Oral Potentially Malignant Disorders

Oral Potentially
Malignant Disorders
21 November 2020
Masita Mandasari
Oral Medicine Department
Faculty of Dentistry Universitas Indonesia
Content
• Introduction to OPMDs
• OPMDs Classifications
• Oral Cancer Screening
• Tobacco Cessation
2 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

Introduction to OPMDs

Definitions
Oral Potentially Malignant (Oral) Premalignant/

Disorders (OPMDs) Precancerous Lesions
• Any oral mucosal abnormality • Benign diseases that will develop
that is associated with a into cancer if followed in a long
statistically increased risk of time.
developing oral cancer.
• Peripheral findings, similar
• Oral cancer can arise at different histological and genomic
site from OPMDs in the oral findings with OSCC.
cavity or de novo lesion.

General Features
Topographic
Color variations Variable sizes
changes
• White • Plaque/plateau • Small
• Red • Smooth
• Mixed • Corrugated
• Verrucous
• Granular
• Atrophic • Large

General Features
• Middle aged or elderly.
• Predominantly males.
• Can have associations with certain cultural factors (betel quid

chewing, reverse smoking habit).

OPMDs Classifications

WHO OPMD Working Group
OPMDs (2005-2020) Updated Classifications (2020)
• Leukoplakia • Limited evidence
• Proliferative verrucous leukoplakia • Epidermolysis bullosa
• Erythroplakia
• Oral submucous fibrosis (OSF) • Insufficient evidence
• Oral lichen planus (OLP) • Chronic hyperplastic candidosis
• Actinic keratosis/actinic cheilosis • Oral verrucous hyperplasia
• Palatal lesions in reverse smokers
• Oral lupus erythematosus
• Dyskeratosis congenital
• Oral lichenoid reactions
• Oral manifestations of chronic GVHD
Leukoplakia

Leukoplakia
• A predominantly white plaque of questionable risk having
excluded (other) known diseases or disorders that carry no
increased risk for cancer.
• Most common OPMD, generally asymptomatic.

• Malignant transformation 7.7% - 22%
• Usually diagnosed after 4th decade of life, more prevalent in males.

• Associated with smoking, alcohol consumption, and betel quid
chewing

Leukoplakia
Considerations for Clinical Diagnosis:
• White patch/plaque that cannot be rubbed off
• Most homogeneous leukoplakias affect a circumscribed area with well-
demarcated borders
• Non-homogeneous leukoplakias typically present with more diffuse
borders and may have red or nodular components.
• No evidence of chronic traumatic irritation to the area
• Not reversible on elimination of apparent traumatic causes (static)
• Does not disappear or fade away on stretching (retracting) the tissue
• Exclusion of other white or white/red lesions

• Types:
• Homogeneous leukoplakia
• Nonhomogeneous leukoplakia
nodular verrucous speckled

Differential Diagnosis
Frictional
Alveolar ridge
keratosis Leukoedema
keratosis
(cheek biting)
White sponge Oral hairy Hyperplastic

nevus leukoplakia candidiasis

Leukoplakia
• Provisional clinical diagnosis of leukoplakia should be followed up
with diagnostic biopsy
dysplasia

Dysplasia Grading
WHO severe/
mild moderate carcinoma-in-situ
Binary low grade high grade

dysplasia dysplasia
Management
Low grade • Observation

• Risk factors management (stop
dysplasia tobacco/alcohol, food in rich antioxidant)
High grade • Conservative managements

• Surgical excision
dysplasia • Ablation (Laser)

Proliferative
Verrucous
Leukoplakia

Proliferative Verrucous Leukoplakia
• Multifocal oral leukoplakia characterized by having a progressive
clinical course, changing clinical and histopathologic features.
• Associated with the highest proportion of oral cavity cancer

development compared with other OPMDs (49.5%).
• Can have lichenoid appearance and mistakenly treated for oral

lichen planus.
• Patients complained discomfort.

• More prevalent in females, mean age of diagnosis 67 y.o.
• Clinical diagnostic criteria

• Affecting more than two different oral sites (primarily the gingiva, alveolar
processes, hard palate)
• Existence of a verrucous area
• Pathognomonic features  chronic proliferation of white lesions,

multiple occurrences, refractoriness to treatment, involvement of
gingival sites and high rate of malignant transformation.


Erythroplakia

Erythroplakia
• A predominantly fiery red patch that cannot be characterized
clinically or pathologically as any other definable disease.
• Clinical appearance of a sharply demarcated, flat or depressed,

erythematous area of mucosa with a matt appearance.
• Most oral erythroplakia at diagnosis are either histopathologically

a squamous cell carcinoma or high-grade epithelial dysplasia.
• Differentials: Erythematous candidiasis, erythema migrants.

Erythroplakia

Oral Submucous
Fibrosis

Oral Submucous Fibrosis
• A chronic, insidious disease that affects the oral mucosa, initially
resulting in loss of fibroelasticity of the lamina propria and as the
disease advances, results in fibrosis of the lamina propria and the
submucosa of the oral cavity along with epithelial atrophy.
• Patients reporting a burning sensation of the oral mucosa and

intolerance to spicy foods and later, restricted mouth opening.
• Malignant transformation rate of 1.2% - 23%.

