Volume 76 • Number 10
Case Report
Squamous Cell Carcinoma Presenting
as an Endodontic-Periodontic Lesion
Paul A. Levi Jr.,*† David M. Kim,‡ Scott L. Harsfield,§ and Erica R. Jacobsonk
Background: Regardless of advances in diagnosis
and treatment during the past 40 years, the overall
5-year survival rates for oral and oropharyngeal squa-
mous cancers have only slightly improved and re-
main around 50%. Thus, the early diagnosis and
treatment of carcinoma by health care providers are
essential in achieving a good prognosis. We report
a case of invasive squamous cell carcinoma that pre-
sented as a benign endodontic-periodontic lesion
with a 7-mm periodontal pocket on tooth #15 in a 40-
year-old, non-smoking woman. The subsequent man-
agement of the case is also discussed. The study was
conducted in accordance with the Helsinki Declara-
tion of 1975, as revised in 2000.
Methods: Our patient was seen for a comprehen-
sive periodontal examination including a periodontal
charting, occlusal analysis, study casts, electronic
pulp test for tooth #15, and complete mouth periapical
radiographs. As there was a periapical radiolucency,
an endodontic consultation was obtained. A peri-
odontal flap surgical procedure was performed on
teeth #13 to #15, and as there was bone erosion into
the maxillary sinus, a biopsy of the soft tissue was sub-
mitted to the local hospital for histological analysis.
Results: The biopsied lesion was diagnosed as in-
vasive, moderately differentiated squamous cell carci-
noma with focal spindle and clear cell differentiation
(grade II to III of IV). Bone invasion was also identified.
The treatment of the carcinoma involved a hemimaxil-
lectomy with the removal of the maxillary left poste-
rior teeth. The patient remained free of tumor for 5
years after the initial presentation.
Conclusions: Patient education and periodic oral
cancer examinations by dental professionals are nec-
essary to reduce diagnostic delay and improve prog-
nosis. This case report emphasizes the important role
of dental professionals, especially periodontists and
endodontists, of being aware that squamous cell car-
cinoma may manifest itself clinically and/or radio-
* Department of Periodontology, Tufts University School of Dental Medicine,
Boston, MA.
† Private practice, Burlington, VT.
‡ Department of Oral Medicine, Infection and Immunity, Harvard School of
Dental Medicine, Boston, MA.
§ Private practice, Sharon, MA.
k Department of Pathology, University of Vermont College of Medicine,
Burlington, VT.
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graphically as a common periodontal or endodontic
lesion. J Periodontol 2005;76:1798-1804.
KEY WORDS
Diagnosis; maxillary sinus; periodontitis; squamous
cell carcinoma.
O
ral and oropharyngeal squamous cell carci-
nomas account for 4% of cancers in men and
2% of cancers in women, and the stage at
diagnosis remains the most important prognosis
indicator.1,2 For example, although the 5-year sur-
vival rates for the patients who were treated at an
early stage (stage I or II) for oral and oropharyngeal
carcinomas ranged from 60% to 80%, the 5-year
survival rates for the late diagnosed patients (stage III
or IV) ranged from 20% to 50% depending on the
site.3,4 In addition, the 5-year survival rate for patients
with localized lesions were four times greater than the
patients with distant metastases.5 Thus, delayed de-
tection of oral cancer results in one of the lowest 5-year
survival rates among the major types of cancer, in-
cluding breast, skin, testis, prostate, uterus, and uri-
nary bladder cancers.6
Although the early diagnosis and treatment of oral
and oropharyngeal carcinoma by health care pro-
viders are essential in achieving a good prognosis,
only 14% of the adults in the U.S. reported ever having
an oral cancer examination.4,7 While 18% of physi-
cians provided oral cancer examinations on 50% or
more of their patients, 47% of these physicians
believed that their knowledge about oral cancer was
not current.8 Thus, dental professionals should assume
the responsibility for the diagnosis and referral of
patients with signs of oral cancer to medical specialists.
