Non-healing tongue ulcer in a tobacco and smokeless tobacco user

The leading diagnosis is oral squamous cell carcinoma. The differential includes a dysplastic leukoplakia or erythroplakia, a traumatic ulcer from the sharp molar, chronic hyperplastic candidosis, tuberculosis, syphilis, a salivary gland malignancy, and lymphoma. Malignancy is the leading concern because of the duration of seven weeks, the site on the lateral border of the tongue, the rolled everted margins, and, most importantly, the induration. A traumatic ulcer usually resolves within two weeks once the cause is removed and does not feel firm and fixed. Chronic candidosis is usually bilateral and improves with antifungal treatment. The absence of pain is not reassuring; early oral cancer is often painless. His tobacco and smokeless tobacco exposure are strong risk factors. The lack of cervical lymphadenopathy is also not reassuring, because nodal metastasis may be microscopic. The failure of two courses of antibiotics and antifungal treatment supports a neoplastic rather than infective process. I would examine the whole oral mucosa, the floor of the mouth, the tonsils, and the neck.

I would not perform an incisional biopsy in a clinic without a histopathology service, because an adequate sample, orientation, and interpretation matter and an inadequate biopsy can delay diagnosis. I would take a clinical photograph with consent, record the size and site, and examine the cervical lymph nodes. I would refer urgently on a two-week suspected cancer pathway to oral and maxillofacial surgery or oral medicine for incisional biopsy and assessment. I would not prescribe further antibiotics or antifungals, because these can mask or delay diagnosis. I would smooth the sharp broken molar, but I would not assume the lesion is traumatic, and removing the tooth does not remove the need for referral. I would explain my concern honestly, give written referral information, and arrange a safety net so that the patient is followed up. Smoking and smokeless tobacco cessation advice should be given, and I would consider blood tests such as full blood count and ferritin if there is any suspicion of anaemia or systemic disease.

Treatment is decided by a multidisciplinary team. For T2N0 oral squamous cell carcinoma, the mainstay is surgical resection with a 1 cm clinical margin and appropriate reconstruction. The decision about an elective neck dissection depends on the depth of invasion: a depth greater than 3–4 mm carries a significant risk of occult nodal metastasis, so elective dissection or sentinel node biopsy is usually recommended. Postoperative radiotherapy or chemoradiotherapy is considered for positive or close margins, perineural or lymphovascular invasion, multiple nodes, extracapsular spread, or deep invasion. Before radiotherapy, the dentist's role is to eliminate sources of infection: extract unsalvageable teeth and treat periodontal disease, ideally at least two weeks and preferably three weeks before radiotherapy starts. I would provide fluoride, hygiene instruction, and advice on mucositis and xerostomia, and I would emphasise that extractions after radiotherapy carry a high risk of osteoradionecrosis.