Leukoplakia and Homoeopathy

Definition

Leukoplakia

Leukoplakia is a clinical descriptive term for a white patch in the oral cavity or pharynx that does not rub off (Psora/ Sycosis). It is characterized by white plaques on the oral mucosa.

It is a precancerous lesion, with malignant transformation occurring in 2 to 6% of patients (Psora/ Sycosis/ Syphilis). It has been noted in children with candidiasis (Pseudopsora) and some viral infections.

Leukoplakia of Tongue

Incidence

The prevalence of premalignant or malignant transformation is variable but has been estimated at approximately 3.1%.

Leukoplakia patches can occur at any time in life, but it is most common in senior adults.

Causes

It is often caused by chronic irritation (Psora) or infection but may also be a cancer (Psora/ Sycosis/ Syphilis). It is the mouth's reaction to chronic irritation of the mucous membranes of the mouth.

If the leukoplakia has areas of redness, it is called erythroplakia (Psora/ Syphilis). Erythroplakia more often represents a cancer (Psora/ Sycosis/ Syphilis). 

On biopsy, the patient may be found to have a fungal infection (Psora/ Syphilis). Fungal infections of the oral cavity may often mimic a cancer both on gross appearance and sometimes even histologically. 

In the larynx, leukoplakia, pachydermia and Reinke’s edema (polypoid degeneration) should be viewed as precursors to the development of carcinoma.

Leukoplakia patches can also develop on the female genital area, however, the cause of this is unknown.

The main causes may be concluded as below-

• Irritation from rough teeth, fillings, or crowns, or ill-fitting dentures that rub against your cheek or gum
• Chronic smoking, pipe smoking, or other tobacco use
• Sun exposure to the lips
• Oral cancer
• HIV or AIDS

Symptoms

Leukoplakia is defined as any white patch or plaque that can-not be characterized clinically or pathologically. It is purely a descriptive term with no histological correlation. Leukoplakia varies from a small, well-circumscribed, homogenous white plaque to an extensive lesion involving large surface areas of the oral mucosa. It may be smooth or wrinkled, fissured and vary in color depending on the thickness of the lesion.

The patches tend to develop slowly over weeks to months and may be thick, slightly raised, and may eventually take on a hardened and rough texture. It usually is painless, but may be sensitive to touch, heat, spicy foods, or other irritation.

Genital Leukoplakia

Leukoplakia of Vocal Cords

Clinical classification

The following sub­divisions are recommended (WHO 1980)-

Homogeneous

Lesions that are uniformly white. These may be-

(a) Smooth
(b) Furrowed (fissured)
(c) Ulcerated

This type is usually otherwise asymptomatic.

Non-homogenous

Nodulo-speckled lesions in which part of the lesion is white and rest appears reddened. They have well demarcated raised white areas, interspersed with reddened areas.

The adjective non-homogeneous is applicable both to the aspect of color i.e. mixture of white and red changes (erythroleukoplakia) and to the aspect of texture i.e exophytic, papillary or verrucous.  These are often associated with mild complaints of localized pain or discomfort.

Speckled leukoplakia

This is a variation of leukoplakia arising on an erythematous base. It has the highest rate of malignant trans-formation.

Speckled leukoplakia

Proliferative verrucous leukoplakia

Proliferative verrucous leukoplakia (PVL) and verrucous hyperplasia (VII) are two related oral mucosal lesions. The terms, however, are not clinically or pathologically interchangeable.
It is an aggressive form of oral idiopathic leukoplakia that has a considerable morbidity.

Histologically, proliferative verrucous leukoplakia (PVL) may represent in three forms-

(1) Verrucous hyperplasia (VH), a histologically defined lesion

(2) Varying degrees of dysplasia, and

(3) Three forms of squamous eel- carcinoma verrucous, conventional and papillary squamous cell carcinoma.

Erythroplakia

Erythroplakia is defined as any lesion of the oral mucosa that presents as a bright red plaque which cannot be characterized clinically or pathologically as any other recognizable condition. The lesions are irregular in outline and separated from adjacent normal mucosa. The surfaces may be nodular. These lesions occasionally coexist with leukoplakia.

