This month Hannah Hook explores white patches in the mouth and explains the reasons behind these and the treatment required.
During regular dental reviews you are bound to see a variety of white patches in the mouth.
These white patches are likely to have numerous differential diagnoses. Some of which may be managed by the general dental practitioner, or some may require referral on to secondary care for further investigation.
Therefore, it is beneficial to know some of the differential diagnoses of white patches, their presentation and treatment options.
Leukoedema (Mortazavi et al, 2019)
- What? Common variation of oral mucosa. Diffuse grey-white milky patch on the oral mucosa that cannot be wiped away. Can present with wrinkled mucosal folds. The white wrinkled appearance disappears on stretching the mucosa, and then re-appears when stretching is stopped (Mortazavi et al, 2019)
- Where? Most commonly the buccal mucosa is affected, can also affect the lateral aspect of the tongue
- Who? More predominant in people of Asian or African descent (Felix, Luker and Scully, 2017). Can also occur in smokers
- Symptoms? Asymptomatic
- Diagnosis? Clinical
- Treatment? No treatment is required.
White Sponge Nevus
- What? Inherited dyskeratoses. Causes dyskeratotic hyperplasia of mucous membranes. Symmetrical thickened, white, corrugated, diffuse, spongey plaques of variable sizes with an elevated irregular fissured surface (Mortazavi et al, 2019)
- Where? Most commonly the buccal mucosa is affected bilaterally. Other intraoral areas may also be affected but this will vary
- Who? Rare condition, autosomal dominant. Usually presents in childhood (Felix, Luker and Scully, 2017). Affects approximately 1:20,000 (Mortazavi et al, 2019)
- Symptoms? Mostly asymptomatic. Dysphagia may occur if the oesophagus is involved
- Diagnosis? Biopsy
- Treatment? Referral to secondary care is indicated due to risk of malignant transformation (Felix, Luker and Scully, 2017).
Thermal or chemical trauma
- What? Thermal trauma caused by hot foods or drinks, usually resulting in a small white-yellow ulcer, which sloughs off. Chemical trauma caused by agents such as aspirin, likely to result in more severe necrosis of tissues compared to thermal burns (Mortazavi et al, 2019)
- Where? Palate and anterior tongue are the most affected areas for thermal burns. For chemical aspirin burns buccal mucosa is commonly affected
- Symptoms? Sore, ulcerated lesion(s)
- Diagnosis? Clinical
- Treatment? Pain relief, antiseptic mouthwash, topical anaesthetic. Antibiotics may be required if lesions become infected (Mortazavi et al, 2019).
Pseudomembranous Candidiasis
- What? Fungal infection of the oral cavity. Most commonly by Candida albicans. Creamy white plaques, which can be wiped away to reveal an erythematous underlying area (Akpan and Morgan, 2002)
- Where? Hard and soft palate, tongue, labial and buccal mucosa, gingiva and oropharynx
- Who? Denture wearers, those at extremities of age, are on broad spectrum antibiotics or use steroid inhalers, or immunocompromised (diabetics, HIV/AIDS, leukaemia) (Akpan and Morgan, 2002)
- Symptoms? Burning sensation and bad taste
- Diagnosis? Clinically or via microbiology swab
- Treatment? Management of predisposing factors. Good oral and denture hygiene. Topical or systemic antifungals.
Lichen Planus
- What? Inflammatory autoimmune condition of the skin and mucous membranes. Reticular lacy striated white patches. One per cent risk of malignant change over 10 years
- Where? Most commonly posterior buccal mucosa. May also occur on the tongue, gingiva, and other sites of the oral mucosa. Desquamative gingivitis if gingiva is involved, this has a red shiny appearance
- Who? Female>male. Onset usually around middle age
- Symptoms? Burning sensation, stinging or discomfort on eating citrus fruits, spicy foods and alcohol
- Diagnosis? Biopsy. Sometimes clinicians may request blood tests
- Treatment? Topical steroids, benzydamine mouthwash, SLS free toothpaste, avoiding spicy and acidic foods/drinks (Felix, Luker and Scully, 2017). Referral to secondary care if lichen planus has not already been diagnosed via biopsy.
