Peer Reviewed

Photo Essay

An Atlas of Lingual Lesions, Part 5

Alexander K. C. Leung, MD
Clinical Professor of Pediatrics, University of Calgary; Pediatric Consultant, Alberta Children’s Hospital, Calgary, Alberta, Canada

Benjamin Barankin, MD
Dermatologist, Medical Director, and Founder, Toronto Dermatology Centre, Toronto, Ontario, Canada

Kin Fon Leong, MD
Pediatric Dermatologist, Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

Amy Ah-Man Leung, MD
Resident Physician, Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada

Alex H. Wong, MD
Clinical Assistant Professor of Family Medicine, University of Calgary, Calgary, Alberta, Canada

Leung AKC, Barankin B, Leong KF, Leung AA-H, Wong AH. An atlas of lingual lesions, part 5. Consultant. 2019;59(9):275-277.

EDITOR’S NOTE: This article is part 5 of a 5-part series of Photo Essays describing and differentiating conditions affecting the tongue and related structures in the oral cavity. Part 1 was published in the May 2019 issue (, part 2 was published in the June 2019 issue (, and part 3 was published in the July 2019 issue ( Part 4 was published in the August 2019 issue (


Oral Leukoplakia

Leukoplakia, as defined by the World Health Organization in 2007, is “a white plaque of questionable risk having excluded (other) known diseases or disorders that carry no risk for cancer.”1 

In 2018, Carrard and van der Waal modified the definition of oral leukoplakia to “a predominantly white, non-wipable lesion of the oral mucosa having excluded clinically, histopathologically or by the use of other diagnostic aids other, well-defined predominantly white lesions.”2 The latter definition is more accurately descriptive and more useful in clinical practice.

Clinically, oral leukoplakia, a potentially malignant condition, presents as an asymptomatic white patch or plaque of the oral mucosa that cannot be rubbed or scraped off (Figure).

Oral Leukoplakia

The two main types of oral leukoplakia are homogeneous leukoplakia and nonhomogeneous leukoplakia.2-4 The homogeneous type is characterized by a flat and uniform white patch or plaque with at least one area that is well-demarcated and has well-defined margins.4 On the other hand, nonhomogeneous leukoplakia is characterized by the presence of speckled, nodular, or verrucous areas.3 Proliferative verrucous leukoplakia, a subset of nonhomogeneous leukoplakia, is characterized by a multifocal appearance, relentless progression and spread, higher rate of recurrence, and a higher rate of malignant transformation.3,4

The pooled prevalence rate of oral leukoplakia is 1.5% to 2.6% in the general population.4 The condition is more common in older individuals, and the prevalence increases with advancing age.4 The male to female ratio is approximately 2 to 1.5 Most cases are idiopathic.6 Risk factors include long-term tobacco use, heavy alcohol consumption, and betel nut chewing.3-5

The diagnosis should be suspected in patients with a white patch or plaque of the oral mucosa that cannot be rubbed or scraped off. A definitive diagnosis requires a biopsy for histological examination to exclude other oral disorders that present with white lesions, since leukoplakia is a diagnosis of exclusion.2,7 Histopathologic features of leukoplakia include hyperkeratosis, parakeratosis, and epithelial hyperplasia with or without epithelial dysplasia.6,7

Spontaneous regression of oral leukoplakia is rare.2 The overall risk of malignant transformation is 2% to 3% per year.8 Risk factors for malignant transformation include old age, female sex, history of heavy smoking, heavy alcohol consumption, betel nut chewing, a large lesion size (>200 mm2), site of the lesion (ventral and lateral borders of the tongue, floor of the mouth), nonhomogeneous leukoplakia (in particular, proliferative verrucous leukoplakia), presence of dysplasia on initial biopsy, long duration, DNA hypermethylation, increased expression of microRNAs, aberrant expression of p53 and p16INK4a, and mutations of genes on chromosomes 3p, 9p, and 17.4-6,8,9

