Cases corner – 65yr old man with mouth ulcer

17th December 2019

Peter, a 65yr old man presents to you with a 4 week history of an ulcer on the inside of his left cheek. He reports he first noticed the ulcer when he was brushing his teeth but the area is painless. He cannot remember any trauma to this area and he does not think it has changed in size. He is otherwise well and denies any other symptoms. Peter is an ex-smoker with a total exposure of 12 pack-years.

On examination there is a small circular ulcerated lesion that is white in colour on the inside of his left cheek. You do not find any other lesions within his oral cavity and you note he has poor dentition. There is no cervical lymphadenopathy and his weight is stable.

What would you do next?

  1. Adopt a watch and wait strategy and reassess in 2 weeks
  2. Make a routine referral to the Maxillofacial team
  3. Advise the patient to see his dentist
  4. Advise the patient to use over the counter choline salicylate gel and return if no improvement
  5. Refer on a 2 week wait head and neck pathway for suspected oral cancer

Peter has an unexplained non-healing mouth ulceration. In these cases NICE guidelines state that you should ‘consider a suspected cancer pathway referral (for appointment within 2 weeks) for oral cancer in people with either:

  • unexplained ulceration in the oral cavity for more than 3 weeks
  • a persistent and unexplained lump in the neck.

There are a number of known risk factors that increase the likelihood of developing oral cancer. The leading risks are alcohol and smoking tobacco. Other risks include:

  • Chewing tobacco
  • Poor diet
  • Human papilloma virus (HPV)
  • Poor oral health
  • Betel nuts (chewed for a stimulant effect similar to coffee and are used by some Southeast Asian communities)


References

https://www.nice.org.uk/guidance/ng12/chapter/1-Recommendations-organised-by-site-of-cancer#head-and-neck-cancers

https://www.nhs.uk/conditions/mouth-cancer/causes/