A nonhealing ulcer of the tongue involving the floor of the mouth

Arpan Manna; Tanha Khan; MK Sunil

doi:10.4103/jpcdoh.jpcdoh_23_22

CASE REPORT

Year : 2023 | Volume : 4 | Issue : 1 | Page : 18-20

A nonhealing ulcer of the tongue involving the floor of the mouth

Arpan Manna, Tanha Khan, MK Sunil
Department of Oral Medicine and Radiology, Teerthanker Mahaveer Dental College and Research Centre, Bagadpur, Uttar Pradesh, India

Date of Submission	12-Aug-2022
Date of Decision	21-Nov-2022
Date of Acceptance	27-Nov-2022
Date of Web Publication	8-Feb-2023

Correspondence Address:
Arpan Manna
Department of Oral Medicine and Radiology, Teerthanker Mahaveer Dental College and Research Centre, Bagadpur, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcdoh.jpcdoh_23_22

Abstract

A diverse category of malignancies called oral squamous cell carcinomas (OSCCs) develops from the mucosal lining of the oral cavity. The bulk of these malignancies are linked to risky lifestyle behaviors such as smoking, binge drinking, and betel nut chewing. The majority of malignant epithelial tumors of the head and neck are OSCCs, which make up 80%–90% of all malignant tumors of the oral cavity. The fifth to eighth decade of life is when the incidence rate is highest. Less than 40-year-old age groups are an uncommon exception to the OSCC rule. Although it occasionally varies on the population and the habits of the people, the border of the tongue is the most common place for OSCC, followed by the lower lip, the floor of the mouth, the ventral tongue, and the alveolar mucosa/gingiva. There have been noticeably better results on recent improvements in diagnostic and therapy planning. Although the standard of care for OSCC remains surgery, adjuvant radiation, and chemotherapy, advancements in these therapeutic modalities have allowed for better prognoses and the saving of many lives. In the present case report, we evaluated an OSCC in a 53-year-old female patient.

Keywords: Head-and-neck squamous cell carcinoma, malignancies, metastasis, oral squamous cell carcinoma, oral squamous cell carcinomas

How to cite this article:
Manna A, Khan T, Sunil M K. A nonhealing ulcer of the tongue involving the floor of the mouth. J Prim Care Dent Oral Health 2023;4:18-20

How to cite this URL:
Manna A, Khan T, Sunil M K. A nonhealing ulcer of the tongue involving the floor of the mouth. J Prim Care Dent Oral Health [serial online] 2023 [cited 2023 Mar 29];4:18-20. Available from: http://www.jpcdoh.org/text.asp?2023/4/1/18/369380

Introduction

The most prevalent malignant epithelial tumor of the oral cavity, oral squamous cell carcinoma, accounts for 80%–90% of all malignant neoplasms of the oral cavity.^[1] Males are affected more frequently than females, making the male-to-female ratio 2:1, and the incidence rate for oral squamous cell carcinoma (OSCC) is greater in older persons, especially in the fifth decade of life.^[2] Smoking, drinking alcohol, Ultra Violate radiation (primarily for lip cancer), the human papillomavirus, Candida infection, genetic susceptibility, and nutritional inadequacies are the most frequent etiological and predisposing factors of OSCC.^[1],[2] According to their size, location, and length of occurrence, OSCC's clinical appearance might vary, but generally speaking, it can seem like an ulcerated lesion with a necrotic center portion surrounding by rolled borders.^[3]

Although oral cancer is essentially a visible lesion, it can be difficult to detect early enough for successful treatment since many dental practitioners mistake it for other harmless lesions that exhibit clinically similar symptoms to oral cancer.

Case Report

The chief complaint of a 53-year-old female patient who visited the oral and maxillofacial radiology department was that she had been experiencing some slight tongue soreness and discomfort for the past 8 months. The patient described how the ulcerative mass was there when she first saw the lesion around 8 months ago and how its size grew over time. She first visited a local doctor, who prescribed her amoxicillin 500 mg and clavulanic acid 125 mg three times daily for 5 days, along with an analgesic. However, the lesion did not heal. She never went to see another doctor after that.

