History

Fact Explanation
Asymptomatic Some patients are asymptomatic and the initial lesions are painless. [1]
Soreness of the mouth Patients complain of soreness of the mouth, burning sensation or metallic taste. Often the lesions bleed and present with hematemesis. [1]
Red colored oral lesions Some patients may notice the red velvety lesions themselves.
Loose denture [1] Loose denture rubs against the oral mucosa causing mucosal irritation and erythroplakia. Sharp edges of fractured tooth or ill fitting dental prosthesis can also cause erythroplakia.
Risk factors Tobacco smoking and chewing and excessive consumption of alcohol are recognized risk factors for the development of oral erythroplakia and cancers. Oral human papillomavirus infection and immunodeficiency increase the risk of erythroplakia. Poor oral hygiene, malposition of teeth and chronic candidiasis are relatively rare risk factors. Exposure to ultraviolet radiation is a risk factor for the development of erythroplakia of the lips. [1,2] Erythroplakia carries 85% risk of malignant transformation. [2]
References
  1. VILLA A, VILLA C, ABATI S. Oral cancer and oral erythroplakia: an update and implication for clinicians. [online] December, 56(3):253-256 [viewed 08 August 2014] Available from: doi:10.1111/j.1834-7819.2011.01337.x
  2. SOUSA FB, DE FREITAS E SILVA MR, FERNANDES CP, SILVA PG, ALVES AP. Oral cancer from a health promotion perspective: experience of a diagnosis network in Ceará. Braz Oral Res [online] 2014 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24964281

Examination

Fact Explanation
Examination of the oral cavity Beetle stains, poor oral hygiene and loose teeth should be looked for. Mucosal lesions of erythroplakia appear as bright red velvety plaques with well defined margins. Surrounding mucosa appears normal. Oral lesions are commonly seen in the floor of the mouth, buccal mucosa, tongue and in the soft palate. These lesions cannot be wiped off. [1,2]
Nicotine stains Patients who smoke tobacco have nicotine stains on their hands.
References
  1. VILLA A, VILLA C, ABATI S. Oral cancer and oral erythroplakia: an update and implication for clinicians. [online] December, 56(3):253-256 [viewed 08 August 2014] Available from: doi:10.1111/j.1834-7819.2011.01337.x
  2. AGBOR M, AZODO C, TEFOUET T. mokeless tobacco use, tooth loss and oral health issues among adults in Cameroon Afr Health Sci [online] 2013 Sep, 13(3):785-790 [viewed 09 August 2014] Available from: doi:10.4314/ahs.v13i3.38

Differential Diagnoses

Fact Explanation
Erythematous candidiasis [1] Erythematous candidiasis is one of the various presentations of oral candidiasis. Oral lesions appear as bright red patches with no evidence of ulceration.
Early squamous cell carcinoma (SCC) [1] Erythroplakia has significant risk of malignant transformation. Carcinoma-in-situ can progress to invasive SCC gradually.
Local irritation [1] Mucosal irritation can also induce inflammatory changes.
Mucositis [1] In mucositis erythematous and ulcerative lesions appear in the oral mucosa. This is commonly seen after radiotherapy to the head and neck area. [3]
Lichen planus [1] Lichen planus refers to mucocutaneous inflammatory disease of unknown origin. Oral lesions are symmetrical and reticular. These lesions characteristically have lace-like surface. [2]
Systemic lupus erythematosus (SLE) [1] SLE can present with oral ulcers. Other clinical symptoms and signs of the disease (discoid rash, malar rash, photosensitivity, arthritis) should also be looked for in order to make the diagnosis. [5]
Drug reaction [1] Topical or systemic drugs can induce allergic reaction in the oral mucosa. Allergic lesions are more widely distributed within the oral cavity.
Median rhomboid glossitis [1] Central papillary atrophy of the tongue is seen in patients affected with median rhomboid glossitis. This is a relatively rare disease affecting 0.01%–1.0% of the population and common in patients with immune-suppression. [4]
References
  1. VILLA A, VILLA C, ABATI S. Oral cancer and oral erythroplakia: an update and implication for clinicians. [online] December, 56(3):253-256 [viewed 08 August 2014] Available from: doi:10.1111/j.1834-7819.2011.01337.x
  2. LE CLEACH LAURENCE, CHOSIDOW OLIVIER. Lichen Planus. N Engl J Med [online] 2012 February, 366(8):723-732 [viewed 09 August 2014] Available from: doi:10.1056/NEJMcp1103641
  3. PS SK, BALAN A, SANKAR A, BOSE T. Radiation Induced Oral Mucositis Indian J Palliat Care [online] 2009, 15(2):95-102 [viewed 09 August 2014] Available from: doi:10.4103/0973-1075.58452
  4. GOREGEN M, MILOGLU O, BUYUKKURT MC, CAGLAYAN F, AKTAS AE. Median Rhomboid Glossitis: A Clinical and Microbiological Study Eur J Dent [online] 2011 Oct, 5(4):367-372 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3170022
  5. UVA LUíS, MIGUEL DIANA, PINHEIRO CATARINA, FREITAS JOãO PEDRO, MARQUES GOMES MANUEL, FILIPE PAULO. Cutaneous Manifestations of Systemic Lupus Erythematosus. Autoimmune Diseases [online] 2012 December, 2012:1-15 [viewed 09 August 2014] Available from: doi:10.1155/2012/834291

