Definition
A.Oral cancer is cancer of the buccal mucosa, tongue, gingiva, hard palate, soft palate, or lips. White patches, known as leukoplakia, or red, velvety patches, known as erythroplakia, on the buccal mucosa may indicate premalignant lesions.
Incidence
A.Oral cancer is primarily seen in the elderly. Approximately 90% of oral cancer is diagnosed as squamous cell carcinoma. Male-to-female predominance is 2 to 1; oral cancer is higher in African American than Caucasian adults. The death rate is fairly high for oral cancer; it is secondary to the cancer being diagnosed in the late stages of development.
B.There were over 49,000 Americans diagnosed with new cases of oral cancer (2017), and 9,000 deaths will occur each year.
C.Oral cancer represents 3% of all newly diagnosed cancers and 2% of all cancer-related deaths.
D.The frequency of oral cancer of cheek and gum rises 50-fold among long-term users of smokeless tobacco.
E.Patients diagnosed with oral cancer are at greater risk of developing cancer in another part of the body, such as the lung, larynx, esophagus, or other site. Therefore, follow-up exams are recommended for the remainder of the patient’s life.
Pathogenesis
A.Pathogenesis is unknown; 50% of oral cancers already have metastasized at time of diagnosis. The following factors are involved:
1.Use of tobacco in all its forms is highly correlated with risk of oral cancer.
2.Risk of oral cancer also is high with heavy alcohol consumption. Whether this is due to a direct effect of alcohol on the oral mucosa or to associated smoking or vitamin deficiency remains unclear.
3.Chronic iron deficiency leading to Plummer–Vinson syndrome is known to alter mucosal tissues, and this change may be related to increased oral cancer. Research has shown that a diet low in fruits and vegetables contributes to oral cancer.
4.Epstein–Barr virus and papillomavirus have been found in cells of the tongue manifesting oral hairy leukoplakia, a hyperplastic change found in AIDS patients. Human papillomavirus (HPV) is found in approximately 20% to 30% of cases of oral cancer.
5.Occupational hazards also exist from sun exposure. It is estimated that 30% of those with oral cancer worked outdoors.
Predisposing Factors
A.Male gender (though leukoplakia is more common in women).
B.Age older than 40 years for men, older than 50 years for women.
C.African American ancestry.
D.Smoking or use of other tobacco products, including such smokeless products as snuff and dip.
E.Alcohol consumption.
F.Sun exposure.
G.Poor diet, deficient in vitamins A, C, and E, and high in salted or smoked meats, fats, and oils.
H.Previous cancer.
Common Complaints
A.Oral sores that do not heal; this is what most commonly leads patients to seek medical care.
B.Poorly fitting dentures.
C.Bleeding mucosa or gingiva without apparent cause.
D.Difficulty swallowing, usually indicating more advanced disease.
E.Altered sensations: Burning or numbness, usually indicating more advanced disease.
F.Leukoplakia (50% occur on tongue) or erythroplakia.
Other Signs and Symptoms
A.No symptoms, possibly.
B.Decreased appetite related to altered taste.
C.Increased salivation.
D.Sore throat.
E.Foul breath odor.
F.Oral or neck mass.
G.Lymphadenopathy.
Subjective Data
A.Review onset, course, and duration of symptoms. Question the patient regarding altered taste, sensations, difficulty swallowing, and foul breath.
B.Evaluate for risk factors. See section Predisposing Factors.
C.Ask the patient about previous history of cancer and treatments.
D.Review the patient’s use of tobacco products, including age of onset, amount of daily use, and quit dates.
E.Evaluate amount of alcohol intake, including age of onset, amount of daily use, and quit dates.
F.Review the patient’s general health history for other chronic conditions.
G.Review medication history, including prescription and over-the-counter drug use, especially aspirin.
H.Take dental history, including previous gum surgery, how long ago dentures were fitted, and if they always fit well.
I.Establish usual weight. Is there any weight loss related to altered taste, and if so, how much and in what length of time?
Physical Examination
A.Check temperature, pulse, respirations, blood pressure, and weight.
B.Inspect:
1.Observe general appearance.
2.Note quality of voice patterns.
3.Note odor of breath.
4.Inspect lips, gums, tongue, buccal mucosa for swelling, discoloration, bleeding, asymmetry, texture, limited movement of tongue, abnormal ulcerations, leukoplakia, and erythroplasia. Take out dentures first.
5.Assess for tenderness or pain in mouth/tongue:
a.Leukoplakia ranges from slightly raised, white, translucent areas to dense, white, opaque plaques, with or without adjacent ulceration. Normal intraoral mucosa is pinkish or salmon-colored.
b.Mucosal erythroplasia is red, inflammatory, or erythroplastic mucosal changes. It appears smooth, granular, and minimally elevated, with or without leukoplakia, and it persists more than 14 days.
c.Erythroplakia may mimic inflammatory lesions, but it can be differentiated by failure of the affected area to blanch with light pressure. Erythroplakia is a malignant change seen as a red, velvety, plaque-like lesion on mucous membrane.
d.Other oral lesions appear black, blue, or brown.
e.Tongue, oropharynx (soft palate, lingual aspect of retromolar trigone, anterior tonsillar pillar), and floor of mouth.
f.Cancer of the lip is a lesion that fails to heal.
g.Signs and symptoms of cancer of tongue are swelling, ulceration, areas of tenderness or bleeding, abnormal texture, and limited movement.
