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Suspicious oral lesions: red, white, and other Nitin Pagedar, MD University of Iowa Otolaryngology – Head and Neck Surgery
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Outline Oral anatomy Epidemiology oral cancer Risk factors for oral cancer Normal variants White and red lesions Screening for oral cancer
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Epidemiology of oral cancer U.S. incidence: 4.2 per 100,000 per year in 2009 SEER: SEER*Stat 7.1.0
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Epidemiology of oral cancer: context SEER: SEER*Stat 7.1.0
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Epidemiology of oral cancer SEER: SEER*Stat 7.1.0
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Epidemiology of oral cancer SEER: SEER*Stat 7.1.0
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Epidemiology of oral cancer SEER: SEER*Stat 7.1.0; 1973-2009
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Epidemiology: Iowa statistics In 2009, 199 new oral cancers
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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
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Oral cavity Vestibule Floor of mouth Gingiva
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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
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Normal anatomy: tongue papillae Circumvallate papillae: 8-10 papillae in a V- configuration 3-5mm each Posterior limit of the oral cavity
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Normal anatomy: salivary ducts Stensen duct (parotid)
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Normal anatomy: salivary ducts Wharton duct (submandibular)
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Lumps and bumps Torus mandbularis Torus palatinus Epulis
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Torus mandibularis Exostosis of the mandible Covered by normal mucosa Bony and nontender Does not require treatment
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Torus mandibularis
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Torus palatinus Exostosis of the palate Centered at the midline Like torus mandibularis, bony, nontender, and otherwise asymptomatic
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Epulis fissuratum Overgrowth of fibrous tissue Gingiva or gingivobuccal sulcus Usually traumatic Ill-fitting (old) dentures Rx: re-evaluation by prosthodontist
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White and red oral lesions Carcinoma Keratosis Aphthous ulcer Lichen planus Amalgam tattoo Geographic tongue
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Carcinoma White or red discoloration Irregular border Ulceration Palpable mass
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Carcinoma Frequently a ‘granular’ appearance with irregular borders
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Carcinoma Frequently a ‘granular’ appearance with irregular borders
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Carcinoma Sometimes can be nodular in appearance
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Carcinoma Sometimes can be nodular in appearance
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Carcinoma Sometimes can be nodular in appearance
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Carcinoma Sometimes an ulceration with raised, irregular borders
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Carcinoma Sometimes an ulceration with raised, irregular borders
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Carcinoma Rarely, only a thin white patch Concern for carcinoma should prompt referral to Otolaryngologist or Oral Surgeon
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Chewing tobacco keratosis Thickened white area where the tobacco is habitually held Chronic, with slow resolution after tobacco cessation
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Chewing tobacco keratosis Look carefully for any irregularity within the keratotic field New pain or nodule should prompt referral
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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
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Aphthous ulcer Consider referral to Otolaryngologist or Oral Surgeon if larger than 1cm, persistent for longer than 3-4 weeks
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Lichen planus White lesion “Lace network” sometimes with ulceration Pain and tenderness Cheek and lip Sides of the tongue
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Lichen planus
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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
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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!
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Amalgam tattoo
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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
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Geographic tongue
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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
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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
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Consultant evaluation: head and neck exam Upper aerodigestive tract −Oral cavity −Pharynx −Larynx Skin Salivary glands Thyroid and parathyroid glands Cervical lymph nodes
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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
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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
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