Non-healing indurated tongue ulcer in a betel quid user with poorly controlled diabetes
A 57-year-old woman from a hill district attends the dental outpatient department with a 2 x 1.5 cm ulcer on the left lateral border of the tongue that has been present for six weeks. The ulcer has a rolled, indurated margin and is fixed to underlying tissue; it is not tender. She has used khaini and betel quid with tobacco for 22 years and smokes about 15 cigarettes daily. Twice in the past two months a local pharmacy gave her amoxicillin and then metronidazole, with no change. No cervical lymph nodes are palpable. Random capillary glucose is 13.4 mmol/L, HbA1c is 9.1% and haemoglobin is 10.2 g/dL. She is frightened of biopsy and asks for a stronger antibiotic and a vitamin injection first, saying she must get back to work.
1. Why is another antibiotic course or a further period of observation wrong here, and what does the clinical picture already tell you?
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The features are those of a suspicious malignant ulcer, not an infection. A six-week duration, a rolled and indurated margin, fixity to deep tissue and absence of tenderness are classic red flags for oral squamous cell carcinoma, and the failure of two appropriate antibiotic courses removes infection from the likely list. Antibiotics act on bacteria; they cannot alter a neoplastic ulcer, and a temporary reduction in surrounding inflammation can even create false reassurance while the tumour advances.
The risk profile reinforces this: 22 years of smokeless tobacco with betel quid plus 15 cigarettes daily gives heavy, combined exposure to carcinogens, and lateral border of tongue is a high-risk site for field cancerisation. Delay is the single commonest reason for advanced stage at diagnosis in this region, and stage determines survival more than any treatment choice.
The diabetes and anaemia do not justify delay. HbA1c 9.1% must be optimised for surgery and anaesthesia, but that is a parallel task for the physician, not a precondition for biopsy. The right action is urgent incisional biopsy, not another prescription.
2. Set out your investigation and referral plan, with the reasoning for the order in which things should happen.
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The sequence is designed so that the diagnosis comes first and the treatment burden is planned around it.
- Urgent incisional biopsy under local anaesthesia, taken from the edge of the ulcer including a margin of adjacent clinically normal tissue, avoiding the necrotic centre. This is the only way to confirm or exclude malignancy and to grade the lesion.
- Baseline bloods and metabolic control: full blood count, fasting glucose and HbA1c, renal and liver function, coagulation screen, and group and save if surgery is likely. Correcting anaemia and hyperglycaemia lowers perioperative risk.
- Imaging if malignancy is confirmed: chest radiograph plus contrast CT or MRI of the neck for staging, with fine-needle aspiration of any node that becomes palpable. Positron emission tomography is added only where staging remains unclear.
- Referral to oral and maxillofacial surgery or the regional cancer centre on the same day as biopsy, not after the report, so that the patient has a confirmed appointment.
- Tobacco and betel quid cessation counselling, offered with the biopsy, because continued use worsens outcomes and second primary risk.
- Dental clearance before radiotherapy if that is planned: extractions and restorations completed with time to heal, fluoride trays and meticulous hygiene to reduce osteoradionecrosis.
3. The patient refuses biopsy today and wants to return to work. How do you manage this ethically and practically, and what do you document?
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A competent adult may refuse, and I must not coerce, but respect for autonomy sits alongside a duty of care and a duty not to abandon.
In practice I would acknowledge her fear directly, explain in plain terms what the ulcer looks like, that it is not an infection, and that a biopsy is a small procedure done with local anaesthesia taking perhaps fifteen minutes, with results in about a week. I would offer to do it the same day to avoid another three-hour journey, invite her to bring a family member, and use simple visual aids. I would ask what specifically worries her, since the fear is often about cancer itself rather than the procedure, and address that concern rather than repeating information.
If she still declines, I would:
- give written information and a definite recall within one to two weeks, not an open-ended 'come back if it gets worse';
- with her consent, contact a family member and her general practitioner so that the message is reinforced;
- treat symptomatic problems, provide analgesia and cessation advice, and correct the anaemia and glucose through the physician;
- record the clinical findings, the diagnosis discussed, the risks of delay, that she had capacity and understood them, and that she declined, with the recall date and the people contacted.
Documentation protects the patient and demonstrates that the professional obligation was met even when the patient's choice differs.