The most common form of head and neck cancer is oral cancer (mouth cancer). Mouth cancer is a growth of cells that starts in the mouth and can affect any part that makes up the mouth, namely: lips, gums, tongue, inner lining of cheeks, the roof, or the floor of the mouth. Since the mouth is called the oral cavity, mouth cancer is referred to as oral cancer or oral cavity cancer.

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Symptoms

Oral cancer can look like a common problem to begin with. You may notice some white patches or sores that bleed. If it is a common problem, it will go away. However, mouth cancer will persist. If you have a mouth sore that will not heal, a white or reddish patch inside the mouth, loose teeth, a growth or lump inside the mouth, pain in the mouth or ear, voice changes (hoarseness), jaw/tongue numbness, difficulty in moving tongue/jaw, and chronic bad breath or ear pain, or difficulty and pain while swallowing, you will need immediate medical attention. If not treated, oral cancer can spread from the mouth and throat to other parts of the head, neck, and even to other areas of the body.

Causes

Oral cancer is mainly linked to lifestyle habits such as tobacco use (smoking or chewing) and heavy alcohol consumption. When these habits are combined, the risk increases significantly. Other causes include certain HPV infections, excessive sun exposure, poor nutrition, genetics, and chronic irritation from sharp or broken teeth, ill-fitting dentures, or poor oral hygiene. These factors damage DNA, leading to abnormal cell growth, with tobacco and alcohol being the biggest threats, responsible for a large majority of cases.  

Stages

Oral cancer progresses via four phases.

  • Stage 1: The tumour is 2 centimetres (cm) or less, and the lymph nodes have not yet been affected by cancer.
  • Stage 2: The tumour is 2-4 cm, and the lymph nodes are free from cancerous cells.
  • Stage 3: The tumour is either larger than 4 cm and hasn’t spread to the lymph nodes, or it’s any size and has spread to one lymph node but not to other parts of the body.
  • Stage 4: Tumors of any size migrate to neighbouring tissues, lymph nodes, or other body areas due to cancerous cells.

Diagnosis

A doctor may start with a physical examination of the lips and mouth. They will check your neck, and throat for unusual sores, lumps, or colour changes, often during a routine checkup. If something suspicious is found, a biopsy (tissue sample) is taken for lab testing. This test confirms the diagnosis by removing a small piece of tissue from the suspected area and analyzing it for the presence of cancer cells. Sometimes, a Fine Needle Aspiration (FNA) test is done where a needle samples cells from swollen neck lymph nodes. 

Further imaging like CT, MRI, or PET scans, plus an endoscopy, help determine the cancer’s extent (staging), checking if it’s spread to lymph nodes or other body parts. Endoscopy uses a thin tube with a camera that looks at the throat, larynx, and pharynx. A CT scangives detailed images to see tumor size, bone/tissue involvement. An MRI is used for detailed soft tissue imaging, often when CT contrast isn’t tolerated. A PET Scan helps detect if cancer has spread (metastasis). X-rays are used to check for cancer in jaw, chest, or lungs. 

Treatment

Treatment for oral cancer often includes a mix of surgery, radiation therapy, and chemotherapy. In more advanced cases, doctors may also use newer treatments such as targeted therapy and immunotherapy. Surgery removes the tumor, often including lymph nodes, while radiation uses high-energy rays to kill cancer cells, and chemotherapy uses drugs to stop cancer growth, often with radiation. The treatment choice depends on the cancer stage, location, and overall health, sometimes involving reconstructive surgery after large tumor removal.  You may undergo a combination of cancer treatments.

Oral cancer surgery removes cancerous growths in the mouth by excising the tumor with a margin of healthy tissue, often involving the tongue, jaw (mandible), or inner cheeks, potentially alongside neck lymph nodes (neck dissection) if cancer has spread, using techniques like robotic surgery or grafts/flaps for reconstruction to restore function (speech, eating) and appearance, with recovery focusing on managing eating/speech challenges via feeding tubes or therapy. 

Collaborative Resection and Reconstruction with Plastic Surgery

Collaborative resection and reconstruction involving surgical oncology and plastic surgery is the gold standard for oral cancer treatment. This multidisciplinary team (MDT) approach ensures the complete removal of cancer while simultaneously planning for optimal functional and aesthetic restoration, which significantly improves a patient’s quality of life. 

The Multidisciplinary Team (MDT) Approach

The collaboration begins during the initial diagnosis and treatment planning phases, involving specialists who work together to create a personalized care plan. 

  • Surgical Oncologists (Head and Neck Surgeons): Focus on the precise and complete removal of the tumor, ensuring clear margins to prevent recurrence.
  • Plastic and Reconstructive Surgeons: Work in tandem with the oncology team to immediately rebuild the resulting defects, often during the same operation.
  • Other Essential Team Members: 
  • Maxillofacial Prosthodontists: They design custom prostheses (e.g., obturators, dental implants) to restore oral structure and function.
  • Speech-Language Pathologists: Help patients regain the ability to speak and swallow through tailored exercises and therapy.
  • Nutritionists: Manage the patient’s dietary needs to ensure adequate nutrition for healing and recovery.
  • Psychologists/Counsellors: Provide support to help patients cope with the emotional and social impacts of cancer treatment and facial changes. 

Reconstructive Techniques

Reconstructive surgeons use various techniques depending on the size, location, and complexity of the defect: 

  • Skin Grafts: Thin layers of skin from the thigh or abdomen are used for smaller, superficial defects.
  • Local or Regional Flaps: Tissue (skin, muscle, fat) from nearby areas like the neck or chest is moved to the surgical site while keeping its original blood supply intact.
  • Microvascular Free Flaps (Free Tissue Transfer): This advanced technique is the gold standard for larger, more complex reconstructions. A piece of tissue (e.g., bone from the lower leg/fibula, soft tissue from the forearm/radial forearm, or thigh/anterolateral thigh flap) is transferred from a distant part of the body along with its blood vessels. The plastic surgeon uses a microscope to connect these tiny blood vessels to vessels in the neck, ensuring the transferred tissue thrives. 
  • Fibula Free Flap: Commonly used for jawbone reconstruction, as it provides strong bone stock and allows for dental implant placement.
  • Radial Forearm Flap: Ideal for rebuilding the tongue or soft palate due to its thin, pliable nature. 

Benefits of Collaboration

  • Optimized Outcomes: Combining radical cancer removal with expert, immediate reconstruction leads to better oncological clearance, functional outcomes (speech, swallowing, chewing), and aesthetic results.
  • Integrated Planning: The team uses advanced imaging and 3D computer modelling to plan the surgery and reconstruction simultaneously, which enhances precision and reduces complications.
  • Faster Recovery and Rehabilitation: Performing reconstruction at the time of tumor removal avoids the need for multiple separate surgeries, often leading to shorter hospital stays and a faster start to rehabilitation.
  • Holistic Patient Care: The MDT approach addresses not just the cancer but also the physical, psychological, and social challenges the patient faces, leading to improved overall well-being and satisfaction. 

Prevention

You can actively participate in preventing oral cancer, and the following suggestions can aid in preventing it:

  • Find out about programmes to stop smoking from your doctor.
  • Take sun protection with you. Your face should be covered in UV-AB-blocking sunscreen and sunblock.
  • Opt for the human papillomavirus vaccine.
  • Eat a healthy, balanced diet.

Have regular dental checkups. People aged 20 to 40 are advised to undergo oral cancer screenings once every three years. After the age of 40, annual exams are recommended.

Summary

Oral cancer is aggressive, and often diagnosed late. If untreated, it can spread (metastasize) to the head, neck, and other parts of the body, significantly reducing survival chances. Treatment through a collaborative approach involves a multidisciplinary team where head and neck surgeons (who perform the resection) and plastic/reconstructive surgeons (who perform the reconstruction) work together to simultaneously treat the cancer and restore form and function. This “two-team” approach is designed to minimize surgical time while maximizing the patient’s ability to speak, swallow, and chew after extensive tissue removal.

Frequently Asked Questions

1. What can I do to prevent developing oral cancer?

To prevent oral cancer, quit all tobacco, limit alcohol, protect lips from the sun (use a sunblock), and maintain excellent oral hygiene with regular dental checkups. Eat a diet rich in fruits/veggies, and get the HPV vaccine. Lifestyle changes and early detection are key to reducing your risk.  

2. Can I spot potential oral cancer?

Yes, you can spot potential oral cancer by checking for persistent mouth sores, red/white patches, lumps, or unexplained bleeding/numbness that don’t heal or go away within two weeks. Pull out your cheek with your finger and check the inside for patches or sores. Look at your tongue, roof of your mouth, and tonsils. Gently squeeze and roll your cheeks and neck area for any lumps or tender spots. These signs, especially when persistent, warrant a visit to your dentist or doctor for proper examination and potential biopsy for early detection, which is crucial for successful treatment.   

3. If I need surgery, will I need reconstructive surgery?

Yes, if oral cancer surgery involves removing a significant amount of tissue (like parts of the tongue, jaw, or mouth lining) to get clear margins, reconstructive surgery is often needed to restore speech, swallowing, appearance, and quality of life, using tissue grafts, flaps, or prosthetics, and is usually done at the same time as cancer removal. For smaller tumors where only a narrow margin is removed, reconstruction may not be necessary. 

4. What can I expect if I have oral cancer?

If you have oral cancer, expect persistent mouth sores, red/white patches, lumps, pain, or difficulty chewing/swallowing/speaking, often accompanied by jaw/ear pain or loose teeth, requiring a medical diagnosis (biopsy) and a treatment plan involving surgery, radiation, chemo, or a combination, all managed by a team to preserve function and appearance. 

5. Where does mouth cancer usually start?

Mouth cancer most commonly begins in the flat, thin squamous cells that line the lips and the inside of the mouth. The majority of mouth cancers originate as squamous cell carcinomas. Unfortunately, the changes in these cells that lead to cancer are not yet fully understood.


Dr. G. Keshavarajan is a Surgical Oncologist at Dr. Rela Hospital, Chennai