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ESSENTIALS OF DIAGNOSIS
White or red patch that may progress to ulcer of mucosal surface, endophytic or exophytic growth.
Lesions presenting for >2 weeks need biopsy.
Common distribution of lesions in order of frequency are the tongue, floor of mouth, and lower lip vermilion,
Risk factors include smoking and alcohol use, HPV, lichen planus, and Plummer-Vinson syndrome.
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General Considerations
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In the United States, cancers of the oral cavity and oropharynx constitute approximately 3% of all cancers among men (the ninth most common cancer among men) and 2% of all cancers among women. The prevalence of these cancers increases with age. Since the 1970s, the incidence of these cancers and the death rates associated with them have been slowly decreasing, except among African American men, for whom the incidence and 5-year mortality estimates are nearly twice as high as for white men.
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The overall survival rate for patients with oral and oropharyngeal cancers is only ∼51% and has not changed substantially since the early 1990s. However, the 5-year survival estimate for patients with lip carcinoma is >90%; this high survival rate is due in part to early detection. Most oral and oropharyngeal cancers are squamous cell carcinomas that arise from the lining of the oral mucosa. These cancers occur most commonly (in order of frequency) on the tongue, the lips, and the floor of the mouth. Approximately 60% of oral cancers are advanced by the time they are detected, and ∼15% of patients have another cancer in a nearby area such as the larynx, esophagus, or lungs. Early diagnosis, which has been shown to increase survival rates, depends on the discerning clinician who recognizes risk factors and suspicious symptoms and can identify a lesion at an early stage.
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Table 46-3 shows the risk factors associated with oral and oropharyngeal cancers. Tobacco use and heavy alcohol consumption are the two principal risk factors responsible for 75% of oral cancers. The incidence of oral cancer is higher among persons who smoke or drink heavily than among those who do not.
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All forms of tobacco, including cigarette, pipe, chewing, and smokeless, have been shown to be carcinogenic in the susceptible host. Alcohol has been identified as another important risk factor for oral cancer, both independently and synergistically when heavy consumers of alcohol also smoke. Therefore, primary prevention in the form of reducing or eliminating the use of tobacco and alcohol has been strongly recommended. The US Preventive Services Task Force (USPSTF) has not endorsed annual screening (secondary prevention) for asymptomatic patients, stating that “there is insufficient evidence to recommend for or against routine screening” and “clinicians may wish to include an examination for cancerous and precancerous lesions of the oral cavity in the periodic health examination of persons who chew or smoke tobacco (or did so previously), older persons who drink regularly, and anyone with suspicious symptoms or lesions detected through self-examination.” However, the American Cancer Society and the National Cancer Institute’s Dental and Craniofacial Research Group support efforts that promote early detection of oral cancers. The American Cancer Society recommends annual oral cancer examinations for persons aged ≥40 years.
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Because primary care providers are more likely than dentists to see patients at high risk of oral and oropharyngeal cancers, providers need to be able to counsel patients about their behaviors and be knowledgeable about performing oral cancer examinations. The primary screening test for oral cancer is the oral cancer examination, which includes inspection and palpation of extraoral and intraoral tissues (Table 46-4).
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A. Symptoms and Signs
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Early oral cancer and the more common precancerous lesions (leukoplakia) are subtle and asymptomatic. They begin as a white or red patch, progress to a superficial ulceration of the mucosal surface, and later become an endophytic or exophytic growth. Some lesions are solitary lumps. Larger, advanced cancers may be painful and may erode underlying tissue.
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According to the definition of the World Health Organization, leukoplakia is “a white patch or plaque that cannot be characterized clinically or pathologically as any other disease.” The lesions may be white, red, or a combination of red and white (called speckled leukoplakia or erythroleukoplakia). Multiple studies have shown that these lesions undergo malignant transformation. Biopsies have shown that erythroplakia and speckled leukoplakia are more likely than other types of leukoplakia to undergo malignant transformation with more severe epithelial dysplasia. Figures 46-12 and 46-13 show leukoplakia.
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Oropharyngeal carcinomas can be found in the intraoral cavity, the oral cavity proper, and the oropharyngeal sites. The most common intraoral site is the tongue; lesions frequently develop on its posterior lateral border. Lesions also occur on the floor of the mouth and, less commonly, on the gingiva, buccal mucosa, labial mucosa, or hard palate.
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A common cancer of the oral cavity proper is lower lip vermilion carcinoma. These lesions arise from a precancerous lesion called actinic cheilosis, which is similar to an actinic keratosis of the skin. Dry, scaly changes appear first and later progress to form a healing ulcer, which is sometimes mistaken for a cold sore or fever blister. Figure 46-14 shows actinic cheilosis.
