Oral Erythroplakia Case Study
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Oral Erythroplakia is considered a rare potentially malignant lesion of the oral mucosa. Oral Erythroplakia is a clinical term to describe any erythematous area on a mucous membrane that cannot be attributed to any other pathology. Oral Erythroplakia are very few, only the true, velvety, red homogeneous oral Erythroplakia has been clearly defined while the terminology for mixed red and white lesions is complex, ill-defined and confusing. Oral Erythroplakia is predominantly seen in the middle aged and elderly. The most common affected areas are the soft palate, the floor of the mouth and the buccal mucosa. A specific type of Oral Erythroplakia occurs in Chutta smokers in India. Lesions of Oral Erythroplakia are typically less than 1.5 cm in diameter.
Keywords - Biopsy, Erythroplakia, Laser,
The word erythroplakia means "red patch", and is derived from the Greek words ερυθρος - "red" and πλÎ¬ξ - "plate"
The World Health Organization defines oral erythroplakia as follows:
“Any lesion of the oral mucosa that presents as bright red velvety plaques which cannot be characterized clinically or pathologically as any other recognizable condition”
It has been reported that prevalence of Oral Erythroplakia varies between 0.02%1 and 0.2%2 (adapted from Reichart et al.)3 Clinically, it can be flat or depressed and sometimes it can be found together with leukoplakia (erythroleukoplakia); it pre-dominantly occurs in the floor of the mouth, the soft palate, the ventral tongue and the tonsillar fauces. There are usually no symptoms. However, some patients may complain of a burning sensation and or sore. Heavy alcohol consumption and tobacco use are known to be important aetiological factors. The main purpose of identifying oral premalignant lesions is to prevent malignant transformation by initiating adequate intervention. It is widely approved that the oral premalignant lesions erythroplakia, show a significant tendency to malignant transformation. The differential diagnosis includes: erythematous candidiasis, early squamous cell carcinoma, local irritation, mucositis, lichen planus, lupus erythematosous, drug reaction and median rhomboid glossitis.4 Surgical excision is the treatment of choice though more studies are needed.The treatment5 modalities include change of lifestyle factors such as tobacco and alcohol intake,medication with retinoids or antimycotics,surgical excision,cryosurgery,laser evaporation or laser excision.Laser surgery has become a reliable treatment6 option for oral cancer as well as for precancerous lesions. Widely used lasers in oral and maxillofacial tumor surgery are the CO2 laser, the Er:YAG laser, the Nd:YAG laser and the KTM laser. The use of lasers in tumor surgery has several advantages: remote application, precise cutting, hemostasis, low cicatrization, reduced postoperative pain and swelling, can be combined with endoscopic, microscopic and robotic surgery. Here we report a case of erythroplakia in soft palate region treated with diode laser.
A, 63 years old, male patient (Fig 1), came to the department of oral and maxillofacial surgery, with the chief complain of red patches at the hard and soft palate region. Patient gave the history of pan, tobacco chewing and smoking since 20 yrs. Medical history was negative for any findings and all the vitals were under the normal limit. No significant findings were noticed on extra oral examination. (Fig-1). On intraoral examination, multiple red patches were seen at the mucosal surface of the palate. All those patches were less than 1.5 cm in diameter. (Fig- 2). On palpation it was soft and velvety on touch. A provisional diagnosis of Erythroplakia, with differential diagnosis Lichen planus , Erythematous candidiasis ,Early squamous cell carcinoma were made. All necessary blood investigation done, and were found under normal limit. To establish a definitive diagnosis, a biopsy was performed using a local anaesthesia. The biopsy specimen was taken from hard and soft palate, and sent for histopathological examination (Fig 3) which confirmed the final diagnosis of Erythroplakia. The red appearance is due to the thin atrophic epithelium with prominent subepithelial vascularity and inflammation. Almost all erythroplakic lesions contain dysplastic cells. The histopathology may be mild or moderate epithelial dysplasia, severe dysplasia or carcinoma in-situ. Carcinoma in-situ is characterized by a complete disorganization of cells throughout all layers of the epithelium, with no keratin pearls. Laser ablation was planned as the treatment modality under local anaesthesia. (Fig-4) Diode laser was used at 2.5watts (Fig 5). Post operative instructions given and patient was recalled after 24 hours. Patient came for follow-up, reported with slight pain. Healing was uneventful. After that patient was asked to report at weekly interval. Healing was satisfactory after 3 weeks.(Fig 6)
Erythroplakia and speckled leukoplakia are uncommon lesions of the mouth. Erythroplakia of the oral cavity is a specific disease entity which must be differentiated from other specific or nonspecific inflammatory oral lesions, although this can only be done in most cases by biopsy. The term "erythroplakia" of the oral cavity as used in this report and as accepted by most authors describes the clinical appearance of a red patch of the mucous membrane which does not represent some specific or nonspecific inflammatory lesion. However, in most cases the clinician cannot distinguish with certainty the true erythroplakia as discussed here and the more innocuous inflammatory lesions, thus mandating biopsy. Most, and probably all, cases of true clinical erythroplakia represent some epithelial atypia, ranging from mild epithelial dysplasia to invasive carcinoma.7 Furthermore; there is no correlation between the clinical appearance of erythroplakia and the histologic findings. Erythroplakia is the leukoplakia like term used to describe clinically red and well demarcated macules of the oral mucosa which cannot be attributed to inflammatory or traumatic factors, and which have a much higher propensity for progression to carcinoma than leukoplakia8. The histopathological9 feature of erythroplakia includes a marked epithelial atrophy associated with epithelial dysplasia. A relative reduction in keratin production and increase in vascularity accounts for the clinical color of the lesion. Cellular infiltration and capillary distention were remarkable. Nowadays laser surgery has become a reliable treatment6 option for precancerous lesions. Widely used lasers in oral and maxillofacial tumor surgery are the CO2 laser, diode laser, the Er:YAG laser, the Nd:YAG laser and the KTM laser. In our case we use diode laser in erythroplakia. Laser has many distinctive advantages, such as the ability to cut, coagulate, ablate or vaporize target tissue elements, enabling dry-field surgery through the sealing of small blood vessels (haemostasis) disinfection of the tissue, reduced post-operative edema (through the sealing of small lymphatic vessels) decreased amount of scarring. It contributes to faster and more effective treatment resulting in improved treatment outcome and increased patient comfort and satisfaction.
Oral cancer is one of the 4 major non communicable diseases leading to Death10. Soft tissue health in the oral cavity is essential for overall dental and medical health and a successful maintenance of any restoration. The clinical and pathological features of the lesions analyzed in our study support the data in other published studies. Although their prevalence is low, histopathological features ranging from epithelial dysplasia to invasive carcinoma. This justifies placing these lesions among the oral lesions with the highest malignant potential. Additionally, regardless of histopathology and therapy, periodic monitoring of these patients and cessation of risk factors are essential measures.
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