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Squamous cell carcinoma of attached gingiva
SHORT COMMUNICATION
Squamous cell carcinoma of attached gingiva Aaron Tolman,a Laurance Jerrold,b and Mark Alarbic Jacksonville, Fla Squamous cell carcinoma is the most common form of oral cancer in adults. Because orthodontists often treat many adult patients, practitioners need to be aware of the clinical signs of this malignancy. In this article, we discuss the epidemiology, clinical appearance, and pathology of squamous cell carcinoma, and present the orthodontic management of a patient. (Am J Orthod Dentofacial Orthop 2007;132:378-81)
A
29-year-old woman sought treatment at the School of Orthodontics at Jacksonville University, Jacksonville, Fla, in July 2003, concerned about the spacing between her teeth. Diagnostic records were taken in August 2003 (Fig 1). Her medical and dental histories were routine, although she had a chronic sinus problem and was then breastfeeding. She had no history of tobacco use and only occasional alcohol consumption. She was diagnosed with a Class III malocclusion secondary to maxillary retrognathism and mandibular prognathism and was advised that the ideal treatment plan required a double-jaw orthognathic procedure after dental decompensation. She was adamantly opposed to surgical intervention, so a camouflage treatment plan was agreed upon, in which the mandibular teeth would be retracted, and the mandibular anterior dentition would be used as a guide to position the maxillary teeth. This would involve shifting anchorage to the maxillary anterior segment and bringing all maxillary posterior teeth forward. Treatment was estimated to take 30 to 36 months. Active therapy began in September 2003. Treatment was uneventful for the first 2 years except for 6 months of missed appointments in the aggregate during that time. In September 2005, the first of 3 consecutive months of poor oral-hygiene notations was made. The patient was referred to her general dentist for a checkup and cleaning in October 2005. She missed several appointments during the latter half of 2006 and was seen only 3 times during that period—in June, September, and December. From the School of Orthodontics, Jacksonville University, Jacksonville, Fla. a Second-year resident. b Dean and program director. c Assistant professor. Reprint requests to: Laurance Jerrold, Jacksonville University School of Orthodontics, 2800 University Blvd N, Jacksonville, FL 32211; e-mail, [email protected]. Submitted, March 2007; revised and accepted, April 2007. 0889-5406/$32.00 Copyright © 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.04.030
378
On January 11, 2007, she came to an appointment complaining of an area of gingival discoloration along with an “itchy” sensation, pointing to the mandibular left first molar. She denied any trauma to the area and any pain associated with the lesion. A clinical examination showed what appeared to be a slightly elevated flap-like area of leukoplakia on the buccal gingiva in the mandibular left quadrant. The lesion began at the distal gingival margin of the left first molar and extended mesially to the middle of the second premolar. Its apical extension was about 5 mm (Fig 2). The orthodontic band on the molar was checked, and, although it was intact, it was removed to facilitate examination by an oral and maxillofacial surgeon for diagnosis and management of the lesion. Our differential diagnosis included squamous cell carcinoma (SCC), peripheral giant cell granuloma, and pyogenic granuloma (PG). A review of these conditions shows that the most common etiologic factors associated with SCC are smoking, which carries a 2 to 3 times greater risk than that of the general population (only 0.03% to begin with); smokeless tobacco use, which increases the general risk fourfold; and chewing paan (a combination that usually includes calcium hydroxide, areca nut, and betel leaf), which increases the general risk by a factor of 8. People who consume alcohol and use tobacco are at greater risk, as are people with syphilis. Phenol use, exposure to ultraviolet radiation, iron deficiency, vitamin A deficiency, candidal infections, oncogenic viruses, and immunosuppression play much smaller roles.1 Clinically, early SCC is leukoplakic, erythroplakic, or erythroleukoplakic in nature, and more advanced cancers are endophytic or exophytic. There is minimal pain associated with developing SCC; this is why patients often wait 4 to 8 months to seek treatment. The most common intraoral areas for SCC to develop, in descending order, are posterior lateral and ventral borders of the tongue, floor of the mouth, soft palate, attached gingiva, buccal muscosa, labial mucosa, and hard palate. When SCC appears on the keratinized
American Journal of Orthodontics and Dentofacial Orthopedics Volume 132, Number 3
Tolman, Jerrold, and Alarbi 379
Fig 1. Pretreatment photos and panoramic radiograph.
gingiva, it usually does so in the posterior part of the mandible, and its appearance often mimics a more benign lesion, the PG. As in this case, SCC of the gingiva is least associated with tobacco use and has the greatest predilection to occur in women.1 Peripheral giant cell granuloma is usually seen on the attached gingiva; it is 2 cm or smaller, is reddishblue and nodular in appearance, and has a marked predilection for middle-aged women. PG, on the other
hand, has a pink to reddish color, is often pedunculated, has a smooth to lobular surface, and has no size predisposition. In 75% of patients, PG occurs on the attached gingiva, often after trauma to the area. PG usually occurs in young women and is commonly called pregnancy tumors.1-3 Each year in the United States alone, over 21,000 cases of oral cancer are diagnosed, resulting in approximately 6000 deaths. Of these, 94% are SCC. When
380 Tolman, Jerrold, and Alarbi
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Fig 2. Lesion at January 11, 2007, visit.
Fig 4. March 15, 2007, 4 weeks after surgery.
Fig 3. February 6, 2007, 8 days after biopsy.
identified early and treated promptly, most SCC can be effectively treated; however, if they are undiagnosed, they often lead to disfigurement or death. In addition to the etiologic factors stated previously, human papilloma and herpes viruses have also been associated with an increase in its occurrence. The incidence of SCC is highest in black men over 40 years old; then the predilection shifts to white men over age 65. Generally, the prevalence is 3 times higher in men than in women.1,2,4 This patient underwent an incisional biopsy on January 29, 2007. On February 6, the surgeon reported that the pathology report showed SCC (Fig 3). The patient was scheduled for a segmental ostectomy including the first premolar through the second molar; the procedure was performed on February 20, 2007. The surgeon reported that the lesion was localized, although the cancer had spread to the crestal bone on the lingual plate between the first molar and the second premolar. There was no nodal involvement, and clean borders were achieved with just the extraction of the second premolar through the second molar, including the
surrounding alveolar bone. The first premolar was saved. Retrospectively, the patient reported no concerns regarding this area at her December 6, 2006, visit. At her January 11, 2007, visit, when we first saw and tentatively identified the lesion, she admitted having felt a fleeting “itchy” sensation in the area for at least 6 months and possibly much longer. This sensation would manifest itself every few months, and she would scratch the area with a toothpick to relieve the irritation. She reported that the sensation was so mild that she chose not to mention it to any health-care professional. During the preceding month, the itchiness had intensified, but she attributed it to gingivitis, a condition for which she had previously been treated. In addition, she reported that she had scratched the area intensely with a toothpick, trying to obtain relief, but the itchiness persisted. Around December 20, she noticed the area turning white; then she began to rinse with warm salt water, hydrogen peroxide, and Listerine 2 to 3 times a day. Around January 5, 2007, she noticed the flap of tissue developing. She called our clinic on January 8 to schedule an appointment, and we saw her 3 days later. We saw the patient again on March 15, about 4 weeks after the surgery (Fig 4). The surgeon had informed us that, assuming the entire lesion was re-
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American Journal of Orthodontics and Dentofacial Orthopedics Volume 132, Number 3
moved and there were large, clean borders with no nodal involvement, neither chemotherapy nor radiation therapy was contemplated, and there was no contraindication for completing the orthodontic therapy. Therefore, we reinitiated treatment at that time. We report this case because it is rare to see SCC on the buccal gingiva. Currently, 15% of the patients in an average orthodontic practice are adults, and in many offices this percentage is much higher.5 It therefore behooves every practitioner to become familiar with the clinical appearance of this disease. In addition, all patient complaints, even of a vague nature, such as the itching in this case, cannot be overlooked and must be evaluated and appropriately managed, including referral when indicated. This case also emphasizes another all-too-common phenomenon: while undergoing orthodontic therapy, many of our patients consider us their primary dental-care provider. They expect us to notice any abnormalities and to appropriately manage their care by performing or making the appropriate treatment, recommendations, or
referrals. Organizationally and professionally, we have been reluctant to accept this situation, and we constantly remind our patients to return to their regular dentist at appropriate intervals for routine checkups and care. The reality of today’s clinical practice all too often allows for these additional responsibilities to be foisted on the orthodontic practitioner. It is just another reminder that we are doctors first, dentists second, and orthodontists third; thus, we must keep our diagnostic, our technical, and, just as important, our interpersonal communicative skills up to date. REFERENCES 1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. 2nd ed. Saunders: Philadelphia: 2002. 2. Bhaskar SN. Synopsis of oral pathology. Mosby; St Louis: 1961. 3. Coleman GC, Nelson JF. Principles of oral diagnosis. Mosby; St Louis: 1993. 4. Oral squamous cell carcinoma. Available at: www.merk.com. Accessed April 19, 2007. 5. Buttke TB, Proffit WR. Referring adult patients for orthodontic treatment. J Am Dent Assoc 1999;130:73-9.
Squamous cell carcinoma of attached gingiva Aaron Tolman,a Laurance Jerrold,b and Mark Alarbic Jacksonville, Fla Squamous cell carcinoma is the most common form of oral cancer in adults. Because orthodontists often treat many adult patients, practitioners need to be aware of the clinical signs of this malignancy. In this article, we discuss the epidemiology, clinical appearance, and pathology of squamous cell carcinoma, and present the orthodontic management of a patient. (Am J Orthod Dentofacial Orthop 2007;132:378-81)
A
29-year-old woman sought treatment at the School of Orthodontics at Jacksonville University, Jacksonville, Fla, in July 2003, concerned about the spacing between her teeth. Diagnostic records were taken in August 2003 (Fig 1). Her medical and dental histories were routine, although she had a chronic sinus problem and was then breastfeeding. She had no history of tobacco use and only occasional alcohol consumption. She was diagnosed with a Class III malocclusion secondary to maxillary retrognathism and mandibular prognathism and was advised that the ideal treatment plan required a double-jaw orthognathic procedure after dental decompensation. She was adamantly opposed to surgical intervention, so a camouflage treatment plan was agreed upon, in which the mandibular teeth would be retracted, and the mandibular anterior dentition would be used as a guide to position the maxillary teeth. This would involve shifting anchorage to the maxillary anterior segment and bringing all maxillary posterior teeth forward. Treatment was estimated to take 30 to 36 months. Active therapy began in September 2003. Treatment was uneventful for the first 2 years except for 6 months of missed appointments in the aggregate during that time. In September 2005, the first of 3 consecutive months of poor oral-hygiene notations was made. The patient was referred to her general dentist for a checkup and cleaning in October 2005. She missed several appointments during the latter half of 2006 and was seen only 3 times during that period—in June, September, and December. From the School of Orthodontics, Jacksonville University, Jacksonville, Fla. a Second-year resident. b Dean and program director. c Assistant professor. Reprint requests to: Laurance Jerrold, Jacksonville University School of Orthodontics, 2800 University Blvd N, Jacksonville, FL 32211; e-mail, [email protected]. Submitted, March 2007; revised and accepted, April 2007. 0889-5406/$32.00 Copyright © 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.04.030
378
On January 11, 2007, she came to an appointment complaining of an area of gingival discoloration along with an “itchy” sensation, pointing to the mandibular left first molar. She denied any trauma to the area and any pain associated with the lesion. A clinical examination showed what appeared to be a slightly elevated flap-like area of leukoplakia on the buccal gingiva in the mandibular left quadrant. The lesion began at the distal gingival margin of the left first molar and extended mesially to the middle of the second premolar. Its apical extension was about 5 mm (Fig 2). The orthodontic band on the molar was checked, and, although it was intact, it was removed to facilitate examination by an oral and maxillofacial surgeon for diagnosis and management of the lesion. Our differential diagnosis included squamous cell carcinoma (SCC), peripheral giant cell granuloma, and pyogenic granuloma (PG). A review of these conditions shows that the most common etiologic factors associated with SCC are smoking, which carries a 2 to 3 times greater risk than that of the general population (only 0.03% to begin with); smokeless tobacco use, which increases the general risk fourfold; and chewing paan (a combination that usually includes calcium hydroxide, areca nut, and betel leaf), which increases the general risk by a factor of 8. People who consume alcohol and use tobacco are at greater risk, as are people with syphilis. Phenol use, exposure to ultraviolet radiation, iron deficiency, vitamin A deficiency, candidal infections, oncogenic viruses, and immunosuppression play much smaller roles.1 Clinically, early SCC is leukoplakic, erythroplakic, or erythroleukoplakic in nature, and more advanced cancers are endophytic or exophytic. There is minimal pain associated with developing SCC; this is why patients often wait 4 to 8 months to seek treatment. The most common intraoral areas for SCC to develop, in descending order, are posterior lateral and ventral borders of the tongue, floor of the mouth, soft palate, attached gingiva, buccal muscosa, labial mucosa, and hard palate. When SCC appears on the keratinized
American Journal of Orthodontics and Dentofacial Orthopedics Volume 132, Number 3
Tolman, Jerrold, and Alarbi 379
Fig 1. Pretreatment photos and panoramic radiograph.
gingiva, it usually does so in the posterior part of the mandible, and its appearance often mimics a more benign lesion, the PG. As in this case, SCC of the gingiva is least associated with tobacco use and has the greatest predilection to occur in women.1 Peripheral giant cell granuloma is usually seen on the attached gingiva; it is 2 cm or smaller, is reddishblue and nodular in appearance, and has a marked predilection for middle-aged women. PG, on the other
hand, has a pink to reddish color, is often pedunculated, has a smooth to lobular surface, and has no size predisposition. In 75% of patients, PG occurs on the attached gingiva, often after trauma to the area. PG usually occurs in young women and is commonly called pregnancy tumors.1-3 Each year in the United States alone, over 21,000 cases of oral cancer are diagnosed, resulting in approximately 6000 deaths. Of these, 94% are SCC. When
380 Tolman, Jerrold, and Alarbi
American Journal of Orthodontics and Dentofacial Orthopedics September 2007
Fig 2. Lesion at January 11, 2007, visit.