Surgical excision with clear margins is the treatment of choice in the presence of moderate to severe dysplasia, because it allows for a complete histopathological examination of the lesion.3 For oral leukoplakia with low malignant potential (no or mild dysplasia), treatment should be individualized. Treatment options include watchful observation, surgical excision, carbon dioxide laser ablation, electrocautery, photodynamic therapy, topical medical agents (such as retinoids, bleomycin, 5-fluorouracil, and imiquimod), and systemic medical treatment (such as vitamin A, carotenoids, lycopene, ketorolac, and celecoxib).3,4,10 Thus far, surgical interventions including surgical excision and laser therapy for oral leukoplakia have not been assessed in a randomized controlled trial. A 2016 systematic review of 14 randomized trials (N = 909) on medical and complementary interventions for oral leukoplakia found no significant difference between these treatments and placebo in the prevention and development of oral cancer.11



  1. Warnakulasuriya S, Johnson NW, van der Waal I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med. 2007;36(10):575-580.
  2. Carrard VC, van der Waal I. A clinical diagnosis of oral leukoplakia: a guide for dentists. Med Oral Patol Oral Cir Bucal. 2018;23(1):e59-e64.
  3. Parlatescu I, Gheorghe C, Coculescu E, Tovaru S. Oral leukoplakia – an update. Maedica (Buchar). 2014;9(1):88-93.
  4. Villa A, Sonis S. Oral leukoplakia remains a challenging condition. Oral Dis. 2018;24(1-2):179-183.
  5. Bewley AF, Farwell DG. Oral leukoplakia and oral cavity squamous cell carcinoma. Clin Dermatol. 2017;35(5):461-467.
  6. Mohammed F, Fairozekhan AT. Oral leukoplakia. StatPearls. Updated June 5, 2019. Accessed August 21, 2019.
  7. van der Waal I. Oral leukoplakia: a diagnostic challenge for clinicians and pathologists. Oral Dis. 2019;25(1):348-349.
  8. Mangold AR, Torgerson RR, Rogers RS III. Diseases of the tongue. Clin Dermatol. 2016;34(4):458-469.
  9. Kumar A, Cascarini L, McCaul JA, et al. How should we manage oral leukoplakia? Br J Oral Maxillofac Surg. 2013;51(5):377-383.
  10. Li Y, Wang B, Zheng S, He Y. Photodynamic therapy in the treatment of oral leukoplakia: a systematic review. Photodiagnosis Photodyn Ther. 2019;25:​17-22.
  11. Lodi G, Franchini R, Warnakulasuriya S, et al. Interventions for treating oral leukoplakia to prevent oral cancer. Cochrane Database Syst Rev. 2016;7:​CD001829.


NEXT: Squamous Cell Carcinoma of the Tongue

Squamous Cell Carcinoma of the Tongue

The clinical presentation of squamous cell carcinoma (SCC) of the tongue is highly variable but is usually asymptomatic.1 For symptomatic cases, pain and ulceration are the most common symptoms.2 The lesion may appear as a nodule, cauliflower-like growth, indurated plaque, or indurated ulcer (Figure). Sites of predilection include the lateral border of the tongue followed by the ventral surface of the tongue.1,3 The dorsal surface of the tongue is rarely involved. Approximately two-thirds of patients with tumor thickness greater than 5 mm have metastasis in the cervical lymph nodes.4 Dysarthria and dysphagia may be present if invasion of the deep glossal muscle is present.1

SCC of the tongue

Incidence rates of SCC of the tongue vary considerably between countries and range from 0.8 to 8 per 100,000 individuals per year.5 Traditionally, SCC of the tongue is a disease of the elderly, with a male to female ratio of 7 to 3.6,7 In recent years, a significant increase of SCC of the tongue has occurred in patients younger than 45 years of age, with less male predominance.7,8 Risk factors for SCC of the tongue include long-term tobacco use, heavy alcohol consumption, betel nut chewing, poor dental hygiene, denture use, lichen planus, leukoplakia, erythroplakia, human papillomavirus (HPV) infection, prior radiation exposure, and long-term immunosuppression.1,2,9

