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198 Journal of Indian Society of Periodontology - Vol 14, Issue 3, Jul-Sep 2010
Case Report
Address for
correspondence:
Dr. Vandana K.L.,
Department of
Periodontics, College
of Dental Sciences,
Davangere - 577 004,
Karnataka, India.
E-mail: vanrajs@gmail.com
Submission: 08-01-2010
Accepted: 18-09-2010
DOI: 10.4103/0972-
124X.75918
Department of
Periodontics, D.A.P.M
R.V. Dental College,
Bangalore, and 1College
of Dental Sciences,
Davangere, Karnataka,
India
Idiopathic linear leukoplakia of
gingiva: A rare case report
N. Sapna, K. L. Vandana1
Abstract:
White lesions of the oral cavity are not uncommon though majority of them are benign. This case report documents
a rare case of idiopathic linear leukoplakia of gingiva with no apparent etiology. Initial examination revealed a
non-scrapable linear white lesion on the marginal and papillary gingiva of upper right teeth region. Incisional
biopsy was taken for pathologic evaluation. Patient was treated with routine oral hygiene procedures and excision
of the lesions. The histopathological results demonstrated hyperparakeratinized/orthokeratinized hyperplastic
oral epithelium with orthokeratin-lled clefts and with no dysplasia. Clinical results demonstrated no recurrence
after electrosurgical intervention. This paper reports a rare case of idiopathic linear leukoplakia of gingiva which
was non-dysplastic in nature. Electrosurgical treatment proved to be successful compared to surgical technique
as there was no recurrence even after two years of follow-up.
Key words:
Gingiva, idiopathic, linear leukoplakia, non-malignant
INTRODUCTION
Any condition that increases the thickness
of the epithelium causes it to appear white
by increasing the distance to the vascular bed.
Most often lesions appear white because of a
thickening of the keratin layer, or hyperkeratosis.
Other common causes of a white appearance
include acanthosis, an increase in the amount
of edema uid in the epithelium, and reduced
vascularity in the underlying lamina propria.
Surface ulcerations covered by a brin cap can
also appear white, as would collapsed bullae.[1]
The development of oral white patches is not
uncommon, but, fortunately, the majority of
lesions are due to benign conditions. However, a
small percentage of white patches may represent
either oral cancer or have an association with the
likelihood of the development of oral cancer. The
presence of sinister lesions cannot be assessed by
clinical appearance alone and clinical diagnosis
of any persistent white patch should therefore
be conrmed histologically.[2]
Oral leukoplakia can be defined as “a
predominantly white lesion of the oral mucosa
that cannot be characterized as any other
definable lesion; some oral leukoplakia will
transform into cancer”.[3]
Leukoplakia can be subdivided according to
etiology and clinical factors and one of the types
is idiopathic leukoplakia where no etiology for
the patch can be found.[4]
This paper describes a case of idiopathic linear
leukoplakia involving the marginal and papillary
gingiva with no apparent etiology.
CASE DISCRIPTION AND RESULTS
Clinical ndings
A 40-year-old male patient came to the
Department of Periodontics, College of Dental
Sciences, Davangere, India, with a chief
complaint of thin white lesion on the gums in the
upper front region since 4 months. He noticed
the lesion when he got his upper front teeth
removed, which was placed irregularly on the
inner side. The lesion was totally asymptomatic
except for the esthetic concern of the patient.
His medical history disclosed that he was a
well-controlled hypertensive patient since four
years. Patient did not smoke tobacco, or chew
areca nut. No history of trauma or surgery was
disclosed in that particular region. However,
patient gave history of vigorous brushing and
taking hot beverages.
Clinical examination revealed a linear white
lesion on the upper right region involving
marginal and papillary gingiva of both labial
and palatal side. It was more prominent on labial
aspect of 11, 12, 13 and 16 and palatal aspect of
11, 12, 13, 15 and 16 [Figures 1 and 2]. Lesions
were non-scrapable. The patient’s oral hygiene
was good. Radiographic examination showed
normal findings. Laboratory investigations
revealed hemoglobin level of 13.4 g%, a white
blood cell count of 5200 cells/mm3 and normal
platelet count. Random blood sugar was within
normal limits [Table 1]. There was no evidence of
skin lesions. HIV testing showed negative results.
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Journal of Indian Society of Periodontology - Vol 14, Issue 3, Jul-Sep 2010 199
Histopathological ndings
An approval from the institution’s review committee and an
informed consent from the patient were obtained. An incisional
biopsy of the lesion was performed in relation to labial gingiva
of 13 and 16 and palatal gingiva of 11 and 14 with patient under
local anesthesia. It was stained with hematoxylin and eosin
and observed under light microscope. Epithelium showed
exophytic proliferations lined by hyperparakeratinized /
orthokeratinized hyperplastic oral epithelium with few broad
and deep clefts lled with orthokeratin. Underlying connective
tissue showed lymphocytic inltration. There was no evidence
of dysplasia [Figure 3].
By correlating clinical and histopathological ndings the lesion
was diagnosed as idiopathic linear leukoplakia of the gingiva.
