Oral ulceration can occur for myriad reasons. Many result from immune-mediated or autoimmune pathologies, while others from physical, chemical or thermal irritation such as trauma. Others herald the development of oral cancer.
maxillofacial pathologist, Nedlands
Oral ulcers can be single or multiple, acute, or chronic, can occur in different anatomical sites, or persist in the same location. A persistent chronic oral ulcer should always raise the possibility of oral malignancy until proven otherwise. Persistent oral ulcers can be caused by ongoing chronic irritation from a physical stimulus such as a sharp tooth, but if appropriate therapy is instigated (e.g. polishing of the offending sharp edge), the ulcer will typically resolve in two weeks.
Ulcers persisting beyond two weeks, regardless of active intervention, should be considered as potentially malignant, and biopsied or referred without delay. Definitive histopathology remains the gold standard for assessment of possible malignancy. Single persistent ulcers should be biopsied with malignancy in mind. Critically, an inadequate biopsy can delay diagnosis or render an incorrect diagnosis and hence inappropriate treatment.
Oral squamous cell carcinoma (OSCC) is the most common oral cancer accounting for up to 95% of all oral malignancies. It has traditionally been considered an environmentally induced (tobacco smoking and/or heavy alcohol consumption) tumour, commonly seen in older males. There is, however, a significant increase in incidence in younger patients (under 40) and in females. Typically, it has been described as indurated and fixated. Whilst true, these features are usually seen in advanced and not early cases.
Two cases
The first, a 92-year-old female was referred by her GP with a history of smoking and regular alcohol consumption and a reported chronic persistent painful ulcer on the left lateral surface of the tongue which had been present for four to five weeks and not relieved by topical steroid cream (Fig 1).
The complex medical history included renal failure, hypertension, gout, multiple myeloma, cutaneous squamous cell carcinoma, depression, discoid eczema, post-herpetic neuralgia, and prior breast cancer. Polypharmacy was another issue.
The oral ulcer measured 10mm x 8mm in greatest dimension, was not indurated on palpation, and was reasonably well circumscribed. It did not appear associated with an offending tooth, did not respond to intra-lesional steroid injection, and following a two-week review, was excised. The histopathology showed a traumatic ulcerative granuloma with stromal eosinophilia with no evidence of dysplasia or malignancy.
The second case is a 74-year-old male, non-smoker, teetotaller, referred by his GP for a persistent oral ulcer present on the left lateral surface of the tongue for three months (Fig 2). The patient’s medical history was also complex with associated polypharmacy for gastro-esophageal reflux, non-insulin dependent diabetes, acute myocardial infarction, fatty liver, pulmonary hypertension, coronary angiography, and stent with coronary artery bypass graft.
Clinically the oral ulcer was irregular in appearance with a ragged margin, was not indurated, did not appear associated with an offending tooth, but did present with an area of white hyperkeratosis both anteriorly and posteriorly. The entire lesion, including the ulcer and keratosis was excised and the histopathology demonstrated moderately well-differentiated keratinising invasive squamous cell carcinoma.
The cases demonstrate that induration and fixation are not seen in early cases of oral cancer, and as such their use as indicators of early oral malignancy should be abandoned. Instead, continual presence of a persistent ulcer in the same anatomical location which has been present for more than two weeks after instigation of appropriate therapy should be used as a sign for early detection of an oral malignancy.
As highlighted in the second case, epithelial changes accompanying the ulceration may include the presence of leukoplakia (white patches) which signal precancerous tissue changes.
Key messages
- A persistent oral ulcer should always raise the suspicion of oral malignancy
- An ulcer persisting two weeks after appropriate therapy requires biopsy
- Fixation and induration are features of advanced oral cancers and should not be relied on to exclude early malignancy.
– References available on request
Author competing interests – the author has written a book on the topic