classification,clinical features, histological features,treatments

1. ERYTHROPLAKIA
SUKHIL T SATHYAN
FINALYEAR PART-A
2014 BATCH
DEPT. OF ORAL MEDICINE
AND RADIOLOGY

2. INTRODUCTION
 RED LESIONS ARE THE LARGE,HETEROGENOUS GROUP OF DISORDER
OF THE ORAL MUCOSA.
 ERYTHROPLAKIA IS A SOLITARY RED LESION , AS WELL AS
PREMALIGNANT LESION IN THE ORAL CAVITY.
 THE RED COLOR OF LESION MAY DUE TO,
 1. THINNIG OF EPITHELIUM
 2. INFLAMMATION
 3. DILATION OR INCREASED NO.OF BLOOD VESSELS
 4. EXTRAVASATION OF BLOOD VESSELS IN TO THE
 ORAL SOFT TISSUES.

3. DEFINITION
 WHO 1978,
 “ANY LESION OF THE ORAL MUCOSA THAT PRESENTS AS BRIGHT RED
VELVETTY PLAQUES WHICH CANNOT BE CHARRECTERIZED CLINICALLY OR
PATHOLOGICALLY AS ANY OTHER RECOGONIZABLE CONDITION”
 ALSO DEFINED AS,
 “A FIERY RED PATCH THAT CANNOT BE CHARRECTERIZED CLINICALLY
OR PATHOLOGICALLY AS ANYOTHER DEFINABLE LESION”
 BY BOUQUOT,
 “A CHRONIC RED MUCOSAL MACULE THAT CANNOT BE GIVEN
ANOTHER SPECIFIC DIAGNOSTIC NAME AND CANNOT BE ATTRIBUTED TO
TRAUMATIC,VASCULAR OR INFLAMMATORY CAUSES”

4. INCIDENCE & PREVALANCE
- LESS COMMON THAN ORAL LEUKOPLAKIA.
- MOST OF THE PREVALANCE FIGURES WERE DERIVED FROMIN SOUTH
AND SOUTH ASIA.
- IT WAS OBSERVED THAT PRESENTLY ERYTHROPLAKIA HAS A RANGE
OF PREVALANCE BETWEEN 0.02 % - 0.83 %.

5. ETILOGY
 IDOPATHIC
 ALCOHOL AND SMOKING – ACT AS PREDESPOSING FACTORS
 TOBACCO CHEWING – RISK FACTORS
 CANDIDA INFECTION – SECONDARY INFECTION OR SUPER INFECTION
MAY ASSOCIATED WITH DYSPLASTIC ORAL MUCOSAL CELLS.

7. PATHOGENESIS
 REPORTS OF LARGE CASE CONTROL STUDY IN
KERALA,INDIA, THE RISK FACTORS OF ERYTHROPLAKIA
WAS CONCLUDED THAT, TOBACCO CHEWING AND
ALCOHOL ARE STRONG RISK FACTORS FOR
ERYTHROPLAKIA IN INDIAN POPULATION.

8. CLASSIFICATION
 ‘SHEAR SUGGESTED A CLASSIFICATION IN 1972’
 BASED ON ,
 1. CLINICAL VARIATIONS
 2. MICROSCOPIC VARIATIONS

9. CLINICAL FEATURES
 AGE & SEX
1. 6TH -7TH DECADE OF LIFE
2. MALE PREDILECTION
 SITES
1. HALF OF ALL CASES FOUND IN VERMILLION BORDER OF LIP
2. SOFT PALATE , BUCCAL MUCOSA , FLOOR OF THE MOUTH
& TONGUE ARE MOST FREQUENTLY INVOLVED
3. LARYNX AND PHARYNX

10.  SYMPTOMS
1. MOSTLY ASYMPTOMATIC
2. SOME PATIENTS C/O BURNING SENSATION
 APPEARANCE
 NON ELEVATED RED MACULE
 SOME CASES COLOR MAY RESULT FROM LACK OF SURFACE
KERATIN OR THINNING OF EPTHELUM
 FLAT ,MACULAR,VELVETTYAPPEARANCE & MAY BE SPECKLED WITH
WHITE SPOTS.
 WELL DEMARCATED BORDERS
 EXTENT
 UNLIKE LEUKOPLAKIA ,IT IS MULTIPLE AND SELDOME COVERES
EXTENSIVE AREAS OF MOUTH.
 EXPAND LATERALLY AFTER INITIAL DIAGNOSIS

