Journal of Dental Implant Research 2022; 41(4): 81-85
Oral squamous cell carcinoma around dental implants: A case report
Gaeun Park , SeungWoo Lee , Baek-Soo Lee , Yong-Dae Kwon , Byung-Joon Choi , Jung-Woo Lee , Jooyoung Ohe , Junho Jung
Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul, Korea
Correspondence to: Junho Jung,
Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea. Tel: +82-2-958-9360, Fax: +82-2-966-4572, E-mail:
Received: August 26, 2022; Revised: October 10, 2022; Accepted: October 18, 2022; Published online: December 30, 2022.
© The Korean Academy of Implant Dentistry. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
The placement of dental implants has been the most popular option for oral rehabilitation after extraction. The use of implants for the restoration of the edentulous area has increased, which has also resulted in an increase in complications such as peri-implantitis and traumatic mucosal chronic ulcers. The repeated irritation and chronic inflammation caused by dental implants may contribute to an increase in the risk of oral malignancy, which emphasizes the need for periodic follow-up examinations after implant rehabilitation. Early malignant lesions can be confused with peri-implantitis. This could delay the diagnosis of oral malignancies. This report presents the case of a patient with an oral squamous cell carcinoma (OSCC) that occurred around a dental implant. The patient failed to keep up with the routine follow-up examinations, post-implant, thus resulting in the delay in the diagnosis of OSCC.
Keywords: Dental implants, Oral squamous cell carcinoma, Peri-implantitis, Surgical flaps

Squamous cell carcinoma (SCC) is the sixth most common malignant type of cancer worldwide. And it accounts for approximately 90% of malignancies occurring in the oral cavity. It is defined as a malignant neoplasm which originates in the stratified epithelium and is typically found in men over the age of 60 who are habitual alcohol and tobacco users. However, such demographic has been shifting toward patients under the age of 40, and even in children, adolescents, and in women who do not have these aforementioned risk factors1,2). Some other risk factors of SCC include: exposure to ionizing radiation, the existence of nutritional deficiencies, immunosuppressant drug3,4). While the epidemiologic profile of oral squamous cell carcinoma (OSCC) has been shifting, utilization of dental implants has been steadily increasing. Oral rehabilitation using dental implants has become one of the best options for the treatment of edentulous patients and is considered by some to be the only type of treatment for partial or total edentulism. Because of the increase in the use of dental implants, literature has also reported an increase in the number of complications associated with dental implants.

Most complications are associated with the inflammatory processes that affect the bone and soft tissues surrounding dental implants, which are known as peri-implantitis. In Peri-implantitis, the soft tissues become inflamed whereas the alveolar bone, which surrounds the implant for the purposes of retention, is lost over time. This state is described as ‘implant histoclasia’ or ‘perimplantoclasia’. The primary cause of peri-implantitis is dental plaque deposition that initiates gingivitis, later progresses to pocketing, and finally results in alveolar bone resorption.

Repeated irritation and chronic inflammation are well-known risk factors for malignancy. Early malignant lesions can be confused with peri-implantitis, which could delay the early diagnosis of oral malignancy.

This report presents a clinical case in which an advanced stage of OSCC around a dental implant was diagnosed in a patient who failed to follow-up for a routine exam for over two years. We need more evidence to prove any causal relationship between dental implants and OSCC; however, the case emphasizes the importance of differential diagnosis in peri-implantitis, due to its similarity in clinical presentation with OSCC.


A 57-year-old male patient was referred from the local clinic to address white, large ulcerative lesion (Fig. 1A, B) around the implant to the department of Oral & Maxillofacial Surgery in Kyunghee university, Seoul, Korea. The patient was present with a maxillary Lt. 1st molar implant with extensive ulcerative lesions and significant bone resorption around the implant (Fig. 1C, D) that was placed 17 years ago. The patient had been periodically checked after implant placement in 2003 until February 2020, however, no follow-up exam has been completed since then until 2022 April. The patient reports smoking, but no alcohol consumption. The patient’s medical history includes diabetes and a history of cerebral infarction treatment. The presence of a suspicious ulcerous lesion around the implant prompted a biopsy. Microscopic examination revealed a moderately well-differentiated squamous cell carcinoma. From the image taken two weeks after the first visit on April 2022, OSCC proliferated toward the palate (Fig. 2A). The surgery was performed a month after the initial visit. Within one month, the size of the lesion increased, and keratinized tissue completely covered the implant (Fig. 2B). The TNM stage was diagnosed as cT4N1Mo. Modified RND (type III) with preservation of the spinal accessory nerve of the left neck and a partial maxillectomy (#24∼#26i) was performed as surgical interventions. Complete excision was performed for the primary lesion with a safety margin. The RFFF (Radial forearm free flap) was harvested with the radial. a. and cephalic vein which is considered one of the best options for reconstruction of soft tissue defects in the oral cavity and oropharynx5) after tumor resection using a pneumatic tourniquet (Fig. 3, 4). And the histopathologic diagnosis of the main mass was SCC, a verrucous subtype (Fig. 5).

