Oral Frictional Hyperkeratosis

4/5/2017 Oral Frictional Hyperkeratosis
Oral Frictional Hyperkeratosis
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Oral Frictional Hyperkeratosis
Author: Jose Luis Tapia, DDS
Chief Editor: William D James, MD
Overview
Clinical Presentation
Differential Diagnoses
Workup
Treatment & Management
Followup
Overview
Background
Pathophysiology
Epidemiology
Clinical Presentation
History
Physical
Causes
Workup
Other Tests
Procedures
Histologic Findings
Treatment & Management
Medical Care
Consultations
Diet
Followup
Further Outpatient Care
Deterrence/Prevention
Complications
Prognosis
Background
The oral mucosa is lined by stratified squamous epithelium and has topographic differences that correlate
with 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 nonkeratinized;
however, the epithelium associated with the gingiva and hard palate is usually keratinized. The dorsal
surface of the tongue is also keratinized, but it is referred to as specialized mucosa because of the
presence of papillae. The dorsum of the tongue, the hard palate, and the gingival tissues are keratinized to
better respond to masticatory demands.
http://misc.medscape.com/pi/android/medscapeapp/html/A1076089business.html 1/15
Hyperkeratinization (excessive formation of tenaciously attached keratin) may be present in a variety of
clinical conditions, including genetic, physiologic, inflammatory, immunologic, premalignant, and
malignant conditions. The change may result from a local insult, including chemical, thermal, or physical
irritants. This article focuses on the oral hyperkeratinization that results from friction. Friction (the
constant rubbing of 2 surfaces against one another) in the oral cavity may result in the development of
clinically observable white patches.
Various names have been used to describe particular examples of frictional keratosis (FK). These include
frictional keratosis arising from excessive force while brushing the teeth (toothbrush keratosis); the
constant rubbing of the tongue against the teeth (tongue thrust keratosis); the constant sucking, pressure,
and irritation of the teeth against the buccal mucosa along the plane of occlusion (linea alba); and the
habit of chronic cheek, tongue, or lip biting (cheek or lipbite keratosis).[1] Injuries to the oral mucosa,
using items such as a pen, toothpicks, or fingernails, may result in frictional keratosis.
References
Pathophysiology
The white patches of frictional keratosis that develop in the oral cavity represent a chronic, lowgrade,
mechanical process that is analogous to the formation of a callus on the skin. The most common local
factors involved in this process are tissue chewing (mainly on the buccal mucosa or lips), illfitting or
irregularly surfaced removable dental prostheses (dentures), fractured or malposed teeth, poorly adapted
dental restorations, orthodontic appliances, improper toothbrushing, and constant mastication on
edentulous alveolar ridges. The constant irritation stimulates the production of excessive keratin, with a
subsequent change in the thickness and the color of the involved mucosa.[2]
References
Epidemiology
Frequency
United States
Few large epidemiologic studies documenting the prevalence of various oral lesions, including oral
frictional keratosis, have been published.
The most comprehensive survey on the prevalence of oral mucosal lesions is the Third National
Health and Nutrition Examination Survey (NHANES III). Oral examinations were performed on
17,235 noninstitutionalized civilian adults. Cheek and lip biting had a point prevalence of 3.05%
and ranked third in oral lesion prevalence, while frictional keratosis had a point prevalence of
2.67% and ranked fourth.[3] In the same national survey, when 10,030 children aged 217 years
were evaluated, the point prevalence for cheek and lip biting was 1.89% and 0.26% for frictional
keratosis.[4]
In another extensive survey of 23,616 white American adults from Minnesota that evaluated a wide
range of oral lesions, the number of cases of cheekbiting keratosis was 1.2 cases per 1000
individuals.[5] In this same study, frictional keratosis was not differentiated from leukoplakic
lesions, so the prevalence of frictional keratosis alone cannot be determined.
Linea alba is a common mucosal variation that is rarely singled out as a specific entity in
prevalence studies. In a limited study of young men, 13% had this mucosal alteration.[6]
International
In a Danish study of 20,333 people aged 15 years and older, the prevalences of cheek and lip biting and
frictional keratosis were slightly higher than those reported in the US studies.[7] The prevalence for cheek
and lip biting was 5.1%, and the prevalence for frictional keratosis was 5.5%. Similarly, the prevalence
for frictional keratosis from a small study sample[8] of Kenyan adults was 5.5%. In Slovenia, the
prevalence was 2.7% for cheek and lip biting and 2.2% for frictional keratosis.[9] In a study of Turkish
adolescents, linea alba was the second most common lesion, with a prevalence of 5.3%.[10]
When studies were limited to individuals seeking care in oral medicine clinics, a wider frequency of
occurrence was noted. In a limited study of patients treated at a dental school in Spain, the rate was
11.5% for frictional keratosis, 10.7% for linea alba, and 6.8% for cheek biting.[11] In an India dental
school study, frictional keratosis was the most common oral lesion detected, occurring in 5.8% of the
patients.[12] When referred hospitalized and clinic patients were evaluated in an Australian oral medicine
clinic, hyperkeratotic lesions, including tobaccoinduced lesions, were documented in 11.6% of the
hospitalized patients and 10.3% of the clinic patients.[13]
The largest study of 23,785 patients, attending a Mexican dental school clinic, found frictional keratosis
to be the third most common oral mucosal finding, with a prevalence rate of 32 cases per 1000 patients,
while cheekbiting lesions were ranked fifth, or 21.7 cases per 1000 patients.[14]
Mortality/Morbidity
Frictional keratosis and its variants do not cause symptoms and are benign mucosal lesions that remain
localized with no associated mortality or morbidity.
Race
No racial predilection seems apparent for oral frictional keratosis.
Sex
In general, frictional keratosis has no known sex predilection, except for cheek biting and lip biting,
which are twice as prevalent in women compared with men.[1]
Age
Oral frictional keratosis affects persons from a wide range of ages, and contributing factors determine
which age group is more commonly affected. In general, oral frictional keratosis lesions are more
common in adults.
References
History
See the list below:
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 hardbristled
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.[15] Occasionally, illfitting or broken
mouthguards or occlusal splints irritate the oral mucosa, resulting in frictional keratosis.
Sucking on the cheeks, lips, or sides of the tongue may be a habit to relieve the discomfort from
temporomandibular disorder or burning mouth syndrome. Forceful or aberrant nutritional sucking
on the nipple of the bottle or breast may result in calluses on the lips of infants.
In rare examples, individuals may give a history of picking the oral mucosa with long fingernails
or some other external object.
References
Physical
The first step in the identification of white patches suspected of being associated with physical trauma is
to use a 2 X 2inch 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 translucenttoopaque 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 t....
View Image
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 Al....
View Image
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).
Prominent linea alba with evidence of cheek biting. The white line shows
a slightly scalloped appearance, which correlates with the buccal surfaces
of....
View Image

