Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2011; 56: 14

REVIEW

doi: 10.1111/j.1834-7819.2011.01337.x

Oral cancer and oral erythroplakia: an update and

implication for clinicians
A Villa,* C Villa, S Abati*
*Department of Medicine, Surgery and Dentistry, University of Milan, Milan, Italy.
Private Practice, Bergamo, Italy.

ABSTRACT
Despite recent advances in therapy and treatment for oral cancer, survival rates are still low. It is generally accepted that oral
cancer may arise from potentially premalignant disorders. Oral erythroplakia has been identified as the one with the highest
malignant transformation rates. The aim of this review was to provide detailed information on oral cancer and oral
erythroplakia. Few data are available on oral erythroplakia and there is an urgent need for randomized controlled trials.
Early detection and diagnosis is still the key to survival rates. Dentists and physicians may play an important role in the
detection of premalignant lesions and therefore improve patients outcome.
Keywords: Erythroplakia, oral cancer, malignant.
Abbreviations and acronyms: ENT = ear, nose and throat; HNSCC = head and neck squamous cell carcinoma; SCC = squamous cell
carcinoma.
(Accepted for publication 17 November 2010.)

INTRODUCTION
Head and neck cancers are a heterogeneous group of
cancers that arise from the mucosa of the larynx,
pharynx, oral cavity, nasal cavity and paranasal sinuses.
The majority of these epithelial malignancies are squamous cell carcinoma of the head and neck (HNSCC),
and the histologic grade can vary from well-differentiated
keratinizing to undifferentiated non-keratinizing.
It is generally accepted that oral cancer may arise
from potentially malignant disorders.1 Oral erythroplakia has been identified as the one with the highest
malignant transformation rates.
Frequently, patients with early-stage cancer present
with only vague symptoms and minimal physical findings; early identification of signs and symptoms of both
oral potentially premalignant disorders and oral cancer
may decrease the burden associated with this disease.
Therefore, the aim of this review was to provide detailed
information on oral cancer and oral erythroplakia to
improve dentists knowledge of these important diseases.
Oral cancer
Oral and pharyngeal cancer is an important component
of the worldwide burden of cancer. Oral cancer
2011 Australian Dental Association

incidence has been rising over the last few decades,

becoming the eighth most common cancer worldwide.
The occurrence of oral cavity and oropharynx cancer is
higher among males than females, and is more common
in developing than developed countries. In 2008, a total
of 263 861 new oral cavity cancers were diagnosed
globally and about 65% of these cancers occurred in
males. This accounts for approximately 2% of all new
cancer diagnosed (male: 2.6%; female: 1.5%). The
disease is more frequent in south-central Asia. For
example, in India the age standardized incidence rate of
oral cancer is reported at 12.6 per 100 000 population.
However, there is also an increase in the incidence rates
in Eastern and Central Europe.1,2
Survival rates for oral cancer have not shown
significant improvement over the past 50 years and
are among the lowest of major cancers. The 5-year and
10-year relative survival rates are 59% and 48%,
respectively.3
Squamous cell carcinoma (SCC) accounts for 95% of
oral cancers. The aetiology of oral cancer is multifactorial. The most important risks factors for oral
cancer are tobacco smoking and chewing, excess
consumption of alcohol, betel quid chewing and being
exposed to UV rays for a long period of time (lip cancer
only). The combination of alcohol and tobacco use
1

A Villa et al.
multiplies the risk. Other emerging risk factors are HPV
infection, immunodeficiencies, diet and nutrition, mate
drinking and socio-economic status. Unconfirmed risk
factors are ethnicity and race, poor oral hygiene, dental
conditions, chronic candidiasis and chronic trauma of
the oral mucosa.4,5
The signs and symptoms can be a mouth sore that
fails to heal or unusual bleeding, a lump, sudden tooth
mobility without apparent cause or a chronic earache
and a lateral lump in the neck. Most early signs are
painless and are difficult to detect without a thorough
head and neck examination by a dental or medical
professional.
Treatment options include radiation therapy and
surgery, separately or in combination and are dictated
by the location and size of the lesion. Early cancers
(Stage I and Stage II) of the oral cavity and lip have a
better prognosis and the choice of treatment is surgery
or radiation therapy (Fig 1). If regional nodes are
positive, cervical node dissection is usually undertaken.
In advanced disease (Stage III or greater) (Fig 2),
chemotherapy is added to surgery and or radiation.68
Of interest, patients who continue smoking during
radiotherapy seem to have shorter survival durations
and lower response rates than those who do not.9
As such, dentists should counsel their patients to quit
smoking.

Fig 2. A 59-year-old male with early stage squamous cell carcinoma of

the right lateral border of the tongue.

cancer syndromes.11,12 The most common are leukoplakia, erythroplakia, lichen planus and submucous
fibrosis.13 Even if erythroplakia is an infrequent disease,
its risk of malignant progression is the highest among
the oral potentially malignant disorders. Therefore, it is
important to identify the correlation between oral
cancer and erythroplakia and the possible implications
for general dental practitioners.
Oral erythroplakia

Oral potentially malignant lesion is an area of genetically and or altered tissue that is more likely to
develop cancer than a normal tissue.10 Potentially
malignant disorders of the oral cavity comprise leukoplakia, erythroplakia, palatal lesions in reverse smokers, submucous fibrosis, actinic cheratosis, lichen
planus, discoid lupus erythematosus, immunodeficiency
in relation to cancer predisposition and some inherited

The term erythroplasia was originally used to describe

a precancerous red colour that develops on the penis.
According to the original 1978 WHO definition, oral
erythroplakia (Fig 3) is defined as any lesion of the oral
mucosa that presents as bright red velvety plaques
which cannot be characterized clinically or pathologically as any other recognizable condition. Reported
prevalence varies between 0.02%14 and 0.2%15
(adapted from Reichart et al.16). Clinically, it can be
flat or depressed and sometimes it can be found

Fig 1. Invasive squamous cell carcinoma of the palate in a 60-year-old

male.