Figure 1. Clinical pictures, panoramic radiograph, and contrast-enhanced CT image (A), (B) In the first visit of the clinical picture, an extensive whitish ulcerative lesion was observed around the maxillary Lt. 1st molar implant. (C) Panoramic radiograph showing significant bone resorption around Lt. 1st molar implant. (D) Bone resorption is observed in contrast-enhanced CT image (marked with an arrow).

Figure 2. Clinical pictures (A) After two weeks, OSCC proliferated toward the palate. (B) Preoperative intraoral view, keratinized tissues covered the implants.

Figure 3. Harvested RFFF (Radial Forearm Free Flap).

Figure 4. Reconstruction with RFFF.

Figure 5. Histopathologic diagnosis of the main mass (A) Photomicrograph of oral squamous cell carcinoma. (B) Photomicrograph of biopsy showing islands of malignant squamous cells with keratin pearl formation (hematoxylin and eosin; original magnification ×20).

Since the oral cavity is constantly influenced by inflammation, DNA damage, chemical abuse, and poor oral hygiene, the oral mucosa becomes susceptible to malignant transformation. The gingival attachment in dental implants is an area where constant inflammation occurs, this may affect the stability of the mucosa, and this inflammation may be a major cause of the development of malignancy due to the action of cytokine mediators: prostaglandins, interleukin-1, interleukin-6, and tumor necrosis factor6). Prostaglandin is responsible for the initiation, promotion, and progression of carcinogenesis. Its mechanism is that it reduces the activity of both humoral and cellular immune response, thus malignant cells are no longer removed7,8). IL-6 causes keratinocytes to increase its activator protein-2 mRNA and protein, and it leads to increased skin inflammation, keratinocyte growth, and carcinogenesis9). This, in turn, causes compensatory cell proliferation, which will promote the accumulation of DNA damages and gene mutations, and incorporate internal and external carcinogenic factors into the growth of stimulated normal cells10). Also, titanium particles may leach into nearby tissues by surface corrosion, and friction, among others11). It has been shown that leaching affects macrophage’s immunomodulation. As a result, DNA damage, oxidative stress, and protein carbonylation are increased, causing increased inflammation12,13). While the implant is suspected by some, to increase carcinogenicity, however, tobacco, betel quid chewing, alcohol consumption, and poor oral hygiene can have similar effects, by causing an increase in the action of cytokine mediator. Such risk factors have been supported with more evidence.

In the case of a 57-year-old patient, it cannot be concluded whether the implant contributed to the development of squamous cell carcinoma at all. More research is required to establish whether there is any causal relationship between peri-implantitis and malignancy as of today, since in many cases patients already had a history of some form of malignancy, or had risk factors such as chronic alcohol consumption, smoking, and nutritional deficiency14-20). Synchronous exposure to chronic tobacco and alcohol use showed an increase in malignancy by five to thirteen folds21,22).

While peri-implantitis or mucositis needs to be kept up with follow-up examination, the possibility of dismissing malignancy as peri-implantitis should not be neglected. OSCC, especially in its early stages, has clinical presentations similar to peri-implantitis. Peri-implantitis is generally treated by improving oral hygiene, periodontal debridement, and sometimes prescribing antibiotics but sometimes, peri-implantitis is surgically removed without performing a biopsy, thus a small number of studies are available regarding microscopic findings of peri-implantitis23). Whether dental implant causes malignancy or peri-implantitis has the potential to progress to OSCC is inconclusive, and more research needs to be conducted. However, as a clinician, a suspicious lesion around the dental implant should not be assumed as peri-implantitis that will resolve with conventional treatment. When the lesions do not respond to the treatment, a biopsy should be performed for histological analysis in order to rule out malignancy, as malignancy has certainly been found in the vicinity of dental implants, and the consequences of omitting them can be detrimental. As witnessed in this case of a 57-year-old patient, due to the rapid progression of malignancy, clinicians should not delay in providing diagnosis and treatment in suspected lesions.


Increased dental implant placement caused an increase in complications such as peri-implantitis. If peri-implantitis is unresolved despite constant treatment, it must be suspected of being malignant. In this case, the affected tissues should be taken for a biopsy for a histopathologic evaluation as soon as possible. Clinical and radiographic evaluation should be performed periodically after dental implants.