11. CLINICAL VARIATION 1
 1. HOMOGENOUS ERYTHROPLAKIA
2. ERYTHROPLAKIA INTERSPERSED WITH PATCHES OF LEUKOPLAKIA
3. GRANULAR OR SPECKLED ERYTHROPLAKIA
 3 2

12. HOMOGENOUS FORM
 BRIGHT RED , SOFT,VELVETTY LESION WITH STRAIGHT OR SCALLOPED
WELL DEMARCATED MARGIN.
 EXTENSIVE IN SIZE, 1. 5 cm, 1 cm, 4cm IN DIAMETERS LESIONS ARE SEEN.
 TYPICALLY SMOOTH SURFACE WITH REGULAR IN COLORATION

13. GRANULAR OR SPECKLED FORM
 SOFT RED LESION
 SLIGHTLY ELEVATED WITH IRREGULAR OUTLINES
 GRANULAR OR FINELY NODULAR SURFACE SPECKLED WITH
 TINY WHITE PLAQUES
SMOOTH ERYTHROPLAKIA
 SOFT TO PALPATION
 FIRM AND HAVING VELVETTY FEEL
 NEVER HARD OR INDURATED UNTIL INVASIVE CARCINOMA DEVELOPS

14. ERYTHRO LEUKOPLAKIA
 ERYTHROPLAKIA ADMIXED WITH OR ADJACENT TO LEUKOPLAKIA
 ERYTHROPLAKIA INTERSPERSED WITH PATCHES OF LEUKOPLAKIA
 IRREGULAE ERYTHEMATOUS AREAS ARE SEEN
 MOST FREEQUENTLY SEEN ON TONGUE AND FLOOR OF THE MOUTH
 BORDERS MAY BE WELL CIRCUMSCRIBED OR BLEND IMPERCIBLY WITH
SURROUNDING ORAL MUCOSA.

15. HISTOPATHOLOGY
 SHOWS SEVERE OR MODERATE DYSPLASTIC FEATURES
 THE RED APPEARANCE IS DUE TO THIN ATROPHIC EPITHELIUM WITH PROMINENT
SUBEPITHELIAL VASCULARITY AND INFLAMMATION.
 RETE PEGS ARE FREQUENTLY BULBOUS OR TEAR DROP SHAPED
 NUCLEI ARE TYPICALLY HYPERCHROMATIC AND ENLARGED,WITH AMOUNT OF CYTOPLASM
DIMINISHED.
 MITOTIC ACTIVITY PRONOUNCED AND ABNORMAL MITOTIC FIGURES MAY BE NOTED
 ENTIRE THICKNESS OF EPITHELIUM IS OCCUPIED BY DYSPLASTIC CELLS, WITH AN INTACT AND
WELL DEFINED BASEMENT MEMBRANE.
 THE BASEMENT MEMBRANE SHOULD BE CAREFULLY EXAMINED FOR AREAS OF MICRO
INVASION.

16. MICROSCOPIC VIEW,

17. MICROSCOPIC VARIATION
 NEOPLASTIC
1. SQUAMOUS CELL CARCINOMA
2. CARCINOMA In SITU & LESS SEVERE FORM OF EPITHELIAL ATYPIA
 INFLAMMATORY
1. CANDIDA ALBICANS INFECTION
2. TUBERCULOSIS
3. HISTOPLASMOSIS SCC
4. MISCELLANEOUS SPECIFIC,NON SPECIFIC AND NON -
. DIAGNOSABLE LESIONS

