Metastatic Neoplasms to the Oral Cavity Clinical Presentation

Updated: Jun 26, 2018
  • Author: Abraham Hirshberg, MD, DMD; Chief Editor: Jeff Burgess, DDS, MSD  more...
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Presentation

History

Symptoms develop in a relatively short period. In the oral soft tissues, most patients report a lump. In the jawbones, swelling, pain, and paresthesia of the affected nerve are the chief reported symptoms.

Give special attention to patients with numb chin syndrome or mental nerve neuropathy. The numb chin syndrome is the consequence of loss of function of the terminal sensory division of the mandibular branch of the trigeminal nerve. Any pathological process involving the mental nerve, the mandibular nerve, and even the mandibular trunk of the fifth nerve may produce this loss of function. The appearance of a mental nerve neuropathy should always raise the possibility of a metastatic disease in the mandible. [27]

With the progression of the disease, oral metastatic lesions (especially those in soft tissues) cause progressive discomfort. Pain, bleeding, superinfection, dysphagia, interference with mastication, and disfigurement are some of the main reported symptoms.

In some cases, the metastasis is discovered in a recent extraction site. The main symptom is a soft tissue mass extruding from a recent extraction wound and accompanied by pain. In many of these cases, the metastatic tumor is present in the area before the extraction; it can cause pain, swelling, and loosening of the teeth. These symptoms lead to the extraction of the affected tooth. In some cases, metastasis probably develops after extraction. Tooth extraction can serve as a promoting factor in the metastatic process.

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Physical Examination

The clinical presentation of the metastatic tumors differs among the various oral sites.

In the oral soft tissues, the attached gingiva is the most commonly affected site, followed by the tongue and, with much less frequency, the remaining mucosa.

The presence of teeth seems to have a crucial effect on the oral site preference of metastases. In the dentulous patient, about 80% have metastasis in the attached gingiva. In the edentulous patient, metastatic lesions are distributed equally between the tongue and alveolar mucosa.

An exophytic, sometimes ulcerated lesion is the most common clinical presentation of metastatic lesions in the oral soft tissues.

In its early manifestation, gingival metastasis resembles hyperplastic or reactive lesions (eg, pyogenic granuloma, peripheral giant cell granuloma, fibrous epulis), [28] as shown in the images below.

A large pedunculated mass on the gingiva resembles A large pedunculated mass on the gingiva resembles a pyogenic granuloma and peripheral giant cell granuloma in a 44-year-old woman with metastatic breast carcinoma.
A large soft-tissue mass on the gingiva resembles A large soft-tissue mass on the gingiva resembles pyogenic granuloma and peripheral giant cell granuloma in a 51-year-old man with metastatic renal cell carcinoma.

In other oral soft-tissue locations, especially in the tongue, the metastatic lesion manifests as a submucosal mass.

With progression of the disease, oral metastatic lesions, especially those located in the soft tissues, may cause progressive discomfort, pain, bleeding, superinfection, dysphagia, interference with mastication, and disfigurement.

In the jawbones, the common location of the metastatic lesion is the mandible; the molar area is the most frequently involved site.

A rapidly progressing swelling accompanied by pain and paraesthesia are the classic symptoms of a metastatic tumor in the jawbone.

Mental nerve neuropathy, or the so-called the numb chin syndrome, should raise the suspicion of metastatic disease in the mandible.

In the jawbones, physical examination reveals a bony swelling with tenderness over the affected area.

Sometimes, tooth mobility and trismus are present.

Metastatic disease to the jaws may extend into the overlying soft tissues, appearing to imitate a dental or periodontal infection.

In some cases, especially those of metastatic hepatocellular carcinoma, severe postbiopsy hemorrhagic episodes had been reported.

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