Talk:Leukoplakia/GA1

GA Review

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Reviewer: LT910001 (talk · contribs) 05:37, 11 April 2014 (UTC)

If there are no objections, I'll take this review. I'll note at the outset I've had no role in editing or creating this article, although I've previously worked with the nominee on several articles. I welcome other editors at any stage to contribute to this review. I will spend a day familiarising myself with the article and then provide a brief assessment, and provide a more thorough assessment after reading some of the relevant sources. Kind regards, LT910001 (talk) 05:37, 11 April 2014 (UTC)

Hey thanks LT. I don't think there is any unref'd content here. Some MEDDATE issues. It is possible that I can get hold of newer editions of some of the textbooks (e.g. 26, 19, 13, 2 and 1), if they are available online. Other main issue is whether the article is not covering non-oral leukoplakia well enough. I tried to cover these, but secondary sources were very hard to find. Typing "leukoplakia" into PubMed gives results dominated by oral med. Indeed the first page is 100% oral med. Not sure any other specialties use this term anymore. We have one review which states bladder leukoplakia is archaic. Lesion 09:04, 11 April 2014 (UTC)

Thanks, I'll leave some feedback on this in the second half of the review, and have a look/think about non-oral leukoplakia. --LT910001 (talk) 01:09, 13 April 2014 (UTC)

Thanks for waiting. In conducting this review, I will:

• Provide an assessment using WP:GARC
• If this article does not meet the criteria, explain what areas need improvement.
• Provide possible solutions that may (or may not) be used to fix these.

Assessment

Rate	Attribute	Review Comment
1. Well-written:
	1a. the prose is clear, concise, and understandable to an appropriately broad audience; spelling and grammar are correct.	See comments
	1b. it complies with the Manual of Style guidelines for lead sections, layout, words to watch, fiction, and list incorporation.
2. Verifiable with no original research:
	2a. it contains a list of all references (sources of information), presented in accordance with the layout style guideline.	Yet to verify
	2b. reliable sources are cited inline. All content that could reasonably be challenged, except for plot summaries and that which summarizes cited content elsewhere in the article, must be cited no later than the end of the paragraph (or line if the content is not in prose).	Some areas lack citations
	2c. it contains no original research.
3. Broad in its coverage:
	3a. it addresses the main aspects of the topic.
	3b. it stays focused on the topic without going into unnecessary detail (see summary style).
	4. Neutral: it represents viewpoints fairly and without editorial bias, giving due weight to each.	Addressed
	5. Stable: it does not change significantly from day to day because of an ongoing edit war or content dispute.	See conclusion
6. Illustrated, if possible, by media such as images, video, or audio:
	6a. media are tagged with their copyright statuses, and valid non-free use rationales are provided for non-free content.
	6b. media are relevant to the topic, and have suitable captions.
	7. Overall assessment.

Commentary

This is a thorough and comprehensive article and owing to the title I expect readers to be familiar with some dental terminology. I really enjoyed reading the 'signs and symptoms' and 'causes' sections and thought they were particularly well-written. I have read up to 'Diagnosis' and will continue my review tomorrow.

I am yet to:

•  Done Check images
  • No problems
• Verify sources
• Finish review of the Diagnosis and later sections.

Lead -> Causes

These sentences need sources:

• "Non-homogenous leukoplakias have a greater risk of malignant transformation than homogenous leukoplakias."

I will have a look in the sources. Lesion 11:23, 13 April 2014 (UTC)

• "Candida in association with leukoplakia should not be confused with white patches which are primarily caused by candida infection, such as chronic hyperplastic candidiasis ("candidal leukoplakia")"

I think this refers to the section #Candidal leukoplakia; and either ref 22 or ref 19 could be used to support it.  Done Lesion 11:23, 13 April 2014 (UTC)

• " Weedon D; Strutton G, Rubin AI (2010). Weedon's skin pathology (3rd ed. ed.). [Edinburgh]: Churchill Livingstone/Elsevier. ISBN 978-0-7020-3485-5. " does not have a page number attached.