Screening a high-risk, asymptomatic population
has been shown to result in the early detection of oral
cancers.9 For example, the American Cancer Soci-
ety recommended screening asymptomatic patients
for cancers of the head and neck, including oral
cancers, every 3 years between the ages of 20 and
40 years and yearly after the age of 40 years.10 Even
J Periodontol • October 2005
though oral cancer should be amenable to early
detection due to identifiable risk factors (smoking
and alcohol abuse) and the ease of performing a
clinical examination, when oral cancer presents as
a common endodontic-periodontic lesion, the find-
ings may be easily misinterpreted, which may result
in the delay of both the diagnosis and therapy.10
The following case report discusses the diagnosis
and surgical treatment of a 40-year-old woman who
presented clinically with a combined endodontic-
periodontic lesion, which was subsequently diagnosed
as squamous cell carcinoma extending into the maxil-
lary sinus.
CASE REPORT
In June 1999, a 40-year-old white woman who has
given consent to be profiled presented at the private
periodontal office of PAL for an emergency peri-
odontal evaluation of pocketing and inflammation
associated with the facial aspect of the maxillary left
second molar. Her general dentist, of whom she had
been a patient for over 16 years, asked that she be
seen immediately. The dentist commented in his
referral note that the patient had a ‘‘fluctuant swell-
ing’’ without severe pain involving the buccal aspect
of the gingiva between the maxillary first and second
molars (teeth #14 and #15).
The patient’s chief complaint was bleeding of the
maxillary left molar when brushing and flossing during
the past 4 months, despite her good oral hygiene on
a daily basis and thorough scaling and root planing
performed by her dental hygienist. Her medical history
was not significant other than a penicillin allergy. The
patient stated that she was in ‘‘good’’ health and
reported receiving regular physical examinations. She
denied a history of smoking, excessive drinking, or
recreational drug use. She reported receiving regular
oral hygiene maintenance care every 6 months.
The clinical evaluations showed that there were
4- to 7-mm pockets associated with teeth #14 and
#15 with gingival enlargement, inflammation, spongi-
ness, and heavy bleeding upon
probing. Radiographs revealed
the presence of a periapical ra-
diolucency associated with the
disto-buccal root of tooth #15
with no caries or restorations
(Fig. 1A). There appeared to
be roughly 30% angular bone
loss interproximally between
teeth #14 and #15, and an
additional 10% bone loss on
the distal of tooth #15. There
was also an absence of a radio- Figure 1.
graphic crestal-septal laminar Radiographic image of maxillary left posterior teeth taken on the day of initial examination in June
1999 (A) and 6 years previously in December 1993 (B).
dura between teeth #14 and
Levi, Kim, Harsfield, Jacobson
#15. A periapical radiograph of teeth #13 to #15
taken in 1993 showed little difference in the alveolar
bone; however, there were no periapical radiolucen-
cies (Fig. 1B). The 1999 radiograph showed two
radiolucent oblique lines, one from the mid-furcation
of tooth #14 and the other parallel to the distal aspect
of the disto-buccal root of tooth #15. Those radiolu-
cent lines were not present in the 1993 radiograph.
Grade I mobility was noted on both teeth #14 and #15
with slight fremitus on tooth #15. There was no
premature contact on the affected teeth, and no pos-
terior interference in protrusive or lateral excursions
was found. Attrition was slight, and there was no
history of bruxism or clenching. Palpation of the mus-
cles of mastication revealed no discomfort. An elec-
trical pulp test of both teeth #14 and #15 was done,
and the teeth responded normally. The tentative
diagnosis at the initial visit was generalized marginal
gingivitis with localized severe periodontitis associ-
ated with teeth #14 and #15, with a possible
endodontic problem on tooth #15. The patient was
placed on 250 mg erythromycin four times a day for
10 days and scheduled for a comprehensive peri-
odontal examination in 5 days.
