Oral Leukoplakia

What is oral leukoplakia? Oral leukoplakia (leuko=white, plakia=patch) is a white patch in the mouth that cannot be scraped off and cannot be diagnosed specifically as something else. It appears white usually because of three main factors alone or in combination: hyperkeratosis or excessive production of keratin (the white flakes that come off when you scratch your skin), thickening of the surface layer of cells, or the presence of pre-cancer (dysplasia) or cancer. Lichen planus, yeast infections (thrush) and chronic cheek and tongue chewing injuries are some of the specific conditions that appear white in the mouth and are therefore not oral leukoplakia. When all such known conditions have been ruled out, a patient is diagnosed with oral leukoplakia. Oral leukoplakia occurs in 1-2% of the population and is most common in patients over age 40. The more common kind of oral leukoplakia is limited to one location in the mouth and is more common in men. It may affect any part of the mouth, but is usually on the tongue, gums and inner cheeks. Research has shown that oral leukoplakias on the underside of the tongue, floor of mouth and soft palate are more likely to become precancerous/dysplastic. Some oral leukoplakias are not just white but may appear red, rough and warty or bumpy. These too, have a higher chance of being precancerous/dysplastic. The much rarer condition, proliferative verrucous leukoplakia is larger and involves different parts of the mouth; it is more common in women. It is present for years, gradually spreads over the mucosa and reappears even after attempts at removal. Multiple biopsies over the years often show only hyperkeratosis without precancer/dysplasia. All oral leukoplakia must be biopsied because 20-40% of cases are precancerous/dysplastic or cancerous at the time they are biopsied; 8-15% of all oral leukoplakias when followed over time become cancer even if the initial biopsy does not show changes of pre-cancer/dysplasia. Furthermore, some cases of oral cancer begin in the early stages as oral leukoplakia. Proliferative verrucous leukoplakia has a 60-100% rate of turning into cancer over time. On the other hand, 60-80% of oral leukoplakias do not show precancerous changes/dysplasia and it is not clear what these represent. Some, but not all, of these are likely to be caused by inflammation and irritation (similar to a callous). What causes oral leukoplakia? The exact cause of oral leukoplakia is still unknown, although certain risk factors have been identified. More than 80% of patients with oral leukoplakia have a history of tobacco use and the condition is six times more common among smokers than non-smokers. Other risk factors include excessive alcohol use (especially in people who also smoke), a weakened immune system, long-term treatment with immune suppressing medications, a history of cancer, a family history of cancer, and in some cultures, the chewing of areca nut and betel leaf.

Division of Oral Medicine and Dentistry, Brigham and Womens Hospital, 75 Francis Street, Boston, MA 02115, (617) 732-6570

How do we know it is oral leukoplakia? If your doctor suspects that a white lesion in your mouth is due to irritation, the source of the irritation will be removed and you will be asked to return in a few weeks for another evaluation. If the white area is unlikely to be caused by irritation or is still present at re-evaluation, a biopsy will be performed. The biopsy result will tell us whether you have a specific condition (such as thrush or a callous caused by friction), pre-cancer/dysplasia or a hyperkeratosis of unknown cause. Leukoplakias that have red, warty or firm areas or ulcers will require biopsies from each of these different areas. How do we treat oral leukoplakia? Depending on the results of the biopsy, as well as the size, appearance and location of the oral leukoplakia, complete removal of the lesion may be recommended, either by surgery or laser removal. If precancer/dysplasia is present, complete removal of the lesion is strongly recommended given that the lifetime risk of developing cancer is as high as 15%. At a minimum, oral leukoplakias should be monitored and rebiopsied periodically for changes. Every patient is different and your doctor will discuss treatment options that are tailored to your particular needs and circumstances. Complete removal is suggested for small leukoplakias (1-2 inches) regardless of the biopsy results, especially if the lesion is located on a high-risk site, such as the under-side of the tongue, floor of the mouth, or the soft palate, where the chance of it turning into cancer is higher than at other sites. For lesions that are large, at several locations, or cannot be completely removed such as proliferative verrucous leukoplakia, careful followup with periodic re-biopsies is a reasonable option. What can I expect? Even after complete removal, oral leukoplakia may recur, so it is important to follow-up for re-evaluation at least once a year. You should return to your doctor for examination as soon as possible if you suspect that your leukoplakia has recurred. If your oral leukoplakia was not removed and it is just being observed periodically, you should also perform a self examination once a month or ask your dentist to do this for you at routine dental visits. If you notice a change in the appearance of the leukoplakia such as development of red, rough or warty areas, a lump or an ulcer, you should also return for another evaluation and possible re-biopsy. It is difficult to predict which leukoplakias will develop into cancer. If it occurs at all, malignant transformation may take place anytime from shortly after the biopsy to more than 10 years after. Those that contain precancer cells/dysplasia are at higher risk for developing into cancer while those that only show hyperkeratosis are at lower risk. As such, it is very important that you see your dentist or a specialist for regular examinations to monitor changes in your mouth.

Division of Oral Medicine and Dentistry, Brigham and Womens Hospital, 75 Francis Street, Boston, MA 02115, (617) 732-6570