Investigations - for Diagnosis

Fact Explanation
Biopsy Biopsy of the suspicious lesions and histological examination is necessary for the diagnosis. Basal cell layer hyperplasia, haphazard arrangement of cells, increased mitotic activity and dysplastic changes (enlarged nuclei, increased nuclear to cytoplasmic ratio, prominent nucleoli and nuclear hyperchromasia) can be seen. Some lesions show carcinoma-in-situ and some progress to invasive carcinoma. [1]
References
  1. VILLA A, VILLA C, ABATI S. Oral cancer and oral erythroplakia: an update and implication for clinicians. [online] December, 56(3):253-256 [viewed 08 August 2014] Available from: doi:10.1111/j.1834-7819.2011.01337.x

Investigations - Followup

Fact Explanation
Biopsy Patients with erythroplakia should be monitored regularly and malignant transformation should be diagnosed and treated early.
References

Investigations - Screening/Staging

Fact Explanation
Three-dimensional optical coherence tomography (OCT) OCT is a non-invasive test, which is useful in estimating the height of the epithelium. In erythroplakia height of the epithelium is increased due to high mitotic index and basement membrane cell hypertrophy. Loss of basement membrane integrity, and subepithelial invasion of tumor cells can also be detected. [1]
References
  1. AHN YC, CHUNG J, WILDER-SMITH P, CHEN Z. Multimodality approach to optical early detection and mapping of oral neoplasia J Biomed Opt [online] 2011 Jul, 16(7):076007 [viewed 09 August 2014] Available from: doi:10.1117/1.3595850

Management - General Measures

Fact Explanation
Health education Public awareness should be raised regarding the harmful effects of tobacco and alcohol use. Use of lip sunscreen during outdoor activities help in reducing the risk of lip erythroplakia. [1] Patients should be stressed about the importance of regular and close follow up even after surgical excision of the lesion, because erythroplakia has significantly high risk of malignant transformation.
Correction of precipitating causes If the underlying etiology for erythroplakia is reversible, correction of the etiology will reverse erythroplakia in most of the patients. Ill fitting denture, loose tooth, fractured tooth, consumption of alcohol and tobacco smoking are correctable causes. Patients should be followed up with biopsy after correction of the etiology to diagnose or to exclude the resolution of the lesions.
References
  1. SOUSA FB, DE FREITAS E SILVA MR, FERNANDES CP, SILVA PG, ALVES AP. Oral cancer from a health promotion perspective: experience of a diagnosis network in Ceará. Braz Oral Res [online] 2014 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24964281

Management - Specific Treatments

Fact Explanation
Excision of the lesion Surgical excision of the lesion is the definitive mode of treatment. [1]
Dietary supplementation Dietary supplementation of vitamin A and beta-carotene is proven to regress the lesions and to prevent the occurrence of erythroplakia.
References
  1. VILLA A, VILLA C, ABATI S. Oral cancer and oral erythroplakia: an update and implication for clinicians. [online] December, 56(3):253-256 [viewed 08 August 2014] Available from: doi:10.1111/j.1834-7819.2011.01337.x