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Received: 3 September 2018    Accepted: 7 September 2018
DOI: 10.1111/odi.12976
LETTER TO THE EDITOR
Oral leukoplakia: A diagnostic challenge for clinicians and
pathologists
Dear Editor,
At present, oral leukoplakia has been defined as “a predominantly
white plaque of questionable risk having excluded (other) known
diseases or disorders that carry no increased risk for cancer”
(Warnakulasuriya, Johnson, & Waal, 2007). A diagnosis of oral leu-
koplakia is probably often based on clinical judgment alone. The in-
dication for a biopsy may be (a) to exclude (other) known diseases
or; (b) in case of a strong suspicion of the diagnosis of leukoplakia, to
assess the presence and degree of epithelial dysplasia and to exclude
the possible presence of squamous cell carcinoma, carcinoma in situ
or verrucous carcinoma. In the latter cases, the provisional clinical
diagnosis of leukoplakia is replaced accordingly. In all other cases,
irrespective of the presence or the absence of epithelial dysplasia,
the provisional clinical diagnosis of leukoplakia will be replaced by a
definitive, clinicopathologic diagnosis of oral leukoplakia. Obviously,
there is a critical role to play both for clinicians and pathologists in
order to arrive at a proper diagnosis.
Based on the present definition a diagnosis of oral leukoplakia
is one by exclusion of well‐defined (“known”) predominantly white
lesions and disorders. Therefore, the accuracy of the clinical diag-
nosis very much depends on the experience of the clinician. In this
respect, non‐reticular presentation of oral lichen planus is probably
the most common challenge.
In the case of an incisional or excisional biopsy, the clinician
should provide the clinical (differential) diagnosis. In case of a strong
clinical suspicion of leukoplakia, the clinician may ask for special
stains, for example, histochemical stains for p53 or Ki67, or DNA
ploidy measurement, since the results of such stains may for some
clinicians play a role in the further management of the patient.
Apart from information on gender and age, oral subsite and seize
of the lesion, course of the disease, the presence or the absence of
symptoms and information on tobacco habits may be provided al-
though one may question the relevance of such information for the
histopathological assessment.
Obviously, the reliability of the histopathological diagnosis
largely depends on the pathologists’ experience in the field or oral
mucosal diseases. For instance, some pathologists may recognize to-
bacco‐induced epithelial changes or are able to recognize epithelial
changes caused by mechanical irritation.
The histopathological findings in oral leukoplakia may range
from hyperkeratosis without epithelial dysplasia to various degrees
of epithelial dysplasia. The clinical relevance of identifying various
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348  |  
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subtypes of epithelial dysplasia, such as koilocytic dysplasia, adenoid
dysplasia, and “lichenoid dysplasia” may be questioned from a clin-
ical point of view. At any rate, the absence of epithelial dysplasia
does not disqualify a leukoplakia of being potentially (pre)malignant,
although the risk of such leukoplakia is in most studies much lower
than in the presence of epithelial dysplasia.
Preferably, the pathology report should consist of two parts,
being (a) a description of the histopathological observations, includ-
ing the results of additional stains or other special techniques, if ap-
plicable; and (b) a conclusion of the histopathological examination
that is meant for the clinician and that also should be understandable
for a patient.
Having more than 45 years experience both as an oral surgeon
and an oral pathologist employed at an university teaching hospital
I consider myself a hybrid. This dual background has enabled me to
have a critical look at the clinicopathological diagnostic aspects of a
wide range of oral mucosal diseases, including leukoplakia and leu-
koplakia‐like lesions.
Particularly, in case of a discrepancy between the clinical and the
histopathological diagnosis, it is generally advised to look for close
collaboration between clinicians and pathologists. Unfortunately,
such collaboration does not seem to be very helpful. Clinicians hardly
have any experience with evaluation of histopathological sections.
On the other hand, pathologists usually have very little knowledge
about the clinical aspects of oral mucosal diseases.
Unfortunately, the clinical and histopathological definitions
and terminologies related to leukoplakia and leukoplakia‐like le-
sions have become rather mixed up in the past decades. Examples
are frictional lesion, frictional keratosis, alveolar ridge keratosis,
keratosis of unknown significance, verrucous hyperplasia, verru-
cous keratosis, and many others. Therefore, there seems a need
for re‐evaluation of the present definition and the clinical and
histopathlogical terminologies of oral leukoplakia and leukoplakia‐
like lesions.
C O N FL I C T O F I N T E R E S T
None declared.
ORCID
Isaäc van der Waal  http://orcid.org/0000-0003-3540-8981
Oral Diseases. 2019;25:348–349.
LETTER TO THE EDITOR |
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Keywords REFERENCE
oral leukoplakia, oral mucosa, potentially (pre)malignant oral lesions Warnakulasuriya, S., Johnson, N. W., & van der Waal, I. (2007).
Isaäc van der Waal Nomenclature and classification of potentially malignant disorders of
the oral mucosa. Journal of Oral Pathology and Medicine, 36, 575–580.
Department of Oral and Maxillofacial Surgery/Pathology, VU medical
https://doi.org/10.1111/j.1600-0714.2007.00582.x
center/ACTA, Amsterdam, The Netherlands
Email: i.vanderwaal@hotmail.com