Introduction

Mouth cancer, also known as oral cancer, is where a tumour develops on the surface of the tongue, mouth, lips or gums.

Tumours can also occur in the salivary glands, tonsils and the pharynx (the part of the throat from your mouth to your windpipe) but these are less common.

Symptoms of mouth cancer include:

  • red or white patches on the lining of your mouth or tongue
  • ulcers
  • a lump

See your GP if these symptoms do not heal within three weeks, especially if you're a heavy drinker or smoker.

Types of mouth cancer

A cancer that develops on the inside or outside layer of the body is called a carcinoma and these types of cancer are categorised by the type of cells the cancer starts in.

Squamous cell carcinoma is the most common type of mouth cancer, accounting for nine out of 10 cases. Squamous cells are found in many places around the body, including the inside of the mouth and under the skin.

Less common types of mouth cancer include:

  • oral malignant melanoma – where the cancer starts in cells called melanocytes, which help give skin its colour
  • adenocarcinomas – cancers that develop inside the salivary glands

What causes mouth cancer?

Mouth cancer occurs when something goes wrong with the normal cell lifecycle, causing them to grow and reproduce uncontrollably.

Risk factors for developing mouth cancer include:

  • smoking or using products that contain tobacco
  • drinking alcohol – smokers who are also heavy drinkers have a much higher risk compared to the population at large
  • infection with the human papilloma virus (HPV), the virus that causes genital warts

Read more about the causes of mouth cancer

Who is affected by mouth cancer?

Mouth cancer is an uncommon type of cancer, accounting for one in 50 of all cancer cases.

In the UK, just over 6,767 new cases of mouth cancer were diagnosed in 2011 (the latest reliable data).

Most cases of mouth cancer first develop in older adults who are between 50-74 years of age.

Mouth cancer can occur in younger adults, but it's thought that HPV infection may be responsible for the majority of cases that occur in younger people.

Mouth cancer is more common in men than in women. This is thought to be due to the fact that, on average, men drink more alcohol than women.

Treating mouth cancer

There are three main treatment options for mouth cancer. They are:

  • surgery – where the cancerous cells are surgically removed and, in some cases, some of the surrounding tissue
  • chemotherapy – where powerful medications are used to kill cancerous cells
  • radiotherapy – where high energy X-rays are used to kill cancerous cells

These treatments are often used in combination. For example, a course of radiotherapy and chemotherapy may be given after surgery to help prevent the cancer returning.

Read more about treating mouth cancer

Complications of mouth cancer

Both surgery and radiotherapy can make speaking and swallowing difficult (dysphagia).

Dysphagia can be a potentially serious problem. If small pieces of food enter your airways and become lodged in your lungs, it could trigger a chest infection, known as aspiration pneumonia.

Read more about the complications of mouth cancer

Reducing the risk

The three most effective ways to prevent mouth cancer from developing – or prevent it reocurring after successful treatment – are:

  • not smoking
  • keeping to the recommended weekly limits for alcohol consumption (21 units for men and 14 units for women (read more about alcohol units)
  • eating a 'Mediterranean-style diet', with plenty of fresh vegetables (particularly tomatoes), citrus fruits, olive oil and fish (read more about healthy eating)

It's also important that you have regular dental check-ups because dentists can often spot the early stages of mouth cancer.

Outlook

If mouth cancer is diagnosed early, a complete cure is often possible using a combination of radiotherapy, chemotherapy and surgery.

The outlook for mouth cancer can vary depending on which part of the mouth is affected and whether it has spread from the mouth into surrounding tissue. The outlook is much better if the cancer is diagnosed early.

Overall, an estimated 40% of people with cancer affecting the mouth and pharyx will live at least five years after their diagnosis and many people live much longer. However, the outlook is better for cancer affecting certain areas of the mouth, such as the lip, tongue or oral cavity.

Symptoms

Mouth cancer can develop on most parts of the mouth, including the lips, gums and occasionally, the throat.

The most common symptoms of mouth cancer include:

  • red or white patches in the mouth or throat
  • a lump
  • ulcers

Other symptoms may include:

  • persistent pain in the mouth
  • pain or difficulty when swallowing (dysphagia)
  • changes in your voice, or speech problems
  • swollen lymph nodes (glands) in your neck
  • unexplained weight loss
  • bleeding or numbness in the mouth
  • a tooth, or teeth, that becomes loose for no obvious reason
  • difficulty moving your jaw

When to seek medical advice

Many of the symptoms listed above can be caused by less serious conditions, such as minor infections.