This is one of the refs from that damn "acquired dyskeratotic leukoplakia" which should never have been merged into the article. A single case from 1988 does not a medical condition make. Consensus said otherwise apparently: [1], [2]. Had a bit of difficulty finding the page number since google books preview not working, but found it on amazon preview. Page 480.  Done

• Neither does this source: " Underwood. General and Systemic Pathology. 4th Edition. Edinburgh, London: Churchill Livingstone 2004[page needed]"

Not yet done.

If possible, I think these words could be replaced by their lay variants:

• "Etiologic" with "Causal"

 Done

• Dorsal/dorsum and ventral/ventrum

Always unsure how best to translate "dorsal tongue"... topsurface, undersurface of the tongue I guess.  Done

Some minor comments about prose:

• This is a little confusing: "Erythroleukoplakia (also termed speckled leukoplakia, erythroleukoplasia or leukoerythroplasia) is a non-homogenous lesion of mixed white (keratotic) and red (atrophic) color", I was expecting "mixed white (leuko-) and red (erythro-) colour"

? I don't understand. Erythro= red, erythema= redness, atrophy is one cause of erythema since the epithelial layer is thinner and the vascular connective tissue shows through more clearly; leuko=white, keratotic= thickened keratin layer, appearing white as the keratin gets supersaturated with water from saliva.

Sorry, a bit of a silly point. I meant it's interesting that you chose to explain by the histological basis rather than the linguistic/symptomatic basis of the lesion. Not that important. --LT910001 (talk) 00:41, 19 April 2014 (UTC)

• "Tobacco chewing (smokeless tobacco)" suggest remove "smokeless" as I think this is implied

 Done

• Suggest "not be applied to a white patch.", " -> "should not be used" in "Where there is a demonstrable cause such as mechanical or thermal trauma, the term idiopathic leukoplakia should not be applied to a white patch."

 Done

• "have no known cause (idiopathic)." -> suggest integrate 'idiopathic' into the sentence

I just deleted idiopathic since it is esoteric medical jargon to most people. Although one time I met a patient (an English teacher) who already knew what it meant with no medical background.  Done

A comment that should be removed because it is tangential and not NPOV:

• "Ironically, some complimentary and alternative medicine practitioners and companies promote the use of sanguinaria as a therapy for cancer." this is unnecessary and non-encyclopedic

Sadly it is true, at least according to our own wiki article: sanguinaria. Anyway, agree off topic for this article.  Done Lesion 11:23, 13 April 2014 (UTC)

I do not expect any problems that would prevent promotion, and look forward to working with you to get there. Unfortunately I don't yet have access to the sources so I will have to wait several days to verify. Kind regards, --LT910001 (talk) 01:06, 13 April 2014 (UTC)

Let me know if you want any of the textbooks, I will see if I can share them via dropbox. Some others I only have in dead-tree format.

No rush. Thanks for feedback. Lesion 11:23, 13 April 2014 (UTC)

Thanks Lesion, I will likely finish this review through this coming weekend. --LT910001 (talk) 10:59, 14 April 2014 (UTC)

Done.--LT910001 (talk) 00:41, 19 April 2014 (UTC)

Doing my routine check of paragraphs for close paraphrasing, this paragraph: “Non-homogenous leukoplakia is a lesion of non-uniform appearance. The color may be predominantly white or a mixed white and red. The surface texture is irregular compared to homogenous leukoplakia, and may be flat (papular), nodular or exophytic.[6][14] "Verrucous leukoplakia" (or "verruciform leukoplakia") is a descriptive term used for thick, white, papillary lesions. Verrucous leukoplakias are usually heavily keratinized and are often seen in elderly people. Some verrucous leukoplakias may have an exophytic growth pattern,[2] and some may slowly invade surrounding mucosa, when the term proliferative verrucous leukoplakia may be used. Non-homogenous leukoplakias have a greater risk of malignant transformation than homogenous leukoplakias.[citation needed]” appears to be directly lifted fom the ICD-11 draft: http://apps.who.int/classifications/icd11/browse/f/en#!/http://id.who.int/icd/entity/823236620. Always the possibility that the ICD was lifted from here. --LT910001 (talk) 01:28, 14 April 2014 (UTC)

