Oral Frictional Hyperkeratosis Clinical Presentation
- Author: Jose Luis Tapia, DDS; Chief Editor: William D James, MD more...
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- Most patients with frictional keratosis are free of symptoms, with the exception of those with aggressive cheek and lip biting habits. In some individuals who repeatedly traumatize the tissues, tenderness, swelling, and a burning sensation may be presenting symptoms.
- Patients with persistent cheek and lip biting habits tend to have increased stress and psychologic disorders.
- A patient may notice a thickening or roughness of the involved mucosal site, or frictional keratosis may be discovered as an incidental finding during a routine oral examination.
- Individuals with a cheek and lip biting habit often report they are able to remove thin strands or tags of mucosa from the involved site.
- Patients may report that they are aware of sucking the mucosa or thrusting their tongue against their teeth. Some patients report that their cheeks and tongue feel swollen. Occasionally, the affected fungiform papillae in persons with a tongue biting or thrusting habit may be tender and sometimes associated with a burning sensation.
- When the gingival tissues are involved, patients may report using a medium- or hard-bristled toothbrush or other oral hygiene aids.
- In some instances, patients give a history of wearing orthodontic appliances or removable full or partial dental prostheses that may traumatize the soft tissues. Occasionally, ill-fitting or broken mouthguards or occlusal splints irritate the oral mucosa, resulting in frictional keratosis.
- In rare examples, individuals may give a history of picking the oral mucosa with long fingernails or some other external object.
The first step in the identification of white patches suspected of being associated with physical trauma is to use a 2 X 2-inch sterile gauze to wipe off the lesion or lesions. If the patch is not easily wiped off, this suggests the presence of hyperkeratinization.
- The lips, the lateral margins of the tongue, the buccal mucosa (mainly along the occlusal line), and the edentulous alveolar ridges are the most common sites to find frictional keratosis and its variants.
- Typically, the lesions appear as distinct, focal, and translucent-to-opaque white asymptomatic patches with sharply delineated borders. The surface of a lesion may appear irregular and feel rough to the tongue.
- Slight variations in the clinical presentation are directly related to the nature and the source of the physical trauma.
- One of the more common presentations of frictional keratosis is the linea alba (white line). This feature manifests as a horizontal thickening of the buccal mucosa along the occlusal line of the teeth. Linea alba is thought to result from chronic cheek biting or sucking of these tissues (see images below).The white line observed on the cheek is level with the biting plane of the teeth. The wear on the occlusal surfaces of the molar teeth suggests that the patient had a habit of bruxism. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.This wider area of roughened mucosa is typical of those produced by the habit of cheek biting or nibbling. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.See the list below:
- In one patient, the surface of the last molar tooth showed considerable occlusal wear, which is evidence that the patient had the habit of grinding his teeth (see first image above). This habit most probably led to the biting of the cheek mucosa.
- Occasionally, the line reflects the irregularity of the adjacent teeth and has a somewhat scalloped appearance (see image below).
- Occasionally, the frictional line is somewhat more diffuse, and this type of change is more likely to be associated with the habit of cheek chewing, also known as morsicatio buccarum (see images below), rather than the occasional accidental friction of teeth against the mucosa during the normal eating process. These white patches are associated with either a conscious or an unconscious chronic oral habit.This frictional keratotic line shows a roughened surface. A thicker patch of mucosa is at the anterior end (under the tongue blade edge). This area is exactly level with the occlusal plane and was being chewed constantly by the patient. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
- The effects of the habit of chronic biting may also manifest on the anterior and lateral borders of the tongue and appear as white, shaggy or mildly wrinkled plaques (see image below).
