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Evaluation of a Suspicious Oral Mucosal Lesion Clinical P RACTIC E Evaluation of a Suspicious Oral Mucosal Lesion Contact Author P. Michele Williams, BSN, DMD, FRCD(C); Catherine F. Poh, DDS, PhD, FRCD(C); Allan J. Hovan, DMD, MSD, FRCD(C); Samson Ng, DDS, MSc, FRCD(C); Dr. Williams Email: Miriam P. Rosin, BSc, PhD [email protected] ABSTRACT Dentists who encounter a change in the oral mucosa of a patient must decide whether the abnormality requires further investigation. In this paper, we describe a systematic approach to the assessment of oral mucosal conditions that are thought likely to be premalignant or an early cancer. These steps, which include a comprehensive history, step-by-step clinical examination (including use of adjunctive visual tools), diagnostic testing and formulation of diagnosis, are routinely used in clinics affiliated with the British Columbia Oral Cancer Prevention Program (BC OCPP) and are recommended for consideration by dentists for use in daily practice. For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-74/issue-3/275.html ver the course of a typical practice day, Approach a dentist will examine the mouths of The diagnostic process begins with a Omany patients. On occasion, a change history that includes a review of the patient’s in the oral mucosa will be detected. The chal- chief complaint followed by completion of a lenge is to decide whether the abnormality thorough medical history. Once this has been requires further investigation. If the answer obtained, a comprehensive clinical examina- is yes, the British Columbia Oral Cancer tion including extraoral, intraoral and mu- Prevention Program (BC OCPP) team recom- cosal lesion assessments should be completed. mends a systematic approach to the evalua- Only then can a diagnosis or a decision about tion of the lesion that includes methodical the need for further investigation be rendered gathering of background information and a and appropriate decisions made regarding pa- step-by-step clinical examination (Box 1). A tient care. methodical process is important given that History of the Current Illness many mucosal conditions have a similar ap- When inquiring about the condition of pearance. A “quick look” provides insufficient concern, the dentist needs to have an ap- information and may result in misdiagnosis preciation of the symptom profile. In some and improper care. Although the recom- situations, the patient will have no com- mended approach is appropriate for use in plaints. If symptoms are present, then in- evaluating any mucosal condition, the focus formation about onset, location, intensity, of this article will be limited to one that can frequency and duration should be obtained. be used to evaluate the lesions that are more If the condition has been present for any likely to be premalignant or an early cancer. length of time, inquire about changes that JCDA • www.cda-adc.ca/jcda • April 2008, Vol. 74, No. 3 • 275 ––– Williams ––– Box 1 A systematic approach to the assessment of a topical or oral form and other medications that dry the suspicious oral mucosal lesion mouth increase risk of development of oral candidiasis, 1. History of current illness which often appears as whitish, nonadherent plaques. • onset, location, intensity, frequency, duration Finally, information regarding previous cancer history • aggravating and/or relieving variables (type and associated treatment) and any known derma- • better, unchanged or worse over time tologic conditions should be gathered. Certain derma- tologic conditions, such as lichen planus, can manifest 2. Medical, tobacco and alcohol history cutaneously and as white lesions intraorally. • medical conditions • medications and allergies Clinical Examination • tobacco and alcohol (type, frequency, duration) The clinical examination should always include extra- 3 3. Clinical examination oral and intraoral components. If a mucosal lesion is • extraoral examination identified, a systematic approach to lesion assessment is • intraoral examination recommended. • lesion inspection (adjunctive visual tools such Extraoral Examination as toluidine blue and direct fluorescence) Complete the extraoral examination first. This in- 4. Differential diagnosis cludes inspection of the head and neck region for asym- 5. Diagnostic tests metry or swelling. Palpate the submental, submandibular, • biopsy cervical and supraclavicular regions paying particular 6. Definitive diagnosis attention to size, number, tenderness and mobility of lymph nodes. A bimanual approach is recommended as it 7. Suggested management enhances the examiner’s ability to appreciate the charac- teristics of any mass and to make comparisons with the contralateral side. This is of particular importance in the neck where some