That same day, the patient had an endodontic
evaluation regarding teeth #14 and #15. The
endodontist’s preliminary diagnosis for tooth #15
was ‘‘a necrotic tooth possibly associated with
fracture.’’ The endodontist stated that the periodon-
tal ligament space on teeth #14 and #15 was within
normal limits, and no common coronal explanation
for the pulpal pathology on tooth #15 could be given
except possibly due to bruxism and occlusal trauma,
which the patient denied. Vitality was once again
tested with cold refrigerant, and another electrical
pulp test on teeth #11 to #15 was done. All teeth
tested within normal limits. No pulpal pain on per-
cussion or with a bite stick was elicited. Overall, the
endodontist was concerned about the chronicity, lack
of pain, and ragged surface of the interproximal lesion,
as well as an abnormal appearance of the sinuses.
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Squamous Cell Carcinoma of the Gingiva Volume 76 • Number 10

After discussing the findings with our patient,

a periodontal flap surgical procedure was planned to
determine the extent of the disease process, help
clarify the diagnosis, and to eliminate the pockets.
The surgery was performed 6 days following the
initial consultation visit. It entailed raising a full thick-
ness mucoperiosteal flap on both the facial and
palatal of teeth #13 to #15. Upon removing the gran-
ulation tissue, which appeared somewhat firmer than
granulation tissues from a chronic inflammatory
periodontal lesion, it was apparent that there was no
facial plate of bone on the disto-buccal root of tooth
#14 and both buccal roots of tooth #15, and there
Figure 2.
was a communication to the maxillary sinus (Fig. 2). Clinical photograph of the affected area (teeth #14 and #15)
After consulting an oral-maxillofacial surgeon and a revealed the absence of facial plate and communication to the
second periodontist, the decision was made to sec- maxillary sinus.
tion the exposed roots (Fig. 3) and elevate and re-
place the flap over the crest of the bone using 4-0 plain
gut sutures. A biopsy of the soft tissue was submitted
to the local hospital for histological analysis.
Our preliminary clinical diagnosis at this point was
a lateral periodontal cyst that expanded and com-
municated to the maxillary antrum along the mesio-
buccal root of tooth #15. It was assumed that the
area became infected by oral bacteria gaining access
through a communication in the sulcus. A periodon-
tal dressing was placed, and the patient was given
clindamycin 150 mg (two stat and then one four times
a day), acetaminophen and codeine (one tablet every
6 hours as needed for comfort), ibuprofen 800 mg
(four times a day for 2 days and then one every
Figure 3.
6 hours as needed for comfort), and clemastine (use Clinical photograph of the affected area (teeth #14 and #15) after
as directed). Chlorhexidine was prescribed as an oral the root sectioning. The septum and communication to the maxillary
rinse (two times a day) during the post-surgical heal- sinus are noticeable.
ing period.
The surgical site appeared
to be healing normally 1 week
following the surgery, although
there was an oral/antral open-
ing around teeth #14 and #15.
The patient was instructed in
plaque control techniques and
placed on chlorhexidine rinses.
The pathologic examination
revealed an invasive, moder-
ately differentiated squamous
cell carcinoma (grade II to III of Figure 4.
Histologic slides using hematoxylin and eosin stain depicting an invasive, moderately differentiated
IV) with focal spindle and clear
squamous cell carcinoma with focal spindle and clear cell differentiation at low power (A, original
cell differentiation (Fig. 4). magnification ·100) and high power (B, original magnification ·400).
The patient was immediately
referred to an otolaryngologist
for further care. The otolaryngologist found no because the knowledge of the extent of gingival cancer
lymphadenopathy, dysphagia, or numbness associ- is important for staging the cancer before surgery or
ated with the affected area. A contrasted computerized radiation therapy (Fig. 5). Due to the extent of the
tomography (CT) scan of the maxilla and a CT scan of carcinoma, a hemimaxillectomy involving the removal
the neck were ordered before initiating treatment of teeth #12 to #15 was performed. At the time of

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J Periodontol • October 2005
Figure 5.
