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Received: 3 September 2018    Accepted: 7 September 2018

DOI: 10.1111/odi.12976


Oral leukoplakia: A diagnostic challenge for clinicians and

Dear Editor, subtypes of epithelial dysplasia, such as koilocytic dysplasia, adenoid
At present, oral leukoplakia has been defined as “a predominantly dysplasia, and “lichenoid dysplasia” may be questioned from a clin-
white plaque of questionable risk having excluded (other) known ical point of view. At any rate, the absence of epithelial dysplasia
diseases or disorders that carry no increased risk for cancer” does not disqualify a leukoplakia of being potentially (pre)malignant,
(Warnakulasuriya, Johnson, & Waal, 2007). A diagnosis of oral leu- although the risk of such leukoplakia is in most studies much lower
koplakia is probably often based on clinical judgment alone. The in- than in the presence of epithelial dysplasia.
dication for a biopsy may be (a) to exclude (other) known diseases Preferably, the pathology report should consist of two parts,
or; (b) in case of a strong suspicion of the diagnosis of leukoplakia, to being (a) a description of the histopathological observations, includ-
assess the presence and degree of epithelial dysplasia and to exclude ing the results of additional stains or other special techniques, if ap-
the possible presence of squamous cell carcinoma, carcinoma in situ plicable; and (b) a conclusion of the histopathological examination
or verrucous carcinoma. In the latter cases, the provisional clinical that is meant for the clinician and that also should be understandable
diagnosis of leukoplakia is replaced accordingly. In all other cases, for a patient.
irrespective of the presence or the absence of epithelial dysplasia, Having more than 45 years experience both as an oral surgeon
the provisional clinical diagnosis of leukoplakia will be replaced by a and an oral pathologist employed at an university teaching hospital
definitive, clinicopathologic diagnosis of oral leukoplakia. Obviously, I consider myself a hybrid. This dual background has enabled me to
there is a critical role to play both for clinicians and pathologists in have a critical look at the clinicopathological diagnostic aspects of a
order to arrive at a proper diagnosis. wide range of oral mucosal diseases, including leukoplakia and leu-
Based on the present definition a diagnosis of oral leukoplakia koplakia‐like lesions.
is one by exclusion of well‐defined (“known”) predominantly white Particularly, in case of a discrepancy between the clinical and the
lesions and disorders. Therefore, the accuracy of the clinical diag- histopathological diagnosis, it is generally advised to look for close
nosis very much depends on the experience of the clinician. In this collaboration between clinicians and pathologists. Unfortunately,
respect, non‐reticular presentation of oral lichen planus is probably such collaboration does not seem to be very helpful. Clinicians hardly
the most common challenge. have any experience with evaluation of histopathological sections.
In the case of an incisional or excisional biopsy, the clinician On the other hand, pathologists usually have very little knowledge
should provide the clinical (differential) diagnosis. In case of a strong about the clinical aspects of oral mucosal diseases.
clinical suspicion of leukoplakia, the clinician may ask for special Unfortunately, the clinical and histopathological definitions
stains, for example, histochemical stains for p53 or Ki67, or DNA and terminologies related to leukoplakia and leukoplakia‐like le-
ploidy measurement, since the results of such stains may for some sions have become rather mixed up in the past decades. Examples
clinicians play a role in the further management of the patient. are frictional lesion, frictional keratosis, alveolar ridge keratosis,
Apart from information on gender and age, oral subsite and seize keratosis of unknown significance, verrucous hyperplasia, verru-
of the lesion, course of the disease, the presence or the absence of cous keratosis, and many others. Therefore, there seems a need
symptoms and information on tobacco habits may be provided al- for re‐evaluation of the present definition and the clinical and
though one may question the relevance of such information for the histopathlogical terminologies of oral leukoplakia and leukoplakia‐
histopathological assessment. like lesions.
Obviously, the reliability of the histopathological diagnosis
largely depends on the pathologists’ experience in the field or oral
mucosal diseases. For instance, some pathologists may recognize to-
bacco‐induced epithelial changes or are able to recognize epithelial None declared.
changes caused by mechanical irritation.
The histopathological findings in oral leukoplakia may range
from hyperkeratosis without epithelial dysplasia to various degrees
of epithelial dysplasia. The clinical relevance of identifying various Isaäc van der Waal

© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. All rights reserved

348  | Oral Diseases. 2019;25:348–349.

oral leukoplakia, oral mucosa, potentially (pre)malignant oral lesions Warnakulasuriya, S., Johnson, N. W., & van der Waal, I. (2007).
Isaäc van der Waal Nomenclature and classification of potentially malignant disorders of
the oral mucosa. Journal of Oral Pathology and Medicine, 36, 575–580.
Department of Oral and Maxillofacial Surgery/Pathology, VU medical
center/ACTA, Amsterdam, The Netherlands