Cancers of the Oral Mucosa Clinical Presentation

Updated: May 05, 2021
  • Author: Chelsia Q Sim, MSc, DDS; Chief Editor: Dirk M Elston, MD  more...
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Some oral squamous cell carcinomas (SCCs) arise in apparently normal mucosa, but many are preceded by clinically obvious potentially malignant disorders, especially erythroplakia (red patch), leukoplakia (white patch), erythroleukoplakia (red and white patch), or verrucous leukoplakia, and lichenoid lesions. [23, 28] Many others are associated with such lesions (especially in Southeast Asia). The challenges in predicting which oral mucosal potentially malignant disorder will progress to neoplasia are discussed more fully elsewhere. [29]

Erythroplastic lesions are velvety red plaques, with a prevalence ranging from 0.01-0.21%, [5, 30] which, in at least 90% of cases, show severe dysplasia or frank malignancy. In contrast, most white lesions are not malignant or premalignant. Speckled or verrucous leukoplakias are more likely to be premalignant. The prevalence of leukoplakias as compared with erythroplakia is higher, and severe dysplasia or carcinomatous change is more common in erythroplakia. Homogeneous leukoplakias are only very occasionally premalignant, but speckled or verrucous leukoplakias are more likely to be premalignant. In a study of 257 patients with oral leukoplakia, Silverman et al followed these patients over a mean period of 7.2 years. Of these patients, 17.5% developed carcinoma. The time from initial diagnosis of either epithelial dysplasia or hyperkeratosis to carcinoma ranged from 6 months to 39 years. [28]

In most cases, a biopsy with histologic examination is required because dysplasia may precede malignant changes. The rate of malignant changes can be as high as 36% when moderate or severe dysplasia is present. Be aware that single ulcers, lumps, red patches, or white patches (particularly if they persist >3 wk) may be manifestations of malignancy.

Oral SCC may manifest as the following:

  • A red lesion (erythroplakia)
  • A granular ulcer with fissuring or raised exophytic margins
  • A white or mixed white and red lesion (erythroleukoplakia)
  • A white (raylike) and red, unilateral lesion on lateral border of the tongue or buccal mucosa.
  • An indurated lump/ulcer (ie, a firm infiltration beneath the mucosa)
  • A nonhealing extraction socket
  • An ulcer or crust on the vermilion border of the lip lasting for over 3 weeks (rule out herpes simplex)
  • A lesion fixed to deeper tissues or to overlying skin or mucosa

Cervical lymph node enlargement, especially if hardness is present in a lymph node or fixation: Enlarged nodes in a patient with oral carcinoma may be caused by infection, reactive hyperplasia secondary to the tumor, or metastatic disease. Occasionally, a lymph node is detected in the absence of any obvious primary tumor. Nodal enlargement is a feature particularly in oropharyngeal cancers.

These potentially malignant disorders and oral SCC should be detected at an early stage; however, many oral SCCs still are seen only when advanced. Diagnosis is often delayed by up to 6-7 months, even in developed countries, despite exhortations over the past 25 years to increase the index of suspicion. Early detection and treatment is the short-term goal because this results in considerably better survival rates. Early carcinomas may not be painful and can mimic other inflammatory conditions that occur in the mouth such as lichenoid lesions and oral lichen planus [23] ; however, as they progress, they can cause pain and difficulty with speech and swallowing.

Oral medicine specialists and dental care professionals should remain vigilant for signs of potentially malignant disorders and oral cancer while performing routine oral examinations. [31]


Physical Examination

A systematic and thorough examination of the mouth, lips, fauces, and cervical lymph nodes should be performed by a clinician trained in the diagnosis of oral diseases, and a general physical examination is indicated. Oral health professionals are trained in the examination of the mouth. Examine the teeth, periodontium, and entire mucosa in good lighting.

In those with oral SCC, advanced caries, periodontal disease, or periapical lesions may need early attention, especially if radiotherapy is to be used in the management of oral SCC to avoid complications that may interrupt therapy.

The most common sites of oral SCC include the tongue, mainly the lateral and ventrolateral aspects, and the floor of the mouth; however, all areas should be scrutinized. A common site for oral SCC is the posterior portion of the tongue, which may be missed on cursory inspection; hence, special care is needed to ensure close examination.

The clinical appearance of oral cancer is highly variable and includes ulcers, red or white areas, lumps, or fissures. Lesions must always be palpated after inspection to detect induration and fixation to deeper tissues.

Erythroplakia is a red and often velvety lesion, which, unlike leukoplakias, may not form a plaque but is level with or depressed below the surrounding mucosa. Of these lesions, 75-90% may show severe epithelial dysplasia, carcinoma in situ, or invasive changes. Erythroplakia can affect patients of either sex in their sixth and seventh decades and typically involves the floor of the mouth, the ventral surface of the tongue, or the soft palate. Erythroplakias (red) oral lesions usually are more dangerous than white oral lesions.

Oral mucosal white patches usually result from increased keratinization or candidosis. Leukoplakia is restricted to white patches for which a cause cannot be established; therefore, the term implies a diagnosis by exclusion (eg, lichen planus, candidiasis). The term leukoplakia is also used irrespective of the presence or absence of epithelial dysplasia. Leukoplakia is a clinical term for a persistent adherent white patch with no histologic connotation and no implied premalignant potential. Some oral SCC can also appear as a white patch.

