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 SEER: SEER*Stat 7.1.0

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

Epidemiology of oral cancer SEER: SEER*Stat 7.1.0

Epidemiology of oral cancer SEER: SEER*Stat 7.1.0

Epidemiology of oral cancer SEER: SEER*Stat 7.1.0;

Epidemiology: Iowa statistics In 2009, 199 new oral cancers

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 Vestibule Floor of mouth Gingiva

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 V- configuration 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

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 long- standing 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

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