American Association of Oral and Maxillofacial Surgeons

Position Paper

Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria
for General Practitioners
Background
The head and neck region is composed of numerous
anatomic structures made of diverse soft and hard tissues
that can give rise to a broad spectrum of head and necklesions and pathologies. The intent of this position paper
is to provide a broad overview in the initial evaluation anddiagnosis of oral, head and neck lesions.
Entities of the oral cavity can generally be broken down
into categories based on their tissue of origin. Tissues in
the oral cavity include mucosa, submucosal tissues (suchas minor and major salivary glands, nerves, muscles,
vessels, adipose tissue), bone, teeth and periodontal
structures. Table 1 – although not meant to be all-inclusive– includes some of the more common oral lesions and theirtissue of origin.

Risk Factors
Risk factors vary for the different entities. For squamouscell carcinoma and dysplasia, major risk factors for theoral cavity and oropharynx include smoking tobacco,
alcohol consumption, the synergistic interaction of tobaccouse and alcohol consumption, and tobacco and betel quid(“paan”) chewing (Table 2).1-4 Natural or artificial sunlight
exposure over long periods of time is a major risk factor
for lip and skin cancers.5
Evidence has shown human papillomavirus (HPV)
infection to be a risk factor for oropharyngeal carcinomas,
with 80 percent of those being caused by HPV. The role of
HPV infections in oral cavity cancer is negligible; this is
an important distinction to understand so as not to cause
confusion among patients and the public. The oropharynxlies directly behind and is contiguous with the oral cavity
and consists of the soft palate, base of tongue, tonsils, andlateral and posterior pharyngeal walls.
Individuals with rare inheritable diseases and otherdisorders such as Fanconi anemia, Li-Fraumeni syndrome,dyskeratosis congenita, Bloom Syndrome, PlummerVinson syndrome and acquired immunodeficiency are also
at increased risk for developing head and neck cancer.1,3,4,6Role of the Oral Healthcare Provider
The dental profession holds an expert status with regard tothe oral cavity and head and neck region. Oral healthcare
providers are able to pick up lesions earlier with subtle
findings than otherwise would be possible. Thus, thedental profession plays a pivotal role in early detection.
Despite all the improvements in surgery, imaging andother adjuvant therapies, early detection remains the single
most important prognostic indicator in improving patient
survival.
A thorough oral, head and neck exam is crucial to early
detection of oral cavity malignant and premalignant
lesions. This examination also may aid in the detectionof other benign or malignant submucosal lesions listed
in Table 1. Based on the current evidence, AAOMS
recommends healthcare providers conduct a history withrisk assessment of patients regularly and perform a visualand tactile exam of the head and neck and oral cavity inpatients identified as having risk factors and/or signs andsymptoms. For dental providers, it is a recommended thata thorough oral, head and neck exam be performed at eachdental visit.7,8The patient’s full medical history, social history andreview of systems should be taken – assessing for risk
factors or signs or symptoms of oral, head and neck cancer
or other oral, head and neck pathologies. A list of signs
and symptoms and exam findings that may be deemed
worrisome on history and exam are listed in Table 3.
The exam requires adequate lighting, a dental mouthmirror or tongue depressor, 2 x 2 gauze and gloves.
With the patient seated, the extraoral and perioral tissues
are examined first, followed by the intraoral tissues.
Inspection of the head/scalp, face, ears and neck isperformed. The regional lymph node areas of the head

PAGE 1 Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners

and neck are palpated bilaterally evaluating for cervicallymphadenopathy and also evaluating for thyroid
enlargement and masses. The preauricular regions shouldbe palpated for parotid lesions. The perioral exam shouldinspect the face and lips. Intraoral exam should include
visual inspection of every mucosal surface within the oralcavity in a systematic manner, including the labial mucosaand vestibules; commissures, buccal mucosa and sulcus,
buccal and lingual gingiva, alveolar ridge, tongue, floor of
the mouth and hard and soft palate (Figure 1). Bimanual
palpation of the floor of mouth also should be performed,along with palpation of the sublingual and submandibular
glands.9
Any suspicious lesions – including red, white, mixed red/white lesions or masses – that do not resolve within two
weeks should be cosidered for a biopsy for definitive
diagnosis and to rule out premalignant or malignant lesions(Figures 2 and 3). Similarly, masses, chronic ulcerationand new or enlarging pigmented lesions should beconsidered for biopsy.10,11
A brief overview of biopsy techniques available to thegeneral provider follows:

Incisional Biopsy
Incisional biopsy provides a representative sample oftissue for diagnostic purposes. It is the method of choice
when the differential diagnosis includes malignancy as
to allow for proper post-biopsy treatment by the treatingsurgeon. The biopsy site selection should be at the mostrepresentative site of the lesion while avoiding areas ofulceration and gross necrosis, as those may yield nondiagnostic tissue. A sample of the most representative
tissue is sufficient without the need to include tissue fromthe periphery. Elliptical biopsy design facilitates primaryclosure when healthy tissue remains.

