Oral Frictional Hyperkeratosis Workup

  • Author: Catherine M Flaitz, DDS, MS; Chief Editor: William D James, MD   more...
 
Updated: Jan 31, 2012
 

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In some cases, the clinical presentation of oral frictional keratosis mimics potentially malignant oral lesions and oral cancer. New optical visualization devices have been developed as an adjunctive aid to a conventional clinical examination for differentiating between benign and malignant mucosal disorders. These optical devices include the use of autofluorescence, multispectral fluorescence and reflectance, diffused white light with acetic acid rinse, and chemiluminescence with acetic acid rinse.[21] At the present time, well-designed clinical trials are not available to confirm the value of these devices for improved specificity and sensitivity in a general patient population.[21]

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Procedures

The diagnosis of frictional hyperkeratinization is typically made based on a detailed clinical examination and the finding of an oral habit or some other agent that has produced the chronic, low-grade irritation of the mucosa. In patients in whom the clinical evidence for frictional keratosis is equivocal or the appearance of the lesion is atypical, a biopsy of the tissue is indicated.

Premalignant and malignant conditions of the oral cavity most often appear benign, and using the clinical history and examination findings alone does not ensure the precise histologic nature of any oral lesion. In most cases, removal of the chronic irritation reverses frictional keratosis in 1-3 weeks.

If any doubt exists concerning a particular lesion or if residual keratotic foci persist despite the removal of the causative factor, then a biopsy is indicated. Most often, this should be a conventional scalpel biopsy.

The use of exfoliative cytology for the collection of cells is not usually appropriate because the frictional keratosis lesion, by definition, shows increased keratin on the surface, which makes the harvesting of the intermediate layer and basal cells much more difficult.

A oral brush biopsy may be used; however, because the thick surface layer of keratin is a barrier, moderate pressure must be applied in order to ensure that an adequate sampling of basal cells is obtained

Important to note is that a definitive diagnosis cannot be obtained from an oral brush biopsy specimen. Only a scalpel biopsy can provide an accurate diagnosis of the white lesion in question.

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Histologic Findings

The oral mucosa is lined by stratified squamous epithelium that exhibits topographical differences correlated with specific physical demands or a higher degree of specialization. For example, the epithelium lining the floor of the mouth, the ventral side of the tongue, the buccal mucosa, and the soft palate is usually nonkeratinized; however, the gingiva and hard palate are keratinized.

Frictional keratosis shows hyperkeratinization (either hyperorthokeratinization or hyperparakeratinization) and acanthosis as the main microscopic features of the surface epithelium (see images below).

Low-power view of stratified squamous epithelium wLow-power view of stratified squamous epithelium with marked hyperkeratinization, acanthosis, and a prominent granular cell layer. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS. High-power view of the surface keratin layer and aHigh-power view of the surface keratin layer and a prominent granular cell layer. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.

The epithelial surface may be smooth, corrugated, or ragged, with multiple keratin projections. Bacterial colonies are frequently found attached to the surface when it is irregular or shaggy. Often, a prominent granular cell layer is present. Occasionally, vacuolated cells can be seen in the upper spinous cell layer, especially in patients with cheek-biting keratosis. The underlying dense, fibrous connective tissue may demonstrate a patchy chronic inflammatory infiltrate. The terms focal keratosis or focal hyperkeratosis are frequently used for the histopathologic diagnosis. Frictional keratosis is a clinical term that conveys the cause and effect of the condition.

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Contributor Information and Disclosures
Author

Catherine M Flaitz, DDS, MS  Professor of Oral and Maxillofacial Pathology and Pediatric Dentistry, Department of Diagnostic Sciences, University of Texas Health Sciences Center at Houston, Dental Branch

Catherine M Flaitz, DDS, MS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, American Academy of Pediatric Dentistry, American Dental Association, International Association for Dental Research, and International Association of Oral Pathologists

Disclosure: Trimira, LLC Clinical contract for study Co-investigator on clinical grant; Trimira, LLC Honoraria Speaking and teaching; GC America Clinical contract for study Co-investigator on clinical grant

Coauthor(s)

Alfredo Aguirre, DDS, MS  Director of Advanced Oral and Maxillofacial Pathology Training Program, Professor, Department of Oral Diagnostic Sciences, State University of New York at Buffalo

Alfredo Aguirre, DDS, MS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology

Disclosure: Nothing to disclose.

Jose Luis Tapia, DDS  Assistant Professor, Department of Oral Diagnostic Sciences, State University of New York at Buffalo

Jose Luis Tapia, DDS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Daniel J Hogan, MD  Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS  Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Alan Drinnan, MB, ChB, FDS, DDS, to the development and writing of this article.

References

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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.
Prominent linea alba with evidence of cheek biting. The white line shows a slightly scalloped appearance, which correlates with the buccal surfaces of the teeth against which the mucosa is rubbed. 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.
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.
Anterior rough surface area at the occlusal plane of the teeth. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
Oral frictional hyperkeratosis of the lateral border of the tongue from chronic biting habit. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
Oral frictional hyperkeratosis of the attached maxillary gingiva from inappropriate toothbrushing technique. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
Oral frictional hyperkeratosis of the retromolar pad is also referred to as a ridge callus. This lesion is caused by masticatory irritation. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
Low-power view of stratified squamous epithelium with marked hyperkeratinization, acanthosis, and a prominent granular cell layer. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
High-power view of the surface keratin layer and a prominent granular cell layer. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
 
 
 
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