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12 • Oral Potentially Malignant Disorders and Oral Cancer
203
with chemotherapy. Surgery for oral cancer can be disfiguring and there can be significant functional side effects such
that eating, drinking and speaking are affected. Oral reconstruction and rehabilitation can improve quality of life after
treatment.
Surgery
On the basis of Cochrane reviews and meta-analysis studies, surgery is generally the preferred modality of treatment for oral cancer. Small lesions may be successfully removed by laser surgery. Radical surgery is used to remove
biopsy-proven larger primary oral cancers. It is first necessary to undertake a full hospital examination including
imaging. This often includes examination of the upper
aerodigestive tract under general anaesthesia to exclude
second primary lesions. Other tests are used to exclude
distant metastases. Informed patient consent and support
are vital. Cases are normally discussed at a meeting of all
health care professions involved in treatment. In the UK,
all new cancer cases are discussed at a MDTM; elsewhere
there may be tumour board meeting. The surgical operation aims to remove the carcinoma, with a 2-cm margin of
normal tissue beyond the clinical edge of the tumour
where possible. When the carcinoma involves bone then
part of the mandible or maxilla must also be removed.
Reconstruction is required to maintain function after excision of all but the smallest lesions. This may be accomplished using local flaps or distant pedicled or microvascular
free flaps. The latter may include bone as well as soft tissues. A large variety of flaps are available and simultaneous resection and reconstruction has revolutionised the
surgical management of patients with oral cancer. The
emphasis is now on improving the quality of the functional and aesthetic result. The reconstruction may also
involve the use of osseointegrated implants (Chapter 6).
Donor sites for flaps used in head and neck surgery include the lower limb, the upper limb and girdle, the anterior
or posterior chest wall, the abdominal wall, the scalp and
forehead. The radial free forearm flap is one of the most
commonly used with the radial artery anastomosed to the
linguofacial trunk or superior thyroid artery. The flap is soft
and pliable and good for intraoral reconstruction and radial
bone can be manipulated to provide a curved mandibular
replacement if required. However, there is risk of radial
fracture and the quality of the bone is not ideal. Microvascular techniques are usually carried out with the aid of
loupes or an operating microscope with care to avoid kinking or twisting of vessels.
A selective (removing lymph nodes at certain levels) or
radical (removing nodes at all levels) neck dissection may be
needed because of possible lymph node involvement. Neck
dissection results in some morbidity and modern surgical
techniques aim to minimise loss of function. Complications
include haemorrhage, haematoma, oedema, Chyle leak,
Horner’s syndrome, loss of shoulder function due to accessory nerve damage and infection. Decisions regarding the
patient’s need for post-operative radiotherapy are guided by
histological evidence of tumour spread to the nodes and, in
particular, to the presence of extranodal extension which is
a biological marker of aggressive tumour behaviour. The issue of neck dissection where there is no clinical, radiological
or cytological evidence of cervical nodal disease is contentious. Many centres routinely perform elective neck dissection in the clinically and radiologically negative neck
because occult metastatic disease may be present in around
25% of cases. Alternatively, dye and radioactive tracers can
be used to identify sentinel nodes in the direct drainage pathway of the tumour and individual nodes can then be removed and sampled thoroughly by the pathologist, avoiding
neck dissection where no nodal disease is found.
Radiotherapy
External beam therapy and rarely internal radiation sources
(brachytherapy) can be used as a primary treatment for
oral cancer. Radiotherapy can also be used as an adjuvant
therapy after surgery and may be combined with chemotherapy. Acute mucositis often occurs during radiotherapy
treatment but modern methods of delivering radiation such
as intensity modulated (IMRT) and image guided (IGRT)
radiation therapy can be used to minimise these. Later complications include:
n
osteoradionecrosis (see Chapter 3)
n
pathological fracture
n
dry mouth
n
radiation scar
n
chronic ulceration.
A very rare late complication is the induction of neo-
plasms such as osteosarcoma or angiosarcoma.
Chemotherapy
Many oral and oropharyngeal cancer patients receive targeted drug therapy and modern chemotherapy as part of
their management. Combinations of surgery, chemotherapy and radiotherapy are increasingly employed along with
the newer immunotherapies in suitable cases.
12.5 Role of the Dentist in Prevention, Detection and Treatment
LEARNING OBJECTIVES
You should:
• understand how the general dental practitioner can
educate patients in prevention of oral cancer.
• be aware of the need to look for and follow-up on suspi-
cious lesions.
• understand post-operative dental care for patients with
oral cancer.
• know how to refer patients to a specialist unit.
PREVENTION
Spending a few moments with a patient discussing giving
up smoking is known as an anti-smoking intervention. It
has been shown that such interventions are most efficacious when undertaken by health care professionals and
are a cost-effective method of prevention.
204
Master Dentistry
EARLY DIAGNOSIS AND SCREENING
Careful history taking and examination are essential for identification of suspicious oral mucosal lesions. Palpation of neck
nodes and systematic examination of the oral mucosa should
be routine practice. Use of toluidine blue as a screening test in
primary care is not widely practised. Lugol’s iodine may be
used to identify the extent of cancer and dysplasia prior to
surgical intervention to improve marginal clearance but has
not been used for screening. Tissue autofluorescence can be
used to aid examination of the oral mucosa but the use of
special instruments for detection has not been widely adopted.