18. CACINOMA IN SITU
 MOST SEVERE FORM OF EPITHELIAL DYSPLASIA
 CHARRECTERIZED BY TOP TO BOTTOM CYTOLOGICAL AND
ARCHITECHTURAL CHANGES OF EPITHELIUM.
 AN INTACT KERATINIZED LAYER
 SOME CONSIDERED AS TO BE A PREMALIGNANCY,WHILE OTHERS
REGARDED AS EVIDENCE OF ACTUAL MALIGNANT CHANGE BUT
WITHOUT INVASION.
 SITE – TONGUE, FLOOR OF THE MOTH, LIPS
 PRESENT AS WHITE PLAQUES, ULCERATED, AND REDDENED AREAS

19. SQUAMOS CELL CARCINOMA
 HOMOGENOUS WHITE OR RED LESIONS
 GROWTH OR ULCERATION OF PIGMENTED AREA
 SORE THROAT AND PAIN IN MOUTH
 DIFFICULTY IN CHEWING OR SWALLOWING
 INCREASED SALIVATION
HISTOPATHOLOGY
 INCREASED MITOTIC ACTIVITY
 ABNORMAL KERATINIZATION
 PLEOMORPHISM
 CONNECTIVE TISSUE STROMA WITH CHRONIC INFLAMMATION
 EPITHELIUM ISLANDS

20. DIAGNOSIS
 CLINICAL – RED WELL DEMARCATED PATH WITH NO SIGN OF INFECTION OR
INFLAMMATION
 TOLUDINE BLUE TEST – USE 1% OF SOLUTION,APPLIED LOCALLY,
MALIGNANT TYPE RETAINING THE COLOR ,OWING TO INCREASED NUCLEAR
DNA CONTENT OF TUMOUR CELL. HELPS TO DIFFERENTIATE MALIGNANT
CHANGES AND EARLY S.C.C
 LABORATORY – BIOPSY HELPS TO KNOW, EPIHELIAL CHANGES RANGING
FROM MILD DYSPLASIA TO INVASIVE CARCINOMA

21. TOLUDINE BLUE STAINING

22. MALIGNANT POTENTIAL
 HIGHEST RISK OF MALIGNANT TRASFORMATION COMPARED TO OTHER
PREMALIGNANT LESIONS IN ORAL CAVITY.
 RATE VARIES FROM 14 % TO 50 %

23. DIFFERENTIAL DIAGNOSIS
 CHEMICAL OR THERMAL ERYTHEMATOUS MACULE –
ULCERATION &PROPERLY STRIPPING OF MUCOSA , BLANCH ON
PRESSURE.
 TRAUMATIC ERYTHEMA
 PURPURIC MACULES – H/O TRAUMA, LESION IS RED LATER
BECOMES CONVERTS BLUE IN COLOR, POORLY DEMARCATED
BORDERS.
 CARINOMA OF PALATE – INDURATED BASE, DUE TO
CONNECTIVE TISSUE INVASION.

24.  HISTOPLASMOSIS – COMMON IN FARMERS AND PRESENT AS SINGLE
ULCERS


DENTURE STOMATITIS – UNUSUALLY SITE IS THE PALATE OR
DENTURE BEARING AREA
TUBERCULOSIS – TUBERCULUS ULCER ARE PRESENT WHICH HAVE
ROLLED MARGINS

25. .
 CANDIDIASIS – LESION CAN BE RUBBED OFAND IT IS
COMMONLY SEEN ON TONGUE



AREA OF MECHANICAL IRRITATION
MACULAR HEMANGIOMA – LESION BLANCH ON PRESSURE
TRAUMATIC LESIONS

26. MANAGEMENT
MEDICAL MANGEMENT
 REMOVAL OF THE CAUSE
 CHEMOPREVENTION
a) EITHER SYSTEMICALLY OR TOPICALLY BY RETINOIDS VITAMINS A , C (ASCORBIC ACID) & E
(ALPHA-TOCOFEROL)
b) CAROTENES OR LYCOPENES
SYSTEMIC APPROACHES,
1. ANTIOXIDANTS AND VITAMINS
2. MOUTH WASH THERAPY CONTAINING AN ATTEUANATED ADENO VIRUS, AND
PHOTODYNAMIC THERAPY
3. HELPFUL IN PATIENTS WITH SURGICAL RISK
4. REDUCE RECCURENCE AFTER SURGICAL EXCISION

