What Is Leukoplakia?

Overview

Leukoplakia is a thick, white patch or plaque that develops in the oral cavity, involving either the inner surface of the cheeks, under the tongue, or even your lips. It is considered as the most frequent oral potentially malignant disorder, with a risk of malignant transformation ranging from 0.1% to 17.5%.¹ According to the World Health Organization, leukoplakia cannot be characterised clinically or pathologically as any other disease, so any causes of oral white patches such as trauma, lichen planus, and candidiasis must be excluded before a white patch is called leukoplakia.

Types of leukoplakia

There are 2 main types of leukoplakia.

Homogenous leukoplakia 

Which appears as a white, uniform, thin, flat, lesion with shallow cracks on the surface.

Non homogenous leukoplakia 

Which appears as an irregular or odd-shaped white or red patch, and there are several types including:

• Speckled leukoplakia:  a mixed white and red lesion with a predominantly white surface
• Nodular leukoplakia: small, rounded, and white protrusions
• Verrucous leukoplakia: an elevated, proliferative, or corrugated surface appearance

There is a subtype of verrucous leukoplakia called proliferative verrucous leukoplakia that has an aggressive evolution, multifocal appearance, greater resistance to treatment, higher chance of recurrence, and a higher rate of malignant transformation.²

• Oral hairy leukoplakia: a type of leukoplakia caused by Epstein-Barr virus and develops in weakened immune systems as in patients with HIV or organ transplant

Causes of leukoplakia

Although the origin of leukoplakia is multifactorial and the causes of the lesion are not completely clear, the following are the most common contributing risk factors.

Tobacco

In either smoked or smokeless form such as snuff usage. There is a high frequency of leukoplakia in populations with a high prevalence of tobacco habits.

Arecanut (betel) chewing 

It is widely practiced in many parts of Asia and is considered the fourth most commonly used psychoactive substance in the world, following caffeine, alcohol, and nicotine. Arecanut chewing habits are associated with multiple oral health implications including:

• Leukoplakia
• Periodontal disease
• Oral submucous fibrosis
• Squamous cell carcinoma

Therefore, it is considered one of the major risk factors for oral cancer.³

Alcohol consumption

Alcohol irritates oral tissues and increases the risk of leukoplakia.

Viral infection 

Human papillomavirus (HPV) infection may develop oral leukoplakia.⁴

Chronic irritation

Mechanical injury and irritation from broken, ill-fitting dentures, or sharp teeth can cause leukoplakia.

Signs and symptoms of leukoplakia

Most leukoplakias are asymptomatic however, white or gray patches that develop on the side of the tongue or inside of the cheeks are a sign of leukoplakia.⁵ These patches are characterized by the following features.

• Uneven shape
• Slightly raised
• Patches that can’t be scraped off
• Discomfort and pain if the patches come into contact with spicy or acidic food

Management and treatment for leukoplakia

Treatment and management of oral leukoplakia should begin with the removal of the risk factors causing irritation influencing patch development.

• Stop smoking and tobacco products (leukoplakia disappeared in 60% of the cases after tobacco use is stopped)⁶
• Stop alcohol consumption
• Removal of any dental causes such as rough denture surfaces, broken and rough teeth, and restorations

Routine follow-up of leukoplakia after the elimination of any risk-associated behaviors or habits is necessary. In cases of no improvement, surgical treatment is considered, and selection of the appropriate treatment option.

Surgical treatment of the patches includes:⁷

• Conventional surgical excision by the scalpel
• Electrocoagulation produces thermal damage in the cancerous tissues
• Cryosurgery using extremely low temperatures to produce damage to abnormal cells
• Laser therapy used in the management of oral leukoplakia

Follow-up is important to monitor the condition and avoid lesion recurrence after treatment.

Diagnosis of leukoplakia

Diagnosis of leukoplakia includes a medical history and clinical examination involving patches examination in the mouth, and trials to wipe off the patches. Biopsy of the lesion may be necessary to test for early signs of cancer, types of biopsies are:

• Oral brush biopsy: a non-invasive method, where cells are removed using a small, spinning brush
• Excisional biopsy: surgical removal of the patch 

Risks factors of leukoplakia

Risk factors increasing the chance of developing leukoplakia include:

• Tobacco use is the most common risk factor for leukoplakia (leukoplakia is six times more common among smokers than non-smokers)⁷
• Daily alcohol consumption⁸
• Chronic irritation especially due to dental prosthesis use⁸
• Immunocompromised patients have a higher risk of leukoplakia development⁹
• Viral infection with human papillomavirus (HPV)⁹

FAQs

How common is leukoplakia?

Oral leukoplakia affects 1% to 2% of the population worldwide and is more common after the fourth decade of life.⁷

Can leukoplakia be prevented?

Although there is no guaranteed way to prevent leukoplakia, there are some steps to help reduce the risk of developing leukoplakia:

• Quit smoking and tobacco use
• Quit drinking alcohol
• Repair rough dental appliances
• Practice good oral hygiene and regular dental check-up
• Better nutritional habits: eating food rich in antioxidants such as fruits and vegetables, to protect against tissue damage and reduce the risk of leukoplakia

When should I see a doctor?

If you notice any unusual changes in your mouth and the development of white or gray patches, see the dentist immediately for evaluation, proper diagnosis, and treatment.

Summary

Oral leukoplakia is the most frequent precancerous lesion of the oral cavity. Knowing the signs and symptoms of oral leukoplakia to help detect leukoplakia early, increases the chances of successful treatment. The main purpose of oral leukoplakia management is to avoid malignant transformation of the lesion. Prevention is the key to eliminating associated risk factors such as smoking and adopting a healthy lifestyle.