White lesions in the mouth, appearing as patches, spots, or plaques, are common findings on the tongue, cheeks, or gums. These alterations are usually due to an abnormal thickening of the surface layer, caused by factors like infection, chronic irritation, or inflammation. The white appearance results from increased keratin production or fluid accumulation within the epithelial cells. While many lesions are benign, others can signal underlying systemic conditions or carry a risk of becoming cancerous. Professional evaluation is necessary to determine the cause.
Common Categories of White Lesions
White patches are grouped based on their underlying cause, which dictates their appearance and behavior. A simple clinical test is whether the white material can be wiped away with gauze. Lesions that scrape off are typically less concerning than those that are firmly fixed to the tissue.
Infectious
Oral Candidiasis, commonly called thrush, is an infection caused by the Candida albicans fungus. It typically presents as creamy, white, or yellowish plaques resembling curdled milk. A defining feature is that these plaques are easily scraped off, revealing an underlying red, sometimes bleeding, area of tissue. Risk factors include recent antibiotic use, which disrupts the normal balance of oral microbes, or a compromised immune status.
Reactive/Inflammatory
Reactive lesions respond to physical trauma or an immune system overreaction. Frictional keratosis results from chronic irritation, such as repeated cheek biting, rubbing against a rough tooth, or a poorly fitting denture. These lesions appear as discrete white plaques with a rough or corrugated surface and are generally non-wipeable. Lichen Planus, an immune-mediated condition, often displays a characteristic lacy, white pattern known as Wickham’s striae, most frequently on the inner cheek lining.
Potentially Malignant
Oral Leukoplakia is a clinical term describing a white plaque that cannot be classified as any other specific disease. It is considered a potentially malignant disorder, carrying a risk of transforming into oral cancer. These patches are firm, fixed, and can appear thin, flat, or as a thick, leathery, opaque plaque. Erythroleukoplakia is a particularly suspicious finding, as this mixed red and white patch indicates a higher likelihood of severe cellular changes.
Steps in Professional Diagnosis
A healthcare provider, often a dentist or oral medicine specialist, follows a systematic approach to identify the cause of a white lesion. The process begins with collecting the patient’s history, including habits like tobacco or alcohol use, and a visual inspection. The provider assesses the lesion’s location, size, texture, and whether the white surface can be wiped away, which helps narrow the possibilities.
Lesions that do not wipe off and persist after removing irritants require definitive investigation. A biopsy is the standard procedure for establishing a final diagnosis. This involves removing a small tissue sample for microscopic examination, which determines if the cells are benign, dysplastic (precancerous), or malignant (cancerous).
Two primary types of biopsy are used: an incisional biopsy removes a representative portion of a large lesion, while an excisional biopsy removes the entire small lesion. For suspected infectious lesions, such as candidiasis, a simple cotton swab or culture test identifies fungal organisms. The pathologist’s report correlates cellular findings with the clinical presentation for the most accurate diagnosis.
Targeted Treatment Approaches
Treatment for white lesions is tailored specifically to the confirmed diagnosis. For infectious lesions like candidiasis, treatment involves antifungal medications. These may be prescribed as a topical rinse or lozenge for localized infections, or as a systemic tablet for widespread cases.
Inflammatory conditions, such as Lichen Planus, are managed by reducing the immune response and alleviating symptoms. Topical corticosteroids, applied directly to the lesion, are the common treatment to suppress inflammation. For lesions caused by friction, like frictional keratosis, the first step is removing the source of irritation, such as adjusting a sharp tooth edge or repairing a dental appliance.
Management of potentially malignant lesions like leukoplakia depends on the microscopic findings from the biopsy. For lesions showing mild or no cellular dysplasia, a “watchful waiting” approach is adopted, combined with eliminating risk factors like tobacco and alcohol use. High-grade dysplasia or confirmed oral cancer necessitates definitive treatment, typically involving surgical excision to remove the affected tissue. Addressing underlying risk factors reduces the chance of recurrence.
When to Seek Urgent Evaluation
Certain characteristics of an oral white lesion should prompt an immediate visit to a healthcare professional. Any white patch that has persisted for two weeks or longer without improvement warrants evaluation, as this suggests the lesion is not a simple inflammatory reaction. Urgent care is also necessary if the lesion is accompanied by new symptoms, such as pain, a burning sensation, or difficulty swallowing or speaking. Concerning physical changes include a rapid increase in size, the development of a warty or rough texture, or bleeding. The presence of a red component mixed with the white (erythroleukoplakia) carries a higher suspicion and requires immediate investigation.