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.