  1. Kademani D. Oral cancer. Mayo Clin Proc 2007;82:878-87.
    Pubmed CrossRef
  2. Kademani D, Bell RB, Schmidt BL, Blanchaert R, Fernandes R, Lambert P, et al. Oral and maxillofacial surgeons treating oral cancer: a preliminary report from the American Association of Oral and Maxillofacial Surgeons Task Force on Oral Cancer. J Oral Maxillofac Surg 2008;66:2151-7.
    Pubmed CrossRef
  3. Jane C, Nerurkar AV, Shirsat NV, Deshpande RB, Amrapurkar AD, Karjodkar FR. Increased survivin expression in high-grade oral squamous cell carcinoma: a study in Indian tobacco chewers. J Oral Pathol Med 2006;35:595-601.
    Pubmed CrossRef
  4. Guha N, Boffetta P, Wünsch Filho V, Eluf Neto J, Shangina O, Zaridze D, et al. Oral health and risk of squamous cell carcinoma of the head and neck and esophagus: results of two multicentric case-control studies. Am J Epidemiol 2007;166:1159-73.
    Pubmed CrossRef
  5. Bozec A, Poissonnet G, Converset S, Lattes L, Chamorey E, Vallicionni J, et al. Oropharyngeal reconstruction with radial forearm free flap: functional results. Rev Laryngol Otol Rhinol (Bord) 2007;128:19-26.
  6. Jeng JH, Wang YJ, Chiang BL, Lee PH, Chan CP, Ho YS, et al. Roles of keratinocyte inflammation in oral cancer: regulating the prostaglandin E2, interleukin-6 and TNF-alpha production of oral epithelial cells by areca nut extract and arecoline. Carcinogenesis 2003;24:1301-15.
    Pubmed CrossRef
  7. Honn KV, Bockman RS, Marnett LJ. Prostaglandins and cancer: a review of tumor initiation through tumor metastasis. Prostaglandins 1982;21:833-64.
  8. ElAttar TMA. Cancer and the prostaglandins: a mini review on cancer research. J Oral Pathol 1985;14:511-22.
    Pubmed CrossRef
  9. Oyama N, Iwatsuki K, Homma Y, Kane KF. Induction of transcription factor AP-2 by inflammatory cytokines in human keratinocytes. J Invest Dermatol 1999;113:600-6.
    Pubmed CrossRef
  10. Okada F. Inflammation-related carcinogenesis: current findings in epidemiological trends, causes and mechanisms. Yonago Acta Med 2014;57:65-72.
  11. Su_arez-L_opez del Amo F, Garaicoa-Pazmi~no C, Fretwurst T, et al. Dental implants_associated release of titanium particles: a systematic review. Clin Oral Implants Res 2018;29:1085-100.
    Pubmed CrossRef
  12. Noronha Oliveira M, Schunemann WVH, Mathew MT, et al. Can degradation products released from dental implants affect peri-implant tissues? J Periodontal Res 2018;53:1-11.
    Pubmed CrossRef
  13. Lappas CM. The immunomodulatory effects of titanium dioxide and silver nanoparticles. Food Chem Toxicol 2015;85:78-83.
    Pubmed CrossRef
  14. Pfammatter C, Lindenmüller IH, Lugli A, Filippi A, Kühl S. Metastases and primary tumors around dental implants: a literature review and case report of peri-implant pulmonary metastasis. Quintessence Int 2012;43:563-70.
  15. Marini E, Spink M, Messina AM. Peri-implant primary squamous cell carcinoma: a case report with 5 years' followup. J Oral Maxillofac Surg 2013;71:322-6.
    Pubmed CrossRef
  16. Moergel M, Karbach J, Kunkel M, Wagner W. Oral squamous cell carcinoma in the vicinity of dental implants. Clinical oral investigations 2014;18:277-84.
    Pubmed CrossRef
  17. Raiser V, Abu-El Naaj I, Shlomi B, Fliss DM, Kaplan I. Primary Oral Malignancy Imitating Peri-Implantitis. J Oral Maxillofac Surg 2016;74:1383-90.
    Pubmed CrossRef
  18. Javed F, Al-Askar M, Qayyum F, Wang HL, Al-Hezaimi K. Oral squamous cell carcinoma arising around osseointegrated dental implants. Implant Dent 2012;21:280-6.
    Pubmed CrossRef
  19. Czerninski R, Kaplan I, Almoznino G, Maly A, Regev E. Oral squamous cell carcinoma around dental implants. Quintessence Int 2006;37:707-11.
  20. Toner M and O'Regan EM. Head and neck squamous cell carcinoma in the young: a spectrum or a distinct group? Part 1. Head Neck Pathol 2009;3:246-8.
    Pubmed KoreaMed CrossRef
  21. Garrote LF, Herrero R, Reyes R, et al. Risk factors for cancer of the oral cavity and oro-pharynx in Cuba. Br J Cancer 2001;85:46-54.
    Pubmed KoreaMed CrossRef
  22. Castellsagu_e X, Quintana MJ, Mart_ınez MC, et al. The role of type of tobacco and type of alcoholic beverage in oral carcinogenesