A Comprehensive Approach to the Oral Cancer Examination

October 1, 2025

By Lisa Germain, DDS, MScD

On August 19, I woke up to very distressing news on“What’s App” about my friend and colleague, Dr. Ashley Joves.  Ashley is a dentist in private practice in Folsom, California, an entrepreneur,  and  host of the very popular podcast, “Little Black Dress”.  The message contained a link to her recent episode  entitled “The Hardest Episode I’ve Ever Shared’[ https://podcasts.apple.com/us/podcast/the-hardest-episode-ive-ever-shared/id1582705860?i=1000722536353] where she revealed that here husband Dr. Brian Jones (a physician) was having surgery to remove an oral cancer lesion from the underside of his tongue.  The palpable pain in Ashley’s voice, the overwhelming sadness of her regret for not exploring some of the symptoms he was having earlier and the disbelief that this young, vibrant, healthy man could have oral cancer made me take pause. In her follow up episode, “Post Op Week 1 with Brian” [https://podcasts.apple.com/us/podcast/little-black-dress-podcast/id1582705860?i=1000723484212], Brian shares his experience of having a partial glossectomy to remove the squamous cell carcinoma and associated lymph nodes.

As traumatic as the entire ordeal was for Ashley and Brian, they were blessed with encouraging news-clean margins and no lymph node involvement. They are grateful, optimistic, and Brian is recuperating from the procedure well. But, what if they had waited?  What if Ashley had not been a tenacious advocate every step of the way?   It is my hope that this article will remind us that, as health care professionals, we can not neglect performing  this simple screening on every single patient that we see on a regular basis.  It should be part of our routine.  Think of the lives we can save with early detection.

Oral Cancer

Oral cancer is a significant health concern worldwide, with an estimated 54,000 new cases diagnosed annually in the United States and nearly 11,500 deaths attributed to the disease each year (American Cancer Society, 2023). Early detection remains the most critical factor influencing survival, as the five-year survival rate is approximately 84% when lesions are detected in localized stages but drops to about 39% once distant metastasis has occurred (National Cancer Institute, 2023). Dentists are in a unique position to perform thorough oral cancer examinations during routine dental visits, thereby identifying suspicious lesions before they progress.

This article provides a detailed, step-by-step approach to examining a patient’s mouth for oral cancer. It will review what findings may be encountered, indications for biopsy, and strategies for communicating with patients about concerning lesions.

The Importance of Oral Cancer Screening in Dental Practice

The oral cavity is readily accessible for examination, yet oral cancers are frequently diagnosed at advanced stages. Studies suggest that more than 50% of oral cancers are not detected until the disease has progressed and become difficult not impossible to treat. (Sankaranarayanan et al., 2015). Routine, systematic screening at every dental appointment increases the likelihood of identifying precancerous and cancerous lesions in early, treatable stages.

Risk factors that increase the importance of careful evaluation include tobacco use (smoking and smokeless), excessive alcohol consumption, human papillomavirus (HPV) infection, age over 40, chronic sun exposure to the lips, immunosuppression, and a prior history of head and neck cancer (Warnakulasuriya, 2018). Even in patients without risk factors, however, a complete examination should never be omitted.

Step-by-Step Oral Cancer Examination

A systematic, head-to-neck approach ensures that no area is overlooked. The examination should always be performed under good lighting, with gloves, a mouth mirror, and gauze. The following steps outline a thorough evaluation:

  1. Extraoral Examination

Begin by observing the face, lips, and skin for asymmetry, swellings, discoloration, ulcerations, or crusted lesions. Palpate the cervical lymph nodes systematically (submental, submandibular, jugulodigastric, cervical chain, supraclavicular) to identify lymphadenopathy. Enlarged, firm, non-tender, and fixed nodes raise concern for malignancy.

  1. Lips

Inspect both the upper and lower lips, noting any ulcerations, crusts, or actinic changes. Actinic cheilitis, characterized by dryness, scaliness, and white patches, is a premalignant condition strongly associated with squamous cell carcinoma of the lip.

  1. Labial and Buccal Mucosa

Evert the lips and cheeks to examine the mucosa. Look for leukoplakia (white patches that cannot be wiped away), erythroplakia (red velvety patches), mixed red-white lesions (erythroleukoplakia), and ulcerations. Palpate the buccal mucosa for induration, particularly along the line of occlusion where chronic trauma may coincide with neoplastic changes.

  1. Gingiva and Alveolar Ridge

Inspect both maxillary and mandibular gingiva, including the vestibules. Gingival squamous cell carcinoma may mimic common periodontal conditions, appearing as non-healing ulcerations or exophytic masses. Persistent swelling or unexplained bleeding in these areas should raise suspicion.

  1. Tongue

The tongue is the most common intraoral site for oral squamous cell carcinoma, particularly the lateral borders and ventral surface. Ask the patient to protrude their tongue and move it side-to-side. Carefully inspect the dorsal, lateral, and ventral surfaces for ulcerations, red or white patches, and exophytic growths. Palpate the tongue between the thumb and fingers to detect firmness or induration not visible to the eye.

