PREMALIGNANT LESIONS Leukoplakia (leuko = white; plakia = patch) term was first used by Schwimmer in 1877, to describe a white lesion of the tongue, which probably represented a syphilitic glossitis. It is a clinical diagnosis of exclusion and not histopathological diagnosis as it does not show any specific microscopic features. It usually involves all intraoral sites and when the tongue is involved, it affects the lateral borders more commonly followed by the dorsum. Leukoplakia occurring on tongue along with floor of the mouth and lip are considered as highrisk sites as they show dysplastic features or squamous cell carcinoma. It presents clinically as a homogenous thick white or grey patch which cannot be wiped away (Fig. 13), or ulcerated and nodular or speckled forms where red nodules are seen projecting above the white patch.14 Oral submucous fibrosis is a chronic debilitating disease, premalignant condition of the oral mucosa first described by Schwartz 1952. It is characterized by inflammation and progressive fibrosis of the submucosal tissues, well recognized for its malignant potential and is particularly associated with use of areca nut in various forms. It is usually seen with prodromal symptoms like burning sensation associated with blisters or ulcers on buccal mucosa and palate and as petechiae on the tongue. This leads to juxtaepithelial inflammatory reaction followed by progressive hyalinization of the lamina propria. As a result the oral mucosa becomes blanched and slightly opaque with palpable white fibrous bands. Impairment of tongue movements and atrophy of papilla on tongue are seen in advanced cases (Fig. 14).15 NEOPLASM Squamous cell carcinoma of the tongue is the most common malignant tumor of the oral cavity in patients younger than 40 years and is more common in men than women.16 It is regarded as a biologically different entity compared to cancer affecting other oral sites. It is more aggressive and generally associated with a higher rate of metastasis. It commonly involves the mobile tongue i.e., anterior two-thirds of the tongue, lateral borders followed by dorsum. It may arise de novo or from an existing leukoplakia or irritation from a sharp tooth or prosthesis. It is clinically silent as there is laxity of the tissue planes separating the intrinsic tongue musculature, which helps cancer cells to spread easily and becomes symptomatic only when tumor size interferes with tongue mobility. Despite, the ease of inspecting the tongue by both patient and physician, they often present late, as they are usually painless and often ignored by the patient. Eventually, they present as a nonhealing ulcer which, demonstrates growth over time usually >2 cm at presentation, with the lateral border being the most common site (Fig. 15). The patient may develop speech and swallowing dysfunction and pain occurs when the tumor involves the lingual nerve, and this pain may also be referred to the ear.17 IMMUNOLOGICAL DISORDERS Recurrent aphthous stomatitis, also called as canker sores, is an inflammatory lesion of unknown etiology, thought to be an immunological disorder. It is seen as painful ulcers affecting both keratinized and nonkeratinized mucosa. There are three clinical forms: aphthous minor, major and herpetiform ulcers. They present clinically as single or multiple, round or oval ulcers, which generally last for 7–14 days and heal 540 Indian Journal of Clinical Practice, Vol. 23, №9 February 2013 ENT without scarring. Floor of the ulcer is yellowish initially then becomes grayish as epithelialization occurs. Minor aphthae are 2–4 cm, usually seen on the nonkeratinizing mucosa on ventrum of tongue and rare on palate and dorsal surface of tongue. Major aphthae are ≥1 cm or more, seen on keratinized mucosa like palate and dorsum of tongue (Fig. 16). Herpetiform ulcers occur in any site of oral cavity. Aphthous ulcer recurs after 1- to 4-month interval. Aphthous ulcers are treated effectively with topical steroid triamcinolone acetonide 0.1% in oral base applied four times daily on to the ulcers and/or 2.5 mg hydrocortisone hemisuccinate lozenges dissolved slowly in the mouth four times daily. Herpetiform ulcers respond to tetracycline 250 mg dissolved in 10–15 ml of water and used as mouthwash held in the mouth for 3–5 minutes and then expectorated. Systemic steroids, cauterization, antibiotics, mouth rinses, active enzymes, laser treatments and combination therapy are also available. Treatment reduces pain, number and size of ulcers and hastens healing time.18 Pemphigus is a chronic autoimmune disorder, which affects skin and mucous membrane, where antibodies are produced against desmoglein 3 between keratinocytes resulting in loss of cellular adhesion. In most cases (70–90%) oral lesions are the first and sole presentation of the disease. It is of four major types namely vulgaris, vegetans, foliaceous and erythematosus. of these, the last two manifest only on skin and are rarely seen orally. Oral lesions start as bulla which easily ruptures due to friction to form ulcers with slight or absent erythematous halo around, and are covered with yellow white pseudomembrane (Fig. 17). In contrast to traumatic ulcers and aphthous ulcers, the base is not concave and so is less painful and can be secondarily infected. Several ulcers in the mouth can interfere with eating and drinking leading to nutritional deficiency.19 Pemphigus vegetans is a common form of pemphigus lesion, which resembles vulgaris in all aspects except that papillomatous hyperplasia is observed following rupture of vesicles seen as vegetations and is known as ‘cerebriform tongue’.20 A mild case of pemphigus is treated by topical or intralesional corticosteroid therapy along with dapsone or tetracycline. For more diffuse disease, steroids along with an immunosuppressant like cyclophosphamide, methotrexate, chlorambucil may be required. Oral lichen planus is a chronic inflammatory disease characterized by remission and recurrences. It is referred to as isolated oral lichen planus as it is not associated with cutaneous lesions. The etiology is not known and psychological problems or immune disorder is currently favored. Women are more commonly
Among the broad-spectrum of lesions that occur on the tongue a few tongue lesions present more commonly. The most important thing to remember is that most tongue lesions will resolve spontaneously or with simple therapy within a week, if they do not, then the lesions will have to be biopsied to rule out malignancies or serious disorders. Diagnosing such common tongue lesions will help in the best interest of the patient which is achieved by both general practitioner and dentists.