Case Report

A case of welldifferentiated squamous

cell carcinoma in an extraction socket
Salika Sheikh, Jovita Dsouza

Department of
Periodontology and
Oral Implantology, M. A.
Rangoonwala College
of Dental Sciences and
Research Center, Pune,
India

Abstract:
Squamous cell carcinomas of the gingiva make up a significant percentage of oral squamous cell carcinomas and
are one of the most common causes of death worldwide. Cancers of the gingiva often escape early detection,
and hence an early intervention, since their initial signs and symptoms resemble common dental and periodontal
infections. This article presents a case of a 29yearold female patient who presented with a nonhealing wound for
about 1.5months postextraction. The wound was associated with pain and suppuration. Aprovisional diagnosis
of alveolar osteitis was derived at with a differential diagnosis of osteomyelitis and carcinoma of the alveolus.
The patient was advised a complete hemogram, orthopantomograph, and intraoral periapical radiograph of the
extraction socket. An incisional biopsy was carried out. Radiographs revealed extensive bone loss, and the biopsy
report confirmed the diagnosis of welldifferentiated squamous cell carcinoma of the alveolus.Carcinoma of the
gingiva often mimics inflammatory lesions and hence is often misdiagnosed. Therefore, any oral lesion should strike
a chord of suspicion, and practitioners should base their diagnosis on careful examination, and valid evidence.
Key words:
Extraction socket, gingiva, squamous cell carcinoma

INTRODUCTION

Access this article online

Website:
www.jisponline.com
DOI:
10.4103/0972-124X.106928
Quick Response Code:

Address for
correspondence:
Dr.Jovita Dsouza,
Department of
Periodontology and
Oral Implantology, M. A.
Rangoonwala College
of Dental Sciences and
Research Center, 2390B,
K. B. Hidayatullah road,
Azam Campus, Camp,
Pune411001, India.
Email:jovs24@gmail.com
Submission: 10032011
Accepted: 12092012
602

ral carcinomas are among the most prevalent

cancers in the world and one of the 10 most
common causes of death. Of these, squamous
cell carcinomas (SSC) form the majority bulk of
cases of oral cancers. Squamous cell carcinoma
has been defined as, a malignant epithelial
neoplasm exhibiting squamous differentiation as
characterized by the formation of keratin and/or
the presence of intercellular bridges.
In parts of Asia, including India, where the use
of tobacco, betel nuts, or lime to form a quid
is widespread, the incidence of oral cancer is
high. In India, oral cancer ranks first among all
cancer cases in males, and third among females
in many regions. In a 10year followup study,
over30,000 individuals in 3 distinct geographic
regions of India were selected because of specific
forms of tobacco habits practiced there. And
the annual incidence rates of development of
potentially malignant disorders were found to
be 1.12.4/1000 in males and 0.21.3/1000 in
females.[1]

Carcinoma of the gingiva constitutes an

extremely important group of oral neoplasms
as the incidence of carcinomas of gingiva is quite
high.[2] Alveolar ridge SSC comprised 9% of all
patients with oral SCC according to a report by
Ildstad etal.[3] About 70% of the carcinomas arise
from the mandibular gingiva and 30% from the
maxillary gingiva. The fixed gingiva is more often
involved than the free gingiva and edentulous

areas more than dentate areas. The similarity

of early cancerous lesions of the gingiva to
common dental infections has frequently led to
delay in diagnosis or even misdiagnosis. Hence,
institution of treatment has been delayed, and
the ultimate prognosis of the patient is poorer.
Occasionally, cases of carcinoma of the gingiva
appear to arise following extraction of a tooth.
However, if such cases are carefully examined,
it can usually be ascertained that the tooth was
extracted because of gingival lesion or disease or
mobility which in fact was a tumor, which at the
time of treatment (surgery) went unrecognized
or undiagnosed.