But it's strongly recommended that you visit your GP if any of the symptoms listed above have lasted for more than three weeks. It's especially important to seek medical advice if you're a heavy drinker or smoker.

Dental check-ups

Mouth cancer tends not to cause any noticeable symptoms during the initial stages of the disease.

This is why it is important to have regular dental check-ups, particularly if you are a smoker, a heavy drinker or a betel chewer, because a dentist may often be able to detect the condition during an examination.

You should have a dental check-up at least every year. However, more frequent check-ups may be recommended if you have a history of tooth decay or gum disease.

Causes

The two leading causes of mouth cancer in the UK are drinking too much alcohol and smoking.

Both alcohol and tobacco are carcinogenic, which means they contain chemicals that can damage the DNA in cells and lead to cancer.

The risk of mouth cancer increases significantly in somebody who is both a heavy smoker and heavy drinker.

Exactly what triggers the changes in DNA that lead to mouth cancer and why only a small number of people develop mouth cancer is still uncertain.

How mouth cancer spreads

There are two ways mouth cancer can spread:

  • directly – the cancer can spread out of the mouth and into nearby tissues, such as surrounding skin or into the back of the jaw
  • via the lymphatic system – the lymphatic system is a series of glands found throughout your body which produce many specialised cells needed by your immune system to fight infection

Mouth cancer that spreads to another part of the body is known as metastatic oral cancer.

Other risk factors

Other risk factors for mouth cancer may include:

  • chewing tobacco or other smokeless tobacco products like snus
  • chewing betel nuts with or without tobacco
  • a poor diet
  • the human papilloma virus (HPV)
  • poor oral hygiene

Smokeless tobacco

There is a range of smokeless tobacco products including:

  • chewing tobacco
  • snuff – powdered tobacco designed to be snorted
  • snus – a type of smokeless tobacco popular in Sweden, which is placed under your upper lip

Smokeless tobacco products are not harmless and many increase your risk of developing mouth cancer, as well as other cancers, such as liver cancer, pancreatic cancer and oesophageal cancer.

Betel nuts

Betel nuts are mildly addictive seeds taken from the betel palm tree, and are widely used in many southeast Asian ethnic communities, such as people of Indian and Sri Lankan origin.

They have a stimulant effect similar to coffee. Betel nuts also have a carcinogenic effect, which can increase the risk of mouth cancer. This risk is made worse as many people enjoy chewing betel nuts along with tobacco.

Due to the tradition of using betel nuts, rates of mouth cancer are much higher in ethnic Indian and Sri Lankan communities than in the population at large.

Diet

There is evidence that a poor diet may increase your risk of some types of mouth cancer.

A healthy, balanced diet with plenty of fruit and vegetables is thought to reduce your risk of developing mouth cancer.

Human papilloma virus (HPV)

The human papilloma virus (HPV) is a family of viruses that affect the skin and moist membranes that line your body, such as those in your cervix, anus, mouth and throat.

You can contract an HPV infection by having sexual contact with a person already infected – you do not have to have 'full sex'; just close skin-to-skin contact.

There is evidence that in rare cases, certain types of HPV can cause abnormal tissue growth inside the mouth, triggering mouth cancer.

Poor oral hygiene

There is evidence that poor oral hygiene, such as having tooth decay, gum disease, not brushing your teeth regularly and having ill-fitted dentures (false teeth) can increase your risk of mouth cancer.

Diagnosis

If you have symptoms of mouth cancer, your GP will carry out a physical examination and ask about your symptoms.

If mouth cancer is suspected, you will be referred to hospital for further tests or to speak to a specialist head and neck surgeon.

In 2015, the National Institute for Health and Care Excellence (NICE) published guidelines to help GPs recognise the signs and symptoms of mouth cancer and refer people for the right tests faster. To find out if you should be referred for further tests for suspected mouth cancer, read the NICE 2015 guidelines on Suspected Cancer: Recognition and Referral.

Biopsy

It may be necessary to remove a small sample of affected tissue to check for the presence of cancerous cells. This procedure is known as a biopsy.

There are three main methods used to carry out a biopsy in cases of suspected mouth cancer.

