Clinical assessment of a squamous cell carcinoma located in the posterior oral cavity

Wahyuning Ratnawidya; Endah Ayu Tri Wulandari; Ening Krisnuhoni; Yuniardini Septorini Wimardhani; Anak Iamaroon

doi:10.4103/SDJ.SDJ_14_19

CASE REPORT

Year : 2019 | Volume : 3 | Issue : 3 | Page : 105-108

Clinical assessment of a squamous cell carcinoma located in the posterior oral cavity

Wahyuning Ratnawidya¹, Endah Ayu Tri Wulandari², Ening Krisnuhoni³, Yuniardini Septorini Wimardhani⁴, Anak Iamaroon⁵
¹ Oral Medicine Residency Program, Faculty of Dentistry, Universitas Indonesia, Jakarta, Indonesia
² Department of Dentistry, Divisions of Oral Medicine, Cipto Mangunkusumo Hospital/Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
³ Department of Anatomical Pathology, Cipto Mangunkusumo Hospital/Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
⁴ Department of Oral Medicine, Faculty of Dentistry Universitas Indonesia, Jakarta, Indonesia
⁵ Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand

Date of Submission	03-Jun-2019
Date of Decision	18-Aug-2019
Date of Acceptance	02-Sep-2019
Date of Web Publication	14-Oct-2019

Correspondence Address:
Dr. Yuniardini Septorini Wimardhani
Department of Oral Medicine, Faculty of Dentistry, Universitas Indonesia, Jakarta
Indonesia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_14_19

Abstract

Background: Any changes in the clinical presentation of the oral mucosa in terms of the color, size, texture, and integrity should be carefully checked. Dentists are responsible for doing a comprehensive oral examination in order to find cancer lesions at the initial stage. The prognosis of an oral squamous cell carcinoma (OSCC) is still determined by the stage of the initial diagnosis. The aim of this report was to describe a posterior tongue OSCC case in a patient who underwent general anesthesia due to the gag reflex in order to obtain a thorough clinical assessment of the primary lesion and a representative biopsy sample. Case Report: A 50-year-old woman with a 4-month history of a sore tongue was referred to the Oral Medicine Clinic of the Cipto Mangunkusumo Hospital. The intraoral examination revealed an ulcer measuring 2 cm × 0.5 cm on the right ventral side of the tongue, facing the area near teeth 46 and 47. There was also a 0.5 cm × 0.5 cm × 0.3 cm white cauliflower-like nodule at the anterior portion of the ulcer. Despite the ulcerative appearance of the lesion, the posterior border of the lesion could not be defined due to its location and the patient's high gag reflex. This patient was referred to the Oral Surgery Department for a further analysis of the clinical lesion and a biopsy. The detailed clinical examination under general anesthesia revealed a much larger lesion measuring 7 cm × 4 cm × 0.3 cm. An incisional biopsy specimen was taken, and the histopathology confirmed the diagnosis of a poorly differentiated OSCC. Conclusion: A thorough clinical examination was needed to assess the oral mucosal lesion in the posterior area of the mouth in order to provide a proper definitive diagnosis.

Keywords: Gag reflex, histopathology, oral cancer examination, oral squamous cell carcinoma, tongue cancer

How to cite this article:
Ratnawidya W, Wulandari EA, Krisnuhoni E, Wimardhani YS, Iamaroon A. Clinical assessment of a squamous cell carcinoma located in the posterior oral cavity. Sci Dent J 2019;3:105-8

How to cite this URL:
Ratnawidya W, Wulandari EA, Krisnuhoni E, Wimardhani YS, Iamaroon A. Clinical assessment of a squamous cell carcinoma located in the posterior oral cavity. Sci Dent J [serial online] 2019 [cited 2023 Mar 20];3:105-8. Available from: https://www.scidentj.com/text.asp?2019/3/3/105/268996

Background

Cancer can affect almost every complex multicellular organism, and it can disturb the proliferation, differentiation, and development of cells.^[1] An oral squamous cell carcinoma (OSCC) is the most common of all oral malignancies, accounting for approximately 80%–90% of all oral cavity malignant neoplasms.^[2] Genetics is one of the relevant factors in oral carcinogenesis, in addition to infectious, chemical, radiation, and environmental factors.^[3]

One of the common clinical features of an OSCC is an indurated ulceration with a necrotic central area surrounded by elevated rolled borders.^[2] Sometimes, the clinical findings cannot indicate whether or not the lesion is malignant. A clinician should always perform a thorough clinical examination of the oral mucosa, primarily of those sites that are especially predisposed, such as the sides of the tongue and the floor of the mouth. The standard of care for providing a definitive diagnosis of nonspecific or nonhealing ulcers is a biopsy of the suspicious tissue(s) and a histopathological examination.^[4] Establishing a definitive diagnosis of an OSCC can improve the prognosis of the disease.^[5] The aim of this case report was to describe the need to do a further clinical examination and incisional biopsy in order to obtain a definitive diagnosis under general anesthesia due to the gag reflex of the patient. The patient had been consented and agreed to have the case being written and published in a scientific journal.