- A frictional keratosis lesion may be elevated from the surface, and patients may find that they develop the habit of nibbling further at these thickened mucosal sites. The first image below shows a frictional keratosis lesion that displays marked keratinization. The patient admitted to nibbling at the thickened mucosa (see second image below), which, in turn, made it thicker and easier to feel and, therefore, encouraged further nibbling.This frictional keratotic line shows a roughened surface. A thicker patch of mucosa is at the anterior end (under the tongue blade edge). This area is exactly level with the occlusal plane and was being chewed constantly by the patient. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
- Occasionally, patchy erythema with or without petechiae is observed with recent trauma to the site.
- Lesions associated with a tongue thrusting habit often demonstrate prominent crenations of the lateral tongue. In addition, the affected fungiform papillae may be red and enlarged from the chronic irritation.
In most patients with frictional keratosis, the cause is easily identified.
- An oral habit of cheek biting, cheek chewing, tongue thrusting, or mucosal sucking can often be identified as the cause if the site of the lesion is carefully examined in relationship to the occlusal plane.
- An ill-fitting, rough, or broken removable dental prosthesis or orthodontic appliance or a fractured or irregular tooth surface frequently affects the adjacent soft tissues.
- Occasionally, a frictional keratosis lesion may develop as a result of the constant rubbing of an external object, such as a tobacco pipe; a musical instrument; or, perhaps, a worker's tool, which, for convenience, is held in the mouth for long periods.
- Another cause may be manipulation of the tissues with long fingernails, which may shred the mucosa.
- Irritation from masticatory function may cause frictional keratosis when the alveolar mucosa and retromolar pad bear the stresses of eating. When lesions occur at these sites, they are referred to as alveolar ridge calluses.
- Pregnancy may significantly increase the risk for cheek biting.
- In rare cases, the overuse of topical anesthetics, overuse of antiseptic mouthrinses, or oromucosal delivery of medications (eg, cannabis) causes keratosis from chemical irritation.
- The identification of such habits depends on obtaining a thorough history.
Neville BW, Damm DD, Allen CM, Bouquot JE. Physical and Chemical Injuries. Oral and Maxillofacial Pathology. 3rd ed. St. Louis, Mo: WB Saunders; 2009. 285-329.
Cam K, Santoro A, Lee JB. Oral frictional hyperkeratosis (morsicatio buccarum): an entity to be considered in the differential diagnosis of white oral mucosal lesions. Skinmed. 2012 Mar-Apr. 10(2):114-5. [Medline].
Shulman JD, Beach MM, Rivera-Hidalgo F. The prevalence of oral mucosal lesions in U.S. adults: data from the Third National Health and Nutrition Examination Survey, 1988-1994. J Am Dent Assoc. 2004 Sep. 135(9):1279-86. [Medline].
Shulman JD. Prevalence of oral mucosal lesions in children and youths in the USA. Int J Paediatr Dent. 2005 Mar. 15(2):89-97. [Medline].
Bouquot JE, Gorlin RJ. Leukoplakia, lichen planus, and other oral keratoses in 23,616 white Americans over the age of 35 years. Oral Surg Oral Med Oral Pathol. 1986 Apr. 61(4):373-81. [Medline].
Kashani HG, Mackenzie IC, Kerber PE. Cytology of linea alba using a filter imprint technique. Clin Prev Dent. 1980. 2:21-4.
Axéll T. Occurrence of leukoplakia and some other oral white lesions among 20,333 adult Swedish people. Community Dent Oral Epidemiol. 1987 Feb. 15(1):46-51. [Medline].
Macigo FG, Mwaniki DL, Guthua SW. Prevalence of oral mucosal lesions in a Kenyan population with special reference to oral leukoplakia. East Afr Med J. 1995 Dec. 72(12):778-82. [Medline].
Kovac-Kovacic M, Skaleric U. The prevalence of oral mucosal lesions in a population in Ljubljana, Slovenia. J Oral Pathol Med. 2000 Aug. 29(7):331-5. [Medline].
Parlak AH, Koybasi S, Yavuz T, et al. Prevalence of oral lesions in 13- to 16-year-old students in Duzce, Turkey. Oral Dis. 2006 Nov. 12(6):553-8. [Medline].
