Trained in dentistry, Sree is currently pursuing lab sciences. She loves researching and sharing information on various health topics.
We all know how important it is to maintain proper oral health and for many of us, this entails regularly brushing our teeth and seeing the dentist regularly. However, what we often forget is that the mouth is made up of many different components-aside from our teeth. All of these components, if neglected, can develop various issues over time. A good example of which would be linea alba (cheek).
What is Linea Alba (Cheek)?
Linea Alba is the white line people often find inside their cheeks, just between where the upper and lower teeth meet. This is a hardened mucosa and is benign. Some people do find their appearance unappealing, however, thus the need for it to get treated.
This white line appears when the oral mucosa found in our mouth becomes irritated constantly, thus leading it to develop a layer of keratin-this is the white line that shows up. Hyperkeratinization, as it is also known, can be present in a variety of different conditions. This includes inflammatory, physiologic, genetic, immunologic, malignant, and premalignant conditions.
What are the white lines made out of? Think of these white patches as something similar to the formation of a callus on our skin. The more the area receives friction, the thicker the mucosa becomes.
The most common causes for it involve frictional irritation, pressure, or sucking trauma often caused by the facial surfaces of our teeth. People who chew tobacco regularly would have this, but can be mistaken for a lesion that would require treatment. Other instances, such as orthodontic appliances (Invisalign is a great example for this), ill-fitting dentures, and crooked teeth can also result in this condition.
Note that Linea Alba can also be related to behavioral and emotional issues, which is why treatment for it also involves finding resolution for those problems as well.
Is It Dangerous?
Frictional Keratosis, as it is also known, is basically a symptom of irritation. It happens as a result of the body laying down more cells in response to an irritation-no different from callouses you get where your fingers often grip. Once the irritation ceases, the white line should also disappear.
There is no evidence that linea alba can cause problems, whether it be for the short or long term. Whilst there is no discomfort or pain reported by those who have, a thorough check by your dentist is still necessary as the appearance of this white line can also point to other underlying problems that need to be addressed.
This happens when the person frequently uses too much force while brushing their teeth.
Tongue Thrust Keratosis
This occurs when the tongue constantly rubs against one's teeth.
This is the result of constant irritation caused by the teeth against the buccal mucosa and results in the white line we see in some people's inner cheek.
This is most common in people who have a habit of constantly biting or chewing on their lips.
Pregnancy has been known to also increase the instances of cheek biting, which then leads to hyperkeratinization.
Though rare, there are instances wherein the over use of antiseptic rinses, topical anesthetics, and the oromucosal delivery of medications causes linea alba or keratosis due to the mucosa being irritated.
Injuries to the oral mucosa, such as ones caused by toothpicks, pens, and even fingernails can also result in frictional keratosis. This happens if there’s repeated friction in that area.
Known Symptoms and Manifestations
- Many of the patients who have frictional keratosis are usually free of any symptoms, save for those who have rather serious cheek and lip biting habits. People who repeatedly "injure" the cheek tissues will experience swelling, tenderness in the affected area, as well as a burning sensation that can be uncomfortable.
- It has been observed that patients who had recurring cheek and lip biting habits also had a tendency to have increased stress, as well as the possibility of psychological disorders.
- Patients may also notice roughness as well as some thickness in the affected area-this is how some people discover that they have this particular issue. In other cases, the frictional keratosis is discovered during routine oral examinations.
- There are also a number of patients who reported that they were able to remove bits and strands of the linea alba on their cheek. There are also a few patients who reported that, out of habit, they would such on the mucosa or push their tongues against their teeth. In this case, their cheeks often become swollen or tender. This is also where the burning sensations in the affected area become more common.
- Should there be gingival tissues involved, some of the patients have been found to be using hard-bristled toothbrushes as well as other types of oral hygiene aids. It has been noted that patients who have a history of using and wearing orthodontic appliances do experience trauma in the soft tissues of their cheek. The same goes for broken mouth guard.
- What brings about the habit of sucking on one's lips, cheeks, or sides of the tongue? The most common cause for this is to help relieve discomfort associated with burning mouth syndrome or temporomandibular disorder. In the same manner, forceful nutritional sucking by infants on the nipple of their feeing bottle or mother's breast can also result in calluses on the infant's lips.
- Though rare, there are instances wherein individuals pick on the linea alba using their fingernails or some other external object-often due to their own curiosity. This, of course, is something that must be avoided as it can cause further damage to the tissue.
How is Linea Alba Cheek Identified?
For your dentist to be able to identify if the white patches on your inner cheek is frictional keratosis, they would need 2 x 2 inch sterile gauze which is then used to wipe of the affected area. If the lesions are not easily removed, this is a good indication that there is hyperkeratinization.
