Case #4 Discussion

Summary: This is a white surface lesion.  It is white due to epithelial thickening because it is rough, asymptomatic, and will not rub off. Lesions to Exclude from Differential Diagonsis: Leukoedema   ~Location – Bilateral buccal mucosa Lichen Planus   ~Bilateral   ~Multifocal Nicotinic Stomatitis   ~Location – Hard Palate Familial Epithelial Hyperplasia (White Sponge Nevus)   ~Diffuse and multifocal   ~Present from early childhood   ~May have a familial history. Hairy Tongue, Geographic Tongue (Erythema Migrans), and Hairy Leukoplakia   ~Location – Tongue Lesions to Include in Differential Diagnosis: Hyperkeratosis – also known as Smokeless Tobacco Keratosis   ~From use of smokeless tobacco Epithelial dysplasia, Carcinoma-in-situ, and Squamous Cell Carcinoma   ~Unlikely because the lesion has a homogeneous appearance without nodular thickenings.  Smokeless tobacco lesions with a homogeneous surface are almost always diagnosed as hyperkeratosis microscopically. Management: Patient Education: Smokeless tobacco keratosis appears to have a low potential for malignant transformation.  The systemic cardiovascular effects of smokeless tobacco and the common periodontal attachment loss associated with smokeless tobacco use should also be explained. Performing an incisional biopsy might motivate the patient to discontinue the habit as well as provide a definitive diagnosis.  Final Diagnosis: Smokeless Tobacco Keratosis