REFERRAL
Delay should be avoided when a suspicious mucosal lesion is
detected. Telephone referral to hospital with a confidential,
detailed, follow-up letter to the specialist is a good option
when cancer is suspected. It is important to avoid undue
alarm to the patient and use of the word “cancer” should be
avoided. Many hospitals have schemes for “fast-track referral” that can be employed effectively when cancer is suspected (Chapter 2). Increasingly, referral protocols are used
and must be completed accurately and sent by secure email
(in the UK, NHS mail) to provide the specialist unit with appropriate clinical information. Primary care practitioners
should maintain an up-to-date referral strategy for referral
of patients with suspected oral cancer (Box 12.3).
DENTAL CARE PRIOR TO RADIOTHERAPY
The dentist is an important clinician in the multidisciplinary team managing oral cancer. Preventive advice and
completion of treatment to render the patient dentally fit
are vital. Teeth with a poor prognosis may be extracted to
avoid later problems with osteoradionecrosis and dental
sepsis when radiotherapy is to be given to the jaws.
POST-TREATMENT CARE
Once the acute mucositis associated with radiotherapy has
subsided, patients may experience dry mouth, bone pain and
increased caries rates. Surgical patients may require specialised restorative care and reconstruction. Recurrence or a
second primary lesion is always possible and it is important
Box 12.3 Key Clinical Features (‘Red Flags’)
that Should Trigger Referral for Oral Cancer
n
Persistent unexplained head and neck lumps for more than
3 weeks.
n
An ulceration or unexplained swelling of the oral mucosa
persisting for more than 3 weeks.
n
All red or mixed red and white patches of the oral mucosa
persisting for more than 3 weeks.
n
Unexplained tooth mobility not associated with periodontal
disease.
n
Persistent, particularly unilateral, discomfort in the throat for
more than 4 weeks.
n
Ear pain without evidence of local ear abnormalities.
(Adapted from the Scottish and NICE Guidelines for referral.)
to undertake regular review both to reassure and to detect
any mucosal changes at the earliest opportunity. Maintenance of dental health is also important; radiotherapy is a
high-risk factor for caries and 6-monthly bitewing radiographs are recommended.
Self-Assessment Questions
TRUE/FALSE
1. Carcinoma of the lip:
a. Is equally common on the upper and lower vermilion
borders
b. Is principally caused by smoking
c. Usually arises in angular cheilitis
d. Has a generally better prognosis than intraoral
cancers
e. Often arises in a field of dysplastic change
2. Submucous fibrosis:
a. Typically produces thickening of the buccal mucosa
and soft palate, resulting in limited mouth opening
and difficulty in swallowing
b. Is caused by chewing betel nuts
c. Is a hereditary disorder
d. Has oral epithelium that usually shows atrophy
e. Results in the presence of a fine fibrillary collagen
layer in the lamina propria
3. Squamous cell carcinoma of the floor of the mouth:
a. Can be caused by irritation from calculus on the
lingual aspect of the teeth
b. May be related to pooling of carcinogens in the floor
of the mouth
c. Can present clinically as a white patch
d. Infiltration of the submandibular duct can cause
symptoms of obstructive sialadenitis
e. Can metastasise to both sides of the neck
4. The classification based on TNM (tumour, nodes, metastasis) findings:
a. Is a system used for recording histopathological
grading
b. Primary carcinoma in the floor of the mouth/ventral
tongue can spread directly to level IV nodes
c. Infiltration of adjacent structures by primary carci-
noma without spread into the neck indicates stage IV
disease
d. Extracapsular spread of metastatic deposits in lymph
nodes is an indicator of poor prognosis
e. Stage I squamous-cell carcinomas have an 80%
5-year and 50% 10-year survival rate overall
5. Histopathological features of oral epithelial dysplasia:
a. Inter-observer agreement of oral epithelial dysplasia
grade among specialist pathologists is excellent
b. Includes all of the following: acanthosis, acantholysis,
drop-shaped rete processes, atypical mitotic activity
and increased nuclear/cytoplasmic ratio
c. Indicate carcinoma in situ when the dysplasia involves
the entire thickness of the epithelium
d. Mild dysplasia progresses through moderate to severe
dysplasia
e. Dysplastic oral epithelium may be found in non-
smokers and non-drinkers
12 • Oral Potentially Malignant Disorders and Oral Cancer
205
6. Of the cancers in the orofacial region:
a. The relative proportion of salivary cancers to adeno-
mas is the same in minor and major salivary glands
b. Malignant melanoma occurs only in the sun-exposed
parts of the skin in the orofacial region
c. Malignant lymphoma can arise as an extranodal
tumour in the tissues of Waldeyer’s ring
d. Intra-oral basal-cell carcinoma most commonly
arises in the floor of the mouth and ventral tongue
e. Kaposi’s sarcoma is caused by HIV (human immuno-
deficiency virus) infection
7. The following pathology reports describe squamous cell
carcinoma:
a. Histological examination shows sheets of squamous
cells supported by fibrous stroma. Keratin pearls are
present and there is focal necrosis. The squamous
cells are pleomorphic and possess hyperchromatic
nuclei. Numerous atypical mitotic figures are present. The invasive front is non-cohesive and there is a
moderate chronic inflammatory infiltrate at the
invasive front
b. Sections show oral mucosa. In the oral epithelium
there is basal cell crowding and hyperplasia. Atypical mitotic figures are present throughout the thickness of the oral epithelium. The squamous cells
show nuclear and cellular pleomorphism, and keratin whorls are present. The rete ridges are drop
shaped and individual cell keratinisation is present
in some areas
c. Sections show buccal mucosa in which there is mild
epithelial atrophy with parakeratosis. The pattern of
epithelial maturation is regular and the overall architecture is preserved. The rete processes are flattened
and bands of hyaline collagen best seen in Van Gieson
stained sections are present in the lamina propria. A
mild chronic inflammatory infiltrate is present in the
subepithelial tissue
d. Histopathological examination shows sheets of po-
lygonal cells with large nuclei possessing prominent
eosinophilic nucleoli and abundant basophilic cytoplasm. Nests of tumour cells are seen at the interface
between the oral epithelium and lamina propria.
