PANCE Blueprint EENT (7%)

Oral leukoplakia

Patient will present as → a 42-year-old male with symptoms of the flu. On social history, the patient describes drinking 2-3 beers per day as well as smoking 1 pack of cigarettes per day. He is noted on physical exam to have a white plaque-like lesion on the side of the tongue which could not be scraped off with a tongue depressor.

Oral leukoplakia is an oral potentially malignant disorder that presents as white patches of the oral mucosa that cannot be wiped off with a gauze (compare this to oral candidiasis)

  • Tobacco use (smoked and especially smokeless), alcohol abuse, HPV infections
  • Leukoplakia is in itself a benign and asymptomatic condition. However, about 5% will eventually develop squamous cell carcinoma (SCC)
  • If there is an associated erythematous appearance (erythroplakia), there is a higher risk of dysplasia or cancer (90%)

*A separate disorder that is not premalignant is oral hairy leukoplakia, an Epstein-Barr virus-induced lesion that occurs almost entirely in HIV-infected patients

The diagnosis of leukoplakia is suspected in patients presenting with a white lesion of the oral mucosa that cannot be wiped off with gauze and that persists after eliminating potential etiologic factors, such as mechanical friction, for a six-week period

  • Excisional biopsy is indicated for any undiagnosed leukoplakia

leukoplakia - all should be treated

  • For 2–3 circumscribed lesions, surgical excision
  • For multiple or large lesions where surgery would cause unacceptable deformity, consider cryosurgery, or laser surgery
  • Removal of predisposing habits (alcohol and tobacco)
  • Complete excision is the standard treatment for dysplasia or malignancy
  • After treatment, up to 30% of leukoplakia recurs, and some leukoplakia still transforms to squamous cell carcinoma

Oral Hairy Leukoplakia is unlikely to progress to squamous cell carcinoma

  • Treatment with zidovudine, acyclovir, ganciclovir, foscarnet, and topical podophyllin or isotretinoin. Therapy is usually not indicated

Question 1
Hairy leukoplakia has the greatest prevalence of distribution on the
See C for explanation.
floor of the mouth
See C for explanation.
lateral tongue
See C for explanation.
Question 1 Explanation: 
The lateral border of the tongue is where hairy leukoplakia is commonly seen.
Question 2
A 45 year-old smoker presents with a sore mouth and increasing difficulty eating for two weeks. Physical examination reveals a 1 cm white lesion on the buccal mucosa that cannot be rubbed off. Which of the following is the most likely diagnosis?
Oral cancer
Oral candidiasis
Oral candidiasis presents with white patches. Unlike leukoplakia, the patches easily rub off.
Aphthous ulcer
While aphthous ulcers are commonly found on the buccal mucosa, they are usually 1 to 2 mm round ulcerative lesions.
Necrotizing ulcerative gingivitis
Necrotizing ulcerative gingivitis is common in young adults under stress. Clinically, it presents with painful acute gingival inflammation and necrosis.
Question 2 Explanation: 
The presence of leukoplakia in a smoker over the age of 40 should be biopsied to rule out the presence of oral cancer.
There are 2 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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