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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 9  |  Issue : 2  |  Page : 100-103

Oral proliferative verrucous leukoplakia with oral submucous fibrosis treated with CO2laser


1 12 Corps Dental Unit, Jodhpur, Rajasthan, India
2 Jodhpur Dental College, Jodhpur, Rajasthan, India
3 Military Hospital, Jodhpur, Rajasthan, India

Date of Web Publication26-Nov-2015

Correspondence Address:
Reenesh Mechery
12 Corps Dental Unit, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-2868.158462

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  Abstract 

Oral leukoplakia is one of the most common physiologic as well as pathologic white lesion in the oral cavity. Of the many variants, oral proliferative verrucous leukoplakia (OPVL) is a rare clinicopathological entity of unknown etiology. OPLV initially develops as a white hyperkeratotic plaque that eventually becomes a multifocal disease with confluent, exophytic and proliferative features. Published case series with long-term follow-up describes OPVL as a disease with aggressive biological behavior due to its high probability of recurrence and a high rate of malignant transformation. This article describes a rare case report of OPVL associated with oral submucous fibrosis in the light of current information with clinical and histological aspect in a young patient, which was successfully treated with CO2Laser.

Keywords: CO2laser, oral proliferative verrucous leukoplakia, oral submucous fibrosis


How to cite this article:
Mechery R, Kumar M, Arora P, Rajkamal T, Dinakar N. Oral proliferative verrucous leukoplakia with oral submucous fibrosis treated with CO2laser. J Dent Lasers 2015;9:100-3

How to cite this URL:
Mechery R, Kumar M, Arora P, Rajkamal T, Dinakar N. Oral proliferative verrucous leukoplakia with oral submucous fibrosis treated with CO2laser. J Dent Lasers [serial online] 2015 [cited 2021 Oct 23];9:100-3. Available from: https://www.jdentlasers.org/text.asp?2015/9/2/100/158462




  Introduction Top


Leukoplakia is a term that has been used for many decades to indicate a white plaque or patch occurring on the surface of a mucous membrane, not only in the oral cavity but also in the uvula, cervix, urinary bladder and upper respiratory tract. This term has often been used to describe a nonscrappable white patch which cannot be diagnosed as any other disease but, many authors believe such a diagnosis should only be given strictly on bases of histologic criterias rather than on loose clinical connotation.[1]

Oral proliferative verrucous leukoplakia (OPVL) is a rare clinicopathological variant of oral leukoplakia (OL) and according to the latest workshop on oral precancerous lesions organized by the World Health Organization Collaborating Centre for Oral Cancer in 2005, OPVL conforms to the new terminology of "potentially malignant disorders" given that it is neither a delimited lesion nor a condition. It is best defined as a continuum of oral epithelial disease with hyperkeratosis at one end of a clinical and microscopic spectrum and verrucous carcinoma or squamous cell carcinoma at the other.[2] Clinically characterized by a slow-growing, long-term progressive lesion that has a very high probability to transform into verrucous carcinoma (Ackerman's tumor) or an oral squamous cell carcinoma (OSCC). Despite extensive researches, the etiology of OPVL is still as enigmatic since, unlike leukoplakia, OPVL is reported in both smokers and nonsmokers equally.[3] Generally OPVL has been reported in 6th and 7th decade of life, but this a rare case of OPVL with oral submucous fibrosis (OSMF) in a young patient.


  Case Report Top


A 33-year-old patient reported with inability to open mouth and a painless, white proliferative growth in the right buccal mucosa for past 1-year. On eliciting a history, patient had the habit of chewing pan with tobacco, lime and arecanut (betel quid) for past 15 years. He noticed burning sensation with restricted mouth opening and white proliferative small hair-like growth in cheek musosa 1-year back. On intra-oral examination, his mouth opening was approximately 3 cm, tongue protrusion of 3.8 cm and cheek flexibility was 0.9 cm. On palpation, vertical fibrotic bands and blanching were present in the buccal mucosa bilaterally along with shrunken uvula and reduced mobility of the soft palate. A raised curdled-white unilateral verrucous growths was seen on the right side of the mucosa approximately 5 cm × 4 cm extending from canine to retromolar trigone area anteroposteriorly and completely extending in vestibule [Figure 1]. The surface of the lesion was rough and was firmly adherent to the underlying connective tissue. Regional submandibular lymph nodes were tender and mobile. To arrive at a definitive diagnosis, an incisional biopsy was done after routine investigations.
Figure 1: Oral proliferative verrucous leukoplakia

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The epithelium showed hyperparakeratinization with papillary projections and parakeratin plugging in the crypts between the papillary projection with broad and bulbous rete ridges and acanthosis and juxtra epithelial hyalinization. The underlying connective tissue showed moderate inflammatory cell infiltration with nondysplastic changes [Figure 2]. A diagnosis of OPVL with OSMF was arrived at.
Figure 2: Hematoxylin and eosin, ×10

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The patient was treated first for OSMF by repeated counseling and restraining from the habit, so as to make the patient realize the damage caused by the habit. Intralesional steroids (prednisolone 75 mg twice a week for 6 weeks), hyaluronidase (1500 IU twice a week for 6 weeks) antoxid and multivitamins were used for improving the mouth opening. After achieving a satisfactory level of mouth opening of more than 20 mm, he was taken up for surgical removal of OPVL with ultra-pulse surgical carbon dioxide laser (CO2 Laser).