Punch biopsy

A punch biopsy may be used if the suspected affected area of tissue is in an easily accessible place, such as your tongue or the inside of your mouth.

The area is first injected with a local anaesthetic to numb it. The doctor will then cut away a small section of affected tissue and remove it with tweezers.

The procedure is not painful, but can feel a little uncomfortable.

Fine needle aspiration (FNA)

A fine needle aspiration (FNA) is a type of biopsy used if it is suspected a swelling in your neck is the result of mouth cancer.

Your neck is numbed and a needle is used to draw out a small sample of tissue and fluids from the lump. The sample is then checked for cancerous cells.

FNA is not painful but it can be uncomfortable and cause bruising.

Panendoscopy

A panendoscope is used if the suspected tissue is at the back of your throat or inside one of your nasal cavities.

This is a long thin tube with a camera and a light which is guided through the nose, then used to remove a small section of tissue for the biopsy.

The panendoscope can also check whether cancer has spread from your mouth to further down your throat, such as your larynx (voice box), oesophagus (gullet) or trachea (windpipe).

Further tests

If the biopsy confirms cancer you will need further tests to check what stage it has reached.

If the cancer is diagnosed late it can have spread from your mouth into the lymphatic system – a series of glands throughout your body which produce many of the specialised cells needed by your immune system.

Once the cancer reaches the lymphatic system, it is capable of spreading to any other part of your body, including your bones, blood and organs.

However, it's uncommon for mouth cancer to spread further than the lymph nodes near your mouth, although in some cases it may also spread to surrounding bones, such as the jaw bone, and in some cases your lungs.

Therefore, the tests will examine your lymph nodes, bones and the tissue near the site of your initial tumour to check for the presence of other tumours.

These tests may include:

Further biopsies on nearby lymph nodes may also be carried out.

Staging and grading

Once these tests have been completed it should be possible to tell what stage and grade your cancer is:

  • staging is a measure of how far the cancer has spread
  • the grade describes how aggressive the cancer is and how fast it is likely to spread in future

This will help determine whether you have:

  • early mouth cancer (usually curable)
  • intermediate mouth cancer (may be curable)
  • or advanced mouth cancer (not usually curable, but it is usually possible to slow the spread of the cancer and extend lifespan)

There are three grades of mouth cancer: low-grade (the slowest), moderate-grade and high-grade (the most aggressive).

Grading your cancer helps the doctor decide how quickly you need to be treated – read more about treating mouth cancer.

Treatment

Your treatment will depend on the type and size of the cancer, the grade and how far it's spread – as well as your general health.

Your treatment plan

If the cancer hasn't spread beyond the mouth or the oropharynx (the bit of your throat at the back of your mouth), a complete cure may be possible using a combination of surgery, radiotherapy and chemotherapy.

If the cancer has spread to other parts of the body, then a cure is unlikely but it will be possible to slow the progress of the cancer and help relieve symptoms by using surgery, radiotherapy and chemotherapy.

Deciding what treatment is best for you can be difficult. Your care team will make recommendations, but the final decision will be yours.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, what are the advantages and disadvantages of particular treatments.

Before treatment begins

Radiotherapy makes the teeth more sensitive and vulnerable to infection so before treatment begins, you'll be given a full dental examination and any necessary work will be carried out.

If you smoke or drink, stopping will increase the chances of your treatment being successful.

Your specialist nurse and your GP can provide help and support if you are finding it difficult to quit smoking and drinking.

Read more about quitting smoking and cutting down on alcohol

Surgery

For mouth cancer, the aim of surgical treatment is to remove any affected tissue while minimising damage to the rest of the mouth.

Photodynamic therapy (PDT)

If the cancer is in its very early stages, it may be possible to remove any tumours using a type of laser surgery known as photodynamic therapy (PDT). PDT involves taking a medicine that makes your tissue sensitive to the effects of light. A laser is then used to remove the tumour.

Other forms of surgery

If your cancer is more advanced, it may be necessary to remove part of your mouth lining and, in some cases, facial skin, which can be replaced using skin grafted from your forearm or chest.

If your tongue is affected, part of the tongue will have to be removed. This is known as a partial glossectomy. The tongue is then reconstructed using grafted tissue.

If the cancer has spread to your jawbone it will need to be surgically removed. The jawbone can be replaced by taking bone from another part of your body and grafting it in place.