Interesting. I didn't access the ICD-11 when writing this... I also note that the ICD-11 draft lacks the inline citation that Wikipedia has in this segment. They also directly lift content from the lead of this article for the main Leukoplakia entry. Heh, worth posting this on WTMED. Lesion 08:38, 14 April 2014 (UTC)

How strange! I am sure we will learn more about this in the coming days. --LT910001 (talk) 10:59, 14 April 2014 (UTC)

"...worth posting this on WTMED"? This is worth posting in NEJM if we found 50-100 of these. Blue Rasberry (talk) 17:44, 14 April 2014 (UTC)

Diagnosis -> History

Differentials

• What are your thoughts on splitting some of the information in "Diagnosis" to a "Pathophysiology" section? This paragraph in particular "Almost all oral white patches are usually the result of keratosis.[3] For this reason oral white patches are sometimes generally described as keratoses..." doesn't entirely relate to the differential diagnosis. I'm not sure - I just find the diagnosis section quite long and hard to read, with a lot of jumping about. Would like to hear your thoughts on this
  • Update: Perhaps move to the 'histologic appearance' section, where it may find a nicer home?
• Two paragraphs need citations:
  • "Almost all oral white patches are usually the result of keratosis.[3] For this reason oral white patches are sometimes generally described as keratoses..."
  • "Leukoplakia cannot be rubbed off the mucosa,[8] distinguishing ..."

Biopsy

• I think this section would benefit from a simplification, as I do not think a lay reader would be able to understand it. For example, "Other methods involve the use of illuminescence, relying on either the property of normal autoflorescent molecules in mucosa such as collagen and keratin which is lost from areas of dysplasia or carcinoma under blue light, or by initially staining of the mucosa with toluidine blue or dilute acetic acid and examination under white light"
• I have removed the definition of ulcers and Toludine blue as they can be found in the child articles

Histology

• Again, would benefit from a simplification and some removal of parentheses if possible, this is hard to read.
  • "Abnormal mitosis may be abnormally located, e.g. occurring in suprabasal cells (cell layers more superficial to the basal cell layer) or of abnormal form, e.g. "tri-radiate mitoses" (a cell splitting into 3 daughter cells rather than only 2)"
  • "the rete pegs may become "drop shaped". wider at their base than more superficially"
• I have tried to remove some instances of self-paraphrasing to help with readability.
• This section could be split into two subsections: 'Increased keratin formation', and 'Indicators of malignancy', and then split accordingly. I think that would help some of the readability, by grouping together like signs.

Treatment

No issues.

Prognosis

• There is a big list here of different indicators I feel could be shortened and simplified.
  • "Older people with white patches are at higher risk", "White patches which have been present for a long period of time have higher risk", ... --> "Lesions in older people, that have been present for a longer time, ... are at increased risk of malignant transformation."

History

• Suggest wikilink the names mentioned here

Lede

• Having read the whole article, I suggest that the fact that Leukoplakia is premalignant be mentioned earlier in the lead, and that the lead is given an extra paragraph (maybe here "Leukoplakia literally means "white patch" and ")

Sources

• I've checked what sources I can (ie the journal articles and websites) and they correlate with what's in text. Unfortunately I don't have access to the text books, but perhaps I can ping Ian Furst for a check of the verifiability of the article? --LT910001 (talk) 00:43, 19 April 2014 (UTC)

LT, apologies but may be a delay while issues above (yours) and below (Ian) are resolved. Many edits required, but happy because article will benefit overall I feel. Regards, Lesion 19:16, 19 April 2014 (UTC)

I have no further interest in this GAN. As DangerousPanda says, I am going away to sulk. Lesion 23:05, 19 April 2014 (UTC)