The medical background of the patients was not important. There is also no history of cancer in the family. She claimed that she had been chewing smokeless tobacco for 9-10 years.

A big ulcerative exophytic mass measuring 5–6 cm was discovered during a clinical evaluation in the left lateral edge of the tongue [Figure 1] and [Figure 2]. The ulceration's edges were indurated and uneven. The lesion was both firm and sensitive to the touch. The tooth's cuspal edge does not have a sharp edge next to the lesion. Moth opening was not a difficulty, and no palpable lymph nodes were seen. In addition, a clinical evaluation found no motor or neurosensory abnormalities in the tongue's normal mobility.

Figure 1: Large ulceroproliferative mass in the left lateral border of the tongue and floor of the mouth

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Figure 2: Superio-inferior expansion of the lesion

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Staging of the tumor according to the tumor–node–metastasis classification was stage II (T2N0M0).

Investigation

The patient was then sent to the department of oral and maxillofacial surgery for further care, and positron emission tomography and magnetic resonance imaging were performed to determine whether the tumor had spread to distant lymph nodes in the area.

The preliminary diagnosis of a malignant ulcer was made based on the clinical features of the lesion, site of the lesion, and patient history, and an incisional biopsy was performed.

H- and E-stained sections showed that neoplastic epithelial cells were proliferating in several islands and had penetrated deeply into the stroma of the connective tissue. Nuclear hyperchromatism, cellular and nuclear pleomorphism, aberrant mitotic patterns, and the production of numerous keratin pearls are characteristics of neoplastic cells.

Therefore, a well-differentiated squamous cell carcinoma is the final diagnosis.

Treatment

Partial glossectomy was done, and the patient was under regular observation with essential medications.

Discussion

Oral cancer, more especially OSCC, is one of the most prevalent cancers in the Indian subcontinent and the leading cause of cancer-related mortality.^[4],[5] Oral cancer develops more frequently in males than in women in developing nations. The Indian subcontinent has a high pan-tobacco use rate (a combination of betel leaf, lime, areca nut, and sun-dried tobacco).^[5]

The average age at which OSCC is diagnosed is 61 years, while 7% of diagnoses occur before age 45 and 2% occur before age 35. Recent studies have indicated a rise in OSCC in younger individuals. According to Kuriakose et al.,^[6] OSCC is more aggressive, has an invasive character, and has a worse prognosis in the early stages compared to older patients. Patel et al.^[7] also confirmed that young individuals are developing oral tongue squamous cell carcinoma more often.

The causes of OSCC are complex. Both extrinsic and intrinsic factors are present. Extrinsic factors include tobacco use, alcohol consumption, betel nut use (paan), and sunlight, while intrinsic factors include malnutrition, iron deficiency anemia, bacteria, Candida, oncogenic viruses, immunosuppression, oncogenes, and tumor suppressor genes.^[8],[9],[10] A few heritable conditions, including dyskeratosis congenita and Fanconi anemia, have been documented to occasionally be linked to OSCC.^[9]

The most prevalent location for OSCC in industrialized nations is the tongue, while in underdeveloped countries, where a high percentage of the population uses tobacco and betel nut products, the most common site is the buccal mucosa, where the users deposit the products in the buccal pouch.^[9],[10]

OSCC often manifests as well-defined red or red and white spots that are well defined and feel slightly abrasive to the touch. Although there may initially be no pain, there could be a little discomfort. Advanced oral cancer has certain well-known characteristics such as ulceration, nodularity, and attachment to underlying tissue.^{[10],[11],[12]}

Incisional biopsy, brush biopsy, the ViziLite (highlighting of keratin), oral autofluorescence, photodynamic detection, toluidine blue, methylene blue, saliva, and optical coherence tomography are only a few of the techniques utilized for early cancer identification.^[8],[13]