Some individual atypical cells extend by Pagetoid
spread into the oral epithelium. The tumour cells are
positive by immunoperoxidase for S 100, Melan-A
and HMB 45 antibody staining
e. Sections of this lesion from the base of the tongue
show islands of submucosal squamous cells with
rounded cytoplasmic outlines and basophilic cytoplasm. Microfocal keratinisation is present and comedo necrosis is seen. At the periphery of the islands
the cells are often columnar and show palisading.
The tumour cells exhibit marked nuclear and cellular
pleomorphism in some areas and there is a high mitotic rate of .15 figures per high-power field
8. The following pathology reports describe a spindle cell
carcinoma:
a. Sections show oral mucosa in which there is acan-
thosis and marked hyperparakeratosis forming
“church spires”. The basal cell layer is crowded and
there is mild cellular atypia, with occasional hyperchromatic nuclei. Overall, the degree of dysplasia
can be graded as mild. Multiple levels have been examined and no invasive activity is seen
b. Examination of this biopsy of an ulcerated polypoid
swelling of buccal mucosa shows sheets of loosely
arranged cigar- and kite-shaped cells. There is nuclear and cellular pleomorphism and the mitotic rate
is ,2 figures per high-power field. The tumour cells
stain with the cytokeratin markers AE1/AE3 and
MNF 116. At the base of biopsy there are small islands of squamous cell carcinoma and the adjacent
mucosa shows severe epithelial dysplasia
c. This tumour is formed by sheets of squamous cells
supported by fibrous stroma. Keratin pearls are present and there is focal necrosis. The squamous cells
are pleomorphic and possess hyperchromatic nuclei.
Numerous atypical mitotic figures are present. Testing by in situ hybridization shows the presence of
human papilloma virus type 16 and immunohistochemistry shows overexpression of tumour p16
(CDKN2A)
d. Sections show a tumour composed of sheets of
large poorly differentiated squamous cells admixed with a large number of lymphocytes. The
tumour cells stained with cytokeratin antibodiesAE1/AE3 and MNF 116. The cells also stained
positively for Epstein–Barr virus (HHV4) using in
situ hybridisation
e. Sections show oral mucosa in which there is atrophy
of the oral epithelium with mild parakeratosis. The
basement membrane is thickened and a band of subepithelial lymphohistiocytic infiltrate is present.
Basal-cell keratinocyte apoptosis is present and reactive cytological atypia is seen
Single Best Questions
1. A 55-year-old man presents to his dentist for the first
time and is found to have a white patch with red areas
involving the floor of his mouth, ventral tongue and
lingual gingiva. He has a smoking habit of 26 pack
years, currently smokes 10 cigarettes per day and drinks
12 units of alcohol each week. He is referred to the hospital and a biopsy is taken. The pathologist describes
hyperkeratosis, atypical mitotic figures throughout the
full thickness of the oral epithelium, prominent nuclear
and cellular atypia and premature keratinisation. There
is lichenoid inflammation and no atypical epithelial cells
are seen in the lamina propria.
What is the appropriate histological diagnosis?
a. Mild epithelial dysplasia
b. Carcinoma in situ
c. Severe epithelial dysplasia
d. Erosive lichen planus
e. Squamous cell carcinoma
2. A 41-year-old woman with no significant medical history is found to have an 8 mm deeply pigmented raised
area of mucosa involving the palatal gingiva. The patient
is referred to hospital and the oral maxillofacial surgeon
is concerned about malignancy and takes an incisional
biopsy. The pathologist describes nests of rounded, bland
melanocytes in the lamina propria. No mitotic figures are
206
Master Dentistry
seen. Melanin pigment is abundant and is also present in
macrophages and in adjacent dendritic cells. A Melan-A
stain is undertaken and this shows that junctional melanocytes are present at intervals of 8–10 basal cells.
What is the most likely histological diagnosis?
a. Malignant melanoma
b. Amalgam tattoo
c. Oral melanocytic naevus
d. Oral melanotic macule
e. Melanin drop out (melanin incontinence)
3. A 78-year-old man with a history of alcohol-related cirrhosis of the liver who is currently a nonsmoker and
nondrinker presents with worsening pain over the left
cheek. He has a recent pricking sensation affecting the
left infraorbital skin. You notice that the left nasolabial
fold appears slightly fuller than the right. He is edentulous and the oral mucosa is clinically normal. No lymph
nodes are palpable in the neck.
What is the most likely diagnosis?
a. Chronic sinusitis
b. Metastatic hepatocellular carcinoma
c. Nasopharyngeal carcinoma
d. Nasolabial cyst
e. Carcinoma of the maxillary antrum
4. A 52-year-old Caucasian man is referred to a specialist
oral medicine clinic. He has sharply defined white areas
of the maxillary gingiva and palate, floor of mouth and
dorsal tongue. White patches have been present in the
mouth for 4 years and a previous biopsy was reported as
hyperkeratosis, but the patches have enlarged steadily.
There is no significant medical history. He has a smoking habit of 15 pack years but has not smoked for 3
months. His alcohol consumption is less than one unit
per week. Three biopsies are taken from various oral
sites and these all show acanthosis with verrucous hyperkeratosis and lichenoid inflammation. Only the palatal and floor of mouth biopsies show dysplasia.
