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Table of Contents
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 53-57

White lesions that can be wiped off: A case report of oral mucosal peeling

Department of Oral Medicine, Faculty of Dentistry, Universitas Indonesia, Indonesia

Date of Submission25-Aug-2021
Date of Decision27-Sep-2021
Date of Acceptance26-Nov-2021
Date of Web Publication21-Feb-2022

Correspondence Address:
Febrina Rahmayanti
Department of Oral Medicine, Faculty of Dentistry, Universitas Indonesia, Jl Salemba Raya No IV, Jakarta Pusat 10430.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_96_21

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Background: Oral mucosal peeling (OMP) refers to an asymptomatic white lesion commonly encountered in daily practice but rarely discussed in the literature. OMP can be induced by various daily oral care products. Although common, some clinicians may not be familiar with OMP. In this case report, we describe a case of widespread OMP associated with toothpaste and mouthwash use. Case Report: A 40-year-old man presented with asymptomatic white lesions, with thin sloughing appearance in the whole oral mucosa. The patient was healthy, with no routine use of medications. The lesions were easily removed using a sterile gauze, with no subsequent erosion or ulceration occurring. The lesions were attributed to the use of sodium lauryl sulfate (SLS)-containing toothpaste and a mouthwash containing chlorhexidine (CHX) and essential oils. The patient was advised about the benign nature of the lesions. Discontinuation of SLS-containing toothpaste was suggested. Conclusion: OMP is commonly associated with the use of SLS-containing toothpastes and dentifrices and mouthwashes containing essential oils or CHX with the use of SLS-containing toothpastes and dentifrices and mouthwashes containing essential oils or CHX. Dentists must be able to identify OMP and provide appropriate patient education.

Keywords: Essential oils, mouthwash, sloughing, SLS, toothpaste, white lesion

How to cite this article:
Astuti AK, Rahmayanti F. White lesions that can be wiped off: A case report of oral mucosal peeling. Sci Dent J 2022;6:53-7

How to cite this URL:
Astuti AK, Rahmayanti F. White lesions that can be wiped off: A case report of oral mucosal peeling. Sci Dent J [serial online] 2022 [cited 2023 Jun 9];6:53-7. Available from: https://www.scidentj.com/text.asp?2022/6/1/53/338006

  Background Top

Oral mucosal peeling (OMP) refers to an asymptomatic white mucosal lesion that can be found anywhere in the oral cavity and scraped off. Such lesions are often ignored by patients. Pnacek was the first to describe these lesions in 1970.[1],[2] OMP is considered a mild type of a chemical burn, but the exact etiopathogenesis remains under discussion.[1],[3] Due to the widespread use of toothpastes containing sodium lauryl sulfate (SLS) and mouthwashes containing essential oils and chlorhexidine (CHX), dentists can be expected to encounter OMP relatively frequently in daily practice.[1],[4] Currently, only a few reports have focused on these lesions, which are an adverse effect of oral care products containing substances such as SLS, CHX, or essential oils.[1],[2],[4],[5] A full patient history and an examination are needed to rule out other possible diagnoses, such as pseudomembranous candidiasis and vesiculobullous disease, associated with white lesions with a similar presentation.[1],[2],[4]

This case report describes the case of a healthy male patient who presented with white lesions, with generalized sloughing of the epithelium of the oral mucosa associated with the use of oral care products, including SLS-containing toothpaste and mouthwash containing essential oils and CHX.

  Case Report Top

A 40-year-old man presented to the Dental Hospital of Universitas Indonesia with a history of a whitish membrane in the oral cavity that could be easily wiped away. The patient had first noticed the whitish membrane 5 years earlier. The white membrane was particularly noticeable after toothbrushing, and it was easy to remove. The membrane was painless and not preceded by a blister. The patient reported no similar lesions on other body parts.

