A 73-year-old male presented to a dental office for a routine checkup. Oral examination revealed a nonpainful ulcer on the floor of mouth.
Joen Iannucci Haring, DDS, MS
History
When questioned about the lesion, the patient stated that he was unaware of its presence. The patient gave a history of cigarette smoking (one pack a day for over 30 years) and moderate alcohol consumption. The patient`s last dental checkup was approximately two years earlier. The patient was not under the care of a physician at the time of the appointment.
Examinations
The extraoral examination revealed no palpable lymph nodes in the head and neck region. The intraoral exam revealed a whitish area on the ventral tongue and anterior floor of the mouth surrounding a small yellow ulceration. The borders of the ulceration appeared to be raised and white (see photo).
Clinical diagnosis
Based on the history and clinical appearance of the lesion, what is the likely diagnosis:
* erosive lichen planus
* discoid lupus erythematosus
* chronic ulcerative stomatitis
* squamous cell carcinoma, intraoral
* mucoepidermoid carcinoma
Diagnosis
squamous cell carcinoma, intraoral
Discussion
Squamous cell carcinoma (SCC) is by far the most common type of oral cancer, comprising 90-95 percent of all oral malignancies diagnosed in the United States. SCC is found both on the lips (see RDH September 2000) and inside the oral cavity.
Many patients who develop oral cancer have identifiable risk factors. The risk factors are tobacco and alcohol use. Approximately 90 percent of people with oral cancer have a history of tobacco use; the risk of developing oral cancer increases with the amount of tobacco smoked or chewed and the duration of the habit. Approximately 75-80 percent of all patients with oral cancer frequently consume alcohol. Oral cancer is six times more common in drinkers than in nondrinkers. Persons who smoke and drink have a much higher risk of cancer than those using only alcohol or tobacco alone.
Clinical features
Intraoral SCC is most often seen in individuals between the ages of 40 and 80, although it may occur at any age. Males are affected by oral cancer twice as frequently as females; this 2:1 ratio occurs because men are more likely to use alcohol and tobacco.
Although SCC can be found anywhere in the oral cavity, the most common intraoral locations include the tongue and the floor of the mouth. The typical tongue lesion is seen on the posterior lateral border, while the anterior floor of the mouth is involved more frequently than the posterior. Other common locations include the soft palate, buccal mucosa, and gingiva.
Intraoral SCC generally presents as a persistent lesion in one of the following forms: an ulceration, erythroplakia, or leukoplakia. The ulceration is a lesion characterized by the complete loss of mucosa; it appears depressed with a yellow, necrotic center and an irregular outline. The borders are often rolled and indurated (hard) and may appear pink, red, or white in color.
Erythroplakia is a clinical term used to describe a noninflammatory lesion that appears as a red patch that cannot clinically be diagnosed as anything else. The erythroplakia appears as a red, flat, well-defined area with a texture that resembles velvet.
Leukoplakia is a clinical term used to describe a white patch or plaque that cannot be rubbed off or clinically diagnosed as anything else. The leukoplakia appears as a white, flat, or slightly elevated area with a smooth or wrinkled surface.
While the usual presentation of intraoral SCC is that of a nonhealing ulceration, it may also appear as an exophytic mass, an erythroplakia, a leukoplakia, or a speckled erythroplakia. Intraoral SCC is typically asymptomatic; however, in some instances, pain and difficulty in swallowing may occur. Unlike SCC of the lip, metastasis to the regional lymph nodes is common with intraoral SCC.
Diagnosis
As with SCC of the lip, if an intraoral lesion is suspected to represent SCC, the patient must be promptly referred to an oral surgeon for biopsy. A biopsy and histologic examination is necessary to establish a definitive diagnosis of SCC. Following diagnosis, staging (the process of determining if and how far a cancer has spread) must be established.
Treatment
Once diagnosis and staging have been determined, treatment can be rendered. Treatment options for intraoral SCC include surgical excision and/or radiation therapy. The type of surgery will depend upon the size and extent of the tumor. Surgery options to remove intraoral SCC include: primary tumor resection, or jaw resection if bone is involved. A neck dissection is necessary if lymph nodes are involved.
Radiation therapy can be used as the main treatment for small lesions, while patients with larger lesions may need both surgery and radiation therapy. After surgery, radiation can be used as adjuvant therapy to destroy any small areas of cancer that cannot be detected or removed during surgery.
Follow-up and prognosis
Treatment success is based on the microscopic differentiation of the lesion and the presence of metastasis. Intraoral SCC is far more likely to metastasize than SCC of the lip. As a result, the prognosis for intraoral SCC with such metastasis is poor - only a 20 percent five-year survival rate.
Upon completion of treatment, a patient with intraoral SCC should receive frequent follow-up physical and oral examinations. People with intraoral SCC are not only at an increased risk for developing a second cancer of the oral cavity, but at an increased risk for developing a second primary cancer (for example, lung, laryngeal, esophageal). Approximately 10-40 percent of patients with oral cancer will develop another primary cancer or a second cancer of the oral cavity. As a result, such people must be carefully followed and continually evaluated by a physician.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.