Fig 4. March 15, 2007, 4 weeks after surgery.
Fig 3. February 6, 2007, 8 days after biopsy.
identified early and treated promptly, most SCC can be effectively treated; however, if they are undiagnosed, they often lead to disfigurement or death. In addition to the etiologic factors stated previously, human papilloma and herpes viruses have also been associated with an increase in its occurrence. The incidence of SCC is highest in black men over 40 years old; then the predilection shifts to white men over age 65. Generally, the prevalence is 3 times higher in men than in women.1,2,4 This patient underwent an incisional biopsy on January 29, 2007. On February 6, the surgeon reported that the pathology report showed SCC (Fig 3). The patient was scheduled for a segmental ostectomy including the first premolar through the second molar; the procedure was performed on February 20, 2007. The surgeon reported that the lesion was localized, although the cancer had spread to the crestal bone on the lingual plate between the first molar and the second premolar. There was no nodal involvement, and clean borders were achieved with just the extraction of the second premolar through the second molar, including the
surrounding alveolar bone. The first premolar was saved. Retrospectively, the patient reported no concerns regarding this area at her December 6, 2006, visit. At her January 11, 2007, visit, when we first saw and tentatively identified the lesion, she admitted having felt a fleeting “itchy” sensation in the area for at least 6 months and possibly much longer. This sensation would manifest itself every few months, and she would scratch the area with a toothpick to relieve the irritation. She reported that the sensation was so mild that she chose not to mention it to any health-care professional. During the preceding month, the itchiness had intensified, but she attributed it to gingivitis, a condition for which she had previously been treated. In addition, she reported that she had scratched the area intensely with a toothpick, trying to obtain relief, but the itchiness persisted. Around December 20, she noticed the area turning white; then she began to rinse with warm salt water, hydrogen peroxide, and Listerine 2 to 3 times a day. Around January 5, 2007, she noticed the flap of tissue developing. She called our clinic on January 8 to schedule an appointment, and we saw her 3 days later. We saw the patient again on March 15, about 4 weeks after the surgery (Fig 4). The surgeon had informed us that, assuming the entire lesion was re-
Tolman, Jerrold, and Alarbi 381
American Journal of Orthodontics and Dentofacial Orthopedics Volume 132, Number 3
moved and there were large, clean borders with no nodal involvement, neither chemotherapy nor radiation therapy was contemplated, and there was no contraindication for completing the orthodontic therapy. Therefore, we reinitiated treatment at that time. We report this case because it is rare to see SCC on the buccal gingiva. Currently, 15% of the patients in an average orthodontic practice are adults, and in many offices this percentage is much higher.5 It therefore behooves every practitioner to become familiar with the clinical appearance of this disease. In addition, all patient complaints, even of a vague nature, such as the itching in this case, cannot be overlooked and must be evaluated and appropriately managed, including referral when indicated. This case also emphasizes another all-too-common phenomenon: while undergoing orthodontic therapy, many of our patients consider us their primary dental-care provider. They expect us to notice any abnormalities and to appropriately manage their care by performing or making the appropriate treatment, recommendations, or
referrals. Organizationally and professionally, we have been reluctant to accept this situation, and we constantly remind our patients to return to their regular dentist at appropriate intervals for routine checkups and care. The reality of today’s clinical practice all too often allows for these additional responsibilities to be foisted on the orthodontic practitioner. It is just another reminder that we are doctors first, dentists second, and orthodontists third; thus, we must keep our diagnostic, our technical, and, just as important, our interpersonal communicative skills up to date. REFERENCES 1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. 2nd ed. Saunders: Philadelphia: 2002. 2. Bhaskar SN. Synopsis of oral pathology. Mosby; St Louis: 1961. 3. Coleman GC, Nelson JF. Principles of oral diagnosis. Mosby; St Louis: 1993. 4. Oral squamous cell carcinoma. Available at: www.merk.com. Accessed April 19, 2007. 5. Buttke TB, Proffit WR. Referring adult patients for orthodontic treatment. J Am Dent Assoc 1999;130:73-9.