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....
View Image
Anterior rough surface area at the occlusal plane of the teeth. Courtesy of
Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
View Image

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).
Oral frictional hyperkeratosis of the lateral border of the tongue from chronic
biting habit. Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre....
View Image

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.
mucosa is at the anterior end (under the tongue blade edge). This area is....
View Image
Anterior rough surface area at the occlusal plane of the teeth. Courtesy of
Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
View Image

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.
References
Causes
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 illfitting, 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.
Improper toothbrushing and other oral hygiene aids affect the attached gingival tissues.
Oral frictional hyperkeratosis of the attached maxillary gingiva from
inappropriate toothbrushing technique. Courtesy of Catherine M. Flaitz, DDS
and ....
View Image

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.[16]
Oral frictional hyperkeratosis of the retromolar pad is also referred to as a
ridge callus. This lesion is caused by masticatory irritation. Courtesy ....
View Image


Pregnancy may significantly increase the risk for cheek biting.[17]
In rare cases, the overuse of topical anesthetics, overuse of antiseptic mouthrinses, or oromucosal
delivery of medications (eg, cannabis) causes keratosis from chemical irritation.[18]
The identification of such habits depends on obtaining a thorough history.
References
Differential Diagnoses
Cancers of the Oral Mucosa
Chronic Mucocutaneous Candidiasis
Contact Stomatitis
Dermatologic Manifestations of Oral Leukoplakia
Dyskeratosis Congenita
Lichen Planus
Mucosal Candidiasis
Nicotine Stomatitis
Nongenital Warts
Oral Lichen Planus
Pachyonychia Congenita
Smokeless Tobacco Lesions
Other Tests
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.
[23] 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.[24] At the
present time, welldesigned clinical trials are not available to confirm the value of these devices for
improved specificity and sensitivity in a general patient population.[24]
References
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, lowgrade 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 13 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.
References
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).
Lowpower view of stratified squamous epithelium with marked hyperkeratinization,
acanthosis, and a prominent granular cell layer. Courtesy of Catheri....
View Image
Highpower view of the surface keratin layer and a prominent granular cell layer.
Courtesy of Catherine M. Flaitz, DDS and Alfredo Aguirre, DDS.
View Image
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 cheekbiting 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.
References
Medical Care
See the list below:
The most important management protocol includes the following:
Establish a diagnosis.
Be sure that any frictional irritant is removed. Biting, sucking, or chewing habits should be
discontinued, and fractured or rough tooth surfaces or irregularly fitting dentures or other
appliances should be corrected.
Observe and monitor the patient to be certain that the frictional area is resolving in a timely
fashion. In general, the patient should be reevaluated in 23 weeks for signs of lesion
regression or resolution.
In the absence of resolution, even when the cause has been eliminated, obtain a biopsy
specimen of the tissue to confirm that no dysplastic or neoplastic change is present.

