Oral Cancer

Oral cancer accounts for 2 to 4 percent of the cancers in the United States. 23 More than 90 percent of all oral malignancies are squamous cell carcinoma.22 Lymphomas (both Hodgkin's and non-Hodgkin's), Kaposi's sarcoma, and melanoma comprise most of the remainder. Several intrinsic and extrinsic etiologic factors for oral squamous cell carcinoma have been identified. Extrinsic factors include tobacco use, especially chewing tobacco or snuff; excessive alcohol consumption; and sunlight exposure (Fiq.,234:7l). Intrinsic factors include general malnutrition and iron-deficiency anemia, especially chronic forms such as Plummer-Vinson syndrome.

FIG. 234-7. Oral squamous cell carcinoma. A. Squamous cell carcinoma of the lip secondary to sun exposure. B. Squamous cell carcinoma of the hard palate. C. Verrucous carcinoma secondary to dipping snuff. (Courtesy of H. Anthony Neil, D.D.S.)

Specific etiologic factors play varying roles in oncogenesis. Oral candidiasis, especially in its hyperplastic form, promotes the development of oral squamous cell carcinoma. Immunosuppressive states such as HIV infection slightly increase one's risk of oral cancer, and oncogenic viruses such as human papillomavirus, herpes simplex virus, and various adenoviruses and retroviruses may play some role in the etiology of oral cancer. 1922

Oral squamous cell carcinoma has four common morphologic presentations. It can be exophytic, or mass-forming, with an irregular or papillary surface. Endophytic, or ulcerative, cancers usually present as depressed irregular ulcers with rolled borders. Leukoplakic and erythroplakic lesions, when malignant, are felt to represent squamous cell carcinomas that have yet to form a mass or ulcerate.19

The most common site involved in oral cancer is the tongue, particularly the posterolateral border, accounting for approximately 50 percent of oral cancers in the

United States. Cancer of the floor of the mouth accounts for nearly 35 percent.19 Cancer of the lips is common and usually secondary to sunlight exposure. Table

2.3.4.-3. lists the common signs and symptoms of oral cancer; unfortunately, oral cancer is generally painless, and patients are often unaware of the presence of a mass until it is advanced. Early diagnosis is the key to successful treatment of oral squamous cell carcinoma. Careful oral screening by emergency physicians through methodical examination of the oral cavity should reveal most oral carcinomas. All ulcers, erythroplakic lesions, and leukoplakic lesions of the oral cavity that do not respond to palliative treatment in 10 to 14 days warrant biopsy.

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