The Significance of Surface Ulceration as a Sign of Malignancy in Exophytic Oral Mucosal Lesions: Myth or Fact?

To compare the spectrum of pathologies in ulcerated versus non-ulcerated exophytic oral mucosal lesions and explore the significance of surface ulceration as an indication of malignancy. Retrospective analysis of exophytic lesions of the oral mucosa, 2009–2011. 713 biopsies of exophytic lesions of oral mucosa were included, of which 9.4 % were ulcerated. Significant differences were found between ulcerated and non-ulcerated lesions. Of the ulcerated lesions 67.2 % were reactive, 31.3 % malignant and 1.5 % benign, compared to 86, 8.4 and 5.6 % respectively in non-ulcerated lesions (p < 0.0001). Malignancies were most prevalent in ulcerated lesions, in patients over 50. Malignancies presented the highest ulceration rate (36.8 %, p < 0.001), compared to reactive (7.5 %) and benign neoplasia (1.8 %), however, the majority of oral mucosal malignancies (63.2 %) presented as non-ulcerated masses. Squamous cell carcinoma presented the highest ulceration rate among malignancies, but even these were only ulcerated in 50 % of cases. Non-epithelial malignancies were non-ulcerated in all cases. One-third of all malignancies were not suspected as such clinically, however, there was a better agreement between the clinical and microscopic diagnosis of malignancy in ulcerated lesions. Although the statistical likelihood of ulcerated masses to represent malignancy was higher than non-ulcerated lesions, especially in patients over 50, the majority of malignancies presented as non-ulcerated masses. Thus, all exophytic lesions should be submitted for microscopic analysis, and the status of ulceration should not be regarded neither as a factor in the decision to biopsy, nor a reliable indicator for malignancy.