Erythroleukoplakia

Hairy leukoplakia

Hairy leukoplakia (Psora/ Sycosis) is caused by the Epstein-Barr virus and is characterized by elevated, corrugated white plaques usually on the lateral borders of the tongue and suggests acquired immune deficiency syndrome. It consists of fuzzy, white patches on the tongue and less frequently, elsewhere in the mouth.

   

Hairy Leukoplakia of Tongue

It may resemble thrush, an infection caused by the fungus Candida which, in adults, usually occurs if immune system is not working properly. Thrush may be one of the first signs of infection with the HIV virus.

Diffuse leucoplakia

Diffuse leucoplakia of the bladder is premalignant and results in squamous bladder cancer.

Preleukoplakia

Preleukoplakia is defined as a low grade or very mild reaction of the oral mucosa, appearing as a grey or greyish-white, but never completely white area with a slightly lobular pattern and with indistinct borders blending into the adjacent normal mucosa.

A modified classification and staging system for oral leukoplakia

A proposal for a modified classification and staging system for oral leukoplakia (OLEP) has been presented by van der Waal et al 2000 in which the size of the leukoplakia and the presence or absence of epithelial dysplasia are taken into account. Altogether four stages are recognized.
(L Size of leukoplakia)

L 1 - size of leukoplakia is < 2cm

L2 - size of leukoplakia is 2 - 4 cm

L3 - size ofleukoplakiais>4cm

Lx - size ofleukoplakia is not specified.

(P - Pathology)

PO - No epithelial dysplasia

P1 - Distinct epithelial dysplasia

Px - Dysplasia not specified in pathology report

OLEP Staging System

Stage I - L 1 PO

Stage II - L2 PO

Stage III - L3 PO or L1 L2 PI

Stage IV - L3 P1

It has yet to be shown whether such staging system may also be helpful in providing guidelines for the management of oral leukoplakias.

Stages of Leukoplakia for transition into Cancer

Diagnosis

Clinical examination and biopsy.