CASE REPORT
A 29yearold female reported to the Department
of Periodontics of M.A. Rangoonwala College
of Dental Sciences and Research Centre, in
the month of January 2010, with a complaint
of pain and bleeding gums in the right side
of the lower jaw since 1.5months. Adetailed
case history revealed that the pain started
8days following extraction of a mobile tooth
in the same region. The pain was localized and
continuous in nature. She experienced difficulty
during mastication and while brushing. The
pain also disturbed her sleep. The pain was
only transiently relieved on taking analgesics.
The patient complained of bleeding on and
off from the extraction site. The patient also
complained of halitosis. On receiving no
permanent relief despite repeated visits to her

Journal of Indian Society of Periodontology - Vol 16, Issue 4, Oct-Dec 2012

Sheikh and Dsouza: Squamous cell carcinoma of alveolus

dentist, she approached M.A. Rangoonwala Dental College

for her problem.

side involving surrounding alveolar bone associated with

45 and 47 on the distal and mesial aspects, respectively
[Figure4].

Her past medical history didnt reveal anything of significance.

The patient gave a history of use of mishri (a roasted, powdered
preparation made by baking tobacco on a hot metal plate until
it is uniformly black and later on powdered)[4,5] 45times a
day for the past 15years. The patient would place the quid of
mishri in the vestibule on the right side. She cleaned her teeth
onceaday with a toothbrush and toothpaste but had stopped
brushing following the onset of pain after the extraction.

The biopsy report revealed that the section showed the

presence of connective tissue stroma showing epithelial pearls
and keratin pearls and dysplastic features such as altered
nuclear cytoplasmic ratio and prominent nucleoli. Amoderate
to dense amount of chronic inflammatory infiltrate could be
appreciated, and a few dilated blood vessels could be noted
[Figure5].

General examination revealed that the patient was of moderate

height and built, and her vital signs were within the normal
range. She, however, had pallor.

The final diagnosis arrived at was welldifferentiated squamous

cell carcinoma of the alveolus (Right). The stage of the tumor
was estimated to be cT4aN0M0.

Extraoral examination revealed a diffuse swelling along the

lower border of the mandible on the right side extending from
the angle of the mandible to the lip commissure. The overlying
skin appeared normal with no sinus or color changes or
temperature changes. The swelling overall was soft and tender
on palpation, except in the submandibular region where it was
indurated. The swelling didnt exhibit any bruit or eggshell
crackling. The patient had partial trismus with mouth opening
of 2.53.0 cms.

The patient was referred to the Department of Oncology,

Command Hospital, Pune, where hemimandibulectomy with
radical neck dissection and mandibular reconstruction using
free fibular microvascular graft was carried out. The patient was
kept on a regular followup. Recurrence was noticed 2months
following surgery in the area adjacent to the surgical site. The
base of the tongue was also found to be involved. Since surgery
was not an option, the patient was put on chemotherapy and
radiotherapy and is being followed up.

Intraoral examination revealed an ulceroproliferative reddish

pink colored growth measuring 2.51.5 cms. in the alveolar
socket of extracted 46 [Figures1 and 2]. The gingiva in relation
to 45, 46, 47 appeared reddishpink, edematous, and swollen.
The intrasocket growth was soft in consistency and extremely
tender and bled on the slightest provocation. 47 was gradeI
mobile, and pus exudation was seen from mesial aspect of47.
Awhite nonscrapable patch was seen on the right buccal
mucosa in the premolarmolar region. The patch extended
inferiorly into the vestibule and involved the attached gingiva.
The surface was wrinkled and irregular with diffuse margins.
There was no difficulty in the movements of the tongue.

DISCUSSION

A provisional diagnosis of Alveolar osteitis was arrived at with

the differential diagnosis including:
1. Osteomyelitis
2. Carcinoma of the alveolus.

