3. Red flags, common lesions and what needs urgent attention
Red-flag features (urgent action)
Have a low threshold for urgent referral when you find:
- An ulcer that has not healed within 3 weeks (or sooner if highly suspicious)
- A persistent unexplained lump in the mouth or neck
- A red patch (erythroplakia) or mixed red-and-white patch
- A white patch that cannot be wiped away (leukoplakia) — especially if speckled, ulcerated or indurated
- Unexplained tooth mobility or non-healing extraction socket
- Unexplained paraesthesia / sensory change
- Persistent hoarseness, dysphagia or referred ear pain with oral/oropharyngeal findings
- Fixed, hard cervical lymphadenopathy
Potentially malignant disorders — overview
- Leukoplakia: white patch that cannot be characterised as another disease. Risk varies; speckled / erosive types and high-risk sites raise concern.
- Erythroplakia: red velvety patch — higher malignant transformation risk; urgent specialist assessment.
- Oral lichen planus / lichenoid lesions: usually bilateral; still examine carefully and refer atypical, unilateral, ulcerative or progressive lesions.
- Actinic cheilitis: chronic UV damage of the lip vermilion — monitor and refer suspicious change.
Common benign findings (usually not cancer — but assess in context)
- Linea alba, frictional keratosis related to a sharp cusp or denture
- Geographic tongue, coated tongue
- Aphthous ulcers (recurrent, typical history)
- Mucocele (typically lower lip in younger patients)
- Fordyce spots, torus / exostosis
Rule of thumb: if a lesion lacks a clear local cause, persists beyond 2–3 weeks after removing irritants, or shows red-flag features, do not “watch and wait” indefinitely — refer.
Practical decision framework
- Identify and remove obvious local irritants where safe (e.g. sharp tooth edge) and review shortly if the lesion is otherwise low-risk.
- Photograph with consent and measure.
- If red-flag features are present → urgent suspected cancer referral.
- If uncertain → discuss with a colleague / oral medicine pathway and refer rather than delay.
Do not biopsy high-suspicion lesions in primary care if local pathway advises otherwise
Urgent specialist assessment is often the safest next step for clearly suspicious lesions. Follow your local cancer network guidance.