The patient reported no history of chronic, recurrent, or multiple oral ulceration. The only instance of oral ulceration reported followed a bitten lip some time ago. The patient reported that he brushed his teeth tooth twice a day. He had used Close Up Deep Action Menthol Fresh (Unilever, Rungkut, Indonesia) toothpaste for the past 5 years but had changed his toothpaste to Pepsodent Action Herbal (Unilever, Surabaya, Indonesia) in the past month. In addition, 2 months earlier, the patient had started to use Listerine Ginger Herbal and Mint (Johnson and Johnson, Jakarta, Indonesia) mouthwash once a day after morning toothbrushing. One month prior to presentation, the patient had undergone periodontal scaling and curettage for periodontal disease, after which he used Minosep (Minorock, Depok, Indonesia) mouthwash. He reported that the whitish membrane had become more noticeable within in the month after commencing Minosep (Minorock, Depok, Indonesia). The patient reported no history of systemic diseases or routine medication use. About 1.5 months earlier, he had been treated for chickenpox. The patient had a history of cigarette use (>25 years), smoking as much as a pack per day. However, he reported that he currently smoked only two to four cigarettes per day. He had no history of mechanical or chemical intraoral trauma. The patient reported that he worked as an online ojek (taxi) driver.

A clinical examination revealed multiple, generalized irregular white lesions in the buccal and labial mucosa. These lesions presented as a white translucent epithelial desquamation that could be easily removed using a sterile gauze [Figure 1]. There were no ulcerative or erosive areas beneath the white lesions, and there was no sign of inflammation or bleeding upon rubbing. The patient reported that these lesions were asymptomatic.
Figure 1: White lesion in the oral cavity that was easily removed using a gloved finger: (A) right lower buccal vestibular lesion, (B) left upper buccal vestibular lesion, and (C) right upper buccal vestibular lesion

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Based on the subjective and clinical examination, the lesions were diagnosed as benign oral mucosal lesions related to routine use of particular oral care products (i.e., SLS-containing toothpaste and mouthwashes containing CHX and essential oils). The patient was advised to stop using these oral care products. At a follow-up visit 2 weeks later, the lesions had disappeared.

  Discussion Top

OMP has several alternate terms, such as oral mucosal desquamation, dentifrice-associated sloughing, desquamative stomatitis, oral mucosal desquamation, oral slough, oral mucosal shedding,[1] oral peeling, and oral epitheliolysis.[4] Although oral mucosal desquamation and OMP are commonly used in the scientific literature, OMP induced by oral care products seems most appropriate, as no one type of oral care product is the causative agent of the lesion.[1]

Among the various causative agents of OMP, it has been linked in particular to the use of oral health care products, such as toothpaste containing the surfactant SLS, which has a detergent-like property. SLS is a very common ingredient in most toothpaste products. OMP can also be associated with components of mouthwashes, such as a tartar control ingredients, flavoring agents, or essential oils.[1],[3] OMP is usually asymptomatic, although painful erosions upon peeling can occur.[1] In many cases, the lesions are located in nonkeratinized mucosa, such as the vestibular, buccal, or alveolar mucosa; lateral, ventral, or dorsal tongue; labial mucosa; floor of the mouth; or gingiva.[4] They would not progress to any concerning lesion.[3]

There are several possible differential diagnoses of OMP, including vesiculobullous disorders, morsicatio buccarum (cheek chewing), morsicatio labiorum (lip chewing), and oral lichenoid lesions.[2] In cases of gingival involvement, OMP should be differentiated from desquamative gingivitis related to oral manifestations of mucocutaneous autoimmune or hypersensitivity disorders, such as mucous membrane pemphigoid, oral lichen planus, pemphigus vulgaris, erythema multiforme, lupus erythematosus, and psoriasis.[1],[4] In cases where the diagnosis of desquamative gingivitis is uncertain, a biopsy is required. In such cases, a peeling biopsy from the desquamative area rather than an incisional biopsy is sufficient to provide enough epithelium for a histological examination or immunofluorescence, with less morbidity to the patient.[1] Due to the scant literature on OMP, some dentists might be unfamiliar with its presentation. This could lead to confusion in terms of the differential diagnosis. The diagnosis of OMP should be based on a subjective and clinical examination. In the anamnesis, the patient should be questioned about oral hygiene practices and oral health care product use.[5]