The lips, the buccal mucosa, the lateral margins of our tongues, and the edentulous aveolar ridges are the areas in our mouth that are often affected by different types of frictional keratosis. In terms of appearance, these lesions often show up as translucent to opaque and easily visible to the eye. The surface of it can also appear irregular and if felt by the tongue, it would be rough-much like a callus, as we've pointed out earlier.
Are there any variations in appearance depending on the type of frictional keratosis? Yes, there will be slight differences as it is directly related to the cause of the surface trauma. In linea alba's case, it manifests as a horizontal thickening of the buccal mucosa along the teeth's occlusal line. This line is often at level with the biting plane of our teeth. If the patient has a habit of bruxism, there will be some noticeable wear on the molar teeth's occlusal surfaces.
Note: In some cases, the linea alba will reflect any irregularities in the patient's adjacent teeth and shows up with a scalloped appearance instead of the line we normally see.
For people who have a habit of cheek biting, the line would often appear more diffuse. This is different from the lines produced by the accidental friction against the mucosa which is caused by our teeth during the eating process. Another thing to note is that these lesions may also be elevated and not flat against the cheek surface. This is one of the reasons why some patients also develop a habit of nibbling at that particular area-which leads to the mucosa becoming even thicker.
Differentiating Line Alba from Other Types of Plaquelike Lesions:
It must be noted that there are conditions which might resemble linea alba or frictional keratosis. For example, lupus erythematosus and lichen planus can appear similar to areas of frictional keratosis-however, these can be easily wiped off with gauze since they consist of either fungal colonies or necrotic ephitelium (especially in cases of superficial chemical burns).
Another thing to note is that clustered Fordyce granules, as well as scars, can also appear similar to frictional keratosis. However, unlike linea alba, the surface of it is smooth. The white patches which often comes about because of smoking and the use of smokeless tobacco can also appear very similar to linea alba or frictional keratosis. For this, clinical information about the patient's use of smokeless tobacco is essential. Keep in mind that tobacco-related keratosis is often causes by chemical and thermal irritation. Note that there are also forms of keratotic lesions that point to an existing precancerous entity.
Differentiating between frictional keratosis and lesions from smoking or smokeless tobacco is of utmost important given that their prognoses is different from that of the typical frictional keratosis. If the cause of the white patches is a precancerous entity, it must be immediately given appropriate attention and treatment.
Contact stomatitis, often associated with using artificially flavored cinnamon products can also appear as white patches that can resembled frictional keratosis. That said, this particular issue also comes with burning and pain-both common symptoms of contact stomatitis.
What is Hairy Leukoplakia?
Another white plaque that can be mistaken for as linea alba would be hairy leukoplakia. This "shaggy" plaque that often appears on the border of the tongue is brought on by the Epstein-Barr virus infection. It is also associated with immunosuppression that is a result of HIV infection.
The long term use of steroids which are used to help treat ulcerative conditions can also cause the formation of white patches on the tongue's lateral borders-these can be indistinguishable from hairy leukoplakia.
The clinical term Leukoplakia is often reserved for white lesions that cannot be identified pathologically or clinically as a particular disease. Leukoplakia is can also be associated with malignant or premalignant ephitelial changes.
Treatment and Medical Care
If you or someone you know is having issues with the appearance of linea alba and want something done to it, the first thing you need to do is get a proper diagnosis. This is important given the fact that there are a number of other oral problems that might appear similar to it-as previously mentioned.
Once the diagnosis and consultation is done, the next thing you and your dentist need to do is figure out the cause. The frictional irritant must be removed in order for the area and the damaged tissue to begin healing. This is the hardest part of the process as some people do find it difficult to discontinue certain habits, especially if they are associated with mental issues such as stress.
In situations wherein the frictional keratosis is brought on by irregularly fitting dentures or other dental appliances, you would need to get refitted for them or find an alternative that would not traumatize the tissue of your inner cheek. Needless to say, for the white lines to completely disappear, some discipline is required on your part.
During the healing period, you would need to monitor the frictional area. Doing so would show you, whether or not your solutions are working. Typically, your dentist would call you in for a reevaluation within two to three weeks to check if there's been a lesion regression.
Now, there are instances wherein patients don't find any improvement even after the cause of the issue has been eliminated. For this, your dentist would have to obtain a biopsy specimen of the damaged issue. This is done to help them confirm that there are no neoplastic or dysplastic change is present.
In children, treatment is a little trickier as they are also more prone to unconsciously traumatizing the affected area. There are also cases wherein children would either poke at the linea alba, further aggravating the irritation. Here, parents should be more observant and monitor their children better. With constant reminder and discipline, the white patches on younger patients' cheeks should resolve in time as well.
Who Should You Consult With?
Should the lesions not resolve itself even after the causes have been identified and removed, you would need further consultation. You would need to work with an oral and maxillofacial pathologist, an oral and maxillofacial surgeon, an otolaryngologist, and a dermatologist.
