COM June 2006

This is a 46-year-old male who presented with a lesion on the right buccal mucosa, from the linea alba through the buccal vestibule to the area of teeth #s 30 and 31. The buccal mucosa appeared white and wrinkled from the mesial of tooth #29 to the distal of tooth #31 (Figure 1A). The lesion was first noticed by the patient’s general dentist in 1999, at which time it was white, wrinkled, soft, non-fixed and non-tender. At both presentations, there were no palpable masses, and head and neck examination was otherwise within normal limits. The patient has an extensive history of tobacco and alcohol use; he has been using tobacco for 20 years and drinks different kinds of alcohols. The lesion has remained relatively unchanged, except for a brief period last winter; it began to improve when the patient stopped using tobacco for two weeks from 12/28/04 to 01/10/05 (Figure 1B). He also developed a similar lesion on the left buccal mucosa as a result of switching tobacco use from right to left (Figure 1C).

His past medical history is significant for hypertension, for which he is being treated with Altace (10 mg per day) and Lexipro (20 mg per day). He also had back surgery in 1984. There are no other significant health issues.

In December 2004, the patient presented with a white and folded right buccal mucosa and vestibule (Figure 2A). It was rough on palpation and had a leathery consistency. The area was biopsied and the patient ceased all use of smokeless tobacco for two weeks, which resulted in regression of the disease and regaining of the normal mucosal structure and texture (Figure 2B). One year later and upon the reuse of smokeless tobacco, the white lesion returned (Figure 1A). A second incisional biopsy was performed in December 2005 in the same area. The patient then decreased his tobacco use to 4 days per week at an average rate of 2-3 times every other day, a decrease of approximately 25%. This lead to regression of the white lesions again, except in the retromolar pad area (Figure 2B), where the mucosa remained white and wrinkled in appearance and rough in consistency. He also developed a similar lesion on the left buccal mucosa as a result of switching tobacco use from right to left (Figure 1C).

Figure 1 A, B, & C This photograph was taken on December 2005 after one year of smokeless tobacco use.

A. Note the white and wrinkled appearance of the right buccal mucosa

B. Two weeks after tobacco cessation, note the normal looking buccal mucosa but the white retromolar pad area

C. Note the white and wrinkled appearance of the left buccal mucosa after three months of use

Figure 2 A & B. This photograph was taken on December 2004, after several years of smokeless tobacco use.

A. Note the white and wrinkled appearance of the right buccal mucosa

B. Two weeks after tobacco cessation, note the normal looking buccal mucosa

The histology of both biopsies was similar in morphology and the photographs demonstrated represent the second biopsy. The histology is typical of this disease; the surface is covered by a thick layer of orthokeratin and parakeratin with small chevrons (Figures 3 & 4). The spinous layer shows evidence of focal thickening but maintains the usual pattern of cell maturation except in the basal and parabasal cell layers, where mild and focal hyperchromatism and nuclear crowding is noted. The underlying connective tissue shows evidence of focal fibrosis.

Figure 3. H & E stained section at 20X magnification (low scanning) demonstrating a mass of lamellar bone covered by a thin mucosa. The surface epithelium is stretched and lacks filliform papillae.

Figure 4. Low power (x100) histology shows a piece of oral mucosa with a thick keratin layer and focal areas of acanthosis and connective tissue fibrosis.