What is the most likely diagnosis?
a. Proliferative verrucous leukoplakia
b. Exophytic verrucous hyperplasia
c. Oral lichenoid lesion
d. Smokers keratosis
e. Chronic hyperplastic candidosis
5. A 62-year-old woman presents with pain affecting the
left side of the palate, temporomandibular joint and infraorbital area. She has no medical history and is a
never smoker. Mouth opening is normal and the patient
reports no difficulty with eating or chewing. The only
finding is that there is a nodular swelling at the junction
of the hard and soft palate with prominent fine vessels
running over the surface. A biopsy of the palatal swelling describes a submucosal tumour composed of basaloid cells with hyperchromatic angular nuclei, double
layered ductal differentiation and small spaces producing a ‘Swiss-cheese’ appearance. No stromal inflammatory response is seen.
What is the most likely diagnosis?
a. Pleomorphic salivary adenoma
b. Adenoid cystic carcinoma
c. Ameloblastoma
d. Temporomandibular joint dysfunction
e. Adenosquamous carcinoma of the maxillary antrum
Case History Questions
CASE HISTORY 1
A 68-year-old man attended his general medical practitioner with pain in his chest. He was referred to a cardiologist
who diagnosed angina and advised him to stop smoking
and to reduce his alcohol intake. The patient mentioned
that he had mouth ulcers and he was advised to see his
dentist as soon as possible. This advice was not followed and
the patient did not make an appointment to see the dentist
until 3 months later when the ulceration under his tongue
was making it difficult to eat (Fig. 12.22).
1. Which factors contributed to delay in diagnosis and providing treatment for this patient?
2. Assuming a provisional diagnosis of oral carcinoma,
how should a biopsy be performed in this case?
3. The oral and maxillofacial surgeon advised surgical
treatment, but the patient was deemed unsuitable for
sentinel node biopsy. Why was this?
CASE HISTORY 2
An 85-year-old man presented with a 2-month history of a
numb lip on the left side. His dentist had suggested that he
leave his lower denture out for 2 weeks, but this made no
difference. A radiograph revealed a diffuse radiolucent lesion in the region of the left mental foramen. He was referred to the hospital where, on taking a full history, the
patient admitted to haematuria and weight loss over the
last 3 months. A lateral skull radiograph reveals multiple
radiolucent lesions in the calvarium and jaws. The radiologist suggests multiple myeloma as a possible diagnosis.
1. Which tests could be used to investigate this?
2. A biopsy from the swelling over the mental foramen reveals carcinoma composed of clear cells and the pathologist suggests that this lesion might be a metastatic
deposit. Which primary sites are likely?
3. How should the patient be managed?
CASE HISTORY 3
A 37-year-old woman presents for routine dental examination. Diffuse, red, velvety lesions are present on the buccal
Fig. 12.22 Ulcer in Case History 1.
12 • Oral Potentially Malignant Disorders and Oral Cancer
207
mucosa and retromolar areas in a bilateral distribution.
The patient smokes 30 cigarettes per day and does not drink
alcohol. A provisional diagnosis of erosive lichen planus is
made, and the patient is referred to the local oral medicine
unit, where a biopsy is performed.
1. The oral medicine consultant made a clinical diagnosis
of erythroplakia following biopsy. Which features are
likely to have been seen in the biopsy specimen?
2. How might the patient be managed?
3. What is the risk of malignant transformation in this case?
CASE HISTORY 4
A 38-year-old Swedish woman developed soreness of the
tongue and was referred to a local otolaryngology unit. She
is found to have iron-deficiency anaemia and she says she
has been experiencing difficulty in swallowing. Endoscopy
and barium swallow reveal an oesophageal web.
1. What syndrome does this patient have?
2. What changes may be seen in the oral epithelium in
chronic iron-deficiency anaemia?
3. The patient used oral snuff (a tobacco product) and was
advised to discontinue its use. She was surprised as snuff
had been advised in a health promotion leaflet in Sweden. What is the basis for advising her to discontinue
snuff use and why is its use advocated in Sweden?
Viva Questions
1. What ingredients are found in paan?
2. A patient presents with cancer in the oropharynx. On
protruding the tongue, it deviates to the left side. What
is the significance of this sign?
3. What factor is common to the oral premalignant
conditions?
4. What is meant by induration?
5. What are the clinical features of a cervical lymph node
involved by metastatic carcinoma?
6. What is a blind biopsy?
Self-Assessment Answers
TRUE/FALSE
1. a. False. Cancer of the vermilion border affects mainly
the lower lip.
b. False. The principal aetiological factor is ultraviolet
(ultraviolet B) exposure from sunlight.
c. False. Angular cheilitis is most often caused by infec-
tion with Candida species or Staphylococci and is not a
precancerous lesion.
d. True. Overall lip cancer has a better prognosis than
intra-oral cancer. Early detection is a factor.
e. True. Ultraviolet exposure is linked to solar keratosis,
which is a dysplastic premalignant lesion often affecting the lower vermilion border.
2. a. True. Fibrous bands are often visible in the buccal
mucosa and the affected areas appear pale and thickened on examination.
b. False. There are no such thing as betel nuts. Paan is
basically betel vine leaf into which areca nut is rolled.
Paan quid is held in the mouth for prolonged periods.
c. False. There is good epidemiological evidence linking
submucous fibrosis to paan use.
d. True. It can be reduced to only a few cell layers in
thickness.
e. True. Submucous fibrosis is characterised by deposi-
tion of fine collagen fibres beneath the oral epithelium. The papillary lamina propria is reduced and the
abnormal collagen fibres tend to be orientated parallel
to the surface of the mucosa.