Occasionally, other bones, such as cheekbones, may have to be removed to completely remove the cancer.

These can be replaced with plastic prosthetic bones which are are usually very realistic, leaving your physical appearance largely unaffected.

During surgery, your surgeon may also remove lymph nodes near the site of the initial tumour. This is often done as a preventative measure in case they contain small numbers of cancerous cells that can't be detected.

Radiotherapy

Radiotherapy uses doses of radiation to kill cancerous cells. It may be possible to remove the cancer using radiotherapy alone, but it is usually used after surgery to prevent the cancer from reocurring.

The treatment is normally given every day over the course of three to seven weeks, depending on the size of the cancer and how far it has spread.

While it kills cancerous cells, radiotherapy can also affect healthy tissue, and it has a number of side effects, including:

  • sore, red skin (like sunburn)
  • mouth ulcers 
  • sore mouth and throat
  • dry mouth
  • loss of, or changes in taste
  • loss of appetite
  • tiredness 
  • feeling sick
  • stiff jaw
  • bad breath 

Any side effects will be monitored by your care team and treated where possible.

The side effects of radiotherapy can be distressing, but most of them will pass once the radiotherapy is complete.

Internal radiotherapy

Internal radiotherapy – also called brachytherapy – is often used to treat cancers of the tongue that are in their early stages. It involves placing radioactive implants directly into the tumour while you are under a general anaesthetic.

They will be left for between one and eight days during which time the cancer cells will receive a much higher dose of radiation than the rest of your mouth.

Visits by friends and family will need to be restricted due to radiation and pregnant women and children won't be able to visit you.

The radioactive implants will cause your mouth to become swollen, and you will experience some pain five to 10 days after the implants are removed.

Chemotherapy

Chemotherapy is sometimes used in combination with radiotherapy when the cancer is widespread, or if it is thought there is a significant risk of the cancer returning.

Chemotherapy involves the use of powerful cancer-killing medicines. These medicines damage the DNA of the cancerous cells, interrupting their ability to reproduce.

Medicines used in chemotherapy can sometimes damage healthy tissue as well as the cancerous tissue. Adverse side effects are common and include:

  • fatigue (tiredness)
  • sore mouth
  • mouth ulcers
  • feeling sick
  • being sick
  • hair loss
  • tiredness

The side effects should stop once the treatment has finished.

Chemotherapy also weakens your immune system and makes you more vulnerable to infection.

Cetuximab

Cetuximab is a new type of medication, known as a biologic, used to treat advanced cases of mouth cancer. It is usually used in combination with radiotherapy or chemotherapy.

Cetuximab targets proteins on the surface of cancer cells, known as epidermal growth factor receptors. These receptors help the cancer to grow, so by targeting these proteins, cetuximab prevents the cancer from spreading.

The National Institute for Health and Care Excellence (NICE) ruled that cetuximab did not represent a cost-effective treatment in most cases and has recommended it only be used in people who:

  • are in a good state of health (likely to make a good recovery if treated)
  • are unable to have chemotherapy for medical reasons (for example, because they have kidney disease or are pregnant)

Complications

Complications of treatment for mouth cancer can include dysphagia (difficulty swallowing), speech problems and emotional disruption.

Difficulty swallowing

Dysphagia is the medical term for difficulty swallowing. It is easy to take your ability to swallow food and liquid for granted, but in reality the process relies on a complex interaction of muscles, which can be easily disrupted.

Surgery and radiotherapy can affect your tongue, mouth or throat, resulting in dysphagia. Dysphagia is a potentially serious problem because, aside from the risk of malnutrition, there is a chance that small particles of food could enter your airways and become lodged in your lungs. This can trigger a chest infection, known as aspiration pneumonia. 

If you are having problems swallowing, a speech and language therapist (SLT) will need to assess your swallowing reflex. One way an SLT can do this is to perform a test known as a videofluoroscopy, which involves adding a special dye to liquid and food that you swallow. The dye highlights your swallowing reflexes and by using X-rays your SLT can see if there is a risk of food entering your lungs.

If this is the case, it may be necessary in the short term to provide you with a feeding tube, which will be directly connected to your stomach. The SLT will teach you exercises so you can "relearn" how to swallow properly.

Your ability to swallow will improve as you learn the exercises and the damaged tissue is allowed to heal. However, there is a chance your swallowing reflex will never fully recover.