C.Palpate:
1.Palpate mouth for masses. Try to remove or scrape patches.
2.Palpate lymph nodes: Cervical (anterior/posterior chain), submandibular, sublingual, and submental, pre/postauricular; check nodes for size, firmness, and tenderness.
D.Auscultate lungs and heart: The lungs are the most frequently involved extranodal metastatic site.
Diagnostic Tests
A.Check serum blood for HIV, if indicated.
B.Stain oral lesion with toluidine blue: Lesion stains dark blue after rinsing with acetic acid. Normal tissue does not absorb the stain.
C.Perform biopsy for persistent lesions (>2 weeks): It is essential to differentiate from blue-black lesion of malignant melanoma.
D.Perform chest radiography to rule out metastasis.
E.Consider CT, MRI, or bone scan to rule out metastasis.
Differential Diagnoses
A.Oral leukoplakia.
B.Actinic keratosis.
C.Periapical abscess.
D.Gingivitis.
E.Periodontitis.
F.Lichen planus.
G.Oral candidiasis.
H.Discoid lupus.
I.Pemphigus vulgaris.
Plan
A.General interventions:
1.If oral cancer is suspected, refer to physician or otolaryngologist/dentist for evaluation.
2.Suspicious lesions should have biopsy.
3.Leukoplakia ranges from slightly raised, white, translucent areas to dense, white, opaque plaques, with or without adjacent ulceration. Normal intraoral mucosa is pinkish or salmon-colored.
4.Mucosal erythroplasia is red, inflammatory, or erythroplastic mucosal changes. It appears smooth, granular, and minimally elevated, with or without leukoplakia, and it persists more than 14 days.
5.Erythroplakia may mimic inflammatory lesions, but it can be differentiated by failure of the affected area to blanch with light pressure.
6.Cancer of the lip is a lesion that fails to heal.
B.Patient teaching:
1.Advise the patient to stop smoking and stop using oral tobacco products.
2.Advise the patient to decrease/eliminate alcohol consumption.
3.Encourage routine dental care and exams.
4.Review dietary intake and educate patient regarding benefits of increasing dietary intake of vitamins A, C, and E. Encourage patient to decrease dietary intake of foods that are high in salt, smoked meats, fats, and oils.
5.Recommend wearing sunscreen/lip balm with sun protection factor (SPF) of 15 or greater.
C.Pharmaceutical therapy:
1.Erythroplakia does not respond to antifungal therapy.
2.Treatment is based on diagnosis.
Follow-Up
A.If immediate biopsy is not indicated, ask the patient to return for reevaluation in 2 weeks, after eliminating irritants and noxious agents.
Consultation/Referral
A.Refer the patient to an otolaryngologist and/or dentist for immediate biopsy for deeply ulcerative or fungating lesions. Follow-up treatment may include one or more of the following: wide excision, radical neck dissection, radiation, and chemotherapy.
Individual Considerations
A.Adults: The American Cancer Society recommends that people between age 20 and 40 undergo an oral cancer screening every 3 years, and those older than 40 years be screened every year. Oral screening should be considered annually in adults who use tobacco and/or alcohol.
Resources
American Academy of Family Physicians: www.aafp.org
American Cancer Society: www.cancer.org
National Cancer Institute: www.cancer.gov
Oral Cancer Foundation: www.oralcancerfoundation.org
B.Geriatrics:
1.Oral cavity cancer within the geriatric population predominantly arises between 50 and 70 years old secondary to susceptibility of mucosal disorders. Natural aging process decreases salivary secretion and risks ulceration and mucosa breakdown, which eventually lead to immune system dysfunction. This increases risk of a potential malignant disorder.
2.Evidence-based research indicated that mortality was reduced when patients over 65 years old with leukoplakia were screened and diagnosed with oral cavity cancer at an early stage.
3.A chronically dry mouth (xerostomia) affects quality of life, reduces adequate ingestion of foods, causes burning sensations and taste disturbances, and increases risk of malnutrition.
4.Thoroughly evaluate any oral pain with the geriatric population to rule out oral cancer. Normal age-related changes include yellowing/darkening of teeth, thickening composition/abrasion, gingival recession leading to root caries, and reduced sensitivity secondary to the number of blood vessels entering the tooth, which decreases the enamel.
5.Precancerous lesions might be subtle and asymptomatic. Meticulously examine lateral borders of tongue, lips, and floor of mouth where oral cancer most commonly occurs. A lesion may be white or dull red and will progress to ulceration.