Your patient is a 43-year-old African American male, Mr. Williams. He complains of a toothache in the area of tooth No. 19, and he frantically tells you that there is something very wrong with his inside cheek area because it is white and rough! Mr. Williams thinks that he has oral cancer, and this is causing the pain in his mouth as well. As you begin your examination, you are relieved by what you find; Mr. Williams has leukoedema. His primary problem will be the dental caries and the restorative work that will need to be completed during future appointments (see Figure 1).

Etiology: Leukoedema is commonly found in the general population. Its cause is not known, but it is considered benign.

Epidemiology: Leukoedema is seen more frequently in darker-skinned individuals, and reported cases are most often found in African Americans. Leukoedema also occurs in the lighter-skinned population, but may be less noticeable in lighter pigmentation with varying degrees of clinical appearance. Males and females are equally affected.

Method of transmission: Leukoedema is normal tissue, is not contagious, and cannot be contracted or given to another individual.

Pathogenesis: The white clinical appearance is caused by intracellular edema and a thickened epithelium. There may be an ethnic component causing the tissue to be more apparent in some individuals such as in African Americans.

Perioral and intraoral characteristics: Patients who exhibit leukoedema are usually unaware of its presence since it is asymptomatic. The tissue exhibits a milky bluish-white, opaque and/or an opalescent appearance. The surface tissue may exhibit a corrugated, folded configuration. Leukoedema is almost always bilateral and considered normal for that individual.

Distinguishing characteristics: The white, opaque appearance will usually diminish when the tissue is stretched (see Figure 2). When rubbed with a gauze, the white area will not be disrupted or subside. In differentiating leukoedema from candida, candida will usually rub off leaving a clear or raw denuded surface, depending upon the extent of the candida.

Significant microscopic characteristics: Leukoedema demonstrates an increased thickness of the epithelium, with intracellular edema of the spinous cell layer. The cell cytoplasm appears clear (vacuolated) with large pyknotic nuclei (a degenerative state of the nucleus).

Dental implications: Occasionally, the patient may notice the white appearance and become alarmed (or the patient may bite the cheek making the area more apparent). The tissue may exhibit a varied appearance if the patient has a combination of other problems such as candida or lichen planus along with the leukoedema.

Differential diagnosis: Several entities may be considered in cases that do not conform to the normal appearance of leukoedema:

• Lichen planus — Check for skin lesions and lichenoid type reactions from medications and dental materials (see this column from February 2007 issue).
• Candida — Use a gauze to try to remove the white film. When in doubt, send in a cytology smear to your oral pathologist.
• Leukoplakia — Is the area in question bilateral? If so, this may assist in ruling out a more serious lesion. Utilizing one of the oral cancer screening devices may be helpful (see this column from the December 2007 issue).
• Cheek biting — Is the area in question bilateral and does the tissue exhibit any ulceration? Questioning the patient about bruxism and cheek-biting (morsicatio buccarum) is useful, if this is suspected (see this column from April 2008 issue).
• White sponge nevus — Is there a family history? The white, opaque area will not disappear when stretched in the case of white sponge nevus or HBID (hereditary benign intraepithelial dyskeratosis).
• Oral cancer — Oral cancer should always be considered and ruled out with a biopsy when the clinician cannot determine a definitive diagnosis (see this column from the February 2008 issue).

Treatment and prognosis: Treatment for leukoedema is not a consideration since this is considered a variant of normal. When definitively diagnosed as leukoedema, there is no malignancy potential.

About the Author

Nancy Burkhart, RDH, EdD, is an adjunct associate professor in the Department of Periodontics at Baylor College of Dentistry and Texas A & M Health Science Center in Dallas. Nancy is also a cohost of the International Oral Lichen Planus Support Group through Baylor (www.bcd.tamhsc.edu/lichen). She is the coauthor of General and Oral Pathology for the Dental Hygienist, published by Lippincott Williams & Wilkins (2007). Nancy presents seminars on oral pathology subjects nationally. She can be contacted at nburkhart@bcd.tamhsc.edu.

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