• Associated with nutritional factors (vitamin B, C, and iron deficiency),
carcinogenic causes (chewing tobacco and betel nut), alcohol,
consumption of spicy food, epigenetic regulation, and genetic
predisposition.

Oral Submucous Fibrosis
• Clinical diagnostics features:

• Blanching of the oral mucosa
• Loss of tongue papilla
• Leathery mucosa
• Fibrous bands
• Limited mobility of the tongue
• Shrunken of deformed uvula
• Limitation of mouth opening (trismus)
• Sunken cheeks

Oral Lichen Planus

Oral Lichen Planus
• A disease with bilateral white reticular patches affecting buccal
mucosae, tongue, and gingivae.
• Common noninfectious oral disorder without clear causative

factor. Ranging from asymptomatics to sore.
• Malignant transformation rate of 0.9% - 5%.
• Diagnosis should be made considering the clinical and

histopathological criterias.

Oral Lichen Planus
Clinical features Histopathological features

• Bilateral, symmetrical white • Well‐ defined band‐like
lesions. predominantly lymphocytic
infiltrate confined to the superficial
• White papular lesions and lace‐ part of the connective tissue.
like network of slightly raised
white lines. • Signs of vacuolar degeneration of
the basal and/or supra basal cell
• Sometimes presents as layers with keratinocyte apoptosis.
desquamative gingivitis. • In the atrophic type: epithelial
thinning and sometimes ulceration

Oral Lichen Planus
papular reticular plaque
bullous erythematous erosive

Management
Pain relief
Topical/systemic corticosteroid
Oral cancer risk factors management
Routine observation
Actinic Cheilitis

Actinic Cheilitis
• A disorder that results from sun damage and affects exposed areas
of the lips, most commonly the vermilion border of the lower lip
with a variable presentation of atrophic and erosive areas and
white plaques.
• Malignancy transformation rate unclear.
• Occurs predominantly in middle-aged and light-skinned men with

outdoor occupations.

Actinic Cheilitis
• Mild form: dry lips.
• Histopathological findings:
• Hyperplastic or atrophic epithelium,
• Disordered maturation.
• Varying degrees of keratinization or parakeratinization
• Cytological atypia.
• Increased mitotic activity.
• Lamina propria often shows basophilic degeneration of collagen, elastosis,
and vasodilatation.

Palatal Lesion in
Reverse Smoking

Palatal Lesion in Reverse Smokers
• White and/or red patches affecting the hard palate in reverse
smokers, frequently stained with nicotine.
• Reverse smoking is prevalent in Andhra Pradesh (India), Carribean

Islands, Latin America, Sardinia, and Pacific Islands (e.g., The
Phillipines).
• Hard palate is usually spared by other OPMDs.

Oral Lupus
Erythematosus

Oral Lupus Erythematosus
• An autoimmune connective tissue disease which may affect the lip
and oral cavity, where it presents as an erythematous area
surrounded by whitish striae, frequently with a “target”
configuration.
• 20% of LE patients show oral lesions (buccal mucosa, palate, lips).
• Clinically similar with OLP.

Dyskeratosis
Congenita

Dyskeratosis Congenita
• Rare hereditary condition of dysfunctional telomere maintenance
that is regarded as a potentially malignant disorder.
• Arise in early childhood, poor prognosis.
• Diagnostic triad:
• Oral leukoplakia
• Skin hyperpigmentation
• Nail dystrophy

Oral Lichenoid
Reaction

Oral Lichenoid Reaction
• Disorders that do not present the clinical and/or histopathological
characteristics considered typical (but compatible) with OLP.
• Asymptomatic to sore.
• OLL includes:
• Atypical OLP and unilateral lichenoid lesions
• In close contact relationship to a dental restoration (amalgam)
• Lichenoid drug-reactions (LDR)
• Oral lesions following intake of food or some substances (e.g., cinnamon)
• Oral lesions of graft versus host disease

Oral Graft versus
Host Disease

Oral Graft versus Host Disease
• Similar lesion with OLL, reported in patients with haematologic
malignancies receiving allogeneic stem cell transplants.
• Complaints of red and atrophic areas, could be sore.
• Possible role of immunosuppressant therapy in development of

oral squamous cell carcinoma.

Oral Cancer Screening

SAMURI
Periksa Mulut Sendiri
images source: detikcom

Tobacco Cessation

Tobacco Cessation
• Nicotine, a powerful addictive substance  more than just will
power to quit smoking
• Dentist as effective as medical doctor for smoking cessation
• Dentist can help by providing brief systematic consultation

• ASK – smoking habit
• ADVICE – oral and health effects
• ASSIST – health promotion material and offer help

• OPMDs have higher risk to develop oral
cancer but not all OPMDs transformed
into malignancy.
Take Home
Messages • Not all oral cancers preceded by OPMDs.
• Dentists should perform full mouth

examination for OPMD/oral cancer
detection
• Dentists can provide smoking cessation

assistance to manage OPMDs.

