Leukoedema of the buccal mucosa in Negro children and youth

Leukoedema of the buccal mucosa in Negro children and youth James L. Martin, DEPARTMENT

D.D.S.,”

OF PEDIATRICS,

and E. Perry MEHARRY

Crump, M.D.,“”

MEDICAL

Nashville,

Tenn.

COLLRGE

Leukoeclema has been reported to occur only in adult populations. In 1953, Sandstead and Lowe suggested that there may be a tendency for leukoplakia or other keratoses to develop in areas of leukoedema. It was further stated that there is a definite predilection for this lesion in the Negro. The etiology is unknown. In the present investigation the buccal mucosae of 1,000 Negro children and teen-aged patients were examined for leukoedema. An incidence of 50.8 per cent was observed. Histopathologic examination of biopsiecl leukoedematous specimens failed to demonstrate any features suggestive of dyskeratosis or carcinoma.

L

eukoedema, a grayish white lesion which characteristically appears on the oral buccal mucosa, has been alleged to occur only in adult populations1 The cause is unknown. Sandstead and Lowe2 examined 646 patients and found the condition in 43 per cent of the Caucasian and 90 per cent of the Negro patients. They concluded that this disease has a definite predilection for the Negro. “It was suggested that leukoedema may represent a lesion of the mucosa in which leukoplakia or other keratoses are more likely to develop than in normal epithelium.“2 Pindborg and colleague& 4 reported this lesion in 96 of 10,000 patients observed in Bombay, India, and in 166 of 10,000 Indians in Lucknow. Martin, Buenahora, and Bolden found leukoedema in 203 of 300 hospitalized male and female Negro patients. The purposes of the present investigation were to determine the incidence of leukoedema in Negro children and to test the leukoedemic occurrence for possible correlation with age, sex, oral hygiene status, syphilis, malocclusion, occurrence and degree of melanin pigmentation of the buccal mucosa, and occurrence in siblings. Presented at the forty-ninth annual meeting of the Research, Chicago, Ill., March, 1971. *Assistant Professor and Director of Dental Services. **Professor, Chairman, and Project Director.

International

Association

for

Dental

49

Oral July,

Fig.

1

Pig. 1. Slight leukoedema in a G-year-old Negro boy. of the buccal mucosa. Fig. 8. Moderate Icukoedenm in a 15year-old Negro delineates the lesion.

Fig. 3. Severe middle and posterior

MATERIALS

Surg. 1972

AND

leukoedema in a 15.year-old areas of the buccal mucosa.

Negro

boy.

Note girl.

Note

t.he faint Note

tho

the

grayish upper

radiating

white

d

area

border

which

striac

in the

METHODS

The buccal mucosae of 1,000 Negro children were examined with artificial light and a mouth mirror. The occurrence and degree of leukoedema were assessed according to the criteria previously defined by Sandstead and Lowe2: Slight-Mucosa was opalescent and thickened, with the capillary network obliterated; the entire mucosa may be involved but the middle and posterior portions of the cheek were principally affected; the edematous appearance disappeared upon stretching. Moderate-Mucosa had a coarsely granular surface with a definite white or whitish gray appearance that persisted upon stretching.

Volume 34 Number1

Leukoedema

of buccaZmucosa in Negroes

51

28.5496 44.6% 26.7%

I 50

1 0

1 0

I 2 0 250

3 0

3 0

I 400 4$0

5bo

5bo 40

80

NUMBER OF CASES

Fig. 4. Incidence of leukoeclema.

Severe-Mucosa appeared grayish white and thickened; in some cases it appeared shaggy and wet, and in other instances it was leathery and dry (Figs. 1, 2, and 3). The buccal mucosa was anesthetized by topical application of 5 per cent lidocaine ointment. Biopsy specimensof the leukoedematous tissues were fixed in 10 per cent formalin, sectioned, and stained with hematoxylin and eosin. The occurrence and degree of melanin pigmentation of the buccal mucosa were assessedas “none,” “slight,” “moderate,” or “heavy.” This determination was arbitrarily based on the presence or absenceof visible melanin pigmentation. RESULTS Population

studied

A random selection consisting of 1,000 Negro patients registered in the Meharry Comprehensive Health Care Program for Children and Youth was made for this study. The series consisted of 501 boys and 499 girls ranging in age from 1 to 18 years, with an average age of 9.2 years. Incidence

Five hundred eight (50.8 per cent) of the subjects had leukoedema of the buccal mucosa. The condition was generally observed bilaterally. “Slight” leukoedema was found in 145 (28.54 per cent) of the cases,whereas “moderate” and

52

Martin

Oral July,

and Grump

53 15

Surg. 1972

- ‘al,. -,,-

I

Fsmrl,?

I 2

II 3;

I 5

II 67

I d

I 3

10

III

11

12

I 13

II 1-l 15

16

I

II 17

I?

