White Patches

Numerous conditions manifest as white patches of the oral mucosa. They may either be transient (such as thrush or an aspirin burn) or persistent.

Leukoplakia

Definition: a white patch on the oral mucosa which cannot be removed by scraping and cannot be attributed to any other diagnosable disease.

The main concern is that it may be associated with dysplastic change or malignancy. Studies have shown dysplasia to range from about 10% in homogenous leukoplakias to about 50% in non-homogenous leukoplakias. Malignant transformation rates for dysplastic lesions have been shown to range from about 10 to 30%.

MANAGEMENT

Record size, site and appearance

Consider referral to a specialist especially if suspicious area or risk factors.

Leukoplakia on lateral border of the tongue

Lichen planus

INCIDENCE

Affects about 1-2% of the population

AETIOLOGY

Unknown

PRESENTATION

Symmetrical lacy pattern of fine white striae lines on the buccal mucosa. Lesions are usually bilateral and symmetrical

Different clinical types:

Reticular

• Atrophic
• Erosive
• Bullous
• Plaque-like
• Papular
• Desquamative gingivitis

Reticular lichen planus on the buccal mucosa

May have painful red or ulcerated areas superimposed on the striae, or the striae may radiate from these erosions.

Erosive lichen planus of the buccal mucosa

Plaques can be seen on the dorsum of the tongue.

Lichen planus can also affect the gingivae often presenting as desquamative gingivitis (smooth and shiny gingivae). This may be widespread or localised with white flecks within the red areas.

PIC DESQUAMATIVE GINGIVITIS

TREATMENT

Lesions that are asymptomatic require no treatment.

Symptomatic lesions are treated with Difflam, topical corticosteroids and in severe cases systemic ones.

Various oral mucosal lesions have a potential for malignant change (studies range from 0.5-2.5% over a 5 year period) and it is important to be able to recognise those lesions at particular risk. Practitioners will see many white oral mucosal lesions but few carcinomas. In general, the most common white lesions have the lowest risk of transformation.

RISK FACTORS FOR MALIGNANT CHANGE IN WHITE LESIONS

HISTORY

Age (>40 years) Tobacco smoking

• High alcohol consumption (especially spirits)
• Previous aerodigestive tract carcinoma (eg. larynx, lung)
• (Family history (cause of concern))

NB It is important to highlight any of these risk factors when making a referral.

CLINICAL FEATURES

•  Site : floor of mouth (sublingual keratosis), posterolateral border of tongue, lingual aspect of lower alveolus. Anterior pillar of fauces (these are all high risk sites)

•  Areas of erythema or speckling in the lesion

•  Enlargement or change in character of pre-existing lesion (e.g. bleeding, ulceration)

•  Idiopathic (no obvious aetiological factors)

If a white patch exhibits any of the above clinical features it should be urgently referred to the department for biopsy.

CLICK HERE FOR FAST TRACK REFERRAL PROCEDURE

Sublingual keratosis (up to 25% become malignant)

Erythroplakia (more than 75% show severe dysplasia or carcinoma)

Picture needed