3. a. False. Poor oral hygiene has been associated with oral
cancer but is not considered a causative factor.
b. True. Particularly from tobacco smoke.
c. True. It also can appear as red patches.
d. True. Squamous-cell carcinoma is often painless. In
the floor of the mouth, direct infiltration of the submandibular salivary duct by the carcinoma may
cause obstruction of the salivary flow. Obstructive
symptoms may be the clinical feature leading to
presentation.
e. True. Particularly if the primary site is in the anterior
floor of the mouth.
4. a. False. The TNM classification is used for tumour staging; grading is based on histological features.
b. True. Although the neck is divided into anatomical
compartments referred to as “levels”, primary oral
carcinoma does not necessarily spread to the first
level and then onwards in sequence from one level to
the next, as was once thought. It has now been established that lymphatic channels communicate directly
between the floor of the mouth/ventral tongue and
level IV in the neck. For example, a carcinoma arising
in the floor of the mouth can spread directly to level
IV without involving levels I–III.
c. True. Infiltration of deep/intrinsic tongue muscle,
bone and anatomical structures indicates stage IV
disease.
d. True. When squamous cell carcinoma spreads to
lymph nodes in the neck, the carcinoma cells travel via
the lymphatic vessels to the lymph nodes. The metastatic cancer cells are seen first in the subcapsular sinus within the node and further proliferation may be
restricted to the node interior. If the cancer cells are
then seen to grow through the lymph node capsule
and out into the surrounding tissue, this is described
as “extracapsular spread” by the pathologist. It is an
important pathological feature because extracapsular
spread is a powerful predictor of poor prognosis.
e. True.
5. a. False. Grading of oral epithelial dysplasia is difficult
and poor agreement even among specialist pathologists is recorded.
b. True. Acanthosis is diffuse hyperplasia; acantholysis is
disruption of the connections between keratinocytes.
c. True. Often severe epithelial dysplasia involving al-
most the entire thickness is said to amount to carcinoma in situ.
d. False. Histological progression of dysplasia is not always
seen and regression of dysplasia is thought to occur.
208
Master Dentistry
e. True. Oral epithelial dysplasia in non-smokers and
non-drinkers causes concern clinically as transformation rates are reportedly higher.
6. a. False. Although minor gland salivary tumours account for only ,10% of all salivary gland tumours,
the proportion of benign to malignant is approximately 55%–45% in minor glands and 85% to 95%
in the parotid.
b. False. Malignant melanoma can occur in the oral
mucosa, particularly in the palate and gingivae.
c. True.
d. False. Basal cell carcinoma does not arise in the oral
mucosa. Basaloid squamous cell carcinoma is a
variant of squamous cell carcinoma with a poor
prognosis.
e. False. Kaposi’s sarcoma is linked to human herpes-
virus 8 infection and is associated with immuno-
deficiency.
7. a. True. These features are typical of squamous cell
carcinoma.
b. False. The description fits best with a diagnosis of se-
vere dysplasia. The term “carcinoma in situ” that was
previously used to describe full thickness dysplasia is
no longer advocated.
c. False. The features are typical of submucous fibrosis.
Dense collagenous bands form in the oral mucosa
and there may be limitation of mouth opening and
difficulty in swallowing. Dysplasia and oral cancer
may arise.
d. False. The pathology report describes malignant mel-
anoma. This tumour may arise in the squamous
mucosa or facial skin.
e. True. Squamous cell carcinoma is quite heteroge-
neous and the report describes variant known as basaloid squamous carcinoma. It tends to be submucosal
and ulceration may not be seen.
8. a. False. The features are most in keeping with proliferative verrucous leukoplakia. This type or OPMD is a
high-risk lesion that often transforms into cancer
despite having minimal cytological atypia.
b. True. The features are typical of spindle cell carci-
noma is another recognized variant of squamous cell
carcinoma that sometimes arises after radiation therapy. The cells are lozenge- or kite-shaped and staining with cytokeratin antibodies is often needed to
identify their epithelial character.
c. False. The description is of HPV-related squamous
cell carcinoma. This variant arises in mostly in the
oro-pharynx.
d. False. The report describes nasopharyngeal carci-
noma. This tumour is more common in the Chinese
and African populations and is linked to Epstein–
Barr (HHV4) infection. This type of cancer is very
radiosensitive and has a good response to treatment
unless bone metastasis is present at diagnosis.
e. False. These features are typical of erosive lichen pla-
nus. Submucous fibrosis and erosive lichen planus
are regarded as oral potentially malignant disorders, possibly because oral epithelial atrophy may
predispose to the development of dysplasia and oral
cancer.
Single Best Answers
1. The pathological features are those of severe epithelial
dysplasia, in an erythroleukoplakia. The term carcinoma in situ was previously used to describe full thickness dysplasia, but the term is no longer recognised by
the WHO. The cytological changes and full-thickness
atypia go way beyond the criteria for mild dysplasia.
Although lichenoid inflammation is present, it is recognised that this can be a feature of oral potentially malignant disorders; the presence of dysplasia excludes lichen
planus. No atypical squamous cells are present in the
lamina propria, indicating that invasion was not found.
A diagnosis of squamous cell carcinoma therefore cannot be made. If clinical suspicion of malignancy existed,
then a further biopsy or excision of the abnormal
mucosa should be considered.
