Mouth cancer

Mouth cancers can start anywhere in the mouth. This includes:

  • lips
  • front of the tongue
  • gums
  • inside lining of the cheeks and lips
  • floor and roof of the mouth
  • behind the wisdom teeth.

The main causes of mouth cancer are drinking heavily and smoking or chewing tobacco. Long term exposure to sunlight and sunbeds (UV light) can increase the risk of lip cancer.

The most common symptoms are an ulcer or sore in the mouth or on the lip that doesn’t heal. Other symptoms include bleeding in the mouth, weight loss or a lump in your neck.

If your GP or dentist thinks your symptoms could be caused by cancer, they will refer you to a specialist. If your only symptom is a lump in your neck, you may be referred to a neck lump clinic. Your mouth will be examined and you might also have a biopsy, or an MRI, CT or ultrasound scan to diagnose the cancer.

Mouth cancer is staged using the TNM or number staging system. Staging describes the size of the cancer and if it has spread. Doctors also decide the grade of the cancer (how quickly it might develop).

Treatments for mouth cancer include surgery, radiotherapy, chemotherapy and targeted therapy.

What is mouth cancer?

Mouth cancers are the most common cancers of the head and neck area. They can begin in any part of the mouth. 

This information should be read with our general information about head and neck cancer, which has more about the tests and treatments mentioned below. We have other information about cancer of the oropharynx or salivary glands.


The mouth

The mouth (oral cavity) includes the:

  • lips
  • front two-thirds of the tongue
  • upper and lower gums
  • inside lining of the cheeks and lips
  • floor of the mouth, under the tongue
  • roof of the mouth (the hard palate)
  • area behind the wisdom teeth.
Side view of structures in the head and neck
Side view of structures in the head and neck

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Causes of mouth cancer

The main causes of mouth cancer are drinking heavily and smoking or chewing tobacco. The risk is greater if you do both.

Other things may also increase the risk. These include:

  • chewing betel quid (even if it doesn’t have tobacco in it)
  • having medical problems that cause a weak immune system
  • infection with a virus called human papilloma virus (HPV)
  • eating an unhealthy diet with not enough fresh fruit and vegetables.

Long-term ultraviolet light exposure (from sunlight, sunbeds or sunlamps) increases the risk of lip cancer.


Symptoms of mouth cancer

The most common symptom of mouth cancer is an ulcer or sore in the mouth or on the lip that doesn’t heal.

Other symptoms may include:

  • a white (leukoplakia) or red (erythroplakia) patch in the mouth that doesn’t go away
  • a lump or thickening in the mouth or on the lip
  • difficulty or pain with chewing, swallowing or speaking
  • bleeding or numbness in the mouth
  • bad breath (halitosis)
  • loose teeth or dentures that don’t fit well anymore
  • a lump in the neck
  • losing a lot of weight over a short time.

These symptoms can be caused by other conditions, but it's important to have them checked by your doctor or dentist. Mouth cancer can be treated more successfully when it’s diagnosed early.


How mouth cancer is diagnosed

Your GP or dentist will examine your mouth closely. If they think that your symptoms could be caused by cancer, or if they aren't sure what the problem is, they will refer you to a specialist doctor. If your only symptom is a lump in your neck, you may be referred to a hospital neck lump clinic.

At the hospital

The specialist doctor will ask about your symptoms and general health. They will check your mouth using a small mirror and light. They may put a very thin, flexible tube with a light and camera at the end (nasendoscope) into your nose to get a better view of the back of your mouth.

To make a diagnosis, the doctor usually removes a small piece of tissue or cells (biopsy). A pathologist (doctor who specialises in analysing cells) examines the tissue or cells under a microscope to look for signs of cancer. A biopsy can be taken in different ways. The doctor may give you an injection to numb the area then take a biopsy while they are examining you. Or they will arrange for you to have a general anaesthetic.

At the neck lump clinic

This is a one-stop clinic where you can have all the tests needed to check for cancer in a neck lump. You’ll usually have an ultrasound scan and a sample of tissue taken from the lump using fine needle aspiration (see below). Sometimes the back of your mouth is also examined using the nasendoscope. The clinic can often give you the results of your tests on the same day, but sometimes you may need to wait longer.


Further tests for mouth cancer

There are several tests that may be used to help diagnose mouth cancer and to check whether it has spread.

Ultrasound scan of the neck

This test uses soundwaves to produce a picture of your neck and lymph nodes on a computer screen. It’s painless and only takes a few minutes. The doctor will put some gel on to your neck and pass a small device which produces soundwaves over the area. The doctor will look for any changes in the size or appearance of the lymph nodes in your neck.