References
Consultations
Consultation with a dentist, an oral and maxillofacial surgeon, an oral and maxillofacial pathologist, a
dermatologist, or otolaryngologist may be indicated if a lesion does not resolve after elimination of the
suspected irritant. For aggressive cheek and lip biting habits, a psychological evaluation may be
appropriate.
References
Diet
The patient's diet is typically not of concern unless the frictional keratosis is a result of constant chewing
of hard foods against an edentulous ridge. The patient should be encouraged to eat on the dentate side, if
possible, to avoid trauma to the alveolar mucosa during mastication.
References
Further Outpatient Care
See the list below:
The patient should receive followup care to ensure the frictional area is resolving.
References
Deterrence/Prevention
See the list below:
Removing the frictional irritant resolves the condition. Irritants include tissue chewing or sucking,
illfitting or irregularly surfaced dentures, jagged teeth, poorly adapted dental restorations, and
constant mastication on edentulous alveolar ridges.
If dental prostheses fit poorly or are broken, relining or fabricating new removable partial and full
dentures decreases the development of frictional keratosis.
Wearing an occlusal splint may be useful for decreasing or eliminating cheek and lip biting.
References
Complications
See the list below:
No significant complications are associated with frictional keratosis. This reactive lesion has no
propensity for malignant transformation.
The risk of mutilating the buccal and labial mucosa following local anesthesia for dental treatment
is increased, especially in children with lesions due to cheek biting. Both the child and the parent
should be warned of the potential complication of unconsciously traumatizing the tissues because
of this chronic habit.[25]
References
Prognosis
See the list below:
The prognosis for frictional keratosis is excellent; resolution is usually accomplished when the
frictional element is eliminated. Most lesions resolve in 13 weeks following the removal of the
causative factor.
References
Patient Education
See the list below:
Encourage patients to stop any habit that may be implicated with this lesion. If the putative
traumatic factors are eliminated and no resolution of the lesions ensues, advise the patient that a
biopsy is indicated.
References
Author
Jose Luis Tapia, DDS, Assistant Professor, Department of Oral Diagnostic Sciences, State University of
New York at Buffalo
Disclosure: Nothing to disclose.
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
Specialty Editors
Michael J Wells, MD, FAAD, Associate Professor, Department of Dermatology, Texas Tech University
Health Sciences Center, Paul L Foster School of Medicine
Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research
Associates of Cincinnati
Chief Editor
William D James, MD, Paul R Gross Professor of Dermatology, ViceChairman, Residency Program
Director, Department of Dermatology, University of Pennsylvania School of Medicine
Additional Contributors
Daniel J Hogan, MD, Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern
University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center
Acknowledgements
Catherine M Flaitz, DDS, MS Professor of Oral and Maxillofacial Pathology and Pediatric Dentistry,
Department of Diagnostic and Biomedical Sciences, University of Texas Health Sciences Center at
Houston School of Dentistry
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 Coinvestigator on clinical grant; Trimira, LLC
Honoraria Speaking and teaching; GC America Clinical contract for study Coinvestigator on clinical
grant; Forward Science LLC Device evaluation Product evaluation for school use
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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.
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.
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 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
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.
acanthosis, and a prominent granular cell layer. Courtesy of Catherine M. Flaitz, DDS
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.
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
acanthosis, and a prominent granular cell layer. Courtesy of Catherine M. Flaitz, DDS

Oral Frictional Hyperkeratosis

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Oral Frictional Hyperkeratosis

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4/5/2017 Oral Frictional Hyperkeratosis

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