Let's Talk About Oral Cancer
A healthy mouth goes far beyond polishing your pearly whites. Here's what to look out for if you're worried about cancer.by Stephanie Wood Health Writer
Who hasn’t had a mouth sore? Those tender, burning ulcers on the inside of your cheek or tongue are seriously annoying. You probably chalk it up to a basic canker sore (and it probably is), but if it doesn’t go away, gets bigger, or starts to bleed, it’s a sign something else could be up. Malignancies of the mouth aren’t common and they are curable, but you don’t want to procrastinate whenever there’s a question of cancer. Here’s the doctor-approved lowdown on what to watch for.
Our Pro Panel
We went to some of the nation's top experts on head and neck cancer to bring you the most up-to-date information possible.
Salvatore M. Caruana, M.D.
Director of the Division of Head and Neck Surgery
New York-Presbyterian Hospital Columbia University Medical Center
New York, NY
Nadia Mohyuddin, M.D.
Head and Neck Surgical Oncologist, Associate Professor of Clinical Otolaryngology
Houston Methodist Hospital
J. Kenneth Byrd, M.D.
Chief of Head and Neck Surgery, Medical Director and Research Director
Georgia Cancer Center at Augusta University
The primary doctor for mouth cancers is usually an otolaryngologist, also known as an ear, nose, and throat (ENT) doctor. These pros are trained to perform many types of surgery on the delicate and complex tissues of the head and neck. Plastic surgeons, dentists, and oncologists may also play a role in your surgery and follow-up treatment.
Surgery is usually the first line treatment for cancers of the mouth that have been caught early. If your surgeon is able to remove all the cancer you may not need any further treatment. Radiation is the next step and often highly effective for these cancers. Drug treatments are usually reserved for more advanced, less responsive cases.
In a word, yes. Research shows that about a third of the time, or in 32.7% of patients, the cancer returns. The earlier your cancer was found and whether it spread to any lymph nodes influence the odds of recurrence. In addition, mouth cancer patients are also at increased risk of a second primary tumor occurring down the road—in the oral cavity or elsewhere. Sometimes this occurs as a side effect of radiation and chemotherapy treatment.
The relationship between dental and oral health is a two-way street: Poor dental hygiene and decay can contribute to cancer development, and cancer treatments like radiation can weaken teeth. Your treatment team will likely want you to have any dental issues taken care of before beginning radiation for this reason. Don’t stress too much: Dental implants can replace original teeth that are damaged or lost due to cancer.
What Is Oral Cancer, Actually?
Consider how amazing your mouth is: It feeds you, brings you air, and allows you to communicate. All it asks in return is that you brush, floss and see a dentist regularly. It’s kind of amazing that your oral cavity—as the docs prefer to call it—doesn’t act up more often, what with all the insults thrown at it everyday like spicy food, coffee, chewing gum, and of course, way too much sugar.
Yet despite the nonchalant attitude most Americans cop toward oral health, cancers of the mouth are not super common: About 30,000 people are diagnosed with them each year, making them the most frequently occurring in the head and neck cancer family, but only 3% of all cancers.
Mouth cancers affect men twice as often as women, as well as mostly older people—the average age of diagnosis is 62. But when mouth cancers do occur, the outlook is not great. Only slightly more than half of all patients (57%) will still be alive five years later. Let’s take an inside look at what’s up with this mystifying malady.
What Are the Types of Mouth Cancer?
The oral cavity consists of essentially everything in your mouth: It starts with the lips, includes the front two-thirds of the tongue, the gums, the lining inside the cheeks and lips (known as the buccal mucousa), the bottom of the mouth under the tongue known as the floor, the hard bony palate at the top of the mouth, and the small area of the gum tucked behind the wisdom teeth (known as the retromolar trigone). In addition, most cancers of the jaw begin in the oral cavity and then extend into the jaw bone.
More than 90% of mouth cancers are squamous cell carcinomas. These cancers develop in the squamous cells, which are flat, fish scale-like cells that form the lining of the mouth and throat. Beyond that, these cancers are named for their location.
Buccal cancer begins inside the mouth in the mucosal lining of the cheek. It may also be referred to as inner cheek cancer.
Gum cancer starts in the upper or lower gums and may be mistaken for gingivitis.
