What Is Leukoplakia?

Leukoplakia is a condition involving thickened white patches on the mucous membranes (lining) of the mouth, gums, and/or tongue that cannot be wiped away. While most cases never become cancerous, others do—even if they have no signs of cancerous changes when diagnosed.

Leukoplakia is most often caused by smoking or chewing tobacco, though there are other causes. If leukoplakia is mild, it often goes away without any intervention. But leukoplakia must be monitored for indications of oral cancer, which requires treatment.

Leukoplakia that is consistent in its appearance (homogenous type) is associated with a higher risk of oral cancer compared with types that are not (non-homogenous type).

Leukoplakia Symptoms and Types

Symptoms and signs of leukoplakia, which may not be noticed in initial stages, may include:

• Grayish colored patches that cannot be wiped off
• Irregular-textured or flat-textured patches in the mouth
• Areas in the mouth that are hardened or thickened
• Raised red lesions (erythroplakia)
• Red patches along with white patches (erythroleukoplakia)
• Pain when the lesions come in contact with acidic or spicy food

These can vary depending on the type.

Leukoplakia is often mistaken for thrush, a yeast infection of the mouth and gums. A notable difference? Thrush causes creamy white patches that can be wiped away. Those associated with leukoplakia cannot.

Homogenous Leukoplakia

Homogenous leukoplakia is characterized by white plaques that are uniform in appearance and have well-defined borders. They are normally found on the gums, inside the cheeks, under the tongue, or on the tongue itself.

Non-Homogenous Leukoplakia

Non-homogenous types of leukoplakia, such as the rare speckled type, cause both white and red areas in the mouth. These areas may also be bumpy or irregular in shape.

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Proliferative verrucous leukoplakia (PVL) is a rare and aggressive type of non-homogenous leuloplakia. It usually begins as thick white patches on the inside of the cheeks and tongue. As it spreads, the patches start to look like warts or cauliflower.

Oral Hairy Leukoplakia

Oral hairy leukoplakia is a different kind of leukoplakia that causes fuzzy white patches that look like folds or ridges. They often appear on the sides of the tongue.

Oral hairy leukoplakia occurs in 1% to 2% of the population and is most common in people over 40. It may affect any part of the mouth. 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, Oral hairy leukoplakia is an outlier, as it is not considered a precancerous condition.

This condition is common in people with a severely compromised immune system, such as those with Epstein-Barr virus (EBV), and may be one of the very first signs of HIV.

Leukoplakia and Oral Cancer Risk

A 2019 study published in Journal of the National Cancer Institute found there was a 40.8-fold increased risk of oral cancer in those with oral leukoplakia. The researchers also found that approximately one in 30 individuals with oral leukoplakia will develop oral cancer over a five-year period.

Still, most of the time, the white patches from leukoplakia are not considered cancerous. When they are an early sign of mouth cancer, they are usually due to non-homogenous types of the condition.

PVL, in particular, is associated with a high risk of oral cancer.

Oral hairy leukoplakia is not associated with a risk for cancer.

When to Visit a Healthcare Provider

Due to the risk of mouth cancer associated with leukoplakia, anyone with unusual or ongoing changes in the mouth of any type should have them evaluated by a healthcare provider.

In particular, be sure to see a healthcare provider if you notice:

• White patches in the mouth do not clear up on their own in two weeks
• Red or dark patches are noticed in the mouth
  
• Ear pain when swallowing
• An inability to open the mouth properly (that progressively worsens)

Although leukoplakia doesn’t normally cause any type of pain, you should still be evaluated. If it is leukoplakia and an early sign of oral cancer, early treatment is key. If it's not, the mouth patches could be a sign of something more serious.

Causes

Long-term use of tobacco (smoking or chewing) or other irritants are the most common cause of leukoplakia. Other causes may include:

• Dentures that do not fit correctly (or broken dentures)
• An injury that occurs on the inside of the cheek (such as from accidentally biting the cheek)
• Broken or uneven teeth
• Long-term alcohol use
• Specific types of conditions that cause inflammation

Diagnosis

A diagnosis of leukoplakia usually involves:

• An oral examination by the healthcare provider
• An attempt to try to wipe away the white patches (if they can be wiped off, leukoplakia is not likely)
• A thorough medical history to uncover certain risk factors, such as smoking or chewing tobacco use
• Ruling out other possible causes of white patches (such as thrush)
• Testing for early signs of cancer

A biopsy involves tissue removal from the body to examine it for a disease such as cancer. Cancer testing for those with leukoplakia may include:

• Oral brush biopsy: This is the removal of cells (to be tested for cancer) from the outer surface of the lesions using a small brush that spins.
• Excisional biopsy: This is the surgical removal of tissue from the patch of leukoplakia (or in some instances the entire plaque) to test for cancer cells. The excisional biopsy is a more decisive method of testing for oral cancer than the oral brush biopsy.

If an excisional biopsy is positive, the healthcare provider may make a referral to an oral surgeon or an ear-nose-throat specialist (otolaryngolosist) for oral cancer treatment.

If the leukoplakia patch was very small and completely removed by the excisional biopsy, no further treatment may be needed other than ongoing observation.

Leukoplakia Treatment

Usually, removing the source of the irritation—smoking, chewing tobacco, excessive alcohol use, or dental causes—is enough to cure leuoplakia.

If the leukoplakia is caused by a dental problem, a referral will be made to a dentist for correction of the ill-fitting dentures, jagged tooth, or other underlying cause.

However, if there is a positive biopsy result, further treatment is necessary. Treatment of leukoplakia is most effective after early diagnosis.

This may include:

• Immediate removal of all leukoplakia to stop the spread of the cancer: This may be done with a laser, scalpel, or a cold-freeze method with a probe (called a cryoprobe).
• Use of a prescription anti-viral medication if the diagnosis is hairy leukoplakia

Keep in mind that even after leukoplakia patches are removed, there is still an increased risk of oral cancer.

In any case, you will need regular follow-up visits to check for recurring symptoms of leukoplakia (which are common).

You will also need to learn to thoroughly and regularly perform self-inspections of the mouth.

Summary

Leukoplakia is a condition involving white patches that form inside the mouth. These patches can appear uniform in color (homogenous), or they can look like red and white areas that are bumpy and irregularly shaped (non-homogenous).

Common causes include smoking, chewing tobacco, drinking, or exposure to other irritants (such as e-cigarettes).

Leukoplakia is often a warning sign, signaling that a person should make some healthy lifestyle adjustments. In some cases, leukoplakia can develop into oral cancer.