Excisional Biopsy
Excisional biopsy is the complete removal of a lesion toprovide a definitive histological diagnosis. This procedure
is appropriate only when the lesion is most certainly
benign with no suspicion of malignancy as in the caseof an irritation fibroma.12

Punch Biopsy
Punch biopsy may be used for either incisional biopsy or
excision of a small lesion. The main advantage of punch
biopsies is they allow the harvesting of a core of tissue
with preserved tissue architecture. The punch device isplaced on the lesion with a downward, twisting motion

Position Paper
to produce a tissue core that can be amputated at its
base and submitted for histopathologic evaluation.13

Biopsy Considerations
For sites involving the attached gingiva and hard palate,biopsies make primary closure difficult and healing is
generally completed by secondary intention. Hemostasis
in such open wounds may be achieved by placing ascaffolding such as absorbable collagen and/or the useof chemical cautery such as silver nitrate.
When handling the specimen, it must be gently grasped
with forceps to prevent crushing of the specimen or
shearing of the mucosal layer. Specimens should be clearlylabeled, and care must taken to avoid mixing of specimens
when biopsying multiple sites.
Specimens are submitted in 10% neutral buffered formalinsolution to allow for proper fixation. Specimens requiring
immunofluorescence studies require a water-based solution
such as Michel’s solution.
Pertinent medical history, clinical history and relevantradiographic imaging should be included with thespecimen and are helpful to the pathologist in renderinga correct diagnosis.
Some lesions may be contraindicated for biopsy or
may require additional expertise. Examples of thoseinclude vascular lesions; lesions with red, purple orblue coloration; or pulsatile lesions. When biopsying
the floor of the mouth, care must be taken to avoid
damage to adjacent anatomic structures – including thesubmandibular duct, lingual nerve and sublingual glands.
Patients with complex medical issues, with bleeding
disorders or on anticoagulants may be best managed
by an oral and maxillofacial surgeon.
For cancerous lesions, providers are encouraged tofamiliarize themselves with head and neck fellowshiptrained oral and maxillofacial surgeons in their area. Suchtraining allows for the optimal treatment of cancer patients
while taking into account the dentition, occlusion andthe temporomandibular joints – all of which are vital for
providing superior reconstructive outcomes.

PAGE 2 Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners

Role of Screening Adjuncts
There are numerous screening adjuncts on the market thatare aimed to help diagnosing dysplastic mucosal disease.
A detailed discussion of each of these modalities is beyond
the scope of this position paper, but these modalities
include vital stains such toluidine blue and Lugol’s iodine.
Adjuncts also include tissue fluorescence imaging suchas VELscope and other systems that use a blue light withwavelengths in the range of 390 – 460 nm to differentiate
the fluorescence between normal and abnormal tissues.
Chemiluminescence, such as ViziLite, utilizes a blue-whitelight in the range of 490 – 510 nm following preparation ofthe oral mucosal tissues with 1% acetic acid (and may use
manufacturer-specific eyewear). Brush biopsies attempt
to obtain cytologic tissue without the need for scalpel
biopsies but have sensitivities and specificities varying
between 71 – 100% and 27 – 100%, respectively.

Position Paper

Although these screening adjuncts may be helpful inencouraging providers and patients to conduct a thoroughoral exam, current evidence does not demonstrate
any advantage of these screening adjuncts over acomprehensive clinical oral exam. Such positions havebeen summarized in different position papers, including
the Head and Neck Cancer Screening and Prevention
Position Paper by the American Association of Oraland Maxillofacial Surgeons, the Position Statement on
Early Detection of Pre-Malignant Oral Cancer by theAmerican Head and Neck Society (AHNS), and Evidencebased Clinical Practice Guideline for the Evaluation ofPotentially Malignant Disorders in the Oral Cavity reportby the American Dental Association.7,14
The position of the current body of evidence is consistentin that there is no substitute for a comprehensive oral headand neck exam; however, if screening adjuncts help ormotivate dental providers to examine patients, then they
may be utilized.