INVESTIGATIONS
A complete hemogram, blood glucose estimation, intraoral
periapical radiographs (IOPA), orthopantomogram (OPG),
and biopsy were advised.
All the parameters of the hemogram and blood glucose
estimation were within the normal range.
The IOPA revealed diffuse, poorlydefined radiolucency with
ragged margins in the region associated with 46 and vertical
and horizontal bone loss with distal aspect of 45 and mesial
aspect of 47, respectively [Figure3].
The OPG revealed a diffuse, poorlydefined radiolucency
with ragged borders in relation to the region of 46, extending
inferiorly up to the mandibular canal and laterally on either
Journal of Indian Society of Periodontology - Vol 16, Issue 4, Oct-Dec 2012

The majority of oral cancers involve the tongue, oropharynx,

and the floor of the mouth. The lips, gingiva, dorsal tongue,
and palate are less common sites. Primary squamous cell
carcinoma of bone is rare.
In India, the majority of oral cancers are unequivocally
associated with tobaccochewing habits, and are usually
preceded by premalignant lesions, most often a persistent
leukoplakia or oral submucous fibrosis. The use of tobacco in
its various forms, including smokeless tobacco, is regarded as
the main cause of oral cancers, particularly when associated
with the use of excess alcohol. Tobacco and alcohol are
acknowledged risk factors for oral and oropharyngeal
cancer.[6-9] Tobacco contains potent carcinogens including
nitrosamines (nicotine), polycyclic aromatic hydrocarbons,
nitrosodicthanolamine, nitrosoprotine, and polonium. Nicotine
is a powerful and addicting drug.
The etiology of carcinoma of gingiva appears to be no
more specific or defined than that of carcinomas of other
areas of the oral cavity. Since the gingiva is a site of chronic
irritation and inflammation, because of calculus formation
and collection of microorganisms in many individuals, one
may speculate on the possible role of chronic irritation in the
development of cancer of the gingiva. The carcinomas can
be insidious in onset and progression and can be mistaken
for persistent gingivitis, periodontal disease, or abscess.
Focus on these masquerades without thorough examination
and appropriate investigations like radiographs can lead to
extraction of these teeth. Many cases of carcinoma of gingiva
occurring following extraction of teeth have been reported.[10]
But this could be explained by the fact that the gingival
lesion or disease led to mobility of the tooth and subsequent
extraction rather than vice versa.
603

Sheikh and Dsouza: Squamous cell carcinoma of alveolus

Figure1: Ulcero-proliferative reddish pink-colored growth in the right mandibular

posterior region

Figure2: Ulcero-proliferative reddish pink-colored growth in the right mandibular

posterior region

Figure4: Orthopantomogram

periodontal ligament and then sudden proliferation after

extraction.
Figure3: Intra-oral periapical radiograph

Carcinoma of the mandibular gingiva is more common than

the maxillary.[11] Carcinoma of the gingiva usually manifests
initially as an area of ulceration, which may be a purely erosive
lesion or may exhibit an exophytic, granular, or verrucous
type of growth. Many times, carcinoma of the gingiva does
not have the clinical appearance of a malignant neoplasm. It
may or may not be painful. The tumor arises most commonly
in edentulous areas, although it may develop in a site in which
teeth are present. The fixed gingiva is more frequently involved
primarily than the free gingiva.[3]

Figure5: H and E section showing epithelial and keratin pearls, altered cytoplasmic
ratio, and prominent nuclei

The proximity of the underlying periosteum and bone

usually invites early invasion of these structures. Although
many cases exhibit irregular invasion and infiltration of the
bone, superficial erosion arising apparently as a pressure
phenomenon sometimes occurs. In the maxilla, gingival
carcinoma often invades into the maxillary sinus, or it may
extend onto the palate or into the tonsillar pillar. In the
mandible, extension into the floor of the mouth or laterally
into the cheek as well as deep into the bone is rather common.
Pathologic fracture sometimes occurs in the latter instance.

