Suspicious oral lesions:
red, white, and other
Nitin Pagedar, MD
University of Iowa
Otolaryngology – Head and Neck Surgery
Outline
• Oral anatomy
• Epidemiology oral cancer
• Risk factors for oral cancer
• Normal variants
• White and red lesions
• Screening for oral cancer
Epidemiology of oral cancer
• U.S. incidence: 4.2 per 100,000 per year in 2009
Incidence of oral cancer, 1973-2009
8
Cases per 100,000
7
6
5
4
3
2
1
0
1970
1975
1980
1985
1990
1995
2000
2005
2010
Year
SEER: SEER*Stat 7.1.0
Epidemiology of oral cancer: context
Oral and other cancers, 1973-2009
90
80
Cases per 100,000
70
60
Breast
50
Lung
40
Colon
Non-Hodgkin Lymphoma
30
Oral
20
10
0
1970
1975
1980
1985
1990
1995
2000
2005
2010
Year
SEER: SEER*Stat 7.1.0
Epidemiology of oral cancer
Incidence by sex, 1973-2009
14
Cases per 100,000
12
10
8
Male
6
Female
4
2
0
1970
1975
1980
1985
1990
1995
2000
2005
2010
Year
SEER: SEER*Stat 7.1.0
Epidemiology of oral cancer
Age distribution at diagnosis, 1973-2009
14000
Number of cases
12000
10000
8000
6000
4000
2000
0
20-29
30-39
40-49
50-59
60-69
70-79
80 +
Age group
SEER: SEER*Stat 7.1.0
Epidemiology of oral cancer
Stage at diagnosis
8
Cases per 100,000
7
6
5
Unstaged
4
Distant
Regional
3
Localized
2
1
0
1973
1977
1981
1985
1989
1993
1997
2001
2005
2009
Year
SEER: SEER*Stat 7.1.0; 1973-2009
Epidemiology: Iowa statistics
In 2009, 199 new oral cancers
Oral cancers, Iowa 2009
Gum
23%
Floor of
mouth
14%
Lip
32%
Tongue
31%
Risk factors for oral cancer
• Alcohol use
• Tobacco use
• Immunodeficiency
− CLL, transplant
• Human papillomavirus for cancer in oropharynx
− Tonsil and tongue base
− Not oral cavity
Oral cavity
Floor of
mouth
Gingiva
Vestibule
Normal anatomy: tongue papillae
Filiform papillae:
• Cover the anterior
tongue
• Less than 1mm
• Whitish color
• Not related to taste
Fungiform papillae
• Red/pink
• Elevated
• Anterior and lateral
dorsal surface
• Taste buds
Normal anatomy: tongue papillae
Circumvallate
papillae:
8-10 papillae in a Vconfiguration
3-5mm each
Posterior limit of the
oral cavity
Normal anatomy: salivary ducts
Stensen
duct
(parotid)
Normal anatomy: salivary ducts
Wharton duct
(submandibular)
Lumps and bumps
• Torus mandbularis
• Torus palatinus
• Epulis
Torus mandibularis
• Exostosis of the
mandible
• Covered by normal
mucosa
• Bony and nontender
• Does not require
treatment
Torus mandibularis
Torus palatinus
• Exostosis of the
palate
• Centered at the
midline
• Like torus
mandibularis,
bony,
nontender, and
otherwise
asymptomatic
Epulis fissuratum
• Overgrowth of
fibrous tissue
• Gingiva or
gingivobuccal sulcus
• Usually traumatic
• Ill-fitting (old)
dentures
• Rx: re-evaluation by
prosthodontist
White and red oral lesions
• Carcinoma
• Keratosis
• Aphthous ulcer
• Lichen planus
• Amalgam tattoo
• Geographic tongue
Carcinoma
• White or red discoloration
• Irregular border
• Ulceration
• Palpable mass
Carcinoma
Frequently a ‘granular’ appearance with irregular borders
Carcinoma
Frequently a ‘granular’ appearance with irregular borders
Carcinoma
Sometimes can be nodular in appearance
Carcinoma
Sometimes can be nodular in appearance
Carcinoma
Sometimes can be nodular in appearance
Carcinoma
Sometimes an ulceration with raised, irregular borders
Carcinoma
Sometimes an ulceration with raised, irregular borders
Carcinoma
Rarely, only a thin white patch
Concern for carcinoma should prompt referral to Otolaryngologist or Oral Surgeon
Chewing tobacco keratosis
Thickened white area where the tobacco is habitually held
Chronic, with slow resolution after tobacco cessation
Chewing tobacco keratosis
Look carefully for any irregularity within the keratotic field
New pain or nodule should prompt referral
Aphthous ulcer
• “Punched-out” look
• Ulcer with white or
yellow base
• Sharp margins
• Less than 1 cm
• Sometimes,
surrounding rim of
erythema
• Painful for 7-10 days
• Frequently traumatic
• Resolve over 1-3
weeks without scar
Aphthous ulcer
Consider referral to Otolaryngologist or Oral Surgeon if larger than 1cm,
persistent for longer than 3-4 weeks
Lichen planus
• White lesion
• “Lace network”
sometimes with
ulceration
• Pain and tenderness
• Cheek and lip
• Sides of the tongue
Lichen planus
Lichen planus
• Erosive lichen planus
• Ulceration
surrounded by more
typical lace-pattern
white streaks
• More irregular
ulceration than
aphthous ulcer
Irregular ulceration: Consider referral to Otolaryngologist or Oral Surgeon:
may require biopsy to distinguish from carcinoma
Amalgam tattoo
• Bluish discoloration
of gingiva
• Asymptomatic
• Does not blanch with
pressure
• Related to longstanding amalgam
dental filling
• Can persist long after
tooth/filling is
removed!
Amalgam tattoo
Geographic tongue
• Irregular pattern of
white patches
• Not palpable
• Usually not painful
• May wax and wane
• Sometimes related
to specific foods or
emotional stress
• No specific
treatment
recommended
Geographic tongue
Screening for oral cancer
• U.S. Preventive Services Task Force:
− Insufficient evidence to recommend for or against routinely
screening adults for oral cancer
− No evidence that screening leads to improved health
outcomes
• Neither average-risk patients nor high-risk patients
• Few data exist on sensitivity and specificity of physical
exam
www.uspreventiveservicestaskforce.org
Other screening tools
• Autofluorescence (VELscope)
− No studies applying this on a population basis
− For identifying dysplasia:
• Sensitivity 84%
• Specificity 15%
− With prevalence ~ 10 per 100,000:
− If 100,000 Americans screened:
• 85,000 positive tests
• Would require referral +/− biopsy
− Very low positive predictive value
Consultant evaluation:
head and neck exam
• Upper aerodigestive tract
− Oral cavity
− Pharynx
− Larynx
• Skin
• Salivary glands
• Thyroid and parathyroid glands
• Cervical lymph nodes
Consultant evaluation:
biopsy
• Incisional biopsy of oral lesion
− Local anesthesia in clinic
− Punch, scalpel, or cup forceps
− Silver nitrate or suture for hemostasis
− Preserves borders in case definitive cancer surgery is needed
Summary
• Oral cancer is uncommon
• Tobacco and alcohol use are the strongest risk factors
• Be aware of normal variants
• Patients with suspicious findings should be referred
− Otolaryngologist
− Oral surgeon
− Oral pathologist
• Current data does not support routine screening