lymph nodes lie under the muscles. In might have occurred — has the symptom improved, patients who have had a prior dental infection or surgical remained unchanged or worsened over time? Identifying procedure in the head and neck region, it is common to significant aggravating or relieving variables may also find small, painless, freely mobile residual lymph nodes. be helpful. It is important to remember that most oral However, if a lymph node is enlarged (i.e., > 1 cm in premalignant lesions or early cancers have few if any diameter) and palpably firm or fixed to adjacent struc- symptoms. Persistent oral sensitivity or a sense of mu- tures, referral or further investigation is indicated. To cosal “roughness” may be warning signs. If a lesion has complete the extraoral examination, inspect and palpate persisted over time or if it has become larger or more the lips and perioral tissues for abnormalities. symptomatic, it is of concern and warrants prompt and thorough investigation. Intraoral Examination Systematically inspect and palpate all oral soft tis- Medical, Tobacco and Alcohol History sues, as oral cancer can develop at any anatomical site. A comprehensive medical history that includes at- Particular attention should be given to high-risk sites, tention to tobacco and alcohol use should be obtained at which include the lateral and ventral aspects of the the time of all new patient examinations and updated at tongue, floor of mouth and the soft palate complex. general dental recall. Remember that 75% of oral cancer patients are regular users of tobacco or alcohol, which Lesion Inspection are conventional risk factors. Information to be collected If a mucosal lesion is identified, additional attention should include habit type, frequency and duration. More to its characteristics is recommended. Oral premalignant detailed information about these risk factors is included lesions and early oral cancers are quite varied in appear- elsewhere in this special issue.1 ance (Fig. 1); clinical characteristics can be used to help Review of the medical history should include a list raise the level of suspicion that a lesion may be premalig- of current medications, as certain drugs may cause oral nant or an early cancer. However, remember that a biopsy tissue changes with characteristics similar to premalig- of the lesion is required to establish a definitive diagnosis, nant or early cancer changes. (For a detailed list of as seemingly benign lesions may still pose a risk. Mucosal medication-associated mucosal changes, see Neville lesions can be predominantly white or red and have vari- and others.2) Notable examples of such drugs include able thickness and texture. A speckled red and white immunosuppressive, anti-inflammatory and antihyper- appearance, nonhealing ulceration or induration should tensive medications. Also, steroids delivered in inhaler, signal a priority need for biopsy or referral. 276 JCDA • www.cda-adc.ca/jcda • April 2008, Vol. 74, No. 3 • ––– Evaluation of Oral Lesions ––– have a rough (leathery or granular) a b or speckled surface. If a nonhomo- geneous leukoplakia contains a red component, it is called an erythrol- eukoplakia. In general, homogeneous leukoplakias are believed to carry a lower risk of transforming into cancer than nonhomogeneous leukoplakias. Erythroplakias, which are predomin- antly red lesions of the oral mucosa, carry the highest risk. c d The outline or borders of the lesion should also be considered. Diffuse le- sions, with irregular or ill-defined edges are more worrisome than dis- crete lesions. The presence of multiple lesions is considered more worrisome than a solitary lesion. As mentioned, the presence of a mucosal lesion at selected anatomic sites (lateral and Figure 1: The varied appearance of oral premalignant lesions and early oral cancer on ventral aspects of the tongue, floor the lateral aspect of the tongue. Images a to d represent lesions of increasing risk based of mouth and the soft palate com- on clinical features: (a) a smooth, white, discrete, homogeneous lesion; (b) a predomi- plex) is of greater concern. Finally, nantly red, diffuse, granular lesion; (c) a diffuse, red ulcerated lesion; (d) a diffuse, raised, speckled, indurated lesion. At biopsy, these lesions were found to be mild dysplasia, mod- leukoplakia size is also correlated erate to severe dysplasia, carcinoma in situ and squamous cell carcinoma, respectively. with cancer risk, although the cutoff size for risk level remains speculative. Most oral lesions are < 2 cm and have Location: anatomic site(s) Size: length and width a low cancer risk. Figure 3 summar- Colour: white, speckled, red; izes the key clinical features of high- homogeneous vs. non- risk and low-risk mucosal lesions. homogeneous
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