Floor of mouth cancer begins in the horseshoe-shaped area under the tongue.
Lip cancer begins on either the upper or, most commonly, lower lips.
Oromandibular cancer involves the lower jaw. It almost always begins elsewhere in the mouth—most typically the gums (alveolar ridge), floor of the mouth, or behind the wisdom teeth (retromolar trigone)—and then invades the jaw.
Palatomaxillary cancer begins in the roof of the mouth (the hard palate) or the upper alveolar ridge (part of the maxilla or upper jaw). It’s also known as hard palate cancer.
Tongue cancer begins in the front two-thirds of the tongue, known as the oral tongue.
What Causes Oral Cancer?
This is not one of those diseases that’s a headscratcher. In the vast majority of oral cancer cases, tobacco (cigarettes, pipes, cigars, chewing) plus drinking more than a little alcohol is to blame. Pipe smoking in particular has been linked to cancer where the lips touch the pipe stem, and chewing tobacco (or snuff) increases the risk of cancer in the cheeks, gums, and inner lips where the tobacco has the most contact. (While it’s too soon to have real data on the effects of vaping, it’s probably not a good idea either.) Here are a few other things that can affect your risk:
Paan (betel quid). This chewable combo of betel leaf and areca nut is popular among Southeast Asians for its stimulant and psychoactive effects (think cocaine) and its use has been strongly associated with an increased risk of oral cancer.
Oral health. Poor oral hygiene and missing teeth may be weak risk factors for cancers of the oral cavity. Use of mouthwash that has a high alcohol content is also a possible, but not proven, risk factor for cancers of the oral cavity.
Poor diet. A diet low in fruits and vegetables and a vitamin A deficiency may increase the risk of oral cancer.
Prolonged sun exposure. Excessive and unprotected exposure to the sun is linked with lip cancer, although some of these are melanomas, a form of skin cancer.
Fair skin. Being light-skinned is also linked to a higher risk of lip cancer.
Signs and Symptoms of Mouth Cancer
Unlike other head and neck cancers which remain hidden, a good thing about oral cavity cancers is that they can be visible to a primary care doctor or dentist. Don’t postpone those checkups and it’s also smart to look at your mouth in a mirror once a month.
Oral cancers often don’t cause symptoms in the early stage, so watching for changes in your mouth is critical, especially if you use tobacco or drink alcohol. These are some (but not all) signs to watch for:
red, white, or dark patches
a sore throat that does not go away
a sore spot (ulcer) or lump that does not go away
mouth or jaw pain
recurrent bleeding from the mouth
bleeding or cracking gums or lips
thick areas of the gums
loose teeth or dentures that don’t fit correctly
If any of these symptoms sound familiar, it’s time to see your doctor—hopefully it’s nothing, but you don’t want to mess with mouth cancer. Any symptoms that don’t clear up in about two weeks need to be checked out. If you’ve got a dental appointment coming up, that’s fine for a first step because these pros know what to look for and can refer you to a head and neck expert for further evaluation if need be (ditto your primary care doc).
How Do Doctors Diagnose Mouth Cancer?
There is no standard screening test, so a cancer work-up will start with taking your personal medical history followed by a complete head and neck exam that includes looking at and feeling for any abnormalities inside your mouth with gloved fingers. The doctor will look carefully for lesions (areas of abnormal tissue), including patches of cells that are white or red—these may become cancerous. These procedures may also be used:
Toluidine blue stain: Lesions in the mouth are coated with a blue dye and then observed for areas that stain darker, which are more likely to be or become cancer.
Fluorescence staining: A fluorescent mouth rinse is given, then lesions in the mouth are viewed using a special light that reveals abnormal tissue.
Exfoliative cytology: Cells are gently scraped from the lips, tongue, or mouth with a piece of cotton or a wooden stick, then examined for abnormalities under a microscope.
This type of test is the gold standard for determining a cancer diagnosis. It involves removing a sample of tissue or cells and examining it under a microscope. Different methods may be used, depending on where the tumor is located. They include:
Incisional biopsy: During this most common type of biopsy, your doctor surgically removes a small piece of the suspected tissue while you’re under general anesthesia.
Punch biopsy: Your doctor will use a tool called a punch forceps to remove a piece of the suspicious area while you are under local anesthesia.