  Surgical Procedure Top


The patient was aseptically draped, and facial skin was scrubbed with 7.5% povidone iodine solution and the intra-oral surgical site was painted with 5% povidone iodine solution. After obtaining local anesthesia, CO2 laser was used with continuous ultra-pulse mode at a frequency of 20 Hz and duration of 450 µs to excise the lesion completely [Figure 3] and [Figure 4]. Postsurgical instructions, antibiotics, analgesics and mouth opening exercise were advised. The patient was kept on regular follow-up and shows improvements in mouth opening with no recurrence of OPVL [Figure 5].
Figure 3: CO2laser

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Figure 4: Immediate postoperative after CO2laser

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Figure 5: Six months postoperative

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  Discussion Top


Although most leukoplakias (80%) are benign rest are either potentially malignant or malignant lesions of the oral cavity. OPVL is known for its aggressive pathology with probability of recurrence rate as high as 87–100% and malignant transformation rate of 60–80%.[4] The gingiva and palate represents the area of highest malignant transformation into OSCCs, therefore biopsy of all leukoplakias is necessary, from the most suspicious area, to arrive at a correct diagnosis and institute a proper therapy at the earliest. These patients should be regularly checked for lifetime for recurrence or malignant transformations even after treatment.[5]

The microscopic findings associated with OPVL are dependent on the stage of the disease and the adequacy of the biopsy. Hansen et al., suggested histologic stages in the continuum of OPVL with intermediates [Figure 6].[6]
Figure 6: Proliferative verrucous leukoplakia continuum

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Grade 0: Normal mucosa

Grade 2: Hyperkeratosis (clinical leukoplakia)

Grade 4: Verrucous hyperplasia

Grade 6: Verrucous carcinoma

Grade 8: Papillary squamous cell carcinoma

Grade 10: Less well-differentiated squamous cell carcinoma.

Because of the lack of specific histological criteria, the diagnosis of OPVL is mainly based on combined clinical and histopathologic evidence of progression. Over a period of time authors have come up with a set of certain diagnostic criterias to come to definitive diagnosis that are mentioned as follows.

Major criteria

  • A leukoplakia lesion with more than two different oral sites, which is most frequently found in
  • The gingiva, alveolar processes and palate
  • The existence of a verrucous area
  • That the lesions have spread or engrossed during development of the disease
  • That there has been a recurrence in a previously treated area
  • Histopathologically, there can be from simple epithelial hyperkeratosis to verrucous
  • Hyperplasia, verrucous carcinoma or OSCC, whether in situ or infiltrating.


Minor criteria

  • An OL lesion that occupies at least 3 cm when adding all the affected areas
  • That the patient be female
  • That patient (male or female) be a nonsmoker
  • A disease evolution higher than 5 years.


Importance of such criterias is that either three major criterias or combined two major and minor criterias should be present to confirm a case of OPVL.[7]

The other important finding in this case was OSMF, which is also a potentially malignant disorder of the oral cavity with multifactorial etiological factors with arecanut chewing to be the main causative factor. It is characterized by progressive inability to open mouth, loss of elasticity of mucosa and development of vertical bands in buccal and labial mucosa due to juxta epithelial hyalinization.[8] Only a few case of OPVL with OSMF has been reported but the importance lies in the fact that, both these conditions are now grouped under potentially malignant disorders, making the patient twice more prone to malignant transformation. Various treatment modalities are advocated for the treatment of OPVL surgery, cryosurgery, laser and photodynamic therapy depending on the extend and severity. Radiotherapy as adjuvant to chemotherapy are also advocated in cases showing malignant changes. Combination techniques with complete wide field onco-clearance resection are advocated to prevent anaplastic transformations. Lasers although in the field of dentistry have been in vogue for intra-oral procedures, generally indicated for soft tissue surgeries. Patient acceptance, absence of bleeding and relative ease of the procedure makes it psychologically patient friendly. The aim/intention of reporting this case was to sensitize the general dentist of such occurrence and surgical management with CO2 laser with successful outcome thus, adding a new dimension and vista in patient care.

 
  References Top

1.
Greer RO, McDowell JD, Hoernig G. Proliferative verrucous leukoplakia: Report of two cases and a discussion of clinicopathology. J Calif Dent Assoc 1999;27:300-5,308.  Back to cited text no. 1
    
2.
Greer RO Jr, Eversole LR, Crosby LK. Detection of human papillomavirus-genomic DNA in oral epithelial dysplasias, oral smokeless tobacco-associated leukoplakias, and epithelial malignancies. J Oral Maxillofac Surg 1990;48:1201-5.  Back to cited text no. 2
    
3.
Slootweg PJ, Müller H. Verrucous hyperplasia or verrucous carcinoma. An analysis of 27 patients. J Maxillofac Surg 1983;11:13-9.  Back to cited text no. 3
    
4.
Cabay RJ, Morton TH Jr, Epstein JB. Proliferative verrucous leukoplakia and its progression to oral carcinoma: A review of the literature. J Oral Pathol Med 2007;36:255-61.  Back to cited text no. 4
    
5.
Gandolfo S, Castellani R, Pentenero M. Proliferative verrucous leukoplakia: A potentially malignant disorder involving periodontal sites. J Periodontol 2009;80:274-81.  Back to cited text no. 5
    
6.
Hansen LS, Olson JA, Silverman S Jr. Proliferative verrucous leukoplakia. A long-term study of thirty patients. Oral Surg Oral Med Oral Pathol 1985;60:285-98.  Back to cited text no. 6
    
7.
Shear M, Pindborg JJ. Verrucous hyperplasia of the oral mucosa. Cancer 1980;46:1855-62.  Back to cited text no. 7
    
8.
Chen BL, Lin CC, Chen CH. Oral verrucous carcinoma: An analysis of 73 cases. Clin J Oral Maxillofac Surg 2000;11:11-7.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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