Martinez Diaz-Canel AI, Garcia-Pola Vallejo MJ. Epidemiological study of oral mucosa pathology in patients of the Oviedo School of Stomatology. Med Oral. 2002 Jan-Feb. 7(1):4-9, 10-6.
Mathew AL, Pai KM, Sholapurkar AA, Vengal M. The prevalence of oral mucosal lesions in patients visiting a dental school in Southern India. Indian J Dent Res. 2008 Apr-Jun. 19(2):99-103. [Medline].
Farah CS, Simanovic B, Savage NW. Scope of practice, referral patterns and lesion occurrence of an oral medicine service in Australia. Oral Dis. 2008 May. 14(4):367-75. [Medline].
Castellanos JL, Díaz-Guzmán L. Lesions of the oral mucosa: an epidemiological study of 23785 Mexican patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Jan. 105(1):79-85. [Medline].
Dabrowa T, Dobrowolska A, Wieleba W. The role of friction in the mechanism of retaining the partial removable dentures with double crown system. Acta Bioeng Biomech. 2013. 15(4):43-8. [Medline].
Natarajan E, Woo SB. Benign alveolar ridge keratosis (oral lichen simplex chronicus): A distinct clinicopathologic entity. J Am Acad Dermatol. 2008 Jan. 58(1):151-7. [Medline].
Sarifakioglu E, Gunduz C, Gorpelioglu C. Oral mucosa manifestations in 100 pregnant versus non-pregnant patients: an epidemiological observational study. Eur J Dermatol. 2006 Nov-Dec. 16(6):674-6. [Medline].
Scully C. Cannabis; adverse effects from an oromucosal spray. Br Dent J. 2007 Sep 22. 203(6):E12; discussion 336-7. [Medline].
Flaitz CM. Differential diagnosis of oral mucosal lesions in children and adolescents. Adv Dermatol. 2000. 16:39-78; discussion 79. [Medline].
Coleman GC, Flaitz CM, Vincent SD. Differential diagnosis of oral soft tissue lesions. Tex Dent J. 2002 Jun. 119(6):484-8, 490-2, 494-503. [Medline].
Scully C, Felix DH. Oral Medicine--update for the dental practitioner: oral white patches. Br Dent J. 2005 Nov 12. 199(9):565-72. [Medline].
Miller RL, Gould AR, Bernstein ML. Cinnamon-induced stomatitis venenata, Clinical and characteristic histopathologic features. Oral Surg Oral Med Oral Pathol. 1992 Jun. 73(6):708-16. [Medline].
Messadi DV, Younai FS, Liu HH, Guo G, Wang CY. The clinical effectiveness of reflectance optical spectroscopy for the in vivo diagnosis of oral lesions. Int J Oral Sci. 2014 Sep. 6 (3):162-7. [Medline].
[Guideline] Rethman MP, Carpenter W, Cohen EE, et al. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc. 2010 May. 141(5):509-20. [Medline].
Flaitz CM, Felefli S. Complications of an unrecognized cheek biting habit following a dental visit. Pediatr Dent. 2000 Nov-Dec. 22(6):511-2. [Medline].
Jones KB, Jordan R. White lesions in the oral cavity: clinical presentation, diagnosis, and treatment. Semin Cutan Med Surg. 2015 Dec. 34 (4):161-70. [Medline].
Gabrić D, Vrdoljak DV, Boras VV. Extensive oral mucosal hyperkeratosis caused by over-the-counter long lasting snoring relief agent. Br J Oral Maxillofac Surg. 2015 Aug 1. [Medline].
Makino T, Mizawa M, Inoue S, Noguchi M, Shimizu T. The expression profile of filaggrin-2 in the normal and pathologic human oral mucosa. Arch Dermatol Res. 2016 Feb 8. [Medline].