Fig 3. Erythroplakia on the soft palate in a 62-year-old male.

Potentially malignant disorders of the oral cavity

2011 Australian Dental Association

Oral cancer and oral erythroplakia

together with leukoplakia (erythroleukoplakia); it predominately occurs in the floor of the mouth, the soft
palate, the ventral tongue and the tonsillar fauces.
There are usually no symptoms. However, some
patients may complain of a burning sensation and or
sore. Erythroplakia shows dysplastic features and often
presents as carcinoma in situ or invasive carcinoma
at the time of biopsy.1719 Heavy alcohol consumption
and tobacco use are known to be important aetiological
factors. Surgical excision is the treatment of choice
though more studies are needed.15,16 The differential
diagnosis includes: erythematous candidiasis, early
SCC, local irritation, mucositis, lichen planus, lupus
erythematosous, drug reaction and median rhomboid
glossitis.20
The epithelium is often atrophic and shows lack of
keratin. Sometimes hyperplasia is seen. The red colour
is due to the epithelial thinness that allows the
underlying microvasculature to show through.
Oral erythroplakia and progression to cancer
Using PubMed, Cochrane Library and Medline
throughout June 2010, we conducted a search of the
medical literature for articles on oral erythroplakia. The
key search terms used were oral erythroplakia. Case
reports were not included for the purpose of this
analysis. The search identified 211 potentially eligible
studies. After examining the abstract and full text of the
articles, 10 papers were considered relevant. Papers
were considered relevant if they reported on prevalence
data or information on the malignant progression to
invasive cancer.
Oral erythroplakia lesions were examined in 10
studies carried out from 1971 to 2007. The largest
studies were carried out in the United States and India.
The total number of subjects was 226 534 and 258 oral
potentially malignant lesions were identified. The mean
prevalence of oral erythroplakia was 0.11%. Hashibe15
reported the highest prevalence of erythroplakia

(0.21%), while Lumerman21 reported the lowest

(0.01%) (Table 1).
Erythroplakia was identified through a clinical oral
examination and biopsy. Sixty-two lesions developed
oral cancer with a malignant transformation rate of
44.9%. However, this is just an estimate of the
progression rate because of the differences across the
studies and because risky behaviours (e.g. tobacco
smoking, alcohol consumption) were not considered in
the majority of the studies. Interestingly, most of the
studies were hospital based, thus the real prevalence
may differ. As such, there is an urgent need for large
population based studies with an active follow-up.
Implications for clinicians
Dentists, ear, nose and throat (ENT) specialists or oral
surgeons may be the first to find a red patch in the
mouth of their patients. Unless a lesion has features
mandating immediate biopsy, oral health professionals
should eliminate the potential causes (such as minimizing frictional sources) and re-evaluate the patient in 10
to 14 days.22 If the lesion is still present, biopsy and
referral to an oral medicine specialist are needed. Areas
of chronic inflammation and traumatic lesions usually
resolve or reduce in size within two weeks. On the
contrary, any persistent mucosal lesion should be
considered suspicious for oral cancer. A thorough
initial evaluation of symptoms and signs is essential,
together with a biopsy and long-term follow-up. Early
detection of such lesions may prevent malignant
transformation.23 Therefore, it is important to improve
the ability of general dental practitioners to detect any
relevant lesions at the earliest stage in order to interrupt
the chain of progression to cancer. Indeed, general
dental practitioners may be the first to see such lesions
and therefore they should be able to recognize them and
institute appropriate treatment such as biopsy or early
referral. Also, clinicians may focus on educating their
patients about oral cancer risk factors, in addition to

Table 1. Erythroplakia: prevalence and malignant transformation rates

Author

Year

Country

Sample
(n)

Erythroplakia (n)

Prevalence
(%)

MT
n (%)

Lapthanasupkul18
Hashibe15
Lumerman21
Vedtofte27
Amagasa28
Silverman29
Lay30
Shafer19
Mincer31
Metha14

2007
2000
1995
1987
1985
1984
1982
1975
1972
1971

Thailand
India
USA
Denmark
Japan
USA
Burma
USA
USA
India

7177
47 773
50 000

9
100
7
14
12
22
5
58
16
9

0.13
0.2
0.01

6 (66.7)

257
6000
64 345
67
50 915

0.08
0.09

1
5
6
8

(14.3)
(35.7)
(50.0)
(36.0)

33 (56.9)
3 (18.8)

0.02

Malignant transformation.
All patients were affected by oral leukoplakia.

2011 Australian Dental Association

A Villa et al.
changing risk behaviours.24 Finally, an increase in
public awareness about the importance of regular oral
screening may have the potential to reduce the burden
of oral cancer.25,26
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Address for correspondence:

Dr Alessandro Villa
Dental Clinic
Department of Medicine, Surgery and Dentistry
University of Milano
Via Beldiletto 1 3
20142 Milano
Italy
Email: alessandro.villa@unimi.it

2011 Australian Dental Association