Excisional biopsy: This procedure removes most or all of the tissue suspected of having cancer while you’re under general anesthesia.
Brush biopsy: A special brush is used to collect cells from a lesion. A traditional biopsy will still need to be performed to confirm a malignancy, but it can be a convenient screening tool to see if an abnormal area needs more investigation.
You may also undergo imaging tests to get more information about the tumor, its location, and any regional spread to the lymph nodes or jawbone, including:
Computed tomography or computed axial tomography (CT or CAT) scans
Magnetic resonance imaging (MRI)
Positron emission tomography (PET) scans
Oral Cancer Staging
Once you’ve been diagnosed with mouth cancer, the next step is to determine how early or advanced it is. This process is called staging and it describes where the cancer is, the size, and whether or not it has spread to other parts of the body. The results from your diagnostic tests and scans will be used to calculate what’s known as TNM staging for the cancer:
Tumor (T): Where and how large is it?
Node (N): Has the cancer reached the tiny, bean-shaped organs known as lymph nodes—and if so, where and how many?
Metastasis (M): Has the cancer spread, and if so, where and how much?
These results are then combined to determine the cancer’s numerical stage, ranging from 1 to 4, and the best course of treatment. Here’s the breakdown for how cancers of the oral cavity are staged:
Stage I: The tumor is 2 cm or smaller, and the depth of invasion is 5 mm or less. The cancer has not spread to lymph nodes or other parts of the body.
Stage II: The tumor is 2 cm or smaller, and the depth of invasion is between 5 and 10 mm. Or, the tumor is between 2 cm and 4 cm, and the depth of invasion is 10 mm or less. The cancer has not spread to lymph nodes or other parts of the body.
Stage III: The tumor is either larger than 4 cm or it has a depth of invasion greater than 10 mm, and the cancer has not spread to lymph nodes or other parts of the body. Alternately, the tumor could be any size, has spread to a single lymph node on the same side (lymph node cancer is less the 3 cm), and has not invaded nearby structures.
Stage IV: There are multiple permutations of stage 4 oral cancer, indicating the degree of spread. In all cases, the cancer has spread to the lymph nodes and/or other tissues in the body.
Treatments for Mouth Cancer
Get ready to make lots of new friends: Treatment for oral cavity cancers involves an entire team of experts, including surgeons, oncologists, radiologists, pathologists, dental oncologists, speech and swallowing therapists, and nurses, as well as mental health pros like psychologists, psychiatrists, and social workers.
Whew. This dream team will be your support network for everything physical and emotional and can help you make the treatment decisions that will lead to the best possible outcome. Let’s run through the possibilities.
The main treatment for most people with mouth cancer is surgery, with the goal of removing all the cancer and preserving your quality of life. Most of these procedures can now be done either robotically or via laser microsurgery. Known as transoral surgery, this through-the-mouth method results in less pain and has a faster recovery time. The type of surgery will depend on the kind of cancer you have and, since mouth cancers often spread first to the lymph nodes in the neck, affected nodes may also be removed at the same time, a procedure known as a lymph node dissection. The options:
Glossectomy: This surgery for tongue cancers may involve taking out the entire tongue or only part of it. The area is then reconstructed using skin and tissue from your forearm, thigh, or abdomen. A sensory nerve from the forearm can also be used to provide sensation in the new tongue and improve your ability to speak and swallow.
Mandibulectomy: This surgery is commonly used for cancers that begin in the lower gums or floor of the mouth and involves the removal of part of the jawbone (mandible) when a tumor is very close or attached to the bone. With a marginal mandibulectomy that involves just a rim of the jawbone, no reconstruction is needed. If the full thickness of the jaw has to come out, known as a segmental mandibulectomy, the jawbone will need to be rebuilt using bone from another part of your body.
Maxillectomy: This surgery for mouth cancers that begin in the hard upper palate or gums leaves a gap in the roof of your mouth that can be repaired with either reconstructive surgery or with a custom-fit prosthesis.
Radiation therapy—the use of high-energy particles like photons and protons to kill cancer cells—has been shown to be highly effective in mouth cancers. It may be used as the main treatment or as a secondary, post-surgery treatment to prevent the cancer from growing back. There are two main approaches:
External-beam radiation therapy: This method aims radiation at the tumor from a machine and is the type most often used for mouth cancers.