PAGE 3 Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners

Position PaperTable 1

Tissue of Origin for Oral Lesions
Epithelial / Mucosal• Hyperkeratosis• Papilloma

Potentially premalignant:• Proliferative Verrucous leukoplakia• Epithelial dysplasia (mild, moderate,severe)• Carcinoma in situ
• Submucous fibrosis

Malignant:• Squamous cell carcinoma• Verrucous carcinoma• Carcinoma cuniculatum

Pigmented Mucosal• Melanotic macule• Racial pigmentation• Amalgam tattoo• Nevus• Oral melanoacanthoma• Melanoma

Mesenchymal Tumors
Benign:• Fibroma• Lipoma• Neuroma• Schwannoma• Neurofibroma• Myofibroma• Leiomyoma• Granular cell tumor• Schwannoma• Vascular lesions including hemangiomas
and arteriovenous malformation• Osteoma

Malignant:• Angiosarcoma• Kaposi sarcoma• Fibrosarcoma• Liposarcoma• Chondrosarcoma• Osteosarcoma

Salivary GlandBenign:• Mucocele• Ranula• Pleomorphic adenomas• Myoepithelioma• Warthin Tumor• Monomorphic adenomas• Canalicular adenoma• Basal cell adenoma

Malignant:• Mucoepidermoid carcinoma• Adenoid cystic carcinoma• Polymorphous adenocarcinoma• Carcinoma ex pleomorphic adenoma• Acinic cell carcinoma• Secretory carcinoma(continued on following page)
PAGE 4 Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners

Position Paper(continued from previous page)

Odontogenic Tumors (2022 WHO Classification)
Epithelial:• Adenomatoid odontogenictumor• Squamous odontogenictumor• Calcifying epithelial
odontogenic tumor• Ameloblastoma, unicystic• Ameloblastoma,extraosseous/peripheral• Ameloblastoma,conventional• Adenoid ameloblastoma• Metastasizing
ameloblastoma

Mesenchymal:• Odontogenic fibroma• Cementoblastoma• Cemento-ossifying
fibroma• Odontogenic myxoma

Mixed:• Odontoma• Primordial odontogenic
tumor• Ameloblastic fibroma• Dentinogenic ghost
cell tumor

Malignant:• Sclerosing odontogenic
carcinoma• Ameloblastic carcinoma• Clear cell odontogenic
carcinoma• Ghost cell odontogenic
carcinoma• Primary intraosseous
carcinoma, NOS• Odontogenic
carcinosarcoma• Odontogenic sarcomasTable 2

Oral Cancer Risk Factors
Established / Strongly Suggestive

Possible / Speculative

Smoking
Chewing tobacco
Snuff dipping
Alcohol misuse
Sunlight (lip)Immune deficiency
Dentition
Ethnicity
Viruses
Periodontal disease
Mouthwashes
Familial

PAGE 5 Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners

Position Paper
Table 3Worrisome Symptoms and Exam Findings
Difficulty chewing, swallowing or managing secretions

May be due to deep neck infection or a mass/tumor invading
the tongue and its adjacent musculature.

Dysphagia or odynophagia

May be due to a supraglottic/hypo/oropharyngeal neoplasm.

Trismus or difficulty opening the mouth

May be due to an infection or neoplasm involving
the masticator space and muscles.

Otalgia or ear pain

May be referred pain due to a head and neck malignancy.

HoarsenessMay be present in patients with laryngeal cancer.

Numbness of the lip, tongue or other areas of the mouth
and/or face

May be the result of malignancy or neoplastic process
involving the inferior alveolar, lingual or other sensory nerves.

Swelling of the jaws that causes dentures to fit poorlyor become uncomfortable

A possible sign of expansion of the maxilla or mandible.

Leukoplakia, erythroplakia, erythroleukoplakia

May represent pre-cancerous or cancerous lesions.

Ulceration

May be due to malignancy, trauma or autoimmune disorders.

Induration

May be associated malignant disease.

Enlarged or fixed cervical lymph nodes

May represent metastatic spread/involvement.

Palatal mass or Swelling

May be a salivary gland neoplasm, lymphoma or infection.

Floor of mouth mass or Swelling

Can be a salivary gland neoplasm, ranula or other process.

Uvular deviation and pharyngeal swelling

Can see with deep lobe parotid tumors or oropharyngealtumors.

Displaced, loose or floating teeth

Can be the result of a destructive lesion of the maxilla
or mandible.

Spontaneous bleeding around teeth, with loose teeth,
jaw expansion, and a palpable pulsation or thrill

Can be seen with arteriovenous malformation.

Facial asymmetry

May be the result of a neoplasm in the soft tissues orexpansion of the maxilla or mandible from a neoplasm.

Facial nerve weakness

Can indicate a malignancy of the parotid.

Pigmented lesion

Needs to be evaluated to rule out oral melanoma.

PAGE 6 Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners

Position Paper
Figure 1abcdef

Figure 1: Examination of a) labial mucosa, lips, buccal gingiva and vestibule; b) lateral border of tongue; c) hard and soft palate;d) ventral tongue and floor of mouth; e) oropharynx and f) maxillary buccal gingiva and vestibule.