Case Report

A 50-year-old woman was referred to the Oral Medicine Clinic at the Cipto Mangunkusumo General Hospital with a working diagnosis of chronic stomatitis. The patient complained about pain on the right side of her tongue for 4 months that prevented her from drinking and eating solid food comfortably. The pain began to worsen 1–2 days after extraction of a carious tooth near the area. Admittedly, she had never experienced any complaints like this before. She had visited two dentists who had given her topical medications and antibiotics for the wound, but no improvements were observed. The patient had also tried to cure the wound with several types of mouthwashes. However, the complaint remained, and she noticed the wound becoming larger and not healing, without bleeding. The rest of her medical history was unremarkable. She never smoked or consumed alcohol; however, her sister had a history of cancer. She admitted that she rarely visited the dentist for oral health maintenance on a regular basis.

Her physical examination was unremarkable. The extraoral examination revealed slight right salivary gland enlargement, and the lymph nodes were unremarkable. Her intraoral examination revealed an ulcer with a white base and irregular edges surrounded by an erythematous area measuring 2 cm × 0.5 cm on the right lateral side of the tongue, facing the area of teeth 46 and 47. There was also a white cauliflower-like 0.5 cm × 0.5 cm × 0.3 cm nodule at the anterior portion of the ulcer [Figure 1]. Upon palpation of the ulcer, the patient complained of pain and nausea. A thorough examination of the lesion could not be performed, especially at the posterior margin of the ulcer. This patient's oral hygiene was average, with supra- and subgingival calculus. The lingual marginal gingiva of teeth 45 and 46 was edematous and erythematous. There were also dentinal caries in teeth 18, 28, and 48.

Figure 1: Clinical appearance of the ulcerated lesion on the right side of the tongue and the white cauliflower-like mass on the floor of the mouth

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Based on the intraoral examination, we rendered an initial diagnosis of the tongue lesion as a traumatic ulcer, with a differential diagnosis of malignancy. In addition, chronic gingivitis and dentinal caries in teeth 18, 28, and 48 were diagnosed. The initial treatment plan was gargling with 10 mL of 0.2% chlorhexidine twice a day and a referral to the Oral Surgery Department for further examination and a biopsy under general anesthesia. The incisional biopsy was performed several days later, and the histopathological results showed a poorly differentiated OSCC [Figure 2], [Figure 3], [Figure 4]. The patient was then referred to the Department of Surgical Oncology for further treatment.

Figure 2: Histopathological appearance of the malignant cells in the connective tissue (H and E, ×40)

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Figure 3: Histopathological features of the malignant cells invading the lipid and muscular tissues (H and E, ×100)

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Figure 4: High-power histopathological features showing epithelial malignant cells with mitoses and prominent nucleoli consistent with a poorly differentiated oral squamous cell carcinoma (H and E, ×400)

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Discussion

An OSCC is the most well-known oral malignancy, representing up to 80%–90% of all malignant neoplasms of the oral cavity.^[2],[3] OSCCs can affect any sites of the oral mucosa, and large lesions can invade the surrounding tissues. The most commonly affected locations are the lateral border of the tongue, the buccal mucosa, the gingiva/alveolar mucosa, and the floor of the mouth/ventral tongue.^[2] The overall 5-year survival rate for an OSCC has remained at approximately 50% or less over the past three decades.^[2] An oral malignancy, particularly tongue cancer, is associated with severe morbidity, despite advances in the treatment, including surgery, radiation, and chemotherapy. The survival rate of these patients remains very low, mainly due to the high risk of developing second primary tumors.^[6],[7] An early diagnosis is the most important factor for improving the patient survival rates to as high as 80%–90%, and this also minimizes the extent of the surgery required.^[8] Some studies have shown that regular dental visits facilitate earlier findings for this disease.^[9]