Fine needle aspiration (FNA) of the lymph nodes

You may have this test if the lymph nodes in your neck don’t feel or look normal on a scan. It is done to see whether there are any cancer cells in the lymph nodes.

The doctor passes a fine needle into the lymph node and withdraws (aspirates) some cells into a syringe. This might feel a little uncomfortable, but it’s very quick. You don’t usually need a local anaesthetic to numb the area. You might have an ultrasound scan at the same time to help guide the needle. After the test, a doctor will examine the sample under a microscope to look for cancer cells.

X-ray

The doctor may take x-rays of your face or neck to see whether the cancer has spread to any bones. They may use a special x-ray known as an orthopantomogram (OPG) to look at your jaw and teeth.

MRI (magnetic resonance imaging) scan

This test uses magnetism to build up a detailed picture of areas of your body.

You may be asked to complete and sign a checklist to make sure it’s safe for you to have an MRI scan. Before the scan, you’ll be asked to remove any metal belongings, including jewellery. Some people are given an injection of dye into a vein in the arm. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test, you'll lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It's painless but can be slightly uncomfortable, and some people feel a bit claustrophobic. It’s also noisy, but you’ll be given earplugs or headphones.

CT (computerised tomography) scan

A CT scan takes a series of x-rays that build up a three-dimensional picture of the inside of the body. The scan is painless and takes 10–30 minutes. It uses a small amount of radiation, which is very unlikely to harm you and will not harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan.

You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. This may make you feel hot all over for a few minutes. It’s important to let your doctor know if you are allergic to iodine or have asthma because you could have a more serious reaction to the injection.


Staging and grading of mouth cancer

Staging

The stage of a cancer describes its size and whether it has spread. Knowing the stage helps doctors decide on the best treatment for you. The two most commonly used staging systems are the TNM and the number system.

TNM staging system

T describes the size of the tumour in the mouth and whether it has grown into areas around the mouth. For example, a T1 tumour is small and hasn’t spread, while a T4 tumour has spread into nearby muscles, bones or skin.

N describes whether the cancer has spread to the lymph nodes. N0 means that no lymph nodes are affected, while N1, N2 or N3 means there are cancer cells in the neck lymph nodes.

M describes if the cancer has spread to another part of the body. This is called metastatic cancer. M0 means the cancer hasn’t spread and M1 means the cancer has spread to distant organs, such as the liver or lungs.

Number staging system

Mouth cancers can also be given a number stage from 1 to 4.

  • Stage 1 The tumour is 2cm or smaller and only in the mouth. This would be called T1 N0 M0 in the TNM system.
  • Stage 2 The tumour is 2 to 4cm and only in the mouth.
  • Stage 3 The tumour is bigger than 4cm and only in the mouth or the tumour is any size in the mouth and has also started to spread into the neck lymph nodes.
  • Stage 4 The tumour has spread to other areas around the mouth and/or has spread into the neck lymph nodes and/or has spread to distant organs.

Talking about staging

Your doctor or nurse will be able to give you more information about staging. To keep things simple, they may use the following words:

  • early or local – a small cancer that is only in the mouth.
  • locally advanced or advanced – mouth cancer that is large or has spread into nearby areas of the head and neck or the neck lymph nodes.
  • metastatic – cancer that has spread further.

Grading

The grade of a cancer gives the doctor an idea of how quickly it may develop. Doctors will look at a sample of the cancer cells under a microscope to find the grade of the cancer.

  • Grade 1 or low grade – the cancer cells tend to grow slowly and look like normal cells.
  • Grade 2 and 3 – the cancer cells look more abnormal.
  • Grade 4 or high grade – the cancer cells tend to grow more quickly and look very abnormal.


Treatment of mouth cancer

Treatments used for mouth cancer include surgery, radiotherapy, chemotherapy and targeted therapy. You may only need one type of treatment. But sometimes two or more treatments are given. When chemotherapy and radiotherapy are given together, it’s called chemoradiation.

Your treatment will depend on the stage and grade of the cancer, as well as your general health. Your specialist doctor or nurse will explain the best treatment for you and any likely side effects.


Surgery for mouth cancer

Surgery is often the only treatment needed to remove an early mouth cancer. The surgeon removes the cancer and a small area (margin) of normal tissue all around the tumour. There is less chance of cancer cells being left behind because the surgeon takes this extra margin of normal tissue.