Late oral SCC may manifest as an exophytic lesion or an area of ulceration with induration.

A typical malignant ulcer is hard with heaped-up and often everted or rolled edges and a granular floor, as shown in the image below.

Advanced oral squamous cell carcinoma presenting a Advanced oral squamous cell carcinoma presenting as a large, ulcerated lump on the left anterior and midlateral border of the tongue.

The floor of the mouth is the second most common intraoral site for cancer and is more commonly associated with leukoplakia. Most cancer arises in the anterior floor of the mouth as a red patch progressing into ulceration and induration, resulting in slurring of speech. Floor-of-the-mouth cancer is often found in heavy drinkers.

Carcinomas of the alveolus or gingiva can present as an exophytic mass or a persistent ulcer. The underlying alveolar bone is invaded in 50% of cases, even in the absence of radiographic changes, and adjacent teeth may be loose.

Carcinomas of the buccal mucosa are mostly seen at the commissure or in the retromolar area. Most start as lumps, and some may arise in candidal-associated leukoplakia.

Any single lesion that persists more than 3 weeks, especially if red, ulcerated, or a lump with or without induration (ie, the RULE mnemonic), should be regarded with suspicion and a histopathological diagnosis established. [2]

Second primary tumors are additional primary carcinomas (synchronous tumors) present in as many as 10-15% of persons with oral carcinoma and are most commonly seen in the mouth in patients with gingival, floor of mouth, lingual, or buccal carcinoma. Second primary tumors may also be present elsewhere in the upper aerodigestive tract.

Lymph node examination is of paramount importance, and general examination and, possibly, endoscopy, may be indicated to detect metastases or second primary tumors. From 30-80% of patients with oral cancer have metastases in the cervical lymph nodes at presentation. Oral cancer predominantly metastasizes locally and to regional lymph nodes, primarily in the anterior neck. Later, dissemination to the lungs, liver, or bones may occur.

Any chronic oral lesion, over 2-3 weeks, should be regarded with suspicion when found in an older or young patient, when lesions appear (see History) with induration, with fixation to underlying tissues, with any recent changes in appearance, with associated lymphadenopathy, and without obvious explanation for the lesion. Examine the entire mucosa because widespread dysplastic mucosa (field change) or a second neoplasm (see Staging) may be present. Carefully record the location of suspicious lesions, preferably on a standard topographic diagram.

Table 1. Practical Clinical Tool for Evaluating Oral Mucosal Lesions (Open Table in a new window)



No Serious Concern

Concern: Consider Referral to Specialist if Clinician or Patient Concerned, Especially if Multiple Issues Apply

Serious Concern: Referral to a Specialist

Historical Features


No change

No reduction in size, even after eliminating trauma to lesion after 10-14 days

Increasing size, even after eliminating trauma to lesion after 10-14 days



Lesion heals

No resolution over brief observation period

Rapid symptom onset

Solitary lesion or change in one area of lesion

Lesion persisting 2-3 weeks or longer

Persistent ulceration

Persistent swelling

Loosening of a tooth

Nonhealing tooth extraction socket




Lack of pain






Speech or voice change




No weight loss

Weight loss


Lifestyle Habits


Tobacco consumption mild/moderate

Betel quid or khat consumption mild/moderate

UV light exposure mild/moderate (lip surface exposure)

Late-onset sexual debut (oral sex)

Moderate number of lifetime sexual partners

Tobacco consumption high

Betel quid or khat consumption high

Alcohol consumption high

UV light exposure high

Early sexual debut

Numerous lifetime sexual partners


Medical History


Deficiencies of iron or vitamins A, C, or E

Fanconi anemia

High-risk human papillomavirus (HPV) infection

Immune defects, including HIV/AIDS or chronic candidosis

Medications: Immunosuppressants, antihypertensives

Periodontitis, poor hygiene

Plummer-Vinson syndrome


Xeroderma pigmentosum

Deficiencies of iron or vitamins A, C, or E

Fanconi anemia

High-risk HPV infection

Immune defects, including HIV/AIDS or chronic candidosis

Medications: Immunosuppressants, antihypertensives

Periodontitis, poor hygiene

Plummer-Vinson syndrome


Xeroderma pigmentosum

Examination and Imaging

Potentially Malignant Disorder



Lichenoid mucositis (unilateral);

Oral lichen planus

Oral submucous fibrosis


Leukoplakia (speckled or verrucous)

lichenoid mucositis(unilateral)

Oral lichen planus


Lesion Features


White patch (leukoplakia)

Lichenoid mucositis (unilateral)

Oral submucous fibrosis

Red patch (erythroplakia)

Mixed red and white patch (erythroleukoplakia/speckled leukoplakia)

Granular surface

Rolled, elevated margins




Cervical Lymph Nodes

No enlargement

Possible enlargement

Enlarged, firm, fixed, nontender, asymmetric



No abnormality

Any bone density change

Poorly defined, uncorticated, irregular radiolucency

Lamina dura loss

Teeth displaced and/or resorbed

Pathological fracture