What is a premalignant lesion? A premalignant lesion is one which is not cancerous but it has a higher chance than normal tissue to become malignant. Source: https://muzzafarzaman.wordpress.com/2018/06/23/mouth-cancer-part-2/

1. Mouth Cancer Part 2 – Dr Muzzafar Zaman
Premalignant Lesions
What is a premalignant lesion? A premalignant lesion is one which is not cancerous
but it has a higher chance than normal tissue to become malignant. A dentist can
identify various signs of anything that may be a premalignant lesion. An erythroplakia
is a red patch in the mouth which is a premalignant lesion and a leukoplakia is a
white patch which is a premalignant lesion. A mixture of red and white patches is
known as erthroleukoplakia. Lichen planus and oral submucous fibrosis are also
premalignant lesions. If a patient has a premalignant lesion, it is important to keep a
record of it so it can be monitored. Photographs are needed for comparison
purposes although the appearance of a premalignant lesion will flutuate even from
week to week. A biopsy will also confirm that there are no malignant cells within the
premalignant lesion. Often the term dysplasia is used also describe a premalignant
lesion.
Smoking
75% of new oral cancer cases will be from smokers. It is thought that the tobacco
contains carcinogens but also the by products from the burning of the tobacco. The
chances of getting oral cancer increases the longer you have been smoking and the
more daily cigarettes are smoked in addition to the tar strength. Recently, we
diagnosed oral carcinoma from a patient who smoked a full packet daily of Capstan
Navy Full Strength for many years. He was immediately told to go to hospital for a
biopsy and the ironic thing is that he smoked a packet on his way there.
Mouth cancer in the UK is on the increase and this is also attributable to the spread
of HPV16 virus.
Drinking alcohol
Heavy drinkers have an increased risk to mouth cancer, just ask Alex Higgins but he
smoked like a chimney as well.
Early Diagnosis.
Early diagnosis is the most important factor to decrease mortality and to reduce side
effects of treatments. All dentists need to carry out Core CPD topics as part of their

2. on-going training and one of the topics that is mandatory is to brush their skills in
oral cancer.
On examination, a dentist would look at all the mouth surfaces including the lateral
border of the tongue and under the tongue itself. In the early stages, the patient is
completely unaware. These early stages would reveal the mucosa to have white or
red patches. The next stage would be an ulcer which could also bleed and has been
present for more than 2 weeks. If this progressed, a lump which is increasing in size
would be apparent. Eventually, this could cause difficulties in eating, drinking,
swallowing and speech. Once this spreads, the effects of the malignancy would be
prevalent in other areas of the body and the patient would also have general signs
weakness, weight loss and malaise.
A referral to the hospital would be to into their Oral and Maxillofacial department
where an oral surgeon will take on the patient's care. The referral by the dentist
would be by fast track so the patient will be seen under the NHS within days rather
than months as for routine referrals. The first step would be to rule out oral
carcinoma because there are other conditions of the oral mucosa that can be
responsible. As an example, an ulcer on the tongue can be due to rubbing on a sharp
tooth or on a denture. In this case, the tooth would be smoothed or a denture ease
carried out. When the patient is re-examined two weeks later, the ulcer will have
disappeared if the cause is not anything sinister.
An oral surgeon is not able to tell by just visual examination if the lesion is pre-
malignant or malignant so a brush biopsy can be done there and then. An example is
the OralCDx brush biopsy also known as computer assisted transepithelial oral brush
biopsy. In the past, before this test was available, the oral surgeon would either keep
a suspicious lesion under review or take a tissue biopsy for analysis.
Another test is to paint the oral mucosa with a dye called Toluidine Blue. An oral
lesion which contains dysplasia or malignancy will be six times more likely to absorb
the dye. Due to the ease of this method, some dentists have this Toluidine Blue dye
available in their dental surgeries.
Further methods to investigate oral cancer could include a chest radiograph, a CT
scan, a MRI scan and blood tests.
Treatments for Oral Cancer
The treatment would be to surgically remove the cancerous tissue or lump.
Depending on the extent of the tumour, radiation with or without chemotherapy can

3. also be considered especially if it is not viable to carry out widespread excision of
affected areas or if the cancer has spread.
The surgeries for oral cancer can be extensive such as maxillectomy,
mandibulectomy, glossectomy, laryngectomy and neck dissection. Once surgery has
been carried out, it is then necessary to carry out further surgery to obtain a
functional and cosmetic result. These surgeries can involve grafting of various tissues
such as a forearm flap. Even after this, the patient will still never be the same and
may need an oral prosthesis such as an implant retained denture. It is likely that the
patient will need feeding through a tube to maintain their nutrition levels.
There will be a long list of side effects from the initial surgery, further surgery, the
radiotherapy and chemotherapy.
Even after all this, only 50% of patients will survive more than 5 years. Geoffrey
Boycott says that he would have faced the 4 West Indian Quicks bowling at him all
day rather than having to face the treatments for his oral cancer. He said that even
the ability for the body to produce its own natural saliva is appreciated by most
people. Without saliva, the teeth and gums deteriorate and rot. Without saliva, one
cannot taste the food. Without saliva, the mouth is constantly parched. Without
saliva, swallowing is a major effort. Without saliva, one can't talk. Saliva is a miracle
that no one contemplates.
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