Lichenoid reaction
- What? Delayed hypersensitivity reaction to certain dental materials such as nickel alloy constituents of amalgam (Mortazavi et al, 2019; Shah et al, 2013)
- Where? White patch is localised to an area of mucosa in contact with dental materials – eg amalgam
- Symptoms? Usually asymptomatic. If the lesion develops into an ulcer some discomfort to spicy and hot foods may be experienced
- Diagnosis? Clinical
- Treatment? Replacement of filling or fixed restoration with an alternative material.
Frictional keratosis
- What? White patch due to hyperplastic hyperkeratosis of the epithelium. Caused by rubbing of oral mucosa against a surface such as teeth, or cheek chewing
- Where? Usually buccal mucosa. Can also occur on the lip and tongue (Müller, 2019)
- Symptoms? Asymptomatic
- Diagnosis? Clinical
- Treatment? No treatment required. Lesions resolve by stopping the cause of friction.
Oral hairy leucoplakia
- What? Benign white verrucous lesion of the mucosa. The appearance may vary from smooth flat lesions to irregular hairy lesions. Clinicians cannot wipe off lesions and they are adherent to the mucosa
- Where? Most commonly on the lateral borders of the tongue, either unilaterally or bilaterally. May also involve the buccal mucosa and gingiva
- Who? Immunosuppressed patients infected with Epstein-Barr virus. Commonly in people with HIV
- Symptoms? Asymptomatic
- Diagnosis? Clinical
- Treatment? May resolve spontaneously. Systemic management with antivirals.
Smokers keratosis
- What? Diffuse white patch of thickened mucosa on the hard palate caused by heat and chemical irritants. The white patch contains small red papules with a white/grey base due to inflammation of the area
- Where? Palate
- Who? Smokers, usually those who smoke pipes, cigars, or reverse smoke
- Symptoms? Asymptomatic
- Diagnosis? Clinical
- Treatment? Stopping smoking.
Oral leukoplakia
- What? Potentially malignant condition. A white patch that cannot be considered as any other definable lesion. Precancerous lesions such as a white patches in the mouth may precede oral cancers (Liu et al, 2012)
- Where? Can occur on any soft tissue surface in the mouth
- Who? People with risk factors for oral cancer such as smoking, high alcohol intake, chronic irritation, age, bacterial and fungal infections
- Symptoms? Asymptomatic
- Diagnosis? Biopsy
- Treatment? Elimination of contributing factors. If biopsy reveals moderate-severe dysplasia then surgical excision or laser ablation.
Key points
- There are a range of differential diagnoses for white patches in the mouth
- Some white patches are benign and will respond to local measures
- Some white patches have a risk of malignant transformation and may require a biopsy
- If unsure of the diagnosis for any white patch in the mouth refer to the hospital for a second opinion.
References
Akpan A and Morgan R (2002) Oral candidiasis. Postgraduate Medical Journal 78: 455-9
Felix D, Luker J and Scully C (2017) Oral Medicine: 6. White Lesions. Dent Update
Liu W, Shi LJ, Wu L, Feng JQ, Yang X, Li J, Zhou ZT and Zhang CP (2012) Oral Cancer Development in Patients with Leukoplakia – Clinicopathological Factors Affecting Outcome. PLoS One 7(4) Epub ahead of print 13 April 2012.
Mortazavi H, Safi Y, Baharvand M, Oral white lesions: An updated clinical diagnostic decision tree. Dentistry Journal 7: Epub ahead of print 1 March 2019
Müller S (2019) Frictional Keratosis, Contact Keratosis and Smokeless Tobacco Keratosis: Features of Reactive White Lesions of the Oral Mucosa. Head Neck Pathol 13: 16
Shah KM, Agrawal MR, Chougule SA and Mistry JD (2013) Oral lichenoid reaction due to nickel alloy contact hypersensitivity. Case Reports