2. The histological features described are those of a benign
oral melanocytic naevus, the mucosal counterpart of a
blue naevus of skin. Malignant melanomas usually have
a junctional component where atypical melanocytes
spread become confluent and may extend into the oral
epithelium (Pagetoid spread). The pathologist describes
normal junctional melanocytes and there is no atypia or
mitosis in the nests of melanocytic naevus cells in the
lamina propria. Amalgam tattoo is a common pigmented mucosa lesion, but no nests of melanocytes
would be seen. Oral melanotic macules are encountered
most often on the vermillion border of the lip and are
essentially freckles that darken after exposure to sunlight. Melanin drop out results from increased melanin
synthesis and pigment is taken up by macrophages in
the lamina propria producing a pigmented lesion. Several factors may simulate melanin synthesis including
drugs and smoking.
3. The most likely diagnosis is carcinoma of the maxillary
antrum. Diagnosis can be difficult and clues here are invasion of the infra-orbital nerve resulting in paraesthesia.
Erosion of the antral bony wall can cause facial swelling.
Chronic sinusitis is typically bilateral and is unlikely to
cause paraesthesia. Metastatic hepatocellular carcinoma
may arise in cirrhosis and is possible but unlikely. Nasolabial cyst could cause fullness of the nasolabial fold but not
paraesthesia. Nasopharyngeal carcinoma does not cause
facial swelling.
4. The presence of steadily enlarging white patches, multifocal distribution, involvement of palate, and gingiva
and histological features makes the most likely diagnosis
proliferative verrucous leukoplakia. Exophytic verrucous hyperplasia occurs in Southeast Asia and has not
been described in Caucasian patients. Although lichenoid inflammation is described, the presence of dysplasia
excludes the diagnosis. Smokers keratosis is a benign
keratosis reactive to smoking, is reversible and has
poorly defined margins. Chronic hyperplastic candidosis
shows neutrophils in the oral epithelium and Candida
hyphae are present in the parakeratin; neither of these
are mentioned in the pathological description.
5. The histological description makes adenoid cystic carcinoma the most likely diagnosis; the Swiss-cheese appearance is pathognomonic. Perineural invasion is a
12 • Oral Potentially Malignant Disorders and Oral Cancer
209
characteristic of adenoid cystic carcinoma and can result in pain or altered sensation. Pleomorphic adenoma
is not painful and is not associated with paraesthesia.
Ameloblastoma does not show ductal differentiation.
The pathology report identifies a submucosal tumour, so
temporomandibular joint dysfunction is not a credible
answer. Unfortunately, temporomandibular joint dysfunction is far more common than maxillary adenoid
cystic carcinoma and the tumour can mimic the condition, causing erroneous diagnosis and delay. Adenosquamous carcinoma arising in the maxillary antrum is
a possibility in this case but does not show double layered differentiation that typically indicates origin from
salivary or other glandular tissue.
Case History Answers
CASE HISTORY 1
1. Oral cancer tends to be painless until advanced and
many patients delay seeking advice until there is pain or
oral dysfunction. Lack of awareness of oral cancer is
common in the general public and in some health care
professionals. When patients complain of ulceration in
the mouth, oral examination should be undertaken.
2. Incisional biopsy is normally performed by taking representative tissue of adequate size and depth from the
margin of the lesion to include normal tissue. Many oral
cancer centres prefer to see any suspected lesions and to
undertake biopsy themselves. Sometimes imaging is undertaken first and biopsy may be done at the time of examination under general anaesthesia to exclude second
primary lesions.
3. Sentinel node biopsy is a technique in which the lymph
node or nodes draining the tumour site are identified by
tracing techniques. The sentinel nodes are sampled and,
if no metastatic neoplasm is found, neck dissection is
avoided. The technique is used only for T1 and T2 tumours and N0 nodes, judged clinically.
CASE HISTORY 2
1. Examination of plasma proteins for monoclonal gammopathy, urine for Bence Jones protein, bone marrow
aspiration or biopsy may be undertaken.
2. Renal clear cell carcinoma, bladder or prostate are possible
primary sites.
3. The patient should be referred to an oncologist.
CASE HISTORY 3
1. Oral epithelial dysplasia is likely to have been seen.
Erythroplakia tends to show drop-shaped rete processes
and marked cellular atypia.
2. Erythroplakia is associated with high malignant transformation rates. The patient should be advised to give up
smoking and to attend for regular follow-up. Consideration might be given to removing discrete areas by laser
excision.
3. Malignant transformation rates of up to 50% (over
many years of follow-up) are recorded in the literature.
Rates are hard to estimate because of the poor quality of
data in the literature.
CASE HISTORY 4
1. Sideropenic dysphagia (Plummer–Vinson or Patterson–
Kelly–Brown syndrome).
2. Oral epithelial atrophy and cellular atypia have been
recorded.
3. Sideropenic dysphagia is a premalignant condition and
the use of oral tobacco should be discontinued as it
may result in malignant transformation. In some
countries, washed oral tobacco (snuff) is promoted as
an alternative to cigarette smoking to avoid the major
health risks of smoking such as lung cancer and vascular disease.
Viva Answers
1. Paan contains areca nut wrapped in piper betel vine leaf.
Tobacco, slaked lime, spices and other ingredients may
be added. Fresh, freeze-dried and other proprietary
forms are available.
2. The tumour is on the left side; fixation of the tongue by
oral cancer tends to cause the tongue to deviate to the
ipsilateral side on protrusion.
3. Epithelial atrophy.
4. Induration is a clinical term referring to the thickening
and fibrous texture of the tissues invaded by carcinoma
cells. It is an important sign to detect when palpating a
suspicious ulcer.
5. The neck node will be enlarged and fixed. It will typically
be nontender unless infection is present. Malignant
nodes may be matted together to form a craggy mass.
Central necrosis may lead to cystic change.