Intensity-modulated radiation therapy (IMRT) is a type of external-beam radiation therapy that delivers more targeted doses of radiation while reducing side effects and damage to healthy cells.
Radiation treatments are usually given five days a week for six or seven weeks. Sometimes lower doses are given twice a day instead, or the treatment is done on an accelerated scheduled that may include two or more doses daily over three weeks instead of six. Radiation side effects include:
changes in skin that look like a sunburn
changes in taste
difficulty swallowing or speaking
dryness of the mouth
loss of appetite
pain, sores, or redness in the mouth
weakening of teeth
Medications used to treat cancer travel through your entire body via your bloodstream. This systemic form of treatment can cause side effects in areas not related to the cancer, but these meds are also highly effective at destroying cancer cells. There are three types of drug therapies for mouth cancers, which may be given separately or in combination and intravenously or in pill form.
Chemotherapy: Often used in conjunction with radiation, chemo targets rapidly growing and dividing cancer cells. Two or more chemo drugs may be given together, and the treatment can last several months, with a new round or “cycle” given every two to three weeks. The therapy can also kill off normal cells, leading to side effects like hair loss and nausea.
Targeted therapy: These next generation meds attack only the specific genes, proteins, and tissue that contribute to the cancer’s growth. Two options are available for more advanced cancers. Cetuximab (Erbitux) is an EGFR (epidermal growth factor receptor) inhibitor that blocks the EGFR protein tumors thrive on. Vitrakvi (larotrectinib) targets specific genetic changes that can occur in head and neck cancers.
Immunotherapy: This promising new category of drugs boosts the body’s natural defenses by blocking a protein that interferes with the immune system’s ability to recognize and attack cancer cells. Drugs Keytruda (pembrolizumab) and Opdivo (nivolumab) are approved for people with recurrent or metastatic head and neck cancers, or who haven’t had good results with chemo.
The side effects of mouth cancer medications typically go away when treatment is completed, but until then, these are some issues you may face:
Loss of appetite
Nausea and vomiting
Risk of infection due to lowered immunity
Living With Oral Cancer
When we’re talking about a disease that can singlehandedly wipe out your ability to eat, breathe, and talk, it’s serious. And while your odds of getting it are much smaller than, say, breast cancer or another form, if you do get it, the chances of beating it aren’t super-great either.
What’s important to remember, though, is that the new classes of drugs are increasing survival rate statistics by the day, and you can expect that to continue as researchers find more and better ways to harness the powers of modern medicine.
Equally important, statistics are just that: Averages of large groups of people, some who fare worse, but some who fare far better. Your job is to try to let go of the things you can’t control and focus on what you can: Eating healthy, following your medical team’s treatment plan, and staying positive in your thoughts. You got this, and we’re right here with you.
- Mouth Cancer Annual Statistic: Memorial Sloan Kettering Cancer Center. (2020). “Mouth Cancer.” mskcc.org/cancer-care/types/mouth
- Oral Cancer: American Society of Clinical Oncologists. (2019). “Oral and Oropharyngeal Cancer Guide.” cancer.net/cancer-types/oral-and-oropharyngeal-cancer/introduction
- Oral Cavity Cancer Overview: Surgical Oncology Clinics. (2016). “Cancer of the Oral Cavity.” ncbi.nlm.nih.gov/pmc/articles/PMC5018209/
- Immunotherapy Effectiveness: Journal of Pharmacy and Bioallied Sciences. (2019). “Immunotherapy in Oral Cancer.” ncbi.nlm.nih.gov/pmc/articles/PMC6555318/
- Chemotherapy Uses: Dental Clinics of North America Journal. (2018). “Chemotherapy for Oral Cancer.” ncbi.nlm.nih.gov/pubmed/29126496
- Radiation and Recurrence: Cancer Letters Journal. (2005). “Radiotherapy for Oral Cancer as a Risk Factor for Second Primary Cancers.” ncbi.nlm.nih.gov/pubmed/15766594
- Oral Cancer Recurrence: Chinese Journal of Cancer. (2013). “The Recurrence and Survival of Oral Squamous Cell Carcinoma.” ncbi.nlm.nih.gov/pmc/articles/PMC3845544/