A 65-year-old female visited the dental office for evaluation of a diffuse white area on the gingiva and alveolar mucosa. A 65-year-old female visited the dental office for evaluation of a diffuse

A 65-year-old female visited the dental office for evaluation of a diffuse white area on the gingiva and alveolar mucosa.

A 65-year-old female visited the dental office for evaluation of a diffuse white area on the gingiva and alveolar mucosa.

Joen Iannucci Haring, DDS, MS

History

When questioned about the white area, the patient stated that she first noticed it about one year earlier. She remarked that the area was not painful and denied any history of trauma. The patient admitted to a previous 15-year history of cigarette smoking, and she appeared to be in a general state of good health. No medications were being taken at the time of the dental appointment.

Examinations

Examination of the head and neck region revealed no palpable lymph nodes. All vital signs were found to be within normal limits. Oral examination revealed a diffuse, wrinkled white plaque extending from the attached gingiva and alveolar mucosa to the buccal mucosa (see photo). The lesion appeared to be slightly raised and could not be removed by wiping or scraping. No other lesions were noted in the oral cavity.

Differential diagnosis

Based on the clinical information presented, which of the following is the most likely diagnosis?

* leukoplakia

* proliferative verrucous leukoplakia

* hyperplastic candidiasis

* lichen planus

* white sponge nevus

Diagnosis

proliferative verrucous leukoplakia

Discussion

A leukoplakia is defined as a white patch or plaque that cannot be rubbed off or characterized clinically as any other disease. The term leukoplakia is a clinical term only and not a histologic diagnosis. A leukoplakia appears white because of a thickened surface of keratin; keratin, when wet, appears white. Proliferative verrucous leukoplakia is one of the many types of leukoplakia found in the oral cavity.

Proliferative verrucous leukoplakia (PVL) can be described as a diffuse white or wrinkled area of the mucosa caused by varying degrees of epithelial hyperplasia. PVL is a recently recognized oral lesion that occurs primarily in elderly patients. Unlike most other leukoplakias that have a strong male predilection, PVL has a strong female predilection (4:1). There are often no causative factors identified. Some cases are believed to be linked to tobacco use or the human papillomavirus.

PVL is characterized by diffuse, extensive white patches or plaques with a surface texture consisting of both smooth and wrinkled, warty areas. PVL tends to spread slowly and involve multiple oral mucosal sites. PVL exhibits ongoing growth, eventually becoming exophytic and verrucous in appearance.

Some lesions have aggressive growth potential. As PVL spreads and progresses in size, a spectrum of histologic changes is seen ranging from hyperkeratosis to verrucous carcinoma. Some long-standing lesions may eventually progress to develop well-differentiated areas of squamous cell carcinoma. Approximately 15 percent of PVL cases may exhibit such malignant transformation.

Diagnosis and treatment

A biopsy and histologic examination are necessary in order to establish a diagnosis of PVL. For small localized lesions, surgical excision is the treatment of choice. As the lesion spreads to involve more mucosal sites, treatment becomes more difficult. For example, in the maxillary arch, involvement of the soft palate, uvula, and tonsillar pillars can be a surgical challenge. In such cases, laser surgery is indicated to remove the diffuse lesions while preserving the underlying anatomic structures necessary for mastication and speech.

Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.

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