6. Blind biopsy is the term used to describe a procedure in
which multiple biopsies are taken (usually of the nasopharynx or tonsil) to detect carcinoma where the primary site is not apparent on clinical examination. It is
used when patients present with metastatic squamous
cell carcinoma in the neck with no obvious primary
lesion.
13
Facial Skin and Neck
CHAPTER OUTLINE
Overview, 210
13.1 Facial Skin Lesions, 210
13.2 Neck Swellings, 212
Overview
A great deal of useful diagnostic information can be ascertained by extra-oral examination as described in Chapter 2.
Dental healthcare professionals are principally concerned
with oral cavity disorders, but they also have an important
role in assessing the whole oro-facial complex and neck.
Facial skin lesions are common, particularly in the aging
population. Recognition, early diagnosis and prompt treatment of skin cancers can reduce morbidity and mortality.
Examination of the neck is an imperative part of extra-oral
examination. The neck contains the regional lymph nodes
draining the oro-facial region, major salivary glands and
midline structures, including the thyroid gland. Examination of the neck by visual inspection and palpation should
be part of routine clinical examination.
13.1 Facial Skin Lesions
LEARNING OBJECTIVES
You should:
• be aware of the wide range of facial skin disorders that
may occur (outside the scope of this chapter).
• know that patients often ignore skin tumours growing
on the face.
• be able to recognise malignant melanoma and nonmel-
anoma skin cancers.
• know that basal cell carcinoma is very common, partic-
ularly in the elderly.
• know how to refer patients with suspicious facial skin
lesions.
There are numerous disorders that affect the facial skin
and the reader should consult dermatology and medical
texts for more detailed accounts. This chapter deals with
some common and important skin tumours that dental
healthcare professional should be aware of and be prepared
to refer onwards.
NON-MELANOMA SKIN CANCER
Basal cell carcinoma (BCC), squamous cell carcinoma and rare
tumours such as Merkel cell carcinoma together constitute
Self-Assessment: Questions‚ 215
Self-Assessment: Answers‚ 217
non-melanoma skin cancer (NMSC). The incidence of
NMSC is rising and is predicted to reach 400,000 cases per
annum in the UK by 2025. The prevalence exceeds all other
malignancies combined. It is thought that the growing incidence is due to increased exposure to ultraviolet light and
people living longer. All forms of NMSC are more common
with increasing age, particularly in those working or seeking leisure outdoors without sun protection.
Cutaneous squamous cell carcinoma typically presents as
an enlarging, firm, skin coloured nodule that may have surface crust, adherent scale or show ulceration (Fig. 13.1). In-
duration (localised hardening and thickening of soft tissue) is
a key feature, and a warty cutaneous horn may be present.
Enlargement over a period of 1 to 3 months is typically described and lesions can vary in size from a few millimetres to
centimetres in diameter. A common differential diagnosis is
actinic keratosis that typically presents as a scaly plaque.
Closely related to actinic keratosis is actinic cheilitis, also
caused by exposure to ultraviolet light and affecting principally the lower vermillion border of the lip. Squamous cell
carcinoma may arise from actinic cheilitis (see Chapter 12).
BCC is the most common NMSC and typically presents as
a “nonhealing” nodule or sore which grows slowly over
months or years (Fig. 13.2). A shiny or pearly appearance
is found in BCC that is helpful for distinguishing it from
squamous cell carcinoma that has a dull appearance due to
surface keratin accumulation. BCC is typically asymptomatic (Fig. 13.3). If left untreated for many years, BCC can
invade the underlying craniofacial skeleton and become
very destructive. A variety of clinical subtypes are recognised that have distinctive features (Table 13.1). Pathologists are able to separate BCC into high risk or low risk of
recurrence on the basis of their histological features.
Patients with suspected cutaneous squamous cell carcinoma should be referred to a dermatologist through their
general medical practitioner and be seen within 2 weeks,
whereas suspected BCC can be handled as a routine referral.
Local referral guidelines should be consulted where doubt
exists. Some dermatology departments offer a teleconsultation service and a digital photograph can be a useful aid to
help to decide how to refer. A number of benign mimics of
NMSC exist including keratoacanthoma, intradermal naevus, sebaceous hyperplasia and dermatofibroma. However,
if a suspicious facial or neck cutaneous lesion is found it is
better to seek advice than disregard.
210
13 • Facial Skin and Neck
211
Fig. 13.1 Squamous cell carcinoma with a crusted surface.
Fig. 13.3 Basal cell carcinoma that was only evident when the patient
removed her spectacles.
MALIGNANT MELANOMA
Around 20% of cutaneous malignant melanomas occur in
the head and neck. Superficial spreading and lentiginous
melanomas account for more than half of head and neck
melanoma, with nodular, amelanotic and desmoplastic
variants less commonly encountered. Lentigo maligna can
be a precursor to melanoma and arises in sun-exposed skin.
It is typically flat, dark brown or black and often has irregular margins. It is seen mostly from late middle age onwards
and steady progressive enlargement is a suspicious feature.
Over time invasive melanoma may develop, clinically presenting as a raised nodular or ulcerated area, which is then
described as lentigo maligna melanoma (Fig. 13.4).
The most common presentation of malignant melanoma
is as a new or changing “pigmented mole”, but ulceration,
itching or bleeding may also be features. The ABCDE scheme
Fig. 13.2 Basal cell carcinoma on the nose that had been present for
over 2 years.
Table 13.1 Subtypes of Basal Cell Carcinoma (BCC).
