With every new patient and re-call exam, a head/ neck exam is recommended. This gives our profession a chance to detect irregularities that are usually not checked for by the patient’s regular physician. In fact, in North America, people visit their dentists more often than their physician, therefore the dental profession can act as a gateway to one’s general health. In this article, we review some of those irregularities – how to predict, detect and manage them, even if we encounter them rarely throughout our careers.
Detection of red or red-white lesions in the mouth can point to anything ranging from transient trauma to benign/ malignant neoplasms. It is our job to detect and manage possible neoplasms. Here we present a guide to do so.
Characteristics of precancerous or cancerous lesions:
- Uniform red coloration (erythroplakia) or mixture of red-white coloration (erythroleukoplakia).
- Flat, elevated or ulcerated surface.
- Could be indurated or non-indurated
- Pain: Although the patient’s perceived pain could be variable, suspicious lesions could be associated with pain, numbness, or sensitivity to hot/spicy foods. Sharp/ stabbing/ electric shock sensation could indicate neural involvement.
- Length of time: The lesion has been present for 2 weeks or longer.
- Location: High-risk areas are the lateral/ventral borders of the tongue or floor of the mouth, tonsils, base of the tongue or retromolar pad area.
- Although cancerous lesions are less often bi-lateral, lesions can present as bilateral or unilateral.
Management of suspicious lesions:
- A thoroughly updated medical history is the key to uncovering possible etiologies. Key points are – smoking and alcohol intake history, prescribed or self-prescribed medication usage, HPV status (as most oropharyngeal cancers are caused by the HPV virus)
- History and duration of the lesion: Short duration could indicate trauma or infection. Medium to long-term duration (longer than 2 weeks) could indicate benign/ malignant neoplasms, infection or abnormal immune/ metabolic activity. Pre-neoplastic lesions can evolve throughout time, so careful/ repeated documentation, monitoring and biopsy is required.
- Thorough head and neck exam should be done to assess surrounding areas of the lesions. Check for any pain/discomfort when palpating cranial nerves. Check for any pain, tenderness on palpation of head/neck lymph nodes on ipsilateral or contralateral sides.
Adjunctive testing:
- Suspicious lesions should be followed up with further testing – biopsy of the area and possible immunofluorescent analysis. Referral to oral medicine, oral pathology or surgery should also be considered.
Differential Diagnosis
Abnormal immune reactions: Hypersensitivity, medication reactions, lupus, or lichenoid mucositis.
Metabolic reactions: Anemia
Infections: Candidiasis, syphilis, gonorrhea
Trauma: Functional, chemical and thermal.
Dysplasia/ neoplasms: Keratosis, soft tissue neoplasms, lymphoma, leukemia, and squamous cell carcinoma.