Computed tomography demonstrates a bony defect within the inferolateral wall of the left maxillary sinus, representing bone involvement
by squamous cell carcinoma (A and B).
resection, a pathologic examination showed three mi-
croscopic foci of residual squamous cell carcinoma,
which were not in proximity to the surgical margins of
resection.
One month post-surgery, the patient was still
experiencing some residual numbness in the left
cheek. However, her oral examination showed that
the mucosa was intact, and the incisions appeared
to be healing well. A removable maxillary obturat-
ing prosthesis, which was placed immediately
following the surgery, was secure (Fig. 6). At her
3-month post-surgery appointment, the patient re-
ported that her speech was normal once again and
that the cheek numbness had essentially resolved.
Her physician reported that the oral-antral opening
was 1.5 cm anteroposterioly and 8 mm laterally and
that the underlying sinus mucosa appeared benign
with no granulation viewed with the flexible fibro-
scope.
Another periodontal evaluation and oral hygiene
therapy were provided 4 months following surgery
(Fig. 7). The patient had some difficulty with
plaque removal on the lingual of tooth #11 due to
residual paresthesia. Following that visit, the patient
moved out of the state and was not able to return
for a follow-up visit until 29 months later. Upon
return, her hygiene appeared excellent, without
signs of periodontitis. A recent communication with
Levi, Kim, Harsfield, Jacobson
her physician in June 2004 (5 years after the cancer
detection) revealed no evidence of recurrence. The
patient was contacted by phone in July 2005, and
she reported that she was healthy and had no further
problems with her mouth.
DISCUSSION
Regardless of advances in diagnosis and treatment
during the past 40 years, the overall 5-year survival
rates for oral and oropharyngeal squamous cancers
have improved only slightly and remained around
50%.2,4 Guggenheimer et al.11 proposed three reasons
for a delayed diagnosis of oral cancer: 1) patients at
risk did not avail themselves for an examination, 2)
oral examinations were not frequently being per-
formed, and 3) the lesions were often overlooked.
Although early detection and treatment improved
the overall prognosis of oral cancer, delays from the
onset of symptoms to clinical diagnosis were com-
mon.12 For example, most lesions were not diagnosed
until they reached advanced stages even though oral
cancer usually occurred in a part of the body that was
readily accessible for early detection.12 In addition,
the Surveillance, Epidemiology, and End Results
(SEER) data revealed 36% of patients exhibited
localized disease, 44% had regional disease, and 9%
showed distant disease at the time of diagnosis of
oral cancer.12
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Squamous Cell Carcinoma of the Gingiva Volume 76 • Number 10

odontium, such as pyogenic

granuloma, periodontitis, pap-
illoma, or even fibroid epulis
(inflammatory hyperplasia).20
Gingival carcinoma typically
arises from keratinized mu-
cosa in a posterior site, most
often in the mandible, where it
often destroys the underlying
bone structure, causing tooth
mobility.21 In fact, in its early
Figure 6. stages, as it was in our case,
Clinical photographs of maxillary obturating prosthesis. A) Intraoral; B) extraoral.
it might closely resemble
an advanced periodontitis or
an endodontic-periodontic le-
sion.22 However, because of
its tendency for early invasion
of bone and spread to regional
lymph nodes, it is one of the
most serious oral cavity ma-
lignancies.20 Thus, gingival
carcinomas are very rare ex-
amples of human neoplasms
that make a direct invasion of
bone. For these reasons, some
authors advocate biopsying all
Figure 7. of the lesions in a patient when
Clinical photograph 4 months following the hemimaxillectomy. A) In centric occlusion; B) oral-antral the removal of local factors
communication.