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Oropharyngeal carcinomas commonly arise on the lateral soft palate and the base of the tongue. Presenting symptoms may include dysphagia, painful swallowing (odynophagia), and referred pain to the ear (otalgia). These tumors are often advanced at the time of diagnosis. Oral cancer metastasizes regionally to the contralateral or bilateral cervical and submental lymph nodes. Distant metastases are commonly found in the lungs, but oral cancer may metastasize to any other organ.
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All patients whose behaviors put them at risk of oral cancer should undergo a thorough oral examination that involves visual and tactile examination of the mouth; full protrusion of the tongue with the aid of a gauze wipe; and palpation of the tongue, the floor of the mouth, and the lymph nodes in the neck. Because oral cancer and precancerous lesions are asymptomatic, primary care providers need to carefully examine patients who are at risk of oral or oropharyngeal carcinomas. Using a scalpel or small biopsy forceps, the primary care physician should perform a biopsy of any nonhealing white or red lesion that persists for >2 weeks. Alternatively, the patient may be referred to a dentist, an oral surgeon, or a head and neck specialist, who can perform the biopsy. Patients with large lesions or advanced disease should undergo a complete head and neck examination, because 15% of these patients will have a second primary cancer at the time of diagnosis. Neck nodules with no identifiable primary tumor may be evaluated by fine-needle aspiration.
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Imaging studies such as computed tomography with contrast and magnetic resonance imaging of the head and neck are used to determine the extent of disease and involvement of the cervical lymph nodes for the purposes of staging.
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Differential Diagnosis
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Precancerous white lesions may be confused with frictional keratosis: lesions that result from chronic chewing of the cheek and nicotine stomatitis, a condition with hyerkeratotic epithelial changes on the hard palate as a result of cigarette smoking.
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Other white lesions include hairy leukoplakia, geographic tongue, and candidiasis, which should be included in the differential of precancerous lesions.
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Treatment for oral and lip cancers includes chemotherapy, surgery, radiation, or some combination of these therapies, depending on the extent of the disease. These treatments can cause severe stomatitis (inflammation of the mouth), xerostomia (dry mouth), disfigurement, altered speech and mastication, loss of appetite, and increased susceptibility to oral infection. The management of these complications requires a multidisciplinary team approach by the clinician, oral surgeon, oncologist, and speech therapist. Early diagnosis allows better treatment, cosmetic appearance, and functional outcome and increases the probability of survival. Patients should be encouraged to visit their dental health provider before beginning cancer therapy so that existing health problems can be treated and some complications can be prevented.
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Mashberg
A, Samit
A. Early diagnosis of asymptomatic oral and oropharyngeal squamous cancers.
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Neville
BW, Day
TA. Oral cancer and precancerous lesions.
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Silverman
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Weinberg
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Oral Effects of Medications
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Medications used to treat certain systemic conditions may have oral manifestations. Most commonly these include xerostomia (dry mouth), gingival hyperplasia, dental caries and erosions, and osteonecrosis of the jaw.
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Xerostomia, commonly seen in the elderly, is caused by hypofunction of the salivary gland, but has also been caused by antihypertensives, antidepressants, protease inhibitors, antihistamines, and diuretics. Xerostomia increases the risk of denture sores and caries, since saliva is a lubricant with antimicrobial properties. Symptoms include a sensation of dry mouth. Treatment is avoidance of medications known to cause xerostomia and careogenic foods, good oral hygiene, and salivary substitutes or stimulants.
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Gingiva hyperplasia has been associated with calcium channel blockers, methotrexate, cyclosporine, and phenytoin. Dental caries may be caused by syrups such as cough medicines, and dental erosions may follow use of β-blockers, calcium channel blockers, nitrates, and progesterone. Treatment is avoidance of medications associated with gingiva hyperplasia.
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Avascular osteonecrosis of the mandible and maxilla have been associated with bisphosphonates. Symptoms include swelling and pain, difficulty eating, bleeding, lower lip paresthesia, and loose and mobile teeth. Since radiographs are nonspecific, lesions should be biopsied for definitive diagnosis. Risk factors include IV bisphosphonates, cancer, invasive dental procedures, smoking, steroid use, radiation therapy, and poor dental hygiene. Patients should be advised to avoid dental procedures while taking these medications.
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Gonsalves
W, Wrightson
AS, Henry
R. Common oral problems in older patients. Am Fam Physician. 2008; 78(7):845–852.
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Ghezzi
E, Ship
J. Systemic diseases and their treatments in the elderly: impact on oral health. J Public Health Dent. 2000; 60(4):289–296.
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Turner
M, Ship
J. Dry mouth and its effects on the oral health of elderly people. J Am Dent Assoc. 2007; 138 (suppl):15S–20S.
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Global References for Oral Health
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Beltram-Aguilar
ED
et al.. Centers for Disease Control and Prevention: surveillance for dental caries, dental sealants, tooth retention, edentulism and enamel fluorosis—United States, 1988–1994 and 1999–2002.
MMWR Surveill Summ. 2005; 54:1.
[PubMed: 16121123]
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US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General—Executive Summary. DHHS, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.