Dermoscopy is helpful for the clinical diagnosis.10 Dermoscopic features include keratin masses in the central part of the tumor lobules surrounded by polymorphous vessels, whitish dots around dotted and glomerular vessels, white structureless zones with blood spots, and ulceration in focal areas.10 The diagnosis should be confirmed histopathologically and preferably with a fine-needle aspiration biopsy. Imaging studies such as magnetic resonance imaging, computed tomography, ultrasonography, and positron emission tomography can be used to assess the degree of local infiltration, regional lymph node involvement, and presence of metastasis.11,12 A sentinel lymph node biopsy will increase the accuracy of overall staging.13

Treatment options include surgical excision, radiation therapy, and chemotherapy. Depending on the location and stage of the primary tumor, monotherapy or combination therapy may be used.14


  1. Stander S, Jeftha A, Dreyer WP, Abdalrahman B, Afrogheh A. Oral medicine case book 46: squamous cell carcinoma of the tongue. SADJ. 2013;68(1):​32-34.
  2. Adeyemi BF, Akinyamoju AO, Kolude B. Association of squamous cell carcinoma of the tongue with cigarette and alcohol exposure: a retrospective clinicopathological study. West Afr J Med. 2018;35(2):117-122.
  3. Okubo M, Iwai T, Nakashima H, et al. Squamous cell carcinoma of the tongue dorsum: incidence and treatment considerations. Indian J Otolaryngol Head Neck Surg. 2017;69(1):6-10.
  4. Ahmed SQ, Junaid M, Awan S, Kazi M, Khan HU, Halim S. Frequency of cervical nodal metastasis in early-stage squamous cell carcinoma of the tongue. Int Arch Otorhinolaryngol. 2018;22(2):136-140.
  5. Mroueh R, Haapaniemi A, Grénman R, et al. Improved outcomes with oral tongue squamous cell carcinoma in Finland. Head Neck. 2017;39(7):1306-1312.
  6. García-Kass A-I, Herrero-Sánchez A, Esparza-Gómez G. Oral tongue cancer in public hospitals in Madrid, Spain (1990-2008). Med Oral Patol Oral Cir Bucal. 2016;21(6):e658-e664.
  7. Paderno A, Morello R, Piazza C. Tongue carcinoma in young adults: a review of the literature. Acta Otorhinolaryngol Ital. 2018;38(3):175-180.
  8. Mannelli G, Arcuri F, Agostini T, Innocenti M, Raffaini M, Spinelli G. Classification of tongue cancer resection and treatment algorithm. J Surg Oncol. 2018;117(5):1092-1099.
  9. Campbell BR, Netterville JL, Sinard RJ, et al. Early onset oral tongue cancer in the United States: a literature review. Oral Oncol. 2018;87:1-7.
  10. Güleç AT. Dermoscopic features of squamous cell carcinoma of the tongue: it looks similar to cutaneous squamous cell carcinoma. J Am Acad Dermatol. 2016;75(2):e53-e54.
  11. Blatt S, Ziebart T, Krüger M, Pabst AM. Diagnosing oral squamous cell carcinoma: how much imaging do we really need? A review of the current literature. J Craniomaxillofac Surg. 2016;44(5):538-549.
  12. Tarabichi O, Bulbul MG, Kanumuri VV, et al. Utility of intraoral ultrasound in managing oral tongue squamous cell carcinoma: systematic review. Laryngoscope. 2019;129(3):662-670.
  13. Hingsammer L, Seier T, Zweifel D, et al. Sentinel lymph node biopsy for early stage tongue cancer—a 14-year single-centre experience. Int J Oral Maxillofac Surg. 2019 Apr;48(4):437-442.
  14. Christopherson K, Morris CG, Kirwan JM, et al. Radiotherapy alone or combined with chemotherapy for base of tongue squamous cell carcinoma. Laryngoscope. 2017;127(7):1589-1594.