1. Suspicious oral lesions: red, white, and other Nitin Pagedar, MD University of Iowa Otolaryngology – Head and Neck Surgery

2. Outline Oral anatomy Epidemiology oral cancer Risk factors for oral cancer Normal variants White and red lesions Screening for oral cancer

3. Epidemiology of oral cancer U.S. incidence: 4.2 per 100,000 per year in 2009 SEER: SEER*Stat 7.1.0

4. Epidemiology of oral cancer: context SEER: SEER*Stat 7.1.0

5. Epidemiology of oral cancer SEER: SEER*Stat 7.1.0

6. Epidemiology of oral cancer SEER: SEER*Stat 7.1.0

7. Epidemiology of oral cancer SEER: SEER*Stat 7.1.0; 1973-2009

8. Epidemiology: Iowa statistics In 2009, 199 new oral cancers

9. 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

10. Oral cavity Vestibule Floor of mouth Gingiva

11. 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

12. Normal anatomy: tongue papillae Circumvallate papillae: 8-10 papillae in a V- configuration 3-5mm each Posterior limit of the oral cavity

13. Normal anatomy: salivary ducts Stensen duct (parotid)

14. Normal anatomy: salivary ducts Wharton duct (submandibular)

15. Lumps and bumps Torus mandbularis Torus palatinus Epulis

16. Torus mandibularis Exostosis of the mandible Covered by normal mucosa Bony and nontender Does not require treatment

17. Torus mandibularis

18. Torus palatinus Exostosis of the palate Centered at the midline Like torus mandibularis, bony, nontender, and otherwise asymptomatic

19. Epulis fissuratum Overgrowth of fibrous tissue Gingiva or gingivobuccal sulcus Usually traumatic Ill-fitting (old) dentures Rx: re-evaluation by prosthodontist

20. White and red oral lesions Carcinoma Keratosis Aphthous ulcer Lichen planus Amalgam tattoo Geographic tongue

21. Carcinoma White or red discoloration Irregular border Ulceration Palpable mass

22. Carcinoma Frequently a ‘granular’ appearance with irregular borders

23. Carcinoma Frequently a ‘granular’ appearance with irregular borders

24. Carcinoma Sometimes can be nodular in appearance

25. Carcinoma Sometimes can be nodular in appearance

26. Carcinoma Sometimes can be nodular in appearance

27. Carcinoma Sometimes an ulceration with raised, irregular borders

28. Carcinoma Sometimes an ulceration with raised, irregular borders

29. Carcinoma Rarely, only a thin white patch Concern for carcinoma should prompt referral to Otolaryngologist or Oral Surgeon

30. Chewing tobacco keratosis Thickened white area where the tobacco is habitually held Chronic, with slow resolution after tobacco cessation

31. Chewing tobacco keratosis Look carefully for any irregularity within the keratotic field New pain or nodule should prompt referral

32. 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

33. Aphthous ulcer Consider referral to Otolaryngologist or Oral Surgeon if larger than 1cm, persistent for longer than 3-4 weeks

34. Lichen planus White lesion “Lace network” sometimes with ulceration Pain and tenderness Cheek and lip Sides of the tongue

35. Lichen planus

36. 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

37. Amalgam tattoo Bluish discoloration of gingiva Asymptomatic Does not blanch with pressure Related to long- standing amalgam dental filling Can persist long after tooth/filling is removed!

38. Amalgam tattoo

39. 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

40. Geographic tongue

41. 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

42. 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

43. Consultant evaluation: head and neck exam Upper aerodigestive tract −Oral cavity −Pharynx −Larynx Skin Salivary glands Thyroid and parathyroid glands Cervical lymph nodes

44. 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

45. 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