In some instances, after extraction of a tooth, the

carcinoma appears to develop rapidly and proliferate
up out of the socket, which could probably be due to the
unobstructed growth of the neoplastic tissue along the

Metastasis is a common sequel of gingival carcinoma.

Carcinoma of mandibular gingiva metastasizes more frequently
than cancer of the maxillary gingiva. Metastasis from carcinoma
of the mandibular gingiva have a predilection for the cervical

604

Journal of Indian Society of Periodontology - Vol 16, Issue 4, Oct-Dec 2012

Sheikh and Dsouza: Squamous cell carcinoma of alveolus

lymphnodes of the submandibular triangle and the upper

jugular regions.[12] This is especially true for subclinical neck
disease, while those patients with clinically positive neck disease
are more likely to have involvement of additional nodal levels.
Approximately 13% of the carcinomas are associated with
2ndprimaries even though the majority are early stage lesions.
Ilstad et al. reported a 66% 2year and 49% 5year overall
survival.[3]
Treatment of carcinomas of gingiva is generally a surgical
problem. Radiation therapy of carcinoma of gingiva is
fraught with hazards because of damaging effect of Xrays
on bone. Prognosis of cancer of gingiva is not particularly
good, and lymph node metastasis worsens prognosis. This
again emphasizes the need for early diagnosis, appropriate
investigations, and treatment of these neoplasms.

REFERENCES
1.

2.

3.

4.

Gupta PC, Mehta FS, Daftary DK, Pindborg JJ, Bhonsle RB,
Jalnawalla PN, et al. Incidence rates of oral cancer and natural
history of oral precancerous lesions in a 10year followup study of
Indian villagers. Community Dent Oral Epidemol 1980;8:287333.
Marocchio LS, Lima J, Sperandio FF, Correa L, de Souza SO. Oral
squamous cell carcinoma: An analysis of 1,564cases showing
advances in early detection. JOral Sci 2010;52:26773.
Ildstad ST, Bigelow ME, Remensnyder JP. Squamous cell
carcinoma of the alveolar ridge and palate. A15year survey.
Ann Surg 1984;199:44553.
Mashburg A, Samit AM. Early detection, diagnosis and

management of oral and oropharyngeal cancer. CA Cancer J Clin

1989;39:6788.
5. Feldman JG, Hazan M, Nagarajan M, Kissen B. Acasecontrol
investigation of alcohol, tobacco, and diet in head and neck cancer.
Prev Med 1975;4:44463.
6. Murti P, Gupta P, Bhosale R. Betel quid and other smokeless
tobacco habits in India: Oral health consequences. Dent J Malaysia
1997;18:1622.
7. WHO, Tobacco or Health, a global status report. Geneva: WHO;
1997.
8. Mashburg A, Garfinkel L, Harris S. Alcohol as a primary risk
factor in oral squamous carcinoma. CA Cancer J Clin 1981;31:
14655.
9. Boyle P, Zheng T, Macfarlane GJ, McGinn R, MaisonneuveP,
LaVecchia C, et al. Recent advances in the etiology and
epidemiology of head and neck cancer. Curr Opin Oncol
1990;2:53945.
10. Van Zile WN. Carcinoma in a healing alveolus after a dental
extraction: Report of case. JOral Surg Anesth Hosp Dent Serv
1959;17:825.
11. E f f i o m O A , A d e v e m o W L , O m i t o l a O G , A i a v i O F ,
EmmanuelMM, Gbotolorum OM. Oral squamous cell carcinoma:
Aclinicopathologic review of 233cases in Lagos, Nigeria. JOral
Maxillofac Surg 2008;66:15959.
12. Shah JP, Johnson NW, Batsakis JG. Textbook of oral cancer.
London: Martin Dunitz; 2003.

How to cite this article: Sheikh S, Dsouza J. A case of

welldifferentiated squamous cell carcinoma in an extraction socket.
J Indian Soc Periodontol 2012;16:602-5.
Source of Support: Nil, Conflict of Interest: None declared.

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