  1. Floor of the Mouth

With gauze retracting the tongue, examine the floor of the mouth, particularly in the anterior region and along the ventrolateral tongue junction. This site has a high risk for squamous cell carcinoma. Erythroplakia in this region is particularly concerning, as studies show up to 50% of these lesions harbor severe dysplasia or carcinoma (Silverman et al., 1984).

  1. Hard and Soft Palate

Inspect the hard palate for ulcers, white patches, or masses. Pay particular attention in patients who smoke pipes or cigars, as these habits predispose to carcinoma of the palate. The soft palate, uvula, and oropharyngeal areas should also be visualized for discoloration, ulceration, or exophytic masses.

Common Clinical Findings and Their Significance

Leukoplakia

Defined as a white patch that cannot be scraped off and has no other clinical or histopathologic diagnosis, leukoplakia carries a malignant transformation rate ranging from 1% to 20% depending on location and risk factors (Warnakulasuriya & Ariyawardana, 2016). High-risk sites include the tongue and floor of the mouth.

Erythroplakia

A red patch with a velvety texture, erythroplakia has the highest malignant potential, with over 90% showing severe dysplasia, carcinoma in situ, or invasive carcinoma upon biopsy (Silverman et al., 1984). These lesions warrant urgent evaluation.

Ulcerations

Any ulceration persisting longer than two weeks without signs of healing should be considered suspicious. Indurated margins, rolled borders, and bleeding are classic warning signs.

Exophytic Masses

A fungating, papillary, or nodular mass in the oral cavity is worrisome, particularly when firm to palpation and non-tender.

Pigmented Lesions

Brown, black, or blue pigmented lesions must be carefully assessed. While many represent benign melanotic macules, the possibility of oral malignant melanoma cannot be overlooked, especially if the lesion is asymmetrical, irregular in border, or demonstrates color variegation.

When to Biopsy

Biopsy remains the gold standard for definitive diagnosis of oral potentially malignant disorders and cancers. The following general guidelines should be followed:

  • Lesions persisting more than 2 weeks without resolution.
  • Any erythroplakia or erythroleukoplakia
  • Non-healing ulcers with indurated borders.
  • Leukoplakia in high-risk sites, especially lateral tongue and floor of mouth.
  • Unexplained exophytic growths, masses, or swellings.
  • Pigmented lesions with irregular borders, rapid growth, or asymmetry.

If biopsy is beyond the general dentist’s scope, immediate referral to an oral surgeon or oral medicine specialist is warranted. Excisional biopsy is preferred for small, accessible lesions, while incisional biopsy is indicated for larger or suspicious lesions.

Communicating with Patients About Suspicious Lesions

Delivering the possibility of oral cancer must be handled with clarity, empathy, and professionalism. The goal is to inform patients of the findings, the rationale for biopsy, and the importance of timely diagnosis without instilling unnecessary panic.

Key communication points include:

  • Explain what you observed: “I see a patch/ulcer that hasn’t healed as expected.”
  • Clarify that most lesions are not cancer: Emphasize that while many abnormalities are benign, further evaluation is essential.
  • Stress the importance of biopsy: Patients should understand that only microscopic examination can confirm the nature of the lesion.
  • Offer reassurance and support: Normalize the process by comparing biopsy to other standard diagnostic tests.
  • Encourage prompt action: Delays in biopsy or referral directly impact prognosis.

Documentation of the discussion and informed consent for biopsy or referral should always be recorded in the patient’s chart.

 

Follow-Up and Long-Term Considerations

For patients with diagnosed premalignant lesions (such as leukoplakia with dysplasia), long-term follow-up is essential due to the ongoing risk of malignant transformation. Regular surveillance appointments, lifestyle counseling (tobacco and alcohol cessation), and patient education play vital roles in prevention and early intervention.

For patients with diagnosed oral cancer, collaboration with oral and maxillofacial surgeons, oncologists, and speech/swallowing therapists ensures comprehensive care. Dentists also play a pivotal role in supportive oral health care before, during, and after cancer therapy.

Conclusion

Oral cancer examinations are a critical responsibility of every dentist. A systematic approach to inspection and palpation, recognition of suspicious findings, timely biopsy or referral, and effective communication with patients are the cornerstones of early detection. As oral health providers, dentists serve as the frontline defense against oral cancer, directly influencing survival outcomes through vigilance and timely action.

 

References

  • American Cancer Society. (2023). Key Statistics for Oral Cavity and Oropharyngeal Cancers. Retrieved from: https://www.cancer.org
  • National Cancer Institute. (2023). SEER Cancer Statistics Review, 1975–2020.
  • Sankaranarayanan, R., Ramadas, K., & Thomas, G. (2015). Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. The Lancet, 365(9475), 1927–1933.
  • Silverman, S., Gorsky, M., & Lozada, F. (1984). Oral leukoplakia and malignant transformation. A follow-up study of 257 patients. Cancer, 53(3), 563–568.
  • Warnakulasuriya, S. (2018). Oral potentially malignant disorders: A comprehensive review on clinical aspects and management. Oral Oncology, 75, 45–57.
  • Warnakulasuriya, S., & Ariyawardana, A. (2016). Malignant transformation of oral leukoplakia: a systematic review of observational studies. Journal of Oral Pathology & Medicine, 45(3), 155–166.