Don't stop on my account Lesion. Even though our viewpoints are too far apart on this topic to reach consensus doesn't mean it isn't an important article or that it doesn't deserve GA status. I wrote what I thought were salient points, you refuted most of them. I stopped the critique on my part assuming consensus would be impossible to reach in the GAN forum and it would be better to conduct further discussions on the talk page at a later date. This is still a well written, scholarly review of the subject. Re LT910001's original question about the textbooks. Of the textbooks you quote, I've only ready access to Neville and Damm and the information you give is in agreement with them. Ian Furst (talk) 23:39, 19 April 2014 (UTC)

No worries, Lesion. I'll put the nomination on hold for a week or two in case you decide to start working on it. Your work is normally of a very high calibre, but there's no reason for you to keep working if you don't want to. Take care, and I hope you enjoy the weekend, --LT910001 (talk) 23:44, 19 April 2014 (UTC)

Input from user:Ian Furst

• Lesion late to the game here and I've got some concerns the way clinical and histologic terms are intertwined. I can see how much work has gone into this article and I realize the changes I propose are major. Please accept or leave them. If you agree, I'm happy to help make some modifications. If not, no offence taken. This is an important page and I'm glad you're working on it but I think the main message that clinical leukoplakia can often be dysplasia or cancer is lost in the discussion of it's historic use as a diagnosis.
  • Leukoplakia cannot be cancer. Carcinoma in situ or carcinoma which has already breached the basement membrane has been diagnosed by a pathologist. The white patch would then be called SCC. This is why Leukoplakia is called a premalignant lesion, when it undergoes malignant transformation, it is no longer leukoplakia, since another diagnosis applies. Lesion 19:13, 19 April 2014 (UTC)

• you've used the disease/disorder template from MEDMOS instead of the Signs and Symptoms. I think the latter may actually better lend itself to the issues with this topic (read below)
  • Leukoplakia is a disease/disorder more than a sign/symptom. Having said this, on other articles I find a mixture of headings which are recommended for both article types is helpful. Lesion 19:13, 19 April 2014 (UTC)

• There is a fundamental issue with this article. Leukoplakia, is both a diagnosis (white patch with no known cause) and a clinical description (a white patch). The latter use is far more common (at least in North America). The article intertwines these two uses of the term and mixes the references to each. For instance, ".....the majority of oral white patches have no known cause." followed by "Almost all oral white patches are usually the result of keratosis" with the same reference. I biopsy white patches every day and rarely (like 1 every 2 years) get a path report back as "normal mucosa".

• • I suspect the concerns about a "fundamental issue" with the article are reflective of where you are coming from. Academia often has ideas about what clinicians should be doing which do not reflect what clinicians are actually doing. To an extent, they are separate worlds. Hence there are 2 ways of writing an article about leukoplakia. The clinical one, might be to call any white patch leukoplakia. The academic sense of the term is that leukoplakia is only correctly used once a specific condition is met: exclusion of any other cause of white patch. This article has been built out of mostly academic sources, and hence reflects the acadmic "world" rather than the "clinical world". I am not saying this is definitely the way it should be, but as far as Wikipedia's source guidelines go, we would have difficulty going around asking clinicians how they defined the term and building the article out of their responses. When the WHO, and most of the sources quoting it are using the academic sense of the term, it is difficult to justify going against it. As such, there is no real option but to follow the academic sources, which also state things like "some clinicians misuse the term leukoplakia". So, article lead makes clear that leukoplakia is not a clinical term in the same way that "ulceration" is a clinical term. Leukoplakia may be etymologically derived from "White patch" in Greek, but not all white patches are rightfully called Leukoplakia. This is supported by the WHO definition. As far as the academic sources are concerned, "Clinical leukoplakia" is a jumping to conclusions, just like clinicians who immediately call a lesion hypertrophic or hyperplasitc just by looking at it. The naked eye is not a microscope. Such terms can only be confidently used after biopsy and histopathologic examination which rules out other causes. As such, it is more appropriate (according to WHO anyway) to clinically call white patches just that... white patches, until they have been properly diagnosed. Lesion 19:13, 19 April 2014 (UTC)
  • "Idiopathic"- refers to unknown cause. You can have a keratotic lesion of no known cause, and you can have keratosis of known cause (e.g. mechanical trauma). "Idiopathic" and "keratosis" are not mutually exclusive in this regard. Lesion 19:13, 19 April 2014 (UTC)
  • I would be shocked if you ever got a histopathologic report which said white mucosa was normal, since mucosa is not supposed to be white... Possible that biopsy was not representative of lesion as a whole, or artifact introduced in preparing the slide is all I can think of. Lesion 19:13, 19 April 2014 (UTC)