Figure 2abcdef

Figure 2: Examples of oral lesions include a) leukoplakia involving the ventral tongue, dysplasia; b) mixed red/white lesioninvolving the left buccal mucosa, dysplasia; c) leukoplakia involving the right mandibular vestibule and gingiva, tobacco pouchkeratosis; d) corrugated and papillary red lesion involving the left buccal mucosa, verrucous carcinoma; e) left submucosal
swelling of the soft palate and oropharynx, lateral pharyngeal mass; and f) left preauricular/facial mass, parotid tail tumor.
PAGE 7 Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners

Position PaperFigure 3abcdefFigure 3: Examples of oral lesions include a) left lower lip scaly lesion, SCCA; b) red lesion involving the anterior
mandibular gingiva, SCCA; c) corrugated leukoplakia involving the left maxillary gingiva, proliferative verrucous leukoplakia;d) right submucosal palatal mass with superficial ulceration, pleomorphic adenoma e) right mandibular vestibule firm mass,osteosarcoma; f) multiple soft-tissue growths involving the floor of mouth, ventral and lateral tongue, neurofibromas.

PAGE 8 Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners

Position Paper

References1.

Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022.
CA Cancer J Clin. 01 2022;72(1):7-33. doi:10.3322/caac.21708

2.

Dhull AK, Atri R, Dhankhar R, Chauhan AK, Kaushal V. Major
Risk Factors in Head and Neck Cancer: A Retrospective Analysisof 12-Year Experiences. World J Oncol. Jun 2018;9(3):80-84.
doi:10.14740/wjon1104w

3.

Shaw R, Beasley N. Aetiology and risk factors for head and neckcancer: United Kingdom National Multidisciplinary Guidelines.
J Laryngol Otol. May 2016;130(S2):S9-S12. doi:10.1017/
S0022215116000360

4.

5.

6.

7.

8.

Chi AC, Day TA, Neville BW. Oral cavity and oropharyngeal
squamous cell carcinoma--an update. CA Cancer J Clin. 2015 SepOct 2015;65(5):401-21. doi:10.3322/caac.21293
Samarasinghe V, Madan V, Lear JT. Management of high-risksquamous cell carcinoma of the skin. Expert Rev Anticancer Ther.
May 2011;11(5):763-9. doi:10.1586/era.11.36
Patel SC, Carpenter WR, Tyree S, et al. Increasing incidence oforal tongue squamous cell carcinoma in young white women,age 18 to 44 years. J Clin Oncol. Apr 10 2011;29(11):1488-94.
doi:10.1200/JCO.2010.31.7883
Head and Neck Cancer Screening and Prevention, Position
Paper, American Association of Oral & Maxillofacial Surgeons.:
American Association of Oral & Maxillofacial Surgeons; 2020.
National Institute of Dental and Craniofacial Research. Detecting
Oral Cancer, A Guide For Health Care Professionals. Available atwww.nidcr.nih.gov/health-info/oral-cancer

9.

World Health Organization, International Agency for Research onCancer. Screening Group, A digital manual for the early diagnosis
or oral neoplasia, Physical examination of the oral cavity. Availableat http://screening.iarc.fr/atlasoral_list.php?cat=H2&lang=1

10. Gilvetti C, Collyer J, Gulati A, Barrett AW. What is the optimalsite and biopsy technique for the diagnosis of oral mucosal
autoimmune blistering disease? J Oral Pathol Med. Mar
2019;48(3):239-243. doi:10.1111/jop.12817
11. Bello IO, Wennerstrand PM, Suleymanova I, et al. Biopsy quality
is essential for preoperative prognostication in oral tongue cancer.
APMIS. Mar 2021;129(3):118-127. doi:10.1111/apm.13104
12. Shanti RM, Tanaka T, Stanton DC. Oral Biopsy Techniques.
Dermatol Clin. Oct 2020;38(4):421-427. doi:10.1016/j.
det.2020.05.003
13. Lynch DP, Morris LF. The oral mucosal punch biopsy: indicationsand technique. J Am Dent Assoc. Jul 1990;121(1):145-9.
doi:10.14219/jada.archive.1990.0149
14. Lingen MW, Abt E, Agrawal N, et al. Evidence-based clinicalpractice guideline for the evaluation of potentially malignant
disorders in the oral cavity: A report of the American Dental
Association. J Am Dent Assoc. 10 2017;148(10):712-727.e10.
doi:10.1016/j.adaj.2017.07.032© 2023 American Association of Oral and MaxillofacialSurgeons. No portion of this publication may be used or
reproduced without the express written consent of theAmerican Association of Oral and Maxillofacial Surgeons.

PAGE 9 Oral Lesion Evaluation, Biopsy Techniques and Referral Criteria for General Practitioners