A 62-year-old man comes to the office for follow-up of diabetes mellitus type 2. He admits missing his appointments and medications and not following a strict diet. The patient does not smoke but has chewed tobacco for many years. He drinks 6-10 beers each weekend. His body mass index is 27.5 kg/m². On oral examination, a white patch is seen on the buccal mucosa. The lesion appears to have a granular texture, is not indurated, and is not removed by scraping with a tongue depressor. There is no regional lymphadenopathy. His hemoglobin A_1c is 8.5%.
Which of the following is the most likely diagnosis?

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Quizplus · Accepted Answer

This lesion, with a white granular patch or plaque over the buccal mucosa in a patient with a history of alcohol and tobacco use, is most consistent with oral leukoplakia. Leukoplakia is a reactive lesion that represents hyperplasia of the squamous epithelium and is associated with an increased risk of malignant transformation. The risk factors for development of leukoplakia are similar to those for squamous cell carcinoma, with smokeless tobacco and alcohol use accounting for the majority of cases. The natural history of oral leukoplakia depends on the degree of dysplasia, with 1%-20% of lesions progressing to squamous carcinoma within 10 years. Fortunately, most lesions resolve within a few weeks after cessation of tobacco use. The development of areas with induration and/or ulceration should prompt biopsy to rule out malignant transformation of the lesion. (Choice A) Aphthous stomatitis refers to localized, shallow, painful ulcers with a gray base. Recurrent aphthous stomatitis is the most common cause of oral ulcers. Aphthous stomatitis (Choice B) Oral candidiasis, or thrush, occurs in patients with diabetes, immunodeficiency states, and use of antibiotics or inhaled glucocorticoids. The lesions of candidiasis typically consist of white plaques on the oral mucosa, tongue, or oropharynx with underlying erythema. In contrast to leukoplakia, the plaques of candidiasis can usually be scraped off with a tongue depressor. Oral candidiasis, or thrush, (Choice C) Herpes simplex virus type 1 can cause gingivostomatitis. It can present with multiple vesicular lesions with an erythematous and inflammatory base and erythematous border within the oral cavity and perioral area. Herpes simplex virus type 1 does not cause the white plaques seen in this patient. gingivostomatitis (Choice E) This patient has several risk factors for squamous cell carcinoma of the oral cavity, including extensive use of tobacco and alcohol. Squamous cell carcinoma usually presents as persistent nodular, erosive, or ulcerative lesions with surrounding erythema or induration. Regional lymphadenopathy can be present as well. The white granular lesions in this patient are more consistent with oral leukoplakia. Educational objective: Oral leukoplakia is characterized by white patches or plaques over the oral mucosa that usually cannot be scraped off. Risk factors for development of leukoplakia are similar to those for squamous cell carcinoma (tobacco and alcohol use). Development of areas with induration and/or ulceration should prompt biopsy to rule out malignant transformation of the lesion. __________ References: How should we manage oral leukoplakia? (http://www.ncbi.nlm.nih.gov/pubmed/23159193)

A 62-Year-Old Man Comes to the Office for Follow-Up of Diabetes