• white oral lesions are white because of increased keratin, candida or fibrin. Not just keratosis.
  • Article does not state that all white lesions are caused by keratosis. You are quoting this "Almost all oral white patches are usually the result of keratosis." cited to ref 3. This problem in that textbook is written by 2 authors, one of which is EW Odell, a prominent professor in oral pathology and oral medicine consultant in the UK. It is reliable... Lesion 19:13, 19 April 2014 (UTC)
• The first 3 sentences are contradictory imo. The first states it a disorder of keratosis, the second a diagnosis of exclusion and the third that it's a clinical term. I believe this derives from Tanaka's paper. Leukoplakia is most commonly used as a clinical term to describe a white patch in the mouth. White patches in the mouth have their appearance because of hyperkeratosis, candida or increased fibrin but they represent a spectrum of disease that includes plaque lichen planus, benign hyperkeratosie, hypertropic candidiasis, the spectrum of epithelial dysplasisias, verrucous hyperplasia, verrucous carcinoma and invasive squamous cell carcinoma.
  • Answered above. Idiopathic and keratosis are not contradictory. Tanaka paper not used to support any content in lead. A diagnosis of exclusion and a clinical descriptive term are not contradictory either... Your comment "Leukoplakia is most commonly used as a clinical term to describe a white patch in the mouth" is unsupported. This goes back to the academic/clinical issue above. Difficult to write a wikipedia article that contradicts WHO and many academic sources. Also, I would point out that hyperkeratosis is the reason that many of the lesions you mention appear white, e.g. lichen planus. Lesion 19:13, 19 April 2014 (UTC)
• Based on Lodi's article (and I presume the WHO, given their use of your article) there are two major classifications now. Homogenous and non-homogenous. erythroleukoplakia, stippled, etc... are all in non-homogenous??? however....
  • Correct, article uses homogenous/non-homogenous terminology as base, but your language suggests this is somehow OR on my part. It is not "new" terminology created in the article... "Stippled" is actually new to me before you mentioned it in a source on WTMED. Almost all sources talk of speckled leukoplakia (erythroleukoplakia). Not sure if stippled leukoplakia is a synonym of speckled, since I have not yet seen that source. Or perhaps stippled refers to texture rather than non-homogenous color distribution in the lesion. Lesion 19:13, 19 April 2014 (UTC)
• The clinical appearance of leukoplakia is homogenous, non-homogenous, etc.... Should these distinctions be in S&S or classification? Personally, I'd "classify" leukoplakias by histologic cause and list the types under appearance/signs. I think this would help clarify things. For instance, erythroleukoplakia (a non-homogenous leukoplakia) has a high probability of being carcinoma when first found (especally in smokers) and if found to be caused by dysplasia has a very high malignant transformation rate. But it is also commonly caused by atrophic candidiasis in people who use inhaled corticosteroids. Therefore, non-homogenous leukoplakia should be treated with great caution and if found to be dyplastic, carefully monitored.
  • Again, confusion between "clinical" and "academic"... atrophic candidiasis is not leukoplakia because that is a distinct diagnosis. Atrophic candidiasis is not even white...it is red, unless I am confused, it is a synonym of "erythematous candidiasis" and "antibiotic sore mouth" etc.
  • I think it is best to discuss the different types of leukoplakia in the classification section, and the different causes in the causes section... Lesion 19:13, 19 April 2014 (UTC)

