Leukoplakia

Also called White patch in the mouth, Erythroplakia

A white patch in the mouth that cannot be rubbed off or explained. A small proportion become cancer, and red patches are more dangerous than white.

What it is

A white patch on the lining of the mouth that cannot be scraped off and cannot be attributed to any other condition.

It is a diagnosis of exclusion: oral thrush rubs off, lichen planus has a lacy pattern, frictional keratosis from a sharp tooth resolves when the cause is removed. What is left is leukoplakia.

**It is a potentially malignant disorder**, meaning a proportion transform into mouth cancer over years, in the region of 1 to 3 per cent per year depending on features.

Certain features raise the risk considerably: a red component, called erythroleukoplakia; a purely red patch, erythroplakia, which carries a much higher risk than white and is the more sinister finding; a location on the floor of the mouth or the underside or side of the tongue; a speckled or nodular surface; and a large size.

**Erythroplakia is the one to act on fastest.** A persistent red velvety patch in the mouth has a high rate of dysplasia or cancer and needs urgent biopsy.

The main causes are smoking, smokeless tobacco including paan, betel quid and areca nut, and alcohol. Betel quid chewing is common in some South Asian communities in the UK and is a substantial and under-addressed risk.

Management is removing the cause, biopsy, and long-term monitoring.

Signs you might notice

A white patch inside the mouth that does not rub off.

Usually painless.

On the inside of the cheeks, gums, floor of the mouth, or tongue.

Higher risk features: any red component; a purely red velvety patch; a speckled or lumpy surface; hardening; ulceration; and location on the floor of the mouth or underside of the tongue.

**Urgent referral: any white or red patch in the mouth lasting more than three weeks**, and any red patch without delay.

Also urgent: an ulcer that has not healed in three weeks, a lump in the mouth or neck, unexplained loose teeth, numbness of the lip or tongue, or difficulty swallowing.

Dentists find most of these at routine check-ups, which is a strong argument for attending.

How it can affect day-to-day life

Regular dental attendance is the detection system, and the people at highest risk, smokers, heavy drinkers and people who chew tobacco or betel quid, are the least likely to attend. Removing barriers to dental care in those groups is genuinely preventive.

Betel quid and areca nut chewing is culturally embedded and often not asked about, and it is not always understood as a risk even by regular users, particularly when used without tobacco. Asking non-judgementally, in the right language, is what surfaces it.

Stopping smoking and tobacco chewing causes a proportion of patches to regress, and stopping alcohol helps; that is real motivation to offer.

Monitoring means regular review, usually with photographs, and re-biopsy if anything changes. People drop out of that once they are told it is not cancer.

Removing a patch surgically or with laser does not eliminate the risk; cancer can still develop nearby, so surveillance continues afterwards.

Self-examination of the mouth monthly, using a mirror and good light, is easy to teach and worth doing for anybody in a high-risk group.

Supporting someone well

Get any white or red patch lasting three weeks referred urgently. Do not wait.

Treat a red patch as more urgent than a white one.

Register with a dentist and attend regularly; this is how most are found.

Stop smoking, and stop chewing tobacco, betel quid and areca nut. Some patches regress.

Reduce alcohol.

Get sharp teeth and ill-fitting dentures dealt with, so friction is excluded as a cause.

Keep the monitoring appointments even after a benign biopsy.

Continue surveillance after any patch is removed.

Learn to examine the mouth monthly with a mirror and good light.

Where to get help

A dentist or GP practice for urgent referral to oral medicine or maxillofacial surgery.

Oral Health Foundation run a dental helpline and a mouth cancer awareness programme.

Macmillan Cancer Support on 0808 808 00 00.