Differential Diagnosis

Disease	Clinical features	Causes	Significance
Leukoderma	Common uniform opacification of buccal mucosa bilatellarly.	Unknown	Remains indefinitely. No ill effects.
White sponge nevus	Asymptomatic bilateral, dense, shaggy, white or gray, generalized opacification, primarily buccal mucosa affected, but other membranes may be involved rare	Hereditary, autosomal dominant (keratin 4 and / or 13)	Remains indefinitely, no ill effects.
Hereditary benign intraepithelial dyskeratosis	Asymptomatic, diffuse shaggy white lesion of  buccal mucosa, as well as other tissues, eye lesion – white plaque surrounded by inflamed conjunctiva, rare	Hereditary, autosomal dominant, duplication of chromosome 4q35	Remains indefinitely
Follicular keratosis	Keratotic papular lesions of skin and, infrequently, mucosa; lesions are numerous and asymptomatic	Genetic, autosomal dominant, mutation in ATP2A2 gene	Chronic course with occasional remissions
Focal (frictional) hyperkeratosis	Asymptomatic white patch, commonly on edentulous ridge, buccal mucosa, and tongue; does not rub off; common	Chronic irritation, low-grade trauma	May regress if cause eliminated
White lesions associated with smokeless tobacco	Asymptomatic white folds surrounding area where tobacco is held; usually found in labial and buccal vestibules; common	Chronic irritation from snuff or chewing tobacco	Increased risk for development of verrucous and squamous cell carcinoma after many years
Nicotine stomatitis	Asymptomatic, generalized opacification of palate with red dots representing salivary gland orifices; common	Heat and smoke associated with combustion of tobacco	Rarely develops into palatal cancer
Solar cheilitis	Lower lip—atrophic epithelium, poor definition of vermilion-skin margin, focal zones of keratosis; common	UV light (especially UVB, 2900– 3200nm)	May result in squamous cell carcinoma
Idiopathic leukoplakia	Asymptomatic white patch; cannot be wiped off; males affected more than females	Unknown; may be related to tobacco and alcohol use	May recur after excision; 5% are malignant and 5% become malignant; higher risk of carcinoma if dysplasia present
Hairy leukoplakia	Filiform to flat patch on lateral tongue, often bilateral, occasionally on buccal mucosa; asymptomatic	Epstein-Barr virus infection	Seen in 20% of HIV-infected patients; marked increase in AIDS; may occur in non– AIDS-affected immunosuppressed patients and rarely in immunocompetent patients
Hairy tongue	Elongation of filiform papillae; asymptomatic	Unknown; may follow antibiotic, corticosteroid use, tobacco habit	Benign process; may be cosmetically objectionable
Geographic tongue (erythema migrans)	White annular lesions with atrophic red centers; pattern migrates over dorsum of tongue; varies in intensity and may spontaneously disappear; occasionally painful; common	Unknown	Completely benign; spontaneous regression after months to years
Lichen planus	Bilateral white striae (Wickham's); asymptomatic except when erosions are present; seen in middle age; buccal mucosa most commonly affected, with lesions occasionally on tongue, gingiva, and palate; skin lesions occasionally present and are purple pruritic papules; forearm and lower leg most common skin areas	Unknown; may be precipitated by stress; may be hyperimmune condition mediated by T cells	May regress after many years; treatment may only control disease; rare malignant transformation
Dentifrice- associated slough	Asymptomatic, slough of filmy parakeratotic cells	Mucosal reaction to components in toothpaste	None
Candidiasis	Painful elevated plaques (fungus) that can be wiped off, leaving eroded, bleeding surface; associated with poor hygiene, systemic antibiotics, systemic diseases, debilitation, reduced immune response; chronic infections may result in erythematous mucosa without obvious white colonies; common	Opportunistic fungus—Candida albicans and rarely other Candida species	Usually disappears 1–2 weeks after treatment; some chronic cases require long- term therapy
Mucosal burns	Painful white fibrin exudate covering superficial ulcer with erythematous ring; common	Chemicals (aspirin, phenol), heat, electrical burns	Heals in days to weeks
Submucous fibrosis	Areas of opacification with loss of elasticity; any oral region affected; rare	May be due to hypersensitivity to dietary constituents such as areca (betel nut), capsaicin	Irreversible; predisposes to oral cancer
Fordyce's granules	Multiple asymptomatic, yellow, flat or elevated spots seen primarily in buccal mucosa and lips; seen in a majority of patients; many consider them to be a variation of normal	Developmental	Ectopic sebaceous glands of no significance
Ectopic lymphoid tissue	Asymptomatic elevated yellow nodules < 0.5cm in diameter; usually found on tonsillar pillars, posterolateral tongue, and floor of mouth; covered by intact epithelium; common	Developmental	No significance; lesions remain indefinitely and are usually diagnostic clinically
Gingival cyst	Small, usually white to yellow nodule; multiple in infants, solitary in adults; common in infants, rare in adults	Proliferation and cystification of dental lamina rests	In infants lesions spontaneously rupture or break; recurrence not expected in adults
Parulis	Yellow-white gingival swelling caused by submucosal pus	Periodontitis or tooth abscess	Periodic drainage until primary cause is eliminated
Lipoma	Asymptomatic, slow-growing, well circumscribed, yellow or yellow- white mass; benign neoplasm of fat; occurs in any area	Unknown	Seems to have limited growth potential intraorally; recurrence not expected after removal

Treatment

Homoeopathy is the only method of treatment.

Rubrics related with Leukoplakia in various repertories

1

MOUTH - LEUKOPLAKIA

3

Repertorization-

borx.

ign.

nit-ac.

Main remedies for Leukoplakia-

Alum. alumn. Arg-n. ars. Atro. Aur-m. Aur. Bar-c. Bell. borx. brom. bry. calc-f. calc. Cann-xyz. carb-an. Carb-v. carc. Caust. chin. clem. con. cupr. Ferr. gamb. hydr. HYOS. ign. kali-chl. kali-i. Lach. Lyc. mag-m. merc-d. merc-i-r. Merc. Mez. mur-ac. nit-ac. NUX-M. petr. ph-ac. Phyt. Puls. Semp. sep. SIL. sul-i. Sulph.