Oral Leukoplakia (OL) – Treatment, Causes, Images, Tongue, Differential Diagnosis

Key Facts

• Oral leukoplakia refers to thickened, white patches that form on the mucous membranes of the mouth, which cannot be wiped away
• It’s among the most common oral lesions, affecting approximately 1% of the global population
• While often benign, some types of leukoplakia can be precursors to oral cancer
• Strongly associated with tobacco use, including smoking and chewing, but can also result from irritations like rough teeth or fillings
• Treatment depends on the lesion’s appearance, the presence of symptoms, and if there’s evidence of cancerous changes

What is Oral Leukoplakia?

Oral Leukoplakia, derived from the Greek words leuko (white) and plakia (patch), describes white patches that form on the oral mucosa – the mouth’s inner lining. Unlike some other conditions, these patches cannot simply be wiped off. They are generally painless but can be sensitive to touch, heat, spicy foods, or other irritants.

The condition manifests in various forms:

• Homogenous Leukoplakia: Uniform, thin white patches that are smooth or slightly wrinkled
• Non-homogenous Leukoplakia: Irregular or nodular patches that might be red and white mixed

While the precise cause of oral leukoplakia remains unknown, several factors increase the risk. The most significant is tobacco use, either smoked or chewed. Other causes include alcohol consumption, chronic oral irritation, and viral infections. Importantly, while many instances of oral leukoplakia are benign, they can indicate or develop into oral cancer. As such, any persistent oral lesion must be evaluated by a dental professional to determine its cause and appropriate treatment.

Types of Leukoplakia

1. Homogeneous Leukoplakia

Homogeneous leukoplakia is characterized by uniformly white patches of oral mucosa. The surface appears smooth, regular, or slightly wrinkled but is generally flat, thin, and not raised. These patches can cover a broad area and may possess a faintly opalescent quality. While this type of leukoplakia carries a lower risk of malignancy compared to its non-homogeneous counterpart, it’s essential to monitor it due to the potential risk of transformation.

2. Non-homogeneous Leukoplakia

Non-homogeneous leukoplakia presents as a white and red lesion (erythroleukoplakia) or exhibits a raised, irregular, or nodular surface, often likened to warts. These can be further divided into speckled (a mix of red and white areas), nodular, or verrucous leukoplakia. Due to its varied appearance, it possesses a higher risk of malignant transformation compared to homogeneous leukoplakia. Thus, close monitoring and frequent evaluations are necessary.

Subtypes of Leukoplakia

Leukoplakia comprises various types and subtypes, each with its own clinical features and risks.

1. Proliferative Verrucous Leukoplakia (PVL)

Proliferative verrucous leukoplakia is a rare but aggressive form of oral leukoplakia. Recognized by its clinical progression, PVL starts as a simple, white plaque but can evolve into a proliferative or verrucous exophytic mass. It’s notorious for its high recurrence rate after removal and a strong potential for malignant transformation. The condition predominantly affects females and non-smokers.

2. Oral Hairy Leukoplakia

Oral hairy leukoplakia is characterized by white, corrugated patches that typically appear on the sides of the tongue. This subtype is unique as it’s caused by the Epstein-Barr virus (EBV). Often seen in individuals with compromised immune systems, especially those with HIV/AIDS, it’s usually an indicator of the progression of the disease. Unlike other types of leukoplakia, oral hairy leukoplakia is not considered precancerous.

Does Leukoplakia Always Become Oral Cancer?

No, leukoplakia does not always become oral cancer. However, it’s important to note that leukoplakia is considered a precancerous lesion, which means it has the potential to develop into cancer. The exact risk varies, but certain types of leukoplakia, especially non-homogeneous and proliferative verrucous leukoplakia, carry a higher risk of malignant transformation than others. Nevertheless, a significant proportion of leukoplakia lesions remain benign and do not progress to cancer. It’s crucial to monitor any leukoplakia through regular examinations by a dental or medical professional to catch any potential changes early.

Is Leukoplakia Common?

Leukoplakia is relatively common, especially in older adults. The prevalence varies among populations, with estimates suggesting that about 1% to 5% of the global population may be affected. Factors such as tobacco use, alcohol consumption, and certain viral infections can increase the risk of developing leukoplakia.

What are the Symptoms?

