A 52-year-old woman comes to the office due to an oral lesion. Medical history is significant for type 2 diabetes mellitus, vitiligo, and hypertension. Her last hemoglobin A1c 6 months ago was 8.3%. The patient works as a bus driver for a local public school. She has a 20-pack-year history. BMI is 32 kg/m². On oral examination, a white patch is seen on the tongue, as shown in the exhibit. The lesion is not indurated and cannot be removed by scraping with a tongue depressor. There is no regional lymphadenopathy. Which of the following is the greatest risk factor for this patient's oral lesion?

Question

Quizplus · Accepted Answer

11ec25c8_d250_08b0_bc81_5b2fe1c4fecb_MD0003_00 This patient has a painless, white mucosal lesion on the lateral and inferior surface of the tongue that cannot be scraped off with a tongue depressor. This is most consistent with oral leukoplakia, a potentially malignant or premalignant lesion with risk factors similar to those of squamous cell carcinoma. Tobacco use and alcohol use are the greatest risk factors and have a synergistic effect (ie, multiplicative rather than additive) on the risk for developing both leukoplakia and oral squamous cell carcinoma. white mucosal lesion Biopsy should be performed to rule out cancer and characterize histopathologic features (eg, degree of dysplasia). If the biopsy sample is benign, patients should be counseled to stop tobacco and alcohol use, which may lead to resolution of the lesion. In addition, patients should have frequent oral examinations, and biopsy should be repeated if the lesion changes (eg, increased thickness/firmness, color, associated adenopathy). (Choice A) Habitual tongue or cheek biting can lead to thickened, white mucosal lesions (ie, morsicatio mucosae oris, morsicatio buccarum). In contrast to this patient's lesion, morsicatio is typically linear and occurs at the level of the occlusal surface. morsicatio buccarum (Choice B) Vitiligo can cause depigmentation of the mucosal surfaces of the oral cavity (most commonly the lips), leading to white patches. Unlike leukoplakia, the patches of vitiligo do not appear raised or thickened like this patient's lesion because depigmentation does not impact the mucosal texture. (Choice C) School bus drivers and other childcare workers have increased risk for acquiring infections commonly seen in children. However, these are not risk factors for leukoplakia or oral cavity cancer, whereas tobacco use and alcohol use are. (Choice D) Although there is some correlation between poor oral hygiene and the development of leukoplakia and squamous cell carcinoma in the oral cavity, the association with tobacco and alcohol use is much stronger. (Choice E) Oral candidiasis, or thrush, occurs more often in patients with uncontrolled diabetes mellitus. In contrast to leukoplakia, the white plaques of candidiasis typically have underlying erythema and can usually be scraped off with a tongue depressor. Oral candidiasis Educational objective: Oral leukoplakia presents as white patches or plaques over the oral mucosa that cannot be easily scraped off. The risk factors for the development of leukoplakia are similar to those for squamous cell carcinoma, with tobacco and alcohol use being the greatest.

A 52-Year-Old Woman Comes to the Office Due to an Oral