Quartz 4

7. OPMDs_integrated

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**Clinical Case Discussion:

Asymptomatic Oral Lesion**

Case presentation

Patient presentation1

  • Patient: 78-year-old male
  • Chief issue: Asymptomatic oral lesion
  • Site: Right lateral surface of the tongue
  • Duration: ~2 years
  • Clinical description: Large, white, mostly homogeneous patch; some areas are thicker and “more white” (heterogeneous in parts). A critical feature is an ulceration within the lesion.

Medical and social history

  • Medical history: Hypertension, hypercholesterolaemia, ischaemic heart disease. The patient is elderly with a complex medical history.
  • Social history: Past smoker; currently consumes six alcoholic drinks per day, described as a heavy alcohol consumer who “drinks like a fish”.

Clinical assessment

Identify the pathosis and describe the clinical features.

Pathosis

A large white patch on the lateral tongue.

Clinical features

  • Homogeneity: Mostly homogeneous, but with some thicker, whiter areas indicating heterogeneity in parts.
  • Ulceration: A non-healing ulcer is present, which represents a worrying clinical sign.
  • Texture/stretch test: Does not disappear when stretched (helps differentiate from leukoedema).
  • Vascularity/erythema: Some red areas are visible, though these may be superficial vessels rather than active pathology.

Red flag feature

Non-healing ulceration within a white lesion is worrying, especially with risk factors (e.g., alcohol use/past smoking).

Differential diagnosis

What is the differential diagnosis?

  • Leukoplakia: Primary clinical suspicion. White patch that cannot be scraped off and is not attributable to any other specific condition.
  • Lichen planus: Considered within the differential, particularly plaque-form lichen planus which can mimic leukoplakia.
  • Frictional keratosis: Possible—check for sharp teeth/restorations. Reactive lesion from chronic mechanical irritation.
  • Leukoedema: Ruled out because the lesion is not uniform and does not disappear upon stretching.
  • Squamous cell carcinoma (SCC): Must be considered due to the presence of a non-healing ulcer (red flag), particularly given the patient’s risk factors.

Investigations

What are the relevant clinical investigations?

Blood tests

Exam note

Simply writing “blood test” is insufficient for exams; specific tests must be named.

  • Fasting glucose: To check for underlying conditions like diabetes, especially with non-healing ulcers.

Hematinics

  • Focus on ulcer (relevant for investigating the cause of oral ulcerations).

Full blood count (FBC)

  • Performed as a routine screening measure.

Liver function tests (LFTs)

  • Rationale: Necessary because the patient is a heavy consumer of alcohol.

Coagulation profile

  • Rationale: Essential screening before performing a biopsy to prevent surgical bleeding complications in a patient with high alcohol intake.

Biopsy

Technique and site selection

Biopsy approach

  • Take the worst-looking area: thickest and heterogeneous (mix of red/white).
  • Because the lesion is large, multiple samples may be required to “map” the area and ensure representativeness.
  • ==Do not biopsy only the center of an ulcer (necrotic tissue); biopsy the margin.==
  • Incisional biopsy is preferred over punch biopsy for this case.

Transport/processing

Specimen handling

==Routine (H&E): formalin pot; no cooling required.
Direct immunofluorescence (DIF): fresh tissue in special medium (e.g., Michel’s solution) or saline.==

Histopathology findings

  • Lab report shows atypia confined to the lower third (basal third) → mild epithelial dysplasia.
  • Therefore need to rule out lichen planus because there is dysplasia.

Diagnosis

What is the diagnosis?

  • ==Mild epithelial dysplasia consistent with leukoplakia==
  • ==Atypia confined to the basal third (lower third) of the epithelium==
  • Note: Lichen planus is excluded if dysplasia is the primary feature

Management plan

How would you manage this patient?

If leukoplakia there are only 2 options:

  1. ==Observation / surveillance==
  2. ==Surgical excision==

Decision for this patient: due to the lesion’s large size and the “mild” grade of dysplasia, observation is often preferred over extensive surgery.

Excision considerations (downsides)

  • Large lesion → excessive surgery
  • Doesn’t guarantee no recurrence
  • Excision does not guarantee SCC won’t develop later, but it may decrease the risk of progression

Aim: get the ulcer to heal / risk reduction

  • Risk reduction strategies:
    • Smoking cessation and reducing alcohol intake
    • Eliminate trauma: smooth sharp teeth or fractured restorations
  • Chlorhexidine to try and heal it and see if the ulcer resolves

Recall intervals

  • Initial phase (after ulcer healing / first couple visits):
    • ==Every 3 months to establish behaviour==
  • Stable phase (no change):
    • 6-monthly intervals
  • Long-term:
    • Recalls remain forever (indefinitely) as risk is for life
    • ==Highest risk of malignant transformation is within first 5 years==
    • After 5 years of stability, interval may be increased to once a year

Risk determination (leukoplakia)

Risk determination of leukoplakia

Factors that increase the risk of malignant transformation:

  • readings
  • premalignant conditions of the oral cavity
  • Gender: females are at higher risk
  • Habits: non-smokers with leukoplakia have higher statistically relative risk of transformation; alcohol use is a significant factor
  • Duration: lesions present for less than 5 years are higher risk (if they haven’t transformed after 5 years, risk drops)
  • Location (high-risk areas): lateral border of the tongue, floor of mouth, retromolar area, soft palate
  • Clinical appearance: large lesions, multifocal lesions, or non-homogeneous (erythroleukoplakia) appearance
  • Pathology: presence of any grade of dysplasia

Footnotes

  1. Original PDF page 1: OPMD Case 1, p.1 ↩

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