

    Oral Oncol

    (2006)
  • Y. Watabe et al.

    Malignant transformation of oral leukoplakia with a focus on low-grade dysplasia

    J Oral Maxillofac Surg Med Pathol

    (2016)
  • S.P. Reddi et al.

    Oral premalignant lesions: management considerations

    Oral Maxillofac Surg Clin North Am

    (2006)
  • A. Kumar et al.

    How should we manage oral leukoplakia?

    Br J Oral Maxillofac Surg

    (2013)
  • A. Mogedas-Vegara et al.

    Oral leukoplakia treatment with the carbon dioxide laser: a systematic review of the literature

    J Craniomaxillofac Surg

    (2016)
  • R.O. Greer

    Pathology of malignant and premalignant oral epithelial lesions

    Otolaryngol Clin North Am

    (2006)
  • G. Arakeri et al.

    Oral submucous fibrosis: an overview of the aetiology, pathogenesis, classification, and principles of management

    Br J Oral Maxillofac Surg

    (2013)
  • S.G. Fitzpatrick et al.

    The malignant transformation of oral lichen planus and oral lichenoid lesions

    J Am Dent Assoc

    (2014)
  • S.M.H. Aghbari et al.

    Malignant transformation of oral lichen planus and oral lichenoid lesions: a meta-analysis of 20095 patient data

    Oral Oncol

    (2017)
  • F. Dost et al.

    Malignant transformation of oral epithelial dysplasia: a real-world evaluation of histopathologic grading

    Oral Surg Oral Med Oral Pathol Oral Radiol

    (2014)
  • M.L. Goodson et al.

    Oral precursor lesions and malignant transformation—who, where, what, and when?

    Br J Oral Maxillofac Surg

    (2015)
  • E.A. Field et al.

    The management of oral epithelial dysplasia: the Liverpool algorithm

    Oral Oncol

    (2015)
  • P.J. Thomson et al.

    Interventional laser surgery for oral potentially malignant disorders: a longitudinal patient cohort study

    Int J Oral Maxillofac Surg

    (2017)
  • M.W. Ho et al.

    Outcomes of oral squamous cell carcinoma arising from oral epithelial dysplasia: rationale for monitoring premalignant oral lesions in a multidisciplinary clinic

    Br J Oral Maxillofac Surg

    (2013)
  • S.B. Woo et al.

    Human papillomavirus-associated oral intraepithelial neoplasia

    Mod Pathol

    (2013)
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