In this case report, the patient had been using toothpaste containing SLS and a menthol flavoring agent for 5 years, during which the white lesion had been present. The white lesions became more evident in the month prior to presentation when the patient had changed his toothpaste to a herbal variant containing various ingredients (SLS, key lime extract, and piper betel leaf oils). He had also used a mouthwash that contained essential oils (thymol, eucalyptol, menthol, and methyl salicylate) and a mouthwash containing 0.2% CHX gluconate. After removal of the oral sloughing, the epithelium beneath showed no sign of significant inflammation. Therefore, erosive lichen planus, oral manifestations of autoimmune disorders, and oral hypersensitivity reactions could be ruled out in the differential diagnosis.[4] The long history of the whitish membrane and increase in its severity after the patient had changed his toothpaste and begun to use a mouthwash containing CHX and essential oils pointed to a dose–response effect instead of an allergic reaction.

The adverse effects of oral care products can be understood in terms of their effects on oral mucosa histology. The superficial layer of the oral epithelium is the primary barrier that protects the underlying tissues from toxins and microorganisms. The oral mucosal epithelium divides and regenerates quickly, with continuous desquamation of superficial cells assisting the removal of debris and microorganisms.[6]

The pathophysiology of OMP remains unclear. However, it is thought to be related to the frequency and duration of contact between of oral mucosal epithelial cells with SLS in oral care products.[1],[4] According to previous studies, SLS likely triggers mucosal sloughing by denaturation of salivary mucins, thereby increasing the permeability of oral mucosa and eventually disturbing the integrity of surface epithelial cells.[4],[6] Some previous studies showed that under experimental conditions, SLS exacerbated oral desquamation in cases of desquamative and erosive lesions.[6] In a preliminary double-blind cross-over study, dentifrice containing 1.5% SLS triggered a desquamative reaction in 60% of participants compared to none in a 0% SLS dentifrice group.[7] In another study, the amount of sloughing increased in accordance with the SLS content in a toothpaste, increasing when the study participant used a toothpaste with a higher amount of SLS and decreasing when they switched to using a toothpaste with a lower SLS content.[8]

Some surfactants have been shown to produce less desquamation than SLS.[6],[9] Using products containing surfactants other than SLS may have benefits in terms of oral health. In a randomized, single-center, double-blind cross-over study, a toothpaste containing Steareth 30 surfactant (Unilever Oral Care, Wirral, United Kingdom) was associated with fewer mucosal lesions than one containing the surfactant SLS.[6] In another study, the incidence of mucosal desquamation decreased in participants using toothpaste containing cocoamidopropyl betaine as compared with that among participants using SLS-containing toothpaste.[9] The difference in irritation between SLS and other surfactants might be related to the effect of stronger protein denaturation of the anionic detergent. Another study reported a dose–response effect of mucosal desquamation to the concentration of various chemical, different adsorptive abilities of the oral products to the oral mucosa, and its effect on oral membrane.[1] Due to those differences, some oral care products might not cause desquamation in some individuals.

In previous research, triclosan, an antibacterial agent, decreased oral mucosal desquamation when used in combination with SLS.[10] Triclosan might assist in controlling mucosal desquamation caused by SLS, with the effect dependent on the triclosan and SLS concentrations. In the same study, the addition of 0.3% triclosan to what product containing 1.5% SLS or 3% SLS could reduce desquamation.[10]

