Non-homogeneous white patch of the floor of mouth
55-year-old male
§Chief complaint
White patch under the tongue noticed by the dentist
§Medical & dental history
- 0125 pack-year smoker; 20 units alcohol weekly
- 02No immunosuppression
- 03No sharp teeth or restorations at the site
§Clinical examination
- 01Non-homogeneous white patch 18 mm with speckled red areas in the anterior floor of mouth
- 02Cannot be rubbed off; surface slightly nodular
- 03No induration, no ulceration, adjacent tissues supple
- 04No cervical lymphadenopathy
§ figuresFigures (3)
Fig. 1Photo taken of patient, who will remain anonymous, treated at the University of Tennessee Health Science Center: College of Dentistry in Memphis, Tennessee. The lesion is an example of leukoplakia. Biopsy was going to be
“Leukoplakia02-04-06” · Photo uploaded by: dozenist. · CC BY-SA 3.0 · Wikimedia Commons
Fig. 2These images are part of the 2013 publication from the NIH "Detecting Oral Cancer: A Guide for Health Care Professionals". Available on the 15/7/14 at https://www.nidcr.nih.gov/oralhealth/topics/oralcancer/detectingoralc
“NIH DOC 17 Leukoplakia” · BodyParts3D/Anatomography · Public domain · Wikimedia Commons
Fig. 3Title Leukoplakia Description Gum damage caused by leukoplakia (with white patches shown). Leukoplakia are patches on the tongue, in the mouth, or on the inside of the cheek that occur in response to long-term irritation
“Leukoplakia” · Unknown photographer · Public domain · Wikimedia Commons
Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Leukoplakia figures pending faculty review.
§Differential diagnosis
§Final diagnosis
Non-homogeneous leukoplakia of the floor of mouth with moderate epithelial dysplasia
A white plaque that cannot be scraped off and has no other identifiable cause is leukoplakia by exclusion; biopsy grading of dysplasia and the high-risk floor-of-mouth site determine management intensity.
§Investigations
- 01Incisional biopsy from the most clinically suspicious (red, nodular) area
- 02Antifungal trial and removal of any irritant before biopsy where appropriate
- 03Photographic documentation and mapping for surveillance
§Radiology
- 01OPG — no bone involvement
- 02No cross-sectional imaging required for a mucosal lesion of this size
§Treatment plan
- 01Complete smoking and alcohol cessation with specialist support
- 02Surgical excision or laser ablation of the dysplastic area with margins
- 03Structured surveillance every 3-6 months for life
- 04Re-biopsy any change in appearance
§Surgical procedure
- 01Excision with a CO2 laser under local anaesthesia with 5 mm margins; specimen sent for histology
§Histopathology report
Hyperkeratotic squamous epithelium with drop-shaped rete ridges, basal cell hyperplasia, nuclear hyperchromatism, increased nuclear-to-cytoplasmic ratio and mitoses in the middle third. Moderate epithelial dysplasia. No invasion; margins clear.
§Follow-up & outcome
- 016 weeks — healed; patient smoke-free
- 023-monthly review in year 1, then 6-monthly
- 0324 months — no recurrence or new lesion
Outcome: Dysplastic lesion excised, habits stopped, remains disease-free under surveillance at 2 years.
§Discussion
- 01Overall malignant transformation of leukoplakia is around 1-3% per year, higher for non-homogeneous lesions, floor of mouth and lateral tongue sites, and severe dysplasia.
- 02Excision reduces but does not eliminate transformation risk, so lifelong surveillance is required.
- 03Proliferative verrucous leukoplakia is a distinct high-risk multifocal variant with transformation rates above 60%.
§Clinical pearls / learning points
- 01Biopsy the red or nodular component — that is where dysplasia is worst.
- 02Leukoplakia is a clinical diagnosis of exclusion, never a histological one.
§Viva questions
Which leukoplakias carry the highest risk?
Non-homogeneous/speckled lesions, floor of mouth and ventrolateral tongue sites, large lesions, non-smokers' idiopathic lesions, and those with severe dysplasia.
How is dysplasia graded?
Mild (lower third), moderate (middle third), severe (upper third) or carcinoma in situ, based on architectural and cytological changes.
§MCQs
Q1Leukoplakia is defined as:
Q2The highest-risk intraoral site for malignant transformation is:
§ evidenceReferences & Evidence
Current Classification
WHO Classification of Head and Neck Tumours
5th Edition — Volume 9
WHO Classification of Tumours Editorial Board · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
Evidence summary
Highest level of evidence linked to this page: WHO / Official Classification.
- L1 · Classification — 2
- L2 · Guideline — 1
- L3 · Systematic review — 1
- L6 · Textbook — 3
1 linked source was published from 2024 onwards. Where guidance is limited or contested, rely on the higher-level sources above rather than this summary. Educational use only — not a substitute for clinical judgement.
Content last reviewed
September 2026
Evidence last reviewed
September 2026
Next scheduled review
September 2027
Review status
EVIDENCE REVIEWED
Search latest PubMed evidence
Last literature search: 7 September 2026
Current Classification
WHO Classification of Tumours Editorial Board. IARC / World Health Organization · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
IARC / WHO. IARC · 2022
Continuously updated online edition of the WHO head and neck tumour classification.
Clinical Guidelines
Warnakulasuriya S, Kujan O, Aguirre-Urizar JM et al.. Oral diseases · 2021 · 27(8):1862-1880
WHO collaborating centre consensus on nomenclature and classification of oral potentially malignant disorders.
Systematic Reviews & Meta-Analyses
Walsh T, Liu JL, Brocklehurst P et al.. The Cochrane database of systematic reviews · 2013 · 2013(11):CD010173
Cochrane review of conventional oral examination and adjuncts for detecting oral cancer and potentially malignant disorders.
Histopathology References
Barnes L. CRC Press · 2008
Detailed histopathological reference for head and neck diagnostic criteria.
Textbook References
Neville BW, Damm DD, Allen CM et al.. Elsevier · 2024
Standard reference textbook of oral and maxillofacial pathology used throughout this atlas.
Rajendran R, Sivapathasundharam B. Elsevier · 2020
Undergraduate and postgraduate oral pathology textbook widely used in BDS and FCPS curricula.
Additional sources cited on this page
- Warnakulasuriya S et al. Oral potentially malignant disorders: WHO collaborating centre report. Oral Dis 2021.
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