In some circumstances, you may have to alter your diet to make swallowing easier. A dietitian can give you dietary advice.

Read more detailed information about how dysphagia is treated

Speech

Much like swallowing, your ability to speak clearly is governed by a complex interaction of muscles, bones and tissue, including your tongue, teeth, lips and soft palate (a section of tissue found at the back of the mouth).

Radiotherapy and surgery can affect this process and make it difficult to pronounce certain sounds. In severe cases, you may have problems making yourself understood.

An SLT will help you improve your verbal communication skills by teaching you a series of exercises that develop your range of vocal movements and teach you new ways of producing sounds.

Emotional impact

The emotional impact of living with mouth cancer can be significant. Many people report experiencing a roller coaster effect.

For example, you may feel down when you receive a diagnosis, but feel up when the cancer responds to treatment. Then you may feel down again as you try to come to terms with the side effects and after effects of your treatment.

This type of emotional disruption can sometimes trigger depression. Signs that you may be depressed include:

  • feeling down or hopeless during the past month
  • no longer taking pleasure in the things you used to enjoy

Contact your GP for advice if you think you may be depressed. There are a range of effective treatments for depression, including antidepressant medication and talking therapies, such as cognitive behavioural therapy (CBT).

Read more about depression and coping with cancer

Living with mouth cancer

Having mouth cancer doesn't necessarily mean you'll have to give up work, but you may need quite a lot of time off, and you may not be able to carry on like you did before treatment.

If you have cancer you're covered by the Disability Discrimination Act. This means that your employer is not allowed to discriminate against you because of your illness. They have a duty to make "reasonable adjustments" to help you cope. Examples of these include:

  • allowing you time off for treatment and medical appointments
  • allowing flexibility with working hours, the tasks you have to perform or your working environment

The definition of what is "reasonable" depends on the situation. For example, how much it would affect your employer’s business.

It will help if you give your employer as much information as possible about how much time you will need off and when. Talk to your human resources department if you have one. Your union or staff association representative should also be able to give you advice.

If you're having difficulties with your employer, you may be able to receive help from your union or your local Citizens Advice Bureau.

Relationships with others

It is not always easy to talk about cancer, either for you or your family and friends. You may sense that some people feel awkward around you or avoid you. Being open about how you feel and what your family and friends can do to help may put them at ease. Do not feel shy about telling them that you need some time to yourself, if that is what you need.

Money and financial support

If you have to stop work or go part-time because of your cancer, you may find it hard to cope financially. If you have cancer or you are caring for someone with cancer, you may be entitled to one of the following areas of financial support:

  • If you have a job, but cannot work because of your illness, you are entitled to Statutory Sick Pay from your employer.
  • If you don't have a job and cannot work because of your illness, you may be entitled to Employment and Support Allowance.
  • If you are caring for someone with cancer, you may be entitled to Carer’s Allowance.
  • You may be eligible for other benefits if you have children living at home or if you have a low household income.

Find out as early as possible what help is available to you. Speak to the social worker at your hospital who can give you the information you need.

Talk to others

If you have questions, your GP or nurse may be able to reassure you. You may find it helpful to talk to a trained counsellor or psychologist, or to someone at a specialist helpline. Your GP surgery will have information on these.

Some people find it helpful to talk to other people who have mouth cancer, either at a local support group or in an internet chatroom, such as:

Caring for others with mouth cancer

Being a carer is not an easy role. When you are busy responding to the needs of others it can deplete your reserves of emotional and physical energy and make it easy for you to neglect your own health and mental wellbeing. Research on carers’ health shows that high numbers of carers suffer health effects through caring. If you are trying to combine caring with a paid job or looking after a family, this can cause even more stress.

If you are caring for someone else, it is important to look after yourself and get as much help as possible. It is in your best interests and those of the person you are caring for.

Look after your health

Eat regularly and healthily. If you do not have time to sit down for every meal, try to make time to sit down for at least one of your day's meals. Instead of relying on fast food snacks, go for healthier options, such as fruit.

Look after your emotional health

As well as exhaustion, isolation and worries about the person you are caring for, it is understandable if there are times when you feel resentful and then guilty for feeling like this. These feelings are natural.

Look for support

Friends and family may not always understand what you are going through and it can be helpful to talk to people in the same situation. Care Information Scotland has a lot of useful information on its website.