In addition to components in toothpaste, those in mouthwashes can have adverse effects on oral mucosa.[11],[12] Nonalcoholic, alcoholic, and CHX mouthwash preparations are available. Mouthwash with a high-alcohol content and CHX-containing mouthwash can cause epithelial peeling, ulceration, inflammation, and other miscellaneous changes in oral mucosa.[11] Chronic use of CHX has been proven to induce chemical trauma, resulting in oral mucosal desquamation, as shown in a study on 50 soldiers who used CHX over a 4-month period.[13] The adverse effect increased in accordance with the concentration of CHX.[13] In a case report, regular use of CHX digluconate 0.2% resulted in nonpainful oral mucosal sloughing in a healthy patient.[14] Other reported possible adverse reactions caused by CHX are desquamative gingivitis, ulcerations, and fixed drug eruptions.[14] Cases of anaphylactic shock and delayed hypersensitivity reactions after topical CHX applications have also been described.[12] Plantinga et al.[11] reported a high incidence of oral lesions in intensive care unit (ICU) patients who used a mouthwash containing CHX 2% intervention as a preventive strategy against infection. In their study, erosive ulcerative lesions, white/yellow plaque formation, and mucosal bleeding were observed in 9.8% of patients. These occurred mainly in the statis zone after application of the mouthwash, including the buccal mucosa and floor of the mouth, showing a dose–response relationship.[11]

Essential oils and flavoring agents in nonalcoholic mouthwashes may induce adverse reactions. Listerine (Johnson and Johnson, Jakarta, Indonesia) is a widely used mouthwash containing essential oils (eucalyptol, menthol, methyl salicylate, and thymol).[15] Eucalyptol has antibacterial and antifungal properties, thymol acts as an antiseptic, and menthol has local anesthetic and counterirritant effects.[15] A study that compared Listerine Green Tea (Johnson & Johnson, Middle East FZ - LLC), a nonalcoholic herbal mouthwash containing essential oils, and a CHX-containing mouthwash found a high rate of mucosal desquamation and ulceration in the Listerine Green Tea (Johnson & Johnson, Middle East FZ - LLC) compared to no cases in CHX mouthwash group.[16] In a systematic review, Listerine (Johnson and Johnson) mouthwash containing alcohol-induced oral desquamation. The authors concluded that it might have a burn-like effect on oral mucosa if used for a prolonged period. Histologically, the lesions in such cases are characterized by tissue edema with epithelial detachment.[17] Kuyama and Yamamoto[18] studied the effect of ethanol-containing mouthwash on human oral mucosa according to internal (sex and menstrual cycle) and external factors (smoking status). Smokers were more susceptible to keratinization, as seen in exfoliative cells cytology. The keratinized cells of smokers’ mucosa were more reactive to irritation caused by the mouthwash and had more noticeable inflammation.[18] In addition to that, estrogen might also play a role in epithelial differentiation.[18]

Several experimental studies have provided data on the relationship between oral products and oral lesions.[1] However, precise epidemiological data of OMP are currently not available due to the limited number of case recorded statistically. Thus, raising awareness of OMP is important. Although previous case reports and case series revealed no gender or age predisposition to OMP, it is generally to be considered more common among women in their 50s.

OMP is often overlooked due to its asymptomatic nature. Unfortunately, some clinicians might feel uncertain to identify OMP presenting as white lesion as a benign lesion. Thus, some clinicians might not be able to discover the cause and provide proper care. An awareness of this condition would allow the clinician to differentiate it from other mucosal lesions and bring a better consideration when prescribing certain oral hygiene products to avoid OMP exacerbation.[1] A comprehensive patient history, including oral care habits and oral care product used, smoking status, and systemic conditions, should be obtained to reach an accurate diagnosis and ensure appropriate treatment. In addition, a comprehensive clinical examination should be undertaken to rule out other possible diagnoses in patients presenting with white lesions that can be readily removed/scraped off with a sterile gauze.

  Conclusion Top

Although OMP and mucosal sloughing are common, there appears to be a lack of awareness of OMP among both practitioners and patients. Dentists must be able to recognize OMP and educate patients about OMP cause and management. To reduce desquamation, patients can be advised to change their toothpaste to a non-SLS-containing brand or to one containing a less irritating surfactant combined with zinc or triclosan-containing toothpaste. They should also be advised to stop using mouthwash products containing essential oils or CHX.

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Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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