Leukoplakia is characterized by the following symptoms:

• White or grayish patches: These patches may appear on the gums, inside of the cheeks, bottom of the mouth, or, most commonly, the tongue.
• Texture: The lesions can feel slightly raised and might have a rough texture. Over time, some patches may become thicker.
• Persistent lesions: Unlike some other oral issues, such as a bite injury, the patches caused by leukoplakia don’t easily heal or go away on their own over a week or two.
• Pain or discomfort: In some cases, the patches may become sensitive when eating spicy, hot, or acidic foods.
• Red areas: Erythroplakia is a less common but more severe form that involves red patches. These red lesions are more likely to show dysplasia or precancerous changes.

If any of these symptoms are observed, it’s essential to consult a dental professional. Early diagnosis and management can prevent potential complications and ensure good oral health.

What Causes Leukoplakia?

The exact cause of leukoplakia remains unknown. Several factors and irritants have been linked to its development:

• Tobacco use: Chronic smoking, whether from cigarettes, cigars, or pipes, is the most common cause of leukoplakia. Chewing tobacco can also contribute to its development.
• Alcohol: Excessive alcohol consumption, especially when combined with tobacco use, can increase the risk.
• Oral injuries: Chronic irritation from rough teeth, dentures, or fillings can sometimes cause leukoplakia.
• HPV (Human Papillomavirus): There’s a connection between HPV, especially the Epstein-Barr virus, and the development of oral hairy leukoplakia, a subtype of leukoplakia.

Risk Factors of Leukoplakia

Certain factors can increase the likelihood of developing leukoplakia:

• Age: Older adults are more commonly affected.
• Tobacco use: As mentioned, both smoking and chewing tobacco are significant risk factors.
• Alcohol: Those who consume alcohol excessively are at a higher risk.
• Weakened immune system: People with weakened immune systems, either due to medications or conditions like HIV, are more susceptible to oral hairy leukoplakia.
• Family history: There might be a genetic component, as having family members with leukoplakia can increase one’s risk.

How is Leukoplakia Diagnosed?

• Clinical Examination: Diagnosis typically begins with a thorough clinical examination of the oral cavity. A healthcare provider or dentist will inspect the white patches and assess their appearance, location, and size.
• Biopsy: To confirm a diagnosis and rule out cancer, a biopsy is often performed. A small sample of the lesion is removed and examined under a microscope to look for any cellular abnormalities.
• Imaging: In certain cases, especially when malignancy is suspected, imaging tests like X-rays or MRIs might be employed.
• Histopathological Examination: This involves looking at the tissue sample’s microscopic structure, which can provide clues about the type of leukoplakia and whether it shows signs of malignancy.

Prompt diagnosis is crucial. If leukoplakia is suspected, one should not wait to see if the patches disappear on their own but should consult a healthcare provider or dentist immediately.

Should All Suspected Leukoplakia be Biopsied?

While not all leukoplakia lesions are cancerous, it can be challenging to distinguish benign leukoplakia from precancerous or cancerous lesions just by looking at them.

• Biopsy as a Standard Procedure: A biopsy is often recommended for most suspected leukoplakia lesions to rule out oral cancer. This ensures that any malignancy is detected early, increasing the chances of successful treatment.
• Consideration of Lesion Appearance: Lesions that appear red (erythroplakia) or have a speckled red and white appearance (erythroleukoplakia) are more likely to show dysplasia or malignant transformation upon biopsy and thus should be prioritized.
• Monitoring: If a biopsy is not immediately conducted, the lesion should be closely monitored for any changes in appearance, size, or symptoms.

How is Leukoplakia Treated?

• Removal: The most straightforward treatment is the removal of the leukoplakic patch, either through surgical excision, laser therapy, or cryotherapy (freezing).
• Medication: Topical medications, including retinoids and certain antiviral drugs, can be applied directly to the lesion or taken orally to treat leukoplakia.
• Address Underlying Causes: If leukoplakia is caused by an irritant, such as rough teeth, an ill-fitting denture, or smoking, addressing the irritant can help in resolving the condition.
• Regular Monitoring: Even after treatment, regular follow-ups are essential to monitor for recurrence or potential malignant transformation.

How Can I Prevent Leukoplakia?