Treatment and follow-ups
The case was followed-up regularly for two years from August
2005 to August 2007. Scaling and oral hygiene procedures were
performed regularly. The linear white lesions were excised
using B.P. blade No. 15 under local anesthesia on the labial
aspect. Palatal lesions were not excised this time, so that they
could serve as reference lesions, if the labial lesions recurred
similar to previous lesion. At one-month reevaluation, the
labial linear white lesions had recurred. Once again the surgical
excision was done on both labial and palatal aspect and sent for
histopathological evaluation second time. Following the second
surgical intervention, linear white lesion had recurred again at
Sapna and Vandana: Leukoplakia of gingiva
Figure 1: First visit, buccal linear white lesions of marginal gingival in relation to
11, 12, 13
Figure 2: First visit, palatal linear white lesions in relation to 11, 12, 13, 15 and 16
Figure 3: H and E stain of tissue biopsy during rst visit showing hyperplastic oral
epithelium, lymphocytic inltration in connective tissue with no evidence
of dysplasia Figure 4: Recall visit, no recurrence of white lesion after two years of follow-up
Table 1: Complete hemogram
Report Normal values
Hb estimation 13.4 g% 14–18 g% (males 11.5–6.5
mg% (females)
ESR count 30 mm/m 0–15 mm (males) 0–20
mm/1 h (females)
RBC count 5.1 millus mm34.5×105–6×105/mm3
Platelet count 2.0 lacs/mm3 1×105–4×105/mm3
Total WBC count 5200 cells/mm34000–10,000/mm3
Bleeding time 1 min 45 s 1–5 min
Clotting time 3 min 15 s 4–9 min
Differential count
Neutrophils 58% 40–75%
Lymphocytes 36% 20–45%
Eosinophils 04% 01–04%
Monocytes 02% 02–08%
Basophils 00% 00–01%
Blood sugar
Random blood sugar 126.0 mg% 70 – 160 mg%
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200 Journal of Indian Society of Periodontology - Vol 14, Issue 3, Jul-Sep 2010
Sapna and Vandana: Leukoplakia of gingiva
one month’s recall. Considering the patient’s esthetic concern
and nondysplastic tissue changes in both the histopathological
report, an attempt was made to eliminate linear white lesions
using electrosurgery approximately 6 months after the rst
excision. The patient’s compliance was highly appreciable
during the maintenance phase. The regular checkup over two
years period did not reveal any recurrence of the white linear
lesion and patient was satised with the treatment and the
results [Figure 4].
DISCUSSION
Oral white lesions reflect many different diseases and
pathological changes. Some of them relate to diseases such
as lichen planus and lupus erythematosus. Others are local
changes with a clearly dened or highly probable etiology.
Leukoplakia is the most prevalent precancerous lesion of
the oral mucosa. The label “leukoplakia” was coined by
Schwimmer.[5] Approximately 70% oral leukoplakias are found
on the lip vermillion, buccal mucosa and gingiva.[6]
Leukoplakia of the gingiva varies in appearance from a
grayish white, attened, scaly lesion to a thick, irregularly
shaped keratinous plaque.[7] The cause of leukoplakia remains
unknown though it can be associated with the use of tobacco.
The lesions where the etiology is not apparent can be termed
as idiopathic leukoplakia.[4]
In the present case, since histopathological reports did not show
any dysplastic changes, premalignant and malignant lesions
were not taken into considerations for the diagnosis.
Among reactive and inammatory white lesions, frictional
(traumatic) keratosis was not considered for the diagnosis since
an identiable source of mechanical irritation like rough or
maladjusted dentures, sharp cusps and edges of broken teeth
was not found. Though patient gave a history of hard brushing
and consuming hot beverages, lesions did not resolve even
after patient left these habits ruling out these habits as source
for the lesion.
Chemical injuries were ruled out since patient did not give any
history of usage of chemicals. Since patient did not smoke or
chew tobacco, tobacco-induced keratosis was excluded from
the diagnosis.
Infectious lesions like candidiasis, bacterial infections or viral
infections were also ruled out since patient’s history was non-
suggestive and also biopsy report did not show any changes.
The use of vigorous brushing by the patient would not lead to
occurrence of lesions on the upper right side excluding the other
quadrants especially the lower right quadrant. Considering the
patient’s history, clinical and histopathological examination,
the lesion can be termed as idiopathic linear leukoplakia of
the gingiva.
Patient has been kept under observation and till date has not
shown any recurrence of the lesion.
CONCLUSION
This case report was considered, as idiopathic leukoplakia
on the gingiva is a very rare nding. It was considered as
idiopathic lesion as no etiology could be related to the present
lesion. Further observations should be done to detect any
recurrence of the lesion.
REFERENCES
1. Bhattacharya I, Cohen DM, Silverman S. Red and white lesions of
the oral mucosa. Burket’s oral medicine diagnosis and treatment.
10th ed. New Delhi: Harcourt (India) Private Ltd; 2003. p. 85-125.
2. Lamey PJ. Oral medicine in practice: White patches. Br Dent J
1990;168:147-52.
3. Axell T. Oral white lesions with special reference to precancerous
and tobacco related lesions: Conclusion of an international
symposium held in Uppsala, Sweden in 1994. J Oral Pathol Med
1996;25:49-54.
4. Axell T. Occurrence of leukoplakia and some other oral white
lesions among 20333 adult Swedish people. Community Dent
Oral Epidemiol 1987;15:46-51.
5. Schwimmer E. Some rare clinical pictures of oral and lingual
mucosa. Arch Dermat Syph 1877;9:641-70.
6. Neville BW, Damm DD, Allen CM, Bouquot JE. Epithelial
pathology. Oral Pathology and Maxillofacial Pathology. 2nd ed.
Philadelphia: Saunders; 2004.
7. Carranza FA, Hogan EL. Gingival enlargement. Carranza’s
clinical periodontology. 9th ed. Philadelphia: Saunders; 2003. p.
279-96.
Source of Support: Nil, Conict of Interest: None declared.
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