There are cases wherein the more aggressive lip and cheek biting habits are the only cause of the linea alba, for this a psychological evaluation would also be needed. Basically, if the patient were to resolve their oral issues, they would first have to deal with the reason behind the bad habits they have.
Note that some patients might also need to get their teeth fixed. This is the case for people whose linea alba is caused by their irregular or uneven teeth. Again, consultation is very important as your dentist must make sure that any dental appliance (such as braces) that you will be using won't further aggravate the lesions.
Can your diet affect the appearance of linea alba on your cheek?
For the most part, a patient's diet does not have direct effect on the lesions. This is because the frictional keratosis is caused by constantly chewing food against an edentulous ridge. To resolve this, patients are asked to eat on the dentate side which should enable them to avoid further trauma to their alveolar mucosa whilst eating.
Note that eating food or soups that are too hot can burn the inner cheek and might leave white patches behind as well.
How Long Does the Healing Process Take?
Resolution should be accomplished within one to three weeks after you have dealt with the frictional element. The lesions also disappear within the same amount of time, regardless of how long you have had them. Again, for younger children, it might take longer as there would be potential inconsistencies when it comes to maintaining proper care. However, it shouldn't take longer than a few months-even for younger kids.
Remember, if the white lines do not disappear even after you've removed the known causes for it, always approach your doctor and talk to them. They should be able to provide you with alternatives or conduct further tests. It is always better to be sure, rather than regret not having it properly checked earlier. Whilst actual linea alba or frictional keratosis does not pose any real danger, note that tests should still be done to properly assess the situation.
Possibility of Complications:
- There are no significant complications that is directly associated with frictional keratosis. The reactive lesions that appear on a patient's cheek does not have a propensity to become malignant.
- There is an existing risk of unintentionally traumatizing the labial and buccal mucosa after the local anesthesia for dental treatment has been increased. This is most common in children who have the lesions because of cheek biting. For this, both the child and their parents would be warned of this possible complication.
Linea Alba Cheek Epidemiology
I. Within the United States of America
In the United States, a survey done by the Third National Health and Nutrition Examination Survey which included 17,235 civilian adults produced the following results:
Cheek and lip biting was ranked third when it comes to oral lesion prevalence, while frictional keratosis ranked fourth. In the same survey where 10,030 children aged 2 to 17 years old were evaluated, cheek and lip biting remained more prevalent than frictional keratosis when it comes to the causes of linea alba on the cheek.
In a limited study done on young men, about 13% of those who were tested had this particular mucosal alteration.
II. International Studies and Cases
In one Danish study that included 20,333 people who were aged 15 and older, the occurrence of cheek and lip biting, as well as frictional keratosis, were a bit higher in comparison to the data reported in the US survey. The occurrence of cheek and lip biting among those evaluated were at 5.1%, those who had frictional keratosis was 5.5%.
Similar numbers were seen in an evaluation of Kenyan adults, whilst in Slovenia the numbers were at 2.7% for cheek and lip biting, and 2.2% for frictional keratosis. On the other hand, in an evaluation done of Turkish adolescents, linea alba was the second most prevalent lesion with 5.3% in occurrence rate.
When these surveys were limited to the people who sought care from oral medicine clinics, a higher frequency of prevalence was noted. Such is the case in Spain wherein the rate was 6.8% for cheek biting, 10.7% for linea alba, and 11.5% for frictional keratosis. In India, the most common oral lesion was frictional keratosis which was noted in about 5.8% of the patients.
In Australia, when referred clinic and hospitalized patients were evaluated, hyperkeratotic lesions-including those that were brought about by tobacco use-were rated at 10.3% for the clinic patients and 11.6% for hospitalized patients. In one of the largest studies done which involved 23,785 patients who attended a Mexican dental school clinic, they found that frictional keratosis was the third most common oral mucosal finding.
This type of oral lesion occurred with a rate of 32 cases for every 1,000 patients. On the other hand, those who had cheek biting lesions were the fifth most common, with a rate of 21.7 cases per 1,000 patients.
Known Cases of Mortality:
Despite the significantly high numbers shown by the aforementioned studies, frictional keratosis and its variants are benign mucosal lesions and do not cause any other symptoms. Its effects are localized and is not associated with mortality or morbidity.
Race, Sex and Age:
Based on the current data, there are no obvious racial predilection for linea alba on the cheek. The same goes for sex-except for lip and cheek biting which was seen to be more common in women than in men. Lastly, oral frictional keratosis can affect people from various ages. That said, the appearance of white oral lesions do tend to be more common in adults than in younger children.
- Symptoms Of And Treatment For Linea Alba, noigloos. Retrieved on Feb 24, 2019
- Oral Frictional Hyperkeratosis, By Jose Luis Tapia, medscape, WebMD. Retrieved on Feb 24, 2019
This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.