Acknowledgement
• Oral Medicine Department
• Faculty of Dentistry Universitas Indonesia

If I have seen further, it is by
standing on the shoulders of
giants.
Isaac Newton
Thank you for your kind attention.
Email to masitamandasari@ui.ac.id
Instagram @oralmedicine.ui

References
• Warnakulasuriya S, Kujan O, Aguirre-Urizar JM, Bagan JV, González-Moles MÁ, Kerr AR, Lodi G, Mello
FW, Monteiro L, Ogden GR, Sloan P, Johnson NW. Oral potentially malignant disorders: A consensus
report from an international seminar on nomenclature and classification, convened by the WHO
Collaborating Centre for Oral Cancer. Oral Dis. 2020 Oct 31. https://doi.org/10.1111/odi.13704
• Warnakulasuriya S. Clinical features and presentation of oral potentially malignant disorders. Oral Surg
Oral Med Oral Pathol Oral Radiol. 2018 Jun;125(6):582-590. https://doi.org/
10.1016/j.oooo.2018.03.011
• van der Waal I. Oral leukoplakia, the ongoing discussion on definition and terminology. Med Oral Patol
Oral Cir Bucal. 2015 Nov 1;20(6):e685-92. https://doi.org/10.4317/medoral.21007
• Woo SB. Oral Epithelial Dysplasia and Premalignancy. Head Neck Pathol. 2019 Sep;13(3):423-439.
https://doi.org/10.1007/s12105-019-01020-6
• Mutalik S, Mutalik VS, Pai KM, Naikmasur VG, Phaik KS.Oral Leukoplakia – Is Biopsy at the Initial
Appointment a Must? [Internet].2014 August;8(8):ZC04-ZC07. Available
from:http://www.jcdr.net//back_issues.asp?issn=0973-
709x&year=2014&month=August&volume=8&issue=8&page=ZC04&id=4659
• Speight PM, Khurram SA, Kujan O. Oral potentially malignant disorders: risk of progression to
malignancy. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018 Jun;125(6):612-627. https://doi.org/
10.1016/j.oooo.2017.12.011

References
• Müller S. Oral epithelial dysplasia, atypical verrucous lesions and oral potentially malignant
disorders: focus on histopathology. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018
Jun;125(6):591-602. https://doi.org/10.1016/j.oooo.2018.02.012
• Ortiz GM, Pierce AM, Wilson DF. Palatal changes associated with reverse smoking in Filipino
women. Oral Dis. 1996 Sep;2(3):232-7. https:/doi.org/10.1111/j.1601-0825.1996.tb00230.x
• Iraji F, Jamshidi K, Pourazizi M, Abtahi-Naeini B. Dyskeratosis Congenita Without Oral
Involvement: A Rare Hereditary Disease. Oman Med J. 2015 May;30(3):212-5.
https://doi.org/10.5001/omj.2015.44
• Kuten-Shorrer M, Woo SB, Treister NS. Oral graft-versus-host disease. Dent Clin North Am.
2014 Apr;58(2):351-68. https://doi.org/10.1016/j.cden.2013.12.007
• Neville, B.W., Damm, D.D., Allen, C.M. and Chi, A.C. Oral & Maxillofacial Pathology. 4th ed.
Elsevier, 2016.
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• Neville, B.W., Damm, D.D., Allen, C.M. and Chi, A.C. Color Atlas of Oral and Maxillofacial
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Oral Potentially Malignant Disorders

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Oral Potentially

• Oral Cancer Screening

2 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

3 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

Oral Potentially Malignant (Oral) Premalignant/

4 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

5 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

• Middle aged or elderly.

• Can have associations with certain cultural factors (betel quid

6 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

7 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

9 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

• Most common OPMD, generally asymptomatic.

• Usually diagnosed after 4th decade of life, more prevalent in males.

10 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

11 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

nodular verrucous speckled

12 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

White sponge Oral hairy Hyperplastic

13 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

14 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

Binary low grade high grade

Low grade • Observation

High grade • Conservative managements

16 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

17 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

• Associated with the highest proportion of oral cavity cancer

• Can have lichenoid appearance and mistakenly treated for oral

• Patients complained discomfort.

18 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

• Clinical diagnostic criteria

• Pathognomonic features  chronic proliferation of white lesions,

19 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

20 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

21 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

• Clinical appearance of a sharply demarcated, flat or depressed,

• Most oral erythroplakia at diagnosis are either histopathologically

• Differentials: Erythematous candidiasis, erythema migrants.

22 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

23 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

24 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

• Patients reporting a burning sensation of the oral mucosa and

• Malignant transformation rate of 1.2% - 23%.

25 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

• Clinical diagnostics features:

26 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

27 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

• Common noninfectious oral disorder without clear causative

• Malignant transformation rate of 0.9% - 5%.

• Diagnosis should be made considering the clinical and

28 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

Clinical features Histopathological features

29 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

papular reticular plaque

bullous erythematous erosive

30 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

Oral cancer risk factors management

32 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

• Malignancy transformation rate unclear.

• Occurs predominantly in middle-aged and light-skinned men with

33 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA

34 FACULTY OF DENTISTRY UNIVERSITAS INDONESIA