BCC Subtype Proportion Key Features
Nodular 50%–70% Rolled margin, telangiectasia,
central depression, with or without erosion or ulceration, may be
invasive histologically
Superficial 5%–10% Slowly growing, scaly, pink patch,
may be multifocal histologically
Morphoeic 5%–10% Slowly enlarging white scar-like
appearance; can have extensive
subclinical spread
Pigmented 5%–10% Brown or black pearly nodule or
plaque, can be confused with
melanoma
has been used for decades and remains a useful guide for
recognising malignant melanomas (Table 13.2).
Malignant melanoma generally has an initial radial
growth phase for a few months but dermal invasion occurs
with continuing growth. Once excised prognosis is made on
histological grounds including thickness (Breslow thickness), depth, mitotic rate, ulceration and subtype. Clinical
staging is undertaken for high risk lesions.
In the United Kingdom, there are NICE guidelines for
recognition and referral of suspected malignant melanoma
using a weighted seven-point checklist. Major features
(change in size, irregular shape, irregular colour) are each
given two points and minor features (larger than 7 mm,
inflammation, oozing and altered sensation) are each given
one point. If a suspicious lesion scores three or more points
fast track cancer referral is indicated under the 2-week rule.
Any change to a pre-existing mole or the discovery of a
pigmented lesion that looks different from other moles
warrants urgent investigation.
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Master Dentistry
Fig. 13.4 Lentigo malignant melanoma. The thickened nodular area
was an invasive melanoma that had arisen in a pre-exisiting lentigo
maligna. Note that the patient has multiple, paler brown, greasy
patches of seborrheic keratosis, which are common in the elderly.
Table 13.2 ABCDE Scheme for Recognition of Malignant
Melanoma.
Asymmetry Non-matching halves across the diameter
Border Edges are ragged, indented or indistinct
Colour Non-uniform pigmentation: tan, brown, black,
white, red, blue
Diameter Greater than 6 mm is typical, may be smaller
Evolving Changes in the lesion over time
13.2 Neck Swellings
LEARNING OBJECTIVES
You should:
• know the clinical anatomy of the lymph nodes of the
neck.
• be aware that lymphadenopathy can be due to a range
of benign, reactive or malignant processes.
• know that self-limiting lymphadenopathy reactive to in-
fection is common in children.
• know that lymphadenopathy that persists for more
than 2 weeks or shows concerning signs and symptoms
may require urgent referral to a specialist.
• be aware of the common types of cysts that occur in
the neck.
• recognise thyroid and other lower neck swellings.
This section will deal principally with lymphadenopathy
and neck cysts. Salivary swellings are covered in Chapter 14.
LYMPHADENOPATHY
the nodes in the neck. It is essential to make an accurate
assessment of the neck using a combination of visual inspection and palpation. In the primary care dental setting particularly, an explanation should be offered before examining
the neck and the patients’ cooperation ensured. Tight collars
should be loosened and the patient should sit in a slightly
reclined position with the clinician standing behind. Any
enlarged lymph nodes should be noted as to location, size,
consistency, fixation to adjacent structures or freely mobile
and whether the node is tender or painful.
Further testing of lymph nodes can be undertaken in the
hospital setting using ultrasound examination, often in
dedicated “neck lump” clinics. Ultrasound can also be used
to guide fine needle aspiration biopsy which can provide
material for cytology or microbiology. Increasingly core biopsies are used to provide tissue samples from enlarged
lymph nodes and open biopsy or whole lymph node removal for diagnosis is now uncommon. Advanced imaging
such as CT, MRI and PET-CT can be used to assess lymphadenopathy in cases of diagnostic ambiguity, or in particular clinical settings such as head and neck cancer.
The principal differential diagnosis of an enlarged lymph
node or group of nodes in the neck should include infection
and malignancy. In generic terms a hard, fixed node is likely
to represent metastatic cancer, rubbery nodes are suspicious
for haematological malignancy and bilateral soft nodes that
are tender on palpation are likely to be reactive to infection.
Transient bilateral or unilateral lymphadenitis is quite common in children in reaction to systemic infection.
Bacterial Infections
In the dental setting, the most common cause of an
enlarged neck node or nodes is as a reaction to a bacterial
infection originating from the teeth or their supporting
structures. A focus of infection, such as apical abscess,
acute necrotising ulcerative gingivitis, pericoronitis or
lateral periodontal abscess is a frequent cause of acute
lymphadenitis in the neck (Fig. 13.5A and B). More distant
infections that can cause lymphadenitis are pharyngitis,
bacterial sialadenitis, skin infections and bacterial sinusitis.
Effective treatment of the infective focus will resolve the
situation and antimicrobial therapy may be required in
certain circumstances.
Some bacteria are able to persist in lymph nodes where
they cause granulomatous inflammation. The most common of these is Mycobacterium tuberculosis which typically
infects the lungs and cervical lymph nodes. The disease is
most prevalent in the developing countries of Asia and
Africa, so a good clinical history is vital to diagnosis. In
Western countries, atypical mycobacteria can cause granulomatous lymphadenitis in children and the affected nodes
are usually removed surgically. In persistent bacterial infections of this type, the lymph node parenchyma is extensively replaced by aggregates of macrophages (granulomas)
and caseating necrosis may be widespread. Rarely lymphadenitis in the neck can be caused by other bacteria including syphilis, brucellosis, leprosy and cat-scratch fever.
Examination and Investigation of Lymph Nodes
The anatomy and examination of lymph nodes in the neck
are described in Chapters 2 and 12. As outlined in Chapter 2,
a wide range of benign and malignant disorders can affect
Viral Infections
Lymphadenitis caused by viral infection is extremely common and often follows upper respiratory tract infection,
pharyngitis and the common cold. As described in Chapter 3,