A thorough examination of the head and neck and the soft and hard tissues within the oral cavity is important for the detection of an OSCC. The examination includes a complete head-and-neck examination, with a detailed evaluation of the cervical lymph nodes for the location, size, mobility, texture, and tenderness.^[10] We completed a clinical oral cavity examination and palpated the lymphoid tissues of the neck (cervical lymph nodes) in order to look for neck masses that could represent metastases.^[8]

A careful and comprehensive mucosal examination requires good lighting for identifying any suspicious oral lesions. A useful method starts with an examination of the anterior floor of the mouth and ventral tongue, and then, one should move backward bilaterally along the lateral tongue surfaces, inspecting both the lingual mucosa and the posterior floor of the mouth. The patient is then asked to protrude their tongue forward as far as they can and to point the tip of their tongue first to the right side and then to the left side so that the posterior tongue and tongue base can be visualized.^[4] It is very important to obtain a good visualization of the poster lateral lingual mucosa, where precancerous tissue commonly presents. As an alternative technique, the clinician can gently manipulate and move the tongue with a damp swab, but this is uncomfortable and intolerant in many patients, which can ultimately lead to a poorer quality examination.^[4],[11]

The patient is then asked to say “Ah,” which allows the direct visualization of the faucial pillars, tonsils, and soft palate. In many cases, tongue depression with a spatula or mirror may improve the view. If a suspicious mucosal lesion is found, its location, size, morphology, and surface characteristics should be recorded.^[4] Then, the lesion should be gently palpated with gloved fingers, which helps to determine whether it is soft and mobile or more crepe-like or indurated. In this case, we checked whether the lesion appeared firm, indurated, fixed to underlying structures, friable, or hemorrhagic; however, the patient felt very uncomfortable.^[4],[12]

During dental treatment or an examination, gagging is a common problem, and this can make therapeutic procedures distressing and difficult or even impossible to perform.^[13] The gag reflex is considered to be a normal protective physiological mechanism that occurs in order to prevent foreign objects or noxious material from entering the pharynx, larynx, or trachea. There are two types of gagging, somatic, and psychogenic. In somatic gagging, any stimulation of the “trigger zones,” including the palatoglossal and palatopharyngeal folds, base of the tongue, palate, uvula, and posterior pharyngeal wall, will induce gagging.^[14] Gagging is also described as a somatic natural response, in which the body attempts to eliminate agents or foreign objects from the oral cavity by muscle contraction at the base of the tongue and the pharyngeal wall.^[12] The trigger zones become more posterior, and they are usually located at the tonsillar pillars after the appearance of the first dentition.^[13]

The patient in this case report was referred to the Oral Surgery Department in order to undergo general anesthesia for further examination and a planned excisional biopsy in order to confirm the clinical diagnosis of the lesion at the posterior of her tongue. It was believed that the examination of this posterior tongue lesion would induce the patient's gag reflex, and therefore, it could not be done properly. Iatrogenic factors, like the manipulation of the oral tissues, can induce a gag reflex.^[13] When stimulation occurs intraorally, the afferent fibers of the trigeminal, glossopharyngeal, and vagus nerves pass to the medulla oblongata. From there, the efferent impulses give rise to the spasmodic and uncoordinated muscle movement of gagging. The center of the medulla oblongata is close to the vomiting, salivating, and cardiac centers.^[13] Various strategies can be used to manage the gag reflex through certain approaches, such as behavior, technique, pharmacological, complimentary, and miscellaneous approaches.^[13],[14] General anesthesia is performed to manage the gag reflex when the patient does not respond to sedation or behavioral therapy.^[13]

A thorough tongue examination was performed under general anesthesia. The tongue was protruded maximally, and hard palpation or induration of the lesion was confirmed. The decision to perform an incisional biopsy was made based on the indurated nature of the lesion, which suggested the possible diagnosis of an OSCC. The incisional biopsy was performed, and the specimen was sent to the Anatomical Pathology Department. The histopathological examination revealed a poorly differentiated OSCC. The patient was then referred to the Department of Surgical Oncology for a further assessment and treatment for the OSCC.

Conclusion

This case report provides information for clinicians about the importance of doing a careful and thorough examination of the oral cavity. General anesthesia was chosen in order to do a thorough examination of the lesion located in the posterior portion of the mouth, and at the same time, an incisional biopsy was performed for a definitive diagnosis. An immediate decision was made to do a biopsy with a subsequent histopathological examination based on the presence of induration of the lesion.

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.

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