Med. J. Malaysia Vol. 38 No.

2 June 1983

ORAL SPECKLED LEUKOPLAKIA REPORT OF

TWO CASES

HASHIM B. YAACOB
MOHD. ALl B MAHFUZ ALl
JASMAH ABD. HAMID

SUMMARY belonging to any known entities like lichen planus,

Two cases of oral speckled leukoplakia with candidiasis, stomatitis nicotina and the rest. It is
differing behaviour are presented. This therefore, a diagnosis by exclusion. Whilst a more
precancerous lesion of unknown aetiology requires improved and complete definition is found for
early diagnosis for proper management. Candida leukoplakia, the one suggested above should prove
albicans are frequently found in these lesions. The very satisfactory.
significance of epithelial dysplasia in relation to Although one type of leukoplakia (speckled
treatment is discussed. Surgical removal is the leukoplakia) carries a higher risk of developing into
treatment of choice. malignancy than the other (homogenous
leukoplakia), the clinican must be equally aware of
INTRODUCTION these lesions. Pindborg et al ? showed that 64
The word "leukoplakia" literally means a white percent of oral carcinomas in his study arose from
speckled leukoplakia. Banoczy 5 showed that 26
patch. Over the years, there has been a lot of
confusion regarding the usage of this term, as there percent of carcinomas developed in speckled
leukoplakia, whilst only 2 percent carcinomas
are numerous specific oral white lesions that must
have been referred to as leukoplakia. WHO developed from the other type ofleukoplakia.
Collaborative Reference Centre for Oral It is well-known that epithelial dysplasia is a
Precancerous Lesion 1 defined leukoplakia as "A common feature of speckled leukoplakia. Studies
white patch, after clinical and laboratory by Banoczy and Csiba, 4 Pindborg et al 5 Kramer et
investigations, cannot be placed into any known al 6 and Kramer 7 were aimed at determining the
category". According to this definition, a lesion importance of dysplastic epithelial features in
should only be termed leukoplakia if it appears leukoplakia in the future development of
white in colour and cannot be recognised as malignancy. The latter regarded derangement in
cellular polarity, abnormal mitoses, nuclear
hyperchromatism, cellular pleomorphism with
Hashim B. Yaacob, BDS, M.Sc, MAAOP, MIHE, AM enlarged nucleoli and individual cell keratinisation
Associate Professor and Head, as being important features for future malignant
Department of Oral Pathology and Oral Medicine, transformations of existing benign lesions.
Faculty of Dentistry
University of Malaya, Kuala Lumpur. The aim of this paper is to present two cases of
Mohd. Ali b Mahfuz Ali, BDS, FICS, FDSRCS, AM oral speckled leukoplakia with totally different
Consultant Dental Surgeon, behaviours, and to discuss the important features
Dental Division, General Hospital, that should influence management.
Kuala Lumpur.
CASE REPORTS
Jasmah Abd. Hamid, DMD, M.Sc.
Lecturer, Case One
Department of Oral Surgery,
University of Malaya, Kuala Lumpur.
A forty-five year old Indian woman presented to
the Dental Faculty, University of Malaya

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Fig. I Speckled Ieukoplakia on the right buccal mucosa. No Fig. 2 Speckled Ieukoplakia on the left buccal mucosa.
sign of malignancy. White elevated keratotic masses are seen within an area of
erythema which suggested malignancy.
complaining of tooth ache. On examination, there
was a painless lesion of raised keratotic masses suspicion, and a biopsy must be carried out as soon
distributed amongst a red area on the buccal as possible, so that a definitive diagnosis may be
mucosa opposite the mandibular second molar arrived at and proper treatment instituted. With
(Fig. 1). leukoplakia, observation of the lesion alone without
biopsy must be discouraged and deprecated. This is
A clinical diagnosis of speckled leukoplakia was more so, as examination and biopsy-taking can be
made and confirmed by histopathology. A performed in the oral cavity with relative ease; an
moderate degree of epithelial dysplasia was evident, early diagnosis is mandatory for good management.
together with candidal hyphae within the epithelial
layer. The lesion was surgically removed and left to Jolly B stated that a lesion may be regarded as
granulate under a whitehead's Varnish ribbon malignant when one or more of the following signs
gauze. The patient is well and healthy with no sign are present: ulceration, induration, elevation,
of recurrence one year later. fungation and fixation. The authors agree with this
statement as this claim was seen in one of our cases
Case Two described. The first case did not show any of the
A 55-year old Indian woman came to the Dental above signs, and looked benign clinically. The
Division, General Hospital, Kuala Lumpur, second one had additional features of induration,
complaining of intermittent soreness for the past erythematous periphery, and feeling of soreness.
three months on her left cheek associated with a These are perhaps the salient features that
white patch. She noticed the lesion several years distinguishes the stable speckled leukoplakia from
earlier but did nothing about it until it became the one that is undergoing transformation into
symptomatic. The lesion comprised an indurated, malignancy.
white area interspersed in an area of reddened
It has been stated that speckled leukoplakia is
buccal mucosa. The periphery were markedly more
frequently associated with candida albicans. 9,10,11
erythematous than the surrounding tissue (Fig. 2).
Both of our cases showed the presence of candidal
A clinical diagnosis of speckled leukoplakia was
hyphae, the role of which is not very certain at the
made. Histopathological examination revealed
moment. Lehner and Shilitoe 12 believed that
squamous cell carcinoma. A smear of the lesion
candida may cause leukoplakia, though there is
showed the presence of hyphae of candida albicans.
little evidence to suggest that it can cause
The lesion was surgically removed and the patient is
carcinomatous transformation in an existing
well and healthy eight months later.
leukoplakia. As these organisms can thrive well in
altered tissue such as those found in leukoplakia, its
DISCUSSION presence may merely indicate a secondary
The above cases demonstrate the precancerous infection. Speckled leukoplakia is best managed
potential of speckled leukoplakia. When according to the degree of dysplastic changes of the
encountered, the lesion must be viewed with associated epithelium. Pindborg 13 suggested that