does not promptly lead to their
resolution.22
Almost all gingival carcino-
According to Onizawa et al.,13 the median du- mas are squamous cell carcinomas, and most are
ration of time associated with the patient delay well differentiated.20 In the U.S., carcinoma of the
(duration from the onset of symptoms or signs to gingiva constitutes 4% to 16% of all oral carcinomas
the initial visit to the medical professional) was 1.6 and is predominantly a disease of the elderly, with
months, while the professional delay (duration from the persons less than 40 years of age accounting for
initial medical professional visit to a final diagnosis of about 2% of patients.23 In other countries, such as in
cancer) was 14 days for the 152 consecutive patients Japan, squamous cell carcinoma of the gingiva is the
who were referred to the oral and maxillofacial surgery second most common carcinoma of the oral cavity,
clinic for oral cancer. Their findings also showed that next to those of the tongue.24 Of all the intraoral
more than half of the patients did not seek treatment carcinomas, gingival carcinoma is least associated
within 1 month following the onset of pain and swelling. with tobacco smoking and has the greatest pre-
Similar patient and professional delays were also dilection for females.21 However, some authors be-
observed in other countries. For example, a median lieve that this discrepancy may be a reflection of the
time of 46 months was reported in The Netherlands for differences in populations studied.22
oral cancer patients from the time of initial symptoms The posterior location of gingival carcinomas fur-
to definitive diagnosis.14 A 3-month median time was ther contributes to delays in diagnosis, as the patient
reported among patients in Canada and Italy, while is typically unaware of the lesion. In the maxilla,
a 4-month median time was reported in Denmark, penetration of the antrum is a frequent occurrence, as
Finland, and Israel.15-19 Thus, patients’ assumptions is seen our case.22 Therefore, the extent of tumor
that a particular lesion was likely benign and self- invasion into the mandible and maxilla and possibly
limited, as well as limited awareness about oral cancer, into the vital anatomic structures, such as adjacent
may have a detrimental effect on prognosis. face and neck spaces, always gives cause for special
Carcinoma of the gingiva is an insidious disease concern because it may lead to a poor prognosis.25
that is usually painless and is often misdiagnosed In general, only 3% of all head and neck cancers
as one of the many inflammatory lesions of the peri- are known to originate from the paranasal sinuses,

1802
J Periodontol • October 2005
representing only a small proportion of newly
diagnosed cancers each year.26 Paranasal sinus
cancer is rare and usually arises in the maxillary
sinus (70% to 80%), followed by the ethmoid sinus
(10% to 20%).27 The most common type of sinus
tumor is squamous cell carcinoma, which accounts
for 60% to 75%.27 Adenocarcinoma is relatively
more common in the ethmoid sinus.27 Primary
sinonasal adenocarcinomas, excluding those of sal-
ivary origin, are uncommon and represent approx-
imately 10% to 20% of malignant neoplasms at
these locations.28 Doig et al.29 analyzed 17 human
maxillae obtained from dissecting room cadavers
and found that the sinus floor was particularly rich in
small foramina, some passing directly to the oral
cavity but many into the cancellous bone of the
alveolar processes. Thus, we may speculate that,
since the floor and walls of the sinus have numerous
portals through which carcinoma might easily
spread, carcinoma invading into a sinus can be
postulated. In our case, however, the tumor invaded
the inferolateral wall of the left maxillary sinus
without obvious sinus mucosal involvement, mak-
ing extension from a primary sinus squamous cell
carcinoma extremely unlikely.
To minimize the delay in diagnosis and treatment
attributed to patients, many investigators have em-
phasized the importance of patient education and
recommended a regular examination by a medical/
dental professional for patients with a high risk of
oral cancer.14,24,30 As expected, patients seeking
regular dental care have been associated with earlier
diagnosis of oral cancer than those who seek dental
care only on an emergency basis. For example, when
Holmes et al.10 investigated the detection rate of oral
cancers by various health care providers, patients
referred from a dental office showed a significantly
lower stage cancer than those from a medical office.
Overall, general dentists and dental hygienists de-
tected and referred smaller (less advanced) oral and
oropharyngeal squamous cancers that were at a lower
clinical and pathologic stage than physicians, oral
and maxillofacial surgeons, otolaryngologists, and
denturists.10 Also, patients who initially saw a regional
specialist (dentist, oral and maxillofacial surgeons, or
otolaryngologist) with symptoms related to their
lesion were more likely to have appropriate treatment
initiated than those who initially sought care from
their primary health care provider.10
The squamous cell carcinoma in our patient pre-
sented as a combined endodontic-periodontic lesion
with 6- to 7-mm pockets on the facial aspect of tooth
#15 and interproximally between teeth #14 and #15.