• The reported rates of malignant transformation of leukoplakia range from less than 1% to 18% (Tanaka) but that assumes a diagnsosis of dysplasia. Leukoplakia due to benign hyperkeratosis is essentially zero. I think the better description is that about 5% of leukoplakia's (clincal term) are found to be carcinoma's (pathologic term) and another 5% will evolve into carcinoma's. 25% of erythroplakias are either dysplasia or invasive carcinoma at the time of first examination and 30% will become carcinoma (Marx 310-311).
  • Are you confusing Lodi (Cochrane review) with Tanaka review? The stats on malignant transformation used in the lead are from Cochrane. I thought that would be the most reliable source to use. We do however immediately follow this with "The vast majority of oral leukoplakias will not turn malignant,[10]" and later in the article, "The annual malignant transformation rate or leukoplakia rarely exceeds 1%,[6]". Perhaps the lead needs to be tweaked with regards the risk. The 20% figure may cause undue alarm, agree. If we have sources which would support different stats with regards malignant transformation rates according to "clinical" and "academic" (currently Cochrane assume), would support this inclusion in the artilce. Lesion 19:13, 19 April 2014 (UTC)
• I disagree with this statement, "There are many known conditions which present with a white lesion of the oral mucosa, but the majority of oral white patches have no known cause.[3]" I rarely receive a biopsy back on a white lesion that says, "normal mucosa". Almost all have a histologic cause and the reference states keratosis (I presume they mean hyperkeratosis?) is the common cause.
  • You can have abnormal mucosa which is abnormal for unknown reasons... Answered this a bit above. Lesion 19:13, 19 April 2014 (UTC)
• "Almost all white patches are benign,..." is a generalization. The incidence of malignancy on first presentation varies with appearance and risk factors. I'd simply remove this.
  • It is a supported generalization... We discuss later in prognosis those features which indicate higher risk, but most are benign. Not sure there is any grounds to remove it... Lesion 19:13, 19 April 2014 (UTC)
• Petersen's paper (WHO) which states that leukoplakia can't be wiped off also says, "Leukoplakia is the most frequent form of oral precancer..." which highlights the confusion with between the clinical and histopath description.
  • I am not following you, sorry Ian. How does this constitute confusion between clinical and histopathologic features?
• Regarding ability to wipe away, this is a soft sign. Often, canadida can't be completely wiped away and frequenly other lesions will appear that they can. It's a really soft sign.
  • Agree. Failure to wipe away a white patch is not pathognomonic for anything, let alone leukoplakia. Failure to wipe away means it is not psuedomembraneous candidiasis and is therefore more likely (but not certain) to be leukoplakia. Agree some types of candida (e.g. hypertrophic candidiasis) cannot be wiped away. SCC cannot be wiped away. Linea alba cannot be wiped away. We can reword. Lesion 19:13, 19 April 2014 (UTC)
• Regarding adjunctive screening, there is a Cochrane review [3], "Furthermore, no robust evidence was identified to support the use of other adjunctive technologies like toluidine blue, brush biopsy or fluorescence imaging within a primary care environment."
  • Didn't see that review. Presumably because it didn't have leukoplakia in the title it did not show up when I searched. You mean to include qualifiers to info about adjunctive technologies having no evidence? Agree. Lesion 19:13, 19 April 2014 (UTC)
• Regarding screening in general - see the Cochrane review, screen should include asking about EtOH and smoking - they're the at risk populations where it has been shown to decrease mortality.
  • You mean to include info about screening into management section? Agree. Lesion 19:13, 19 April 2014 (UTC)
• Histologic appearance, I don't think this section should be in here as the article stands. We've listed at least a dozen causes of clinical leukoplakia and stated that histologically, it's normal mucosa if used as a diagnostic. Almost the entire description is about dysplasia. Personally, I'd rather see the article narrowed to the use of leukoplakia as used as a clinical description which is most often either hyperkeratosis or dysplasia (in which case this would stand).
  • Where have we stated that white patches are normal mucosa? White mucosa is never normal mucosa. Benign =/= normal. I do not feel there are any grounds to remove the histopathologic appearance section. Lesion 19:13, 19 April 2014 (UTC)
  • Suggestion to narrow (or rather broaden) scope of article to "clinical" leukoplakia has been addressed above. Problem is the sources like WHO and Cochrane on one hand with lack of sources which say leukoplakia = all white patches on the other hand. Perhaps as a compromise, the definition section could be expanded to make it more prominent info about how term leukoplakia is used clinicially. Lesion 19:13, 19 April 2014 (UTC)
• Re Treatment, 1st paragraph only stands if a diagnosis of dysplasia is made. Most other causes (lichen planus, benign hyperkeratosis, etc....) this doesn't apply.
  • Clinical/academic.... Lesion 19:13, 19 April 2014 (UTC)
• "xx had been studied" without giving results. I'd remove the "have been studied" and simply state the conclusions. I think you summed it up well though as most have been shown ineffective.
  • OK, will do. Lesion 19:13, 19 April 2014 (UTC)
• the article is specific to oral leukoplakia (almost all references). I think discussion of leukplakia in other sites should be removed or redirect to relavent pages.