The surgeon may also remove some lymph nodes from your neck. They may do this to remove cancer that has spread to the lymph nodes or to reduce the risk of the cancer coming back.

How the surgeon removes the cancer depends on its size and where it is in your mouth. The aim is to remove the cancer while doing as little damage to your mouth and appearance as possible. Some people need a bigger operation and may need to have part of their jawbone or tongue taken out. The surgeon may use tissue, skin or bone taken from somewhere else in the body to rebuild these areas.

Sometimes small cancers on the lip are treated with an operation called Mohs micrographic surgery (MMS). The surgeon numbs your lip with an injection and then removes the cancer in thin layers. The tissue that has been removed is examined under a microscope during the operation. The surgeon continues to remove more layers until no cancer cells are seen in the tissue. This technique makes sure that all the cancer cells are removed and only a very small amount of healthy tissue is removed.

How long you stay in hospital depends on the type of operation you need. Some people will have a small operation at an outpatient clinic and go home the same day. But if your surgery is more complicated, you might stay in hospital for up to three weeks. You may be looked after in a high dependency unit or intensive care for a while after the operation. You may see a dietitian and speech therapist to help you to cope with any changes to your speech or how you swallow.

Effects of surgery

Depending on the type of operation you have, your speech, your sense of taste and smell, or how you swallow might be affected. Some operations will leave scars or a change in your appearance.

Your surgeon will explain what to expect.


Radiotherapy for mouth cancer

Radiotherapy uses high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells. Two types of radiotherapy are used to treat mouth cancer.

External radiotherapy

External radiotherapy is sometimes given instead of surgery to treat early mouth cancers. It is often used after surgery to reduce the risk of the cancer coming back or to treat cancer that has come back. Radiotherapy may also be used to treat the neck area if there are signs of cancer in the lymph nodes.

You have treatment as a series of short, daily sessions (called fractions) over a few weeks from a machine similar to a large x-ray machine. Radiotherapy only treats the area of the body that the rays are aimed at. It doesn’t make you radioactive. A newer way of giving radiotherapy called intensity-modulated radiotherapy (IMRT) is available in some hospitals. IMRT may cause fewer side effects than standard radiotherapy.

External radiotherapy may also be used to control symptoms, such as pain, if the cancer has spread to other areas of the body. In this case, you might only need a few days of treatment or even just a single dose.

Internal radiotherapy (brachytherapy)

Sometimes internal radiotherapy is given to treat small lip cancers. This involves putting a solid radioactive material beside or in the tumour for a short time. A surgeon places very thin radioactive needles, wires or tubes in the tumour while you’re asleep under a general anaesthetic. These are left in place until the right amount of radiation has been given, which may take up to six days. After this, you have another short operation to remove them.

You stay in hospital during this treatment. While the radioactive needles are in the lip, there is a small risk of radiation exposure for the people around you. Your doctor or nurse will give you advice about keeping yourself and others safe. You'll need to stay in one room and your visitors may only be allowed in for a short time each day. Once the needles are taken out, you are not radioactive and you should be able to go home.

Side effects of radiotherapy

You may have side effects during radiotherapy. These usually disappear gradually over a few weeks or months after treatment finishes. Your radiotherapy team will let you know what to expect. Tell them about any side effects you have. There are often things that can be done to help.

Your radiotherapy team will give you advice about skin care during treatment. It’s common to have a skin reaction in the area of your face and neck being treated. The skin can become sore, red and may peel or become blistered. This usually starts about 2–3 weeks after treatment starts and may last for 3–4 weeks after treatment ends. Let your radiotherapy team know if your skin becomes sore. They can give you painkillers and advice about caring for your skin until it heals.

It’s also important to look after your mouth during radiotherapy. Following a mouth care routine to keep your mouth clean will help to prevent problems. Your mouth and throat may become sore after a couple of weeks of treatment. You may get some mouth ulcers and your voice may become hoarse. You might find that your sense of taste and smell changes. Eating food can become difficult and swallowing can be painful. Your doctor can prescribe medicines to help.

If you find it hard to eat and drink because of any side effects, let your doctor or nurse know. They can give you advice and medications to help. They may refer you to a dietitian for more advice. You may need food supplements to add extra energy and/or protein to your diet. Some can be used to replace meals, while others are used in addition to your normal diet. Although a few of these products are available directly from your chemist or the supermarket, your doctor, nurse or dietitian can also prescribe them for you.

Some people need to be fed through a tube if they can’t eat and are losing lots of weight. This is known as enteral nutrition. It is only done for a short time until treatment is finished and your swallowing is back to normal.