The lesion was biopsied because the defect eroded
through the facial bony plate and into the maxillary
sinus, and the granulation tissue did not appear
Levi, Kim, Harsfield, Jacobson
normal. The treatment of this lesion consisted of
a hemimaxillectomy with the removal of the maxillary
left posterior teeth. A biopsy of the lesion could have
easily been overlooked since clinically the lesion re-
sembled a benign condition, such as a severe chronic
periodontitis or a simple cyst. This case report alerts
us to the importance of obtaining biopsies if there is
even the slightest question of the diagnosis.
As the radiographs and clinical findings suggested
a common one-site endodontic-periodontic lesion, it
is clear that continuing with the evaluation to obtain
a definitive diagnosis and treatment was life saving
in this case. In addition, the commonly regarded risk
factors for oral carcinoma (advanced age, smoking,
and alcohol use) are not always present, as evidenced
by this case. Chronic periodontitis is generally non-
painful, and gingival bleeding does not tend to alarm
patients. In this case report, the patient was fastidious
about her periodontal health and was concerned
about her periodontal problem. While there are many
patients who do not recognize the signs and symp-
toms of potentially serious problems, there are even
more who are content to watch a problem and
consider therapy only when it becomes significantly
symptomatic. We, as a profession, have an ethical
and moral obligation to educate our patients to
the value of maintenance therapy and be consum-
mately thorough in our clinical examinations and
radiographs.
REFERENCES
1. Hoffman HT, Karnell LH, Funk GF, Robinson RA,
Menck HR. The National Cancer Data Base report on
cancer of the head and neck. Arch Otolaryngol Head
Neck Surg 1998;124:951-962.
2. Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer
statistics, 2000. CA Cancer J Clin 2000;50:7-33.
3. Mashberg A, Samit AM. Early detection, diagnosis,
and management of oral and oropharyngeal cancer.
CA Cancer J Clin 1989;39:67-88.
4. Mashberg A, Samit AM. Early diagnosis of asymptom-
atic oral and oropharyngeal squamous cancers. CA
Cancer J Clin 1995;45:328-351.
5. Ries L, Eisner M, Kosary C, et al., eds. SEER Cancer
Statistics Review, 1973-1997. Bethesda, MD: National
Cancer Institute; 2002. Available at: http://seer.cancer.
gov/csr/1973_1997/.
6. Pisani P, Parkin DM, Bray F, Ferlay J. Estimates of
the worldwide mortality from 25 cancers in 1990. Int
J Cancer 1999;83:18-29.
7. Horowitz AM, Nourjah PA. Factors associated with
having oral cancer examinations among US adults
40 years of age or older. J Public Health Dent 1996;
56:331-335.
8. Meskin LH. Oral cancer – The forgotten disease. J Am
Dent Assoc 1994;125:1042-1045.
9. Mashberg A, Meyers H. Anatomical site and size of
222 early symptomatic oral squamous cell carcino-
mas: A continuing prospective study of oral cancer. II.
Cancer 1976;37:2149-2157.
1803
Squamous Cell Carcinoma of the Gingiva
10. Holmes JD, Dierks EJ, Homer LD, Potter BE. Is de-
tection of oral and oropharyngeal squamous cancer by
a dental health care provider associated with a lower
stage at diagnosis? J Oral Maxillofac Surg 2003;61:
285-291.
11. Guggenheimer J, Weissfeld JL, Kroboth FJ. Who has
the opportunity to screen for oral cancer? Cancer
Causes Control 1993;4:63-66.
12. Pitiphat W, Diehl SR, Laskaris G, Cartsos V, Douglas
CW, Zavras AI. Factors associated with delay in the
diagnosis of oral cancer. J Dent Res 2002;81:192-197.