• Tobacco Cessation: The most effective prevention strategy is to quit smoking or using tobacco products, including smokeless tobacco.
• Limit Alcohol Consumption: Reducing alcohol intake, especially in conjunction with tobacco use, can lower the risk.
• Dental Hygiene: Regular dental check-ups can detect early signs of leukoplakia and other oral conditions. Maintaining good oral hygiene practices like brushing and flossing daily can also reduce risk.
• Avoid Irritants: Address any chronic irritants in the mouth, such as rough teeth or dental fixtures.
• Diet: Consuming a balanced diet rich in fruits and vegetables can bolster the immune system and possibly reduce the risk of leukoplakia and other oral conditions.
• Stay Informed: Being aware of the risks and early signs of leukoplakia can prompt early consultation and intervention.

By understanding the causes, risk factors, and treatments of leukoplakia, individuals can take proactive steps towards prevention and early detection, thereby ensuring better oral health outcomes.

Does Leukoplakia Come Back (Recur)?

• Recurrence Potential: Even after successful treatment and removal, leukoplakia can come back, especially if the underlying cause, such as tobacco use or alcohol consumption, is not addressed.
• Site of Recurrence: Leukoplakia may recur at the same site or appear at a different location in the mouth.
• Follow-up Care: Due to the potential for recurrence, individuals who have had leukoplakia should undergo regular check-ups to monitor for new or returning lesions.

Will Leukoplakia Go Away on Its Own?

• Natural Resolution: Some cases of leukoplakia may resolve on their own, especially if the irritant causing the condition is removed. For instance, leukoplakia caused by a rough tooth or dental fixture might disappear once the irritant is addressed.
• Potential for Progression: While some leukoplakia patches may remain benign, others can progress. Some lesions may develop dysplasia or even transform into oral cancer over time.
• Observation vs. Intervention: Due to the unpredictability of leukoplakia’s natural course, it’s essential to seek a professional evaluation even if the lesion seems to fade or diminish.
  

  When Should I See My Healthcare Provider?

  • Persistent Lesions: Any white patches or oral lesions that don’t heal or disappear within two weeks should be evaluated by a healthcare provider.
  • Change in Appearance or Sensation: If the leukoplakic patch changes in size, shape, or color, becomes painful, or if you experience a burning sensation, it’s crucial to seek medical attention.
  • Other Oral Symptoms: Experiencing symptoms like bleeding, difficulty swallowing, or an earache in conjunction with a white patch necessitates a visit to a healthcare provider.
  • Post-Treatment Monitoring: If you have been previously diagnosed with and treated for leukoplakia, regular follow-ups are crucial to monitor for recurrence or potential malignant transformation.

  What Questions Should I Ask My Healthcare Provider?

  • What makes you think this is leukoplakia?
  • Could it be any other oral condition?
  • What could have caused this lesion in my mouth?
  • Are there specific risk factors I should be aware of?
  • Is there a risk of this leukoplakia turning into oral cancer?
  • Should I undergo a biopsy to rule out malignancy?
  • What are the treatment options available for leukoplakia?
  • Are there any side effects or risks associated with the recommended treatments?
  • Are there lifestyle changes I can make to prevent leukoplakia from recurring?
  • How can I minimize the risk of it progressing or becoming malignant?
  • How often should I come in for check-ups?
  • What signs should prompt me to return for an earlier consultation?
  • Does leukoplakia have implications for my general health or indicate other underlying conditions?
  • Can my current medications or health conditions contribute to the development of leukoplakia?
  • Would it be beneficial to consult with a specialist or seek a second opinion?
  • Are there support groups or resources you recommend for individuals with leukoplakia?
  • Can you provide educational materials or references for further reading on the subject?

  Bottom Line

  Oral Leukoplakia refers to white patches that form inside the mouth, often on the inner cheeks, gums, or tongue. These patches are the result of chronic irritation in the oral cavity. Most cases are asymptomatic, but some might experience discomfort, pain, or a burning sensation, especially when consuming spicy or acidic foods. While oral leukoplakia is often benign, it requires attention due to its potential to turn malignant. A combination of clinical examination and biopsy is typically employed to diagnose and determine the potential for malignancy. Depending on the biopsy results, treatments range from monitoring to surgical removal. Even after treatment, leukoplakia can come back, especially if the underlying cause (like smoking) isn’t eliminated.

  This article is complete and was published on October 30, 2023, and last updated on January 31, 2024.