Radiotherapy to the mouth affects your salivary glands. This is less likely with brachytherapy. Your saliva may become thicker, stringy and sticky. Your mouth and throat may also feel dry, which can make eating and talking difficult. Your doctor can prescribe mouthwashes, lozenges, artificial saliva sprays or gels to help. Changes in your saliva usually get better within about eight weeks of radiotherapy ending.

Most of these side effects get better after treatment ends. However, many people have a dry mouth after their treatment is over. Radiotherapy to the head and neck can cause other long-term effects. These aren’t as common but can happen months or even years after your treatment.


Chemotherapy for mouth cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells.

This treatment can be given:

  • before surgery or radiotherapy to shrink the cancer and make it easier to treat
  • at the same time as radiotherapy (chemoradiation)
  • after radiotherapy or surgery to reduce the risk of the cancer coming back
  • to treat cancer that has spread or has come back after earlier treatment.

The chemotherapy drugs most often used to treat mouth cancer are cisplatin and fluorouracil (5FU). These are usually given into a vein (intravenously). Chemotherapy isn’t usually used to treat lip cancer.

Side effects of chemotherapy

The side effects depend on the drug or combination of drugs you are given. Your doctor or nurse will explain the treatment you are offered and what to expect.

Chemotherapy drugs can reduce the number of white cells in your blood during treatment. This will make you more likely to get an infection. Your doctor or nurse will give you advice about what to do if this happens.

Chemotherapy can also cause other side effects, such as:

Let your doctor or nurse know about any side effects during treatment. They can often give you advice and help to reduce these.

We have more information about coping with the side effects of chemotherapy and about different chemotherapy drugs.


Chemoradiation for mouth cancer

Your doctor may talk to you about having chemotherapy and radiotherapy together. This can be given instead of surgery to treat early mouth cancers or after surgery to reduce the risk of cancer returning. Having both treatments together is more effective than either treatment alone. However, the side effects are also worse during treatment. It’s important that you're well enough to cope with having both treatments together.


Targeted therapies for mouth cancer

Targeted therapies are drugs that target the differences between cancer cells and normal cells. Cetuximab is the most commonly used targeted therapy to treat mouth cancer. This drug may stop the cancer cells growing and dividing. It may also make the cancer more sensitive to the effects of radiotherapy. It’s given as a drip (infusion) into a vein once a week. You might have this with radiotherapy if you can’t have chemoradiation or with chemotherapy to treat cancer that has spread or come back.

Side effects of cetuximab

The most common side effect of cetuximab is a skin rash on the face, neck or body. This may begin during the first three weeks of treatment. Your specialist nurse or doctor will give you advice on what can help. It usually goes away completely when treatment stops.

Cetuximab may also cause an allergic reaction while the drip is being given. This is more common with the first treatment, so you have the first dose slowly over a few hours. The nurse will give you drugs to help prevent or reduce this. If you have a reaction, they will treat it quickly.

Signs of a reaction can include: a headache; a rash; a high temperature or chills; feeling itchy, sick, breathless or unwell; or having pain in your back, tummy or chest. Tell your nurse straight away if you have any of these symptoms. Rarely, a reaction can happen a few hours after treatment. If you develop any of these symptoms or feel unwell after you get home, contact the hospital straight away for advice.


Follow-up after treatment

After your treatment is completed, you will have regular check-ups and possibly scans or x-rays. These may continue for several years. If you have any problems or notice new symptoms between these times, let your doctor know as soon as possible.


Your feelings about mouth cancer

You may have many different emotions, from shock and disbelief to fear and anger. At times, these feelings can be overwhelming and hard to control. But they are natural and it’s important to be able to express them.

Everyone has their own way of coping. Some people find it helps to talk to family or friends, while others get help from people outside their situation. Sometimes it’s helpful to share your experiences at a local cancer support group. You may want to talk to our cancer support specialists free on 0808 808 00 00, Monday–Friday, 9am–8pm. Some people prefer to keep their feelings to themselves. There’s no right or wrong way to deal with this, but help is available if you need it.

For some people, it takes several months to recover from treatment for mouth cancer. It can be hard to cope if treatment has changed your appearance or voice or how you eat and drink. Talking to other people in a similar position may help you feel less alone. Useful organisations such as The Mouth Cancer Foundation, Changing Faces, Let's Face It and Saving Faces can provide this, as well as specialist advice and counselling. Our online community is also a good place to meet people who may be in a similar situation.