27. .
 ROLE OF CAROTENES
BETA CAROTENE – HELPS IN IMMUNO MODULATION ,INHIBIT MUTAGENESIS AND CANCER
GROWTH
 ROLE OF LYCOPENES
1. LYCOPENE ISA CAROTENIOD WITHOUT PROVITAMIN ‘A’ ACTION
2. PREVENT CARCINOGENESIS BY PROTECTING CRITICAL CELLULAR BIOMOLECULES,INCLUDING
LIPIDS, LIPOPROTIENS AND DNA.
 ROLE OF VITAMIN C
IMPORTANT FREE RADICAL SCAVENGER OF PLASMA
 ROLE OF VITAMIN E
LIPID SOLUBLE ANTIOXIDANT OF CELL MEMBRANE

28.  PHOTODYNAMIC THERAPY
IT INVOLVING LIGHT AND A PHOTO SENSITIZING SUBSTANCE (AMINOLEVULINIC ACID),
USED IN CONJUCTION WITH MOLECULAR OXIGEN TO ELICIT CELL DEATH (PHOTOTOXICITY
 CLINICAL TRIALS

29. .
SURGICAL MANAGEMENT
 INCISIONAL BIOPSY – ALWAYS PREFFERED METHOD FOR A MICROSCOPIC
DIAGNOSIS.
 SURGICAL STRIPPING - MUCOSAL STRIPPING PERFORMED WITH MINIMAL
DAMAGE TO THE DEEPER CONNECTIVE TISSUE. A
CONSERVATIVE SURGICAL PROCEDURE.
 DESTRUCTIVE TECHNIQUE – LASER ABLATION ,
ELECTRO COAGULATIONAND CRYOTHERAPY ARE USED.
 CLINICAL FOLLOW UP – PATIENT SHOULD BE EXAMINE EVERY 3 MONTHS
FOR FIRST POST.OPERATIVE YEAR& EVERY 6 MONTHS FOR ADDITIONAL
FOUR YEAR.AFTER THAT ANNUAL RE EVALUATION WITH A THOROUGH HEAD
AND NECK EXAMINATION IS ADVISABLE.

30. RECCURENCE
 REGULAR FOLLOW UPAND EXAMINATION NEEDED
 AMAGSA et al in 1985 RECORDED THAT RECCURENCE IS FIVE OF SEVEN
CASES.
 THE LASER THERAPY PROVIDES A RELATIVELY BLOOD LESS FIELD AND
REPORTED REDUCED RECCURENCE

31. CONCLUSION
 ERYTHROPLAKIA IS A SOLITARY RED LESION HAS BEEN CALLED
‘DANGEROUS ORAL MUCOSA’ BECAUSE IT TYPICALLY PRESENT AS
CARCINOMA In situ, SEVERE DYSPLASIA OR SUPERFICIALLY INVASIVE
CARCINOMA UNDER THE MICROSCOPE.
 THERE IS CURRENTLY NO UNIQUE RELIABLE PARAMETER TO IDENTIFY
THESE LESIONS PREDICTIVE OF MALIGNANT TRANSFORMATION,RISK
ASSESMENT USUALLY BASED ON CLINICAL, PATHOLOGICAL AND MORE
RECENTLY ON BIOMOLECULAR EVALUATION.
 IT HAS HIGH MALIGNANT POTENTIAL AND TREATED BY ,THE CAUSE,
BIOPSY AND SURGICAL PROCEDURE FOLLOWED BY PERIODIC
EXAMINATION.

32. REFERENCES,
 SHAFER’S TEXTBOOK OF ORAL PATHOLOGY,SIVAPATHASUNDARAM,ORAL PRE
MALIGNANT LESIONS.
 TEXTBOOK OF ORAL MEDICINE,ORAL DIAGNOSIS AND ORAL RADIOLOGY,
RAVIKIRAN ONGOLE ,PRAVEEN BN ,RED LESIONS
 TEXTBOOK OF ORAL MEDICINE, ANIL GOVINDARAO GHOM,ORL PRE
MALIGNANT LESIONS AND CONDITION.
 ORAL AND MAXILLOFACIAL PATHOLOGY ,NEVILLE, ORAL CANCER PRE
CANCEROUS LESIONS.