13. Onizawa K, Nishihara K, Yamagata K, Yusa H,
Yanagawa T, Yoshida H. Factors associated with
diagnostic delay of oral squamous cell carcinoma. Oral
Oncol 2003;39:781-788.
14. Jovanovic A, Kostense PJ, Schulten EA, Snow GB,
van der Waal I. Delay in diagnosis of oral squamous
cell carcinoma; a report from The Netherlands. Eur
J Cancer B Oral Oncol 1992;28B:37-38.
15. Elwood JM, Gallagher RP. Factors influencing early
diagnosis of cancer of the oral cavity. Can Med Assoc
J 1995;133:651-656.
16. Mashberg A, Merletti F, Boffetta P, et al. Appearance,
site of occurrence, and physical and clinical character-
istics of oral carcinoma in Torino, Italy. Cancer 1989;
63:2522-2527.
17. Wildt J, Bundgaard T, Bentzen SM. Delay in the diag-
nosis of oral squamous cell carcinoma. Clin Otolaryngol
1995;20:21-25.
18. Söderholm AL. Oral carcinoma of the mandibular
region. Br J Oral Maxillofac Surg 1990;28:383-389.
19. Gorsky M, Dayan D. Referral delay in diagnosis of oro/
oropharyngeal cancer in Israel. Eur J Cancer B Oral
Oncol 1995;31B:166-168.
20. McClatchy KD, Zarbo RJ. The jaws and oral cavity. In:
Sternberg SS, ed. Diagnostic Surgical Pathology, 3rd ed.
Philadelphia: Lippincott Williams and Wilkins; 1999:822.
21. Neville BW, Damm DD, Allen CM, et al. Epithelial
pathology. In: Oral and Maxillofacial Pathology, 2nd
ed. Philadelphia: W.B. Saunders; 2002:356-367.
1804
Volume 76 • Number 10
22. Barnes L, Verbin RS, Guggenheimer J. Cancer of the
oral cavity and oropharynx. In: Barnes L, ed. Surgical
Pathology of the Head and Neck, 2nd ed. New York:
Marcel Dekker; 2001:387-391.
23. Hollows P, McAndrew PG, Perini MG. Delays in the
referral and treatment of oral squamous cell carci-
noma. Br Dent J 2000;188:262-265.
24. Uchida Y. Statistical and epidemic studies oral cancers
diagnosed and treated by oral surgeons in Japan. Jpn
J Oral Biol 1988;7:16-26.
25. Hirai T, Korogi Y, Hamatake S, et al. Stages III and
IV squamous cell carcinoma of the mouth: Three-
year experience with superselective intraarterial
chemotherapy using cisplatin prior to definitive treat-
ment. Cardiovasc Intervent Radiol 1999;22:201-
205.
26. Myers LL, Nussenbaum B, Bradford CR, Teknos TN,
Esclamado RM, Wolf GT. Paranasal sinus malignan-
cies: An 18-year single institution experience. Laryn-
goscope 2002;112:1964-1969.
27. Waldron J, Witterick I. Paranasal sinus cancer:
Caveats and controversies. World J Surg 2003;27:
849-855.
28. Yom SS, Rashid A, Rosenthal DI, et al. Genetic
analysis of sinonasal adenocarcinoma phenotypes;
distinct alterations of histogenic significance. Mod
Pathol 2005;18:315-319.
29. Doig TN, McDonald SW, McGregor IA. Possible routes
of spread of carcinoma of the maxillary sinus to the
oral cavity. Clin Anat 1998;11:149-156.
30. Kerdpon D, Sriplung H. Factors related to delay in
diagnosis of oral squamous cell carcinoma in southern
Thailand. Oral Oncol 2001;37:127-131.
Correspondence: Dr. Paul A. Levi Jr., Department of Peri-
odontology, Tufts School of Dental Medicine, One Knee-
land St., Boston, MA 02111. Fax: 617/636-0911; e-mail:
levishuman@aol.com.
Accepted for publication February 28, 2005.