Although the oral cavity is a common and simple site for clinical assessment, the majority of OSCCs are only discovered in advanced stages. This can be a result of patients' ignorance and inexperienced practitioners' lack of expertise, as OSCC's basic stage is painless.^[14]

Conclusion

OSCC may occasionally imitate an inflammatory lesion or a red-white lesion in the tongue or mucosa in its early stages. These lesions often persist for more than a few weeks. The right information is necessary for the doctor to diagnose an early lesion. To lower the morbidity and mortality associated with oral cancer, biopsy and other diagnostic tools should be performed as soon as a preliminary diagnosis has been obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Patel SC, Carpenter WR, Tyree S, Couch ME, Weissler M, Hackman T, et al. Increasing incidence of oral tongue squamous cell carcinoma in young white women, age 18 to 44 years. J Clin Oncol 2011;29:1488-94.
2.	Markopoulos AK. Current aspects on oral squamous cell carcinoma. Open Dent J 2012;6:126-30.
3.	Chole RH, Patil RN, Basak A, Palandurkar K, Bhowate R. Estimation of serum malondialdehyde in oral cancer and precancer and its association with healthy individuals, gender, alcohol, and tobacco abuse. J Cancer Res Ther 2010;6:487-91.
4.	de Freitas Cordeiro-Silva M, Oliveira ZF, de Podestá JR, Gouvea SA, Von Zeidler SV, Louro ID. Methylation analysis of cancer-related genes in non-neoplastic cells from patients with oral squamous cell carcinoma. Mol Biol Rep 2011;38:5435-41.
5.	Marichalar-Mendia X, Acha-Sagredo A, Rodriguez-Tojo MJ, Rey-Barja N, Hernando-Rodriguez M, Aguirregaviria JI, et al. Alcohol-dehydrogenase (ADH1B) Arg48His polymorphism in Basque Country patients with oral and laryngeal cancer: Preliminary study. Anticancer Res 2011;31:677-80.
6.	Varsha BK, Radhika MB, Makarla S, Kuriakose MA, Kiran GS, Padmalatha GV. Perineural invasion in oral squamous cell carcinoma: Case series and review of literature. J Oral Maxillofac Pathol 2015;19:335-41. [PUBMED] [Full text]
7.	Majchrzak E, Szybiak B, Wegner A, Pienkowski P, Pazdrowski J, Luczewski L, et al. Oral cavity and oropharyngeal squamous cell carcinoma in young adults: a review of the literature. Radiol Oncol 2014;48:1-10.
8.	Warnakulasuriya S, Sutherland G, Scully C. Tobacco, oral cancer, and treatment of dependence. Oral Oncol 2005;41:244-60.
9.	Zygogianni AG, Kyrgias G, Karakitsos P, Psyrri A, Kouvaris J, Kelekis N, et al. Oral squamous cell cancer: Early detection and the role of alcohol and smoking. Head Neck Oncol 2011;3:2.
10.	Ogden GR. Alcohol and oral cancer. Alcohol 2005;35:169-73.
11.	Su CC, Yang HF, Huang SJ, Lian IeB. Distinctive features of oral cancer in Changhua County: High incidence, buccal mucosa preponderance, and a close relation to betel quid chewing habit. J Formos Med Assoc 2007;106:225-33.
12.	Ko YC, Huang YL, Lee CH, Chen MJ, Lin LM, Tsai CC. Betel quid chewing, cigarette smoking and alcohol consumption related to oral cancer in Taiwan. J Oral Pathol Med 1995;24:450-3.
13.	Subapriya R, Thangavelu A, Mathavan B, Ramachandran CR, Nagini S. Assessment of risk factors for oral squamous cell carcinoma in Chidambaram, Southern India: A case-control study. Eur J Cancer Prev 2007;16:251-6.
14.	Manna A, Handa R, Nayak A, Lehri S. Non healing ulcer of tongue: The most commonest yet the most camouflaged lesion of oral cavity. J Pearldent 2020;11:27-1.