Oral cancer red flags – a case of misdiagnosis

A 65-year-old male presented to the emergency department with pain on the left-hand side of his mandible after feeling a ‘crack’ whilst eating cornflakes. The patient was a retired builder living with his wife and had an unremarkable medical history with the exception of spinal stenosis. He was a non-smoker and consumed a minimal alcoholic intake. On presentation, he was examined by an A&E doctor who requested an orthopantomogram (Figure 1) which was reported by a non-dental radiologist. No fracture or change in bone density was noted and an appointment with the maxillofacial department was organized without prior request for maxillofacial review.

At the maxillofacial review, the patient complained of a dull pain in the left side of his mandible which was much worse when chewing food. He denied otalgia or dysphagia and was managing to eat a good diet. On inspection, there was an extra-oral swelling involving the left body of mandible and intra-oral examination revealed an irregular, ulcerated, exophytic, granular lesion of the mandibular alveolus in the left premolar region and extending laterally to the buccal sulcus. There was associated grade II mobility of the LL7 and LL8, and neither the lingual nerve nor the inferior alveolar nerve had altered sensation at this point. The orthopantomogram was reviewed and reported by a dental clinician who commented on the area of radiolucency within the left body of the mandible and associated undisplaced pathological fracture. Additional imaging was ordered. At the next appointment, the patient's history had evolved to symptoms of numbness of the lower lip and the spontaneous exfoliation of a molar on the left side of the mandible. On examination, this evolution in clinical symptoms was accompanied by a dramatic increase in bony expansion of the left body of the mandible.