Oral cancer screening: who, what to look for, when to biopsy

What it is

Most oral cancers are squamous cell carcinomas of the lateral tongue, floor of mouth, gingiva, palate or lip. The main risk factors are tobacco in any form (smoked or chewed), alcohol (which multiplies the risk of tobacco), areca nut and betel quid, sun exposure for the lip, and immunosuppression. Human papillomavirus causes a growing share of cancers of the oropharynx (tonsils and base of the tongue) in younger non-smokers. Opportunistic screening means examining the mouth during routine care rather than population programmes; adjuncts such as dyes or lights do not replace biopsy.

Findings and interpretation

• Warning signs: an ulcer that does not heal in three weeks, a red or mixed red-white patch, induration, a lump, numbness, a loose tooth with no periodontal reason, a non-healing extraction socket.
• Erythroplakia carries a much higher risk of dysplasia or cancer than homogeneous leukoplakia.
• Persistent sore throat, a unilateral earache with a normal ear or a painless neck lump in a younger adult can be HPV-related oropharyngeal cancer.
• Survival is far higher when the cancer is small and confined to the mouth.

How it is done

1. Ask about tobacco, alcohol, areca nut, sun exposure, previous oral cancer and HIV or transplant status.
2. Perform the full systematic oral exam, including lateral tongue, floor of mouth and bimanual palpation.
3. Palpate all neck node levels.
4. Remove any obvious cause (a sharp tooth, an ill-fitting denture) and review the lesion in two to three weeks.
5. Biopsy (or refer for biopsy) any lesion that persists, is indurated, or grows.

Common mistakes

• Treating a persistent ulcer with repeated courses of antibiotics or antifungals delays diagnosis.
• A normal-looking area next to a lesion can already be dysplastic (field cancerisation) in heavy smokers.
• Adjunctive dyes and light devices have false positives and negatives; histology decides.

Next step / Initial management

• Lesion with a clear cause: remove the cause and review in two to three weeks.
• Lesion persisting beyond three weeks, any erythroplakia, induration or fixation: refer for biopsy with urgency.
• Suspected cancer with a neck lump, numbness or trismus: urgent referral to head and neck surgery (maxillofacial or ENT) through the suspected-cancer route.
• Advise stopping tobacco and reducing alcohol at every visit; refer to cessation services.

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Elsewhere in DurgiPedia

• Oral premalignant lesions: leukoplakia and erythroplakia
• Head and neck cancer: red flags and urgent referral

Connections

← All of dentistry

Educational content; it does not replace assessment by a dentist or doctor and is not a clinical instruction. For facial or neck swelling with difficulty swallowing or breathing, a knocked-out tooth or bleeding that will not stop, go to an emergency department at once.

Sources: Cancer of the Oral Mucosa (StatPearls Publishing (NCBI Bookshelf), 2024); Premalignant Lesions of the Oral Mucosa (StatPearls Publishing (NCBI Bookshelf), 2023); Oral Cancer (National Institute of Dental and Craniofacial Research (NIDCR, NIH), 2024); HPV and Oropharyngeal Cancer (Centers for Disease Control and Prevention, 2024).

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