What is the recommended management for oral leukoplakia?

Management of Oral Leukoplakia

Photodynamic therapy (ALA-PDT) is recommended as the preferred treatment for oral leukoplakia, particularly for extensive lesions or those located in areas with underlying functional structures, due to its minimally invasive nature, efficacy, and low risk of systemic side effects and disfigurement. 1, 2

Diagnosis and Risk Assessment

• Oral leukoplakia is defined as a predominantly white patch or plaque of the oral mucosa that cannot be wiped away and is not clinically or histologically characterized as any other definable disorder 1
• Incisional biopsy with histopathological examination is essential for diagnosis and to rule out malignancy 3
• Non-homogeneous leukoplakia carries a higher risk of malignant transformation compared to homogeneous type 4
• The reported rate of malignant transformation ranges from 0.13% to 17.5%, highlighting the importance of proper management 3

Treatment Approaches

1. Photodynamic Therapy (ALA-PDT)

• ALA-PDT has emerged as the fourth alternative therapeutic approach after chemotherapy, surgery, and CO2 laser ablation/cryosurgery 1
• Benefits of ALA-PDT include:
  • Minimally invasive nature
  • High efficacy
  • Low risk of systemic side effects
  • Minimal disfigurement
  • Ability to treat large and recurrent lesions 1
  • Particularly valuable for treating lesions in regions with underlying functional structures 1

2. Traditional Treatment Options

• Non-surgical approaches:

  • Chemoprevention (vitamin A, retinoids, beta carotene)
  • Observation without intervention 1
  • Note: Randomized controlled trials have shown no promising evidence regarding prevention of malignant transformation with chemoprevention 1, 5

• Surgical approaches:

  • Traditional excision
  • Electrocauterization
  • CO2 laser ablation
  • Cryosurgery 1, 2
  • Limitations: Less feasible for extensive lesions or those in certain anatomical sites; may cause postoperative pain, edema, and scarring 1

ALA-PDT Protocol

• Preparation:

  • Dissolve ALA to yield a 20% aqueous solution immediately before use 1
  • Apply photosensitizer solution to the lesion with salivary isolation 1

• Treatment parameters:

  • Use semiconductor laser light source at 630 nm ± 5 nm
  • Power of 100 mW•cm−2
  • Alternate 3-min irradiation sessions with 3-min rest periods
  • Total light exposure dose: 100 J•cm−2 1
  • Treat once every 2-3 weeks, depending on lesion healing 1

• Post-treatment care:

  • Keep mouth clean
  • Avoid irritating foods and drinks
  • Prevent exposure of treated area to light for at least 48 hours 1

Management of Side Effects

• Common adverse reactions include mild to moderate pain, hyperemia, edema, erosion, ulceration, and bleeding 1
• For mild cases: No treatment needed (spontaneous healing) 1
• For severe cases:
  • 0.1% chlorhexidine gargling solution
  • Topical glucocorticoid preparations
  • Compound benzocaine gel for severe pain
  • Short-term (3-5 days), low-dose (15-30 mg) oral prednisone for extensive erosion/ulceration 1

Follow-up and Monitoring

• Regular follow-up is essential due to risk of recurrence and malignant transformation 3
• Monitor for:
  • Clinical changes in appearance
  • Development of new lesions
  • Signs of malignant transformation 6
• No universal consensus exists on the duration or interval of follow-up 3

Important Considerations and Pitfalls

• Despite various treatment options, there is currently no evidence of effective treatment in preventing malignant transformation of leukoplakia 5
• High rate of relapse is common with all treatment modalities 5
• Studies with standardized parameters and protocols, as well as randomized clinical trials with adequate sample sizes and long-term follow-up, are needed 1
• The tongue and floor of the mouth may be high-risk sites for malignant transformation in some populations 7
• Cessation of tobacco use, a common etiological factor, has been shown to be an effective preventive measure 7