119
in severe epithelial dysplasia, surgical removal of Surg 1977,5,69-75.
the lesion is indicated possibly with skin grafting. 4 Banoczy J, Csiba A. Occurrence of epithelial dysplasia in oral
The patient with slight to moderate dysplasia leukoplakia. Oral Surg 1976; 42, 766-74.
should be kept under strict surveillance and must
5 Pindborg J J, Daftary D K, Mehta F S. A follow-up study of
be seen every 3-4 months. The above set of rules may
sixty-one oral dysplastic precancerous lesions in Indian
not be as satisfactory as it seems, as carcinomatous
Villagers. Oral Surg 1977; 43, 383-90.
changes in leukoplakia are known to have occurred
in leukoplakias which showed no epithelial 6 Kramer I RH, EI-Labban N, Sonkodi S. Further studies on
dysplasia. lesions of the oral mucosa using computer-aided analysis of
histological features. BritJ Cancer 1974,29,223-31.
Poswillo 14 advocated the use of cryosurgery but
7 Kramer I R H. Computer aided analysis in diagnostic histo-
Sako et at 15 found a recurrence rate of 20 percent
pathology. Postgrad MedJ 1975; 51, 690-94.
in his leukoplakia patients treated by cryosurgery.
The use of high dosages of Vitamin A is not 8 Jolly M. White lesions of the mouth. IntJ Dermat 1977; 16(19),
recommended as there is a high recurrence rate 713-25.
after withdrawal 15,16 together with toxic side effect 9 Kramer I RH. Changing Views on oral disease. Proc Roy Soc
in the form of extreme,hypertension that may lead Med 1974; 67 (April), 271-76.
to cerebrovascular accident.
10 Renstrup G, Occurrence of candida in oralleukoplakia. Acta
The oral speckled leukoplakia is certainly a pathol microbiol Scand 1970; 78, 421-24.
precancerous lesion. Its early recognition is most
desirable. The management of such a lesion does 11 PindborgJJ. Oral leukoplakia. Aust DentJ1971; 16,83-93.
not fall within the field of the general practitioner, 12 Lehner T, Shilitoe E. Immunological aspect of cancer. In :
but nevertheless when encountering it, it is his duty Cohen B, Kramer I RH, eds. Scientific foundation of Dentistry,
to refer the patient to a specialist at the earliest London: William Heinemann Med. Books Ltd, 1976: 168-69.
possible time.
13 Pindborg J J. Oral Cancer and precancer. Bristol: John
Wright and Sons, 1980.
REFERENCES
14 Poswillo D E. Electrosurgery and Cryosurgery. In: Cohen B,
I WHO Collaborative Reference Centre for Oral Precancerous
Kramer I R H, eds. Scientific foundations of Dentistry
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2 Pindborg J J, Daftary D K, Mehta F S. Studies in oral cytologic and haefnotologic responses. Acta Odontol Scand
leukoplakia - a preliminary report on the period prevalance of 1968; 21, 271-92.
malignant transformation in leukoplakia based on a follow-up
studyof248patients.j. Amer, Dent. Assoc 1968; 76, 767-71. 16 Schrey M, Esser E. Exfoliativ Zytologie in Verlauf der
Lokalbehandlung der intraoralen leukoplakia mit. Vitmin -
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