Ian Furst (talk) 12:55, 19 April 2014 (UTC)

• • We have no pages like esophageal leukoplakia, etc. currently. I am not particularly in favor of created several stubs which will likely never grow due to lack of sources (oral medicine is only area where leukoplakia is still a commonly used term). Lesion 19:13, 19 April 2014 (UTC)

Try and respond to these points today. For now, the article lead makes clear that leukoplakia is not a clinical term in the same way that "ulceration" is a clinical term. Leukoplakia may be etymologically derived from "White patch" in Greek, but not all white patches are rightfully called Leukoplakia. This is supported by the WHO definition. The fact that the term is commonly misused by clinicians is discussed (section Definition). "Clinical leukoplakia" is a jumping to conclusions, just like clinicians who call a lesion hypertrophic or hyperplasitc just by looking at it. The naked eye is not a microscope. Such terms can only be confidently used after biopsy and histopathologic examination which rules out other causes. As such, it is more appropriate (according to WHO anyway) to clinically call white patches just that... white patches, until they have been properly diagnosed. Lesion 13:15, 19 April 2014 (UTC) These arguments unclear, will respond in full when I get a moment. Lesion 14:49, 19 April 2014 (UTC)

Are you suggesting that this article deals only with oral white patches without any clinical or pathologic cause? Ian Furst (talk) 14:29, 19 April 2014 (UTC)

Also, I don't think "clinical leukoplakia" is jumping to conclusions, if anything it's an oxymoron as leukoplakia is a clinical term only.Ian Furst (talk) 14:33, 19 April 2014 (UTC)

"Idiopathic"- refers to cause. You can have a keratotic lesion of no know cause. "Idiopathic" and "keratosis" are not contradictory in this regard.

"Clinical descriptive term" and "diagnosis of exclusion" are also not contradictory. Clinical descriptive term implies no specific histopathologic characteristics, diagnosis of exclusion implies that the term is only used after all other possibilities are ruled out. Try and answer rest this evening. Regards, Lesion 13:21, 19 April 2014 (UTC)

• • Comment-- support some more prominent content, in lead e.g. that leukoplakia is used by some clinicians to cover all white patches, but must be sourced. I would also point out that I did not perform a literature search and then reject any source which followed that meaning of the term. All the sources I have found seem to follow WHO... Lesion 19:13, 19 April 2014 (UTC)

Thanks for the responses Lesion. Nothing further to add here. Ian Furst (talk) 21:22, 19 April 2014 (UTC)

Update

Lesion has sadly resigned from Wikipedia ([4]). I am awaiting Ian Furst ([5]), who may take on the editing side of the review. I'll keep this review on hold for another week (or two if there's a definite editor being recruited for this article). --LT910001 (talk) 01:26, 3 May 2014 (UTC)

Update: Ian Furst plans to make major changes to the article. I will fail this review on the 'stability' grounds and renomination in the future. Lesion's contributions are excellent in quality in comprehensibility in my mind, and I hope he or she chooses to return here in the future. --LT910001 (talk) 03:26, 8 May 2014 (UTC)