AGE IN YEAS

Fig. 5. Incidence

of leukoedema

in relation

to age and sex.

“severe” leukoedema were found in 227 (44.69 per cent) and 136 (26.77 per cent), respectively (Fig. 4).

The youngest patient with leukoedema was 3 and the oldest was 18 years of age. The majority of casesof leukoedema was observed in the 13- to 18-year age group, but the condition was most prevalent in U-year-old boys and in 12- and 15-year-old girls (Fig. 5). A direct relationship between the severity of leukoedema and age groups was demonstrated (Fig. 6). Sex Two hundred sixty-eight boys (52.76 per cent) and 240 girls (47.24 per cent) exhibited leukoedema. There was no sex predilection (Fig. 4). Oral

hygiene

status

Although a definite relationship between leukoedema and the variables of excellent, good, and fair oral hygiene was not evident, a direct correlation between the occurrence of leukoedema and poor oral hygiene was established (Fig. 7).

Volume Number

Leukoedema

34 1

lOO-

0

Slight

95-

69 m

Moderate Severe

of buccal mucosa in Negroes

53

9085807570 6560555045-

AGE GROUPS

Fig.

6. Severity

of leukoedema

in relation

to age groups.

Serology

Negative Wassermann reactions were reported for all the children comprising this study. Malocclusion

Four hundred twenty-three subjects were examined for possible correlation between leukoedema and malocclusion. Forty-two patients presented with both leukoedema and malocclusion, whereas 154 children exhibited leukoedema and normal occlusion. In comparison, 187 patients of this study had normal buccal mucous membranes and normal occlusion. Forty patients had malocclusion and normal buccal mucosae. Melanin

pigmentation

A direct relationship between the severity of leukoedema and the degree of melanin pigmentation of the buccal mucosae was noted. Two patients of this series did not have pigmented buccal mucous membranes and did not have leukoedema. Of the 155 patients with slight pigmentation of the buccal mucosae, 25

Oral July,

Surg. 1972

260240-

160

60

Excellent

Good ORRL HYGIENE STATUS

Fiy.

7. The

relation

of leukoedema

and oral

hygiene.

(16.13 per cent) exhibited leukoedema. Leukoedema was present in 376 subjects with moderately pigmented buccal mucosae (51.62 per cent) and in 116 (87.88 per cent) of those children with heavily pigmented buccal mucosae (Table I). Oral

habits

The buccal mucosae of 383 subjects were examined for possible correlation between the presence of leukoedema and the oral habits of finger-sucking, thumbsucking, tooth-grinding, cheek-biting, and tongue-sucking. Of the 182 children who exhibited leukoedema, 36 patients had an oral habit. One hundred forty-six of these subjects did not have abnormal oral habits. Siblings

The occurrence of leukoedema among siblings is not directly related. All the siblings of thirty-five families exhibited leukoedema, whereas all the children of forty families presented with either leukoedema or normal buccal mucosae. Thus, some of the children of the same family exhibited the condition while others did not (Table II). Histologic

findings

Selections of biopsied leukoedematous tissue from thirty patients revealed essentially the same characteristics as previously reported in an adult popula-

Leukoedema

Fig. 8. Note the group of irregular darker area in the upper right-hand (Hematoxylin and eosin stain. Magnification,

Table

of buccal mucosa in Negroes

leukoedematous portion of x16.)

this

cells near the surface. The photomicrograph is an

55

circular, artifact.

I. The relation of leukoedema and melanin pigmentation

Degree of melanin

Heavy Moderate Slight Negative

132 711 155 2

Tots1

Table

116 367 25 0 508

1,000

87.88 51.62 16.13 0

12.12 48.38 83.87 100

3:: 130 2

100 100 100 100

492

II. The occurrence of leukoedema in siblings ~ Number 1 1

Conddion of buccal mucosa Leukoedema Normal Leukoedema normal

of siblings 3

(

4

per family 1

5

1

6

Number families 35” 40t

26 37

6 2

2 0

1 2

0 0

19

13

6

5

1

of

Number children

of Per

ii

cent 27.67 28.33

or 44t

Total

132

119 *Number

of families

in which

all siblings

had leukoedema.

tNumber

of families

in which

all siblings

had normal

$Number

of

families

in which

some

siblings

exhibited

44.00

300

buccal

100

mucosae.

leukoedema

while

others

did

not.

tion by Martin and associates6: (1) Th ere was intracellular edema of the Malpighian layer. (2) Leukoedematous cells assumedirregular polyhedral shapes. (3) Vacuolization of the cytoplasm was quite common; the vacuoles appeared to contain a pale-staining homogeneous fluid. (4) There was a wide variation in nuclear size, and the contained chromatin material was either irregularly condensed, eccentrically positioned or completely absent (Figs. 8,9, and lo),

56

Martin

Pig. Malpighian x16.) Fig. vacuolated

and

9. Note layer

Grump

the eccentrically positioned extend to the basal-cell layer.

10. High-pan-er and enucleated

pyknotic nuclei. Leukoedematous (Hematoxylin and eosin stain.

viem of an area from the specimen shown in Fig. cells. (Hematoxylin and eosin stain. Magnification,

cells in Magnification,

0. Note x40.)

the

the large

DISCUSSION Leukoedema of the buccsl mucosa was previously thought to occur only in adult populations. An incidence of 50.8 per cent was observed in the children and teen-agers comprising this study. This condition, of unknown etiology, generally occurred bilaterally and appeared to have no sex predilection. The youngest child with this clinical entity was 3 years of age. ‘(Severe” leukoedema was found to occur only in children 5 years of age or older. The severity of leukoedema appeared to increase with age. The highest incidence was observed in U-year-old boys and 12- and 15-year-old girls. The high percentage of cases of “moderate” severity may represent a transitory phase between “slight” and “severe” stages. A previous investigation by

Leukoederna

of buccal mucosa in Negroes

57

Martin and associate@ revealed a low percentage of “moderate” cases of leukoedema in Negro adults. This apparent inverse relationship could be attributed to progressive changes of this condition from “slight” to “moderate” in the earlier years of the patient’s life, since the severity of leukoedema increased with age. The high incidence of leukoedema in children with poor oral hygiene suggests that poor oral hygiene may play a supportive role in its etiology. Syphilis, malocclusion, and oral habits were not causative factors. A direct relationship between the severity of leukoedema and the degree of melanin pigmentation of the buccal mucosa was observed. Leukoedema appears to be a condition that is manifested in the buccal mucosa of the patient; some siblings exhibit this entity while others have perfectly normal buccal mucosae. Leukoedematous tissues of the buccal mucosae of Negro children and teenaged patients gave the same clinical and histologic response that was previously reported in Negro adults.G The primary histologic characteristic of leukoedema and the key to its etiology may be centered in those cells which become edematous, vacuolated, and eventually enucleated. Although the etiology of leukoedema is unknown, future investigations should encompass children and teen-aged populations. SUMMARY

AND

CONCLUSIONS

A study was made of the incidence of leukoedema of the buccal mucosa in 1,000 Negro children and teen-agers. 1. Leukoedema of the buccal mucosa occurred in Negro children and youth. An incidence of 50.8 per cent was observed in this study. 2. Leukoedema occurred in a 3-year-old child, but the highest incidence was observed in U-year-old boys and 12- and 15-year-old girls. 3. The severity of leukoedema increased with age. 4. There was no sex predilection. 5. Syphilis, malocclusion, and oral habits did not appear to be causative factors. 6. A definite relationship between leukoedema and poor oral hygiene was established. 7. The severity of leukoedema was directly proportional to the degree of melanin pigmentation of the buccal mucosa. 8. The large number of “moderate” cases suggests a transitory stage between “slight” and “severe.” 9. No relationship between leukoedema and its occurrence in siblings was observed. 10. Histologically, leukoedema was defined as a benign entity with no features of dyskeratosis or malignancy. REFERENCES

1. Archard, H. O., Carlson, K. P., and Stanley, H. R.: Leukoedema of the Human Oral Mucosa, OFCALSUEW. 26: 717-728, 1968. 2. Sandstead, H. R., and Lowe, J. W.: Leukoedema and Keratosis in Relation to Leukoplakia of the Bucca.l Mucosa in Man, J. Natl. Cancer Inst. 14: 423-437, 1953.

Oral July, 3. Pindborg, J. J., Kalapessi, II. K., Kale, d. A., Singh, G., and Talyerkhan, Frequency of Oral Leukoplakias and Related Conditions Among 10,000 Bombayites, India Dent. Assoc. 37: 1102, 1965. 4. Pindborg, 5. J., Chawla, T. N., Misra, R. I~., Nagpaul, R. K., and Gupta, B. K.: and Lichen Planus in 10,000 lndians in Lucknow, Uttar Pradesh, India, J. Dent. 615, 1965. 5. Martin, 5. L., Buenahora, A. M., and Bolden, T. E.: Leukoedema of the Bnccal The Meharri-Dent. 29: 7-9, 1970. 6. Martin, J. L., Buenahora, A. M., and Bolden, T. E.: Cyto-histology of Leukoedema Buccal Mucosa, J. DC Dent. Sot. 44: 47-52, 1969. Reprint requests to: Dr. James L. Martin School of Dentistry Meharry Medical College 1005 Eighteenth Ave., N. Nashville, Tenn. 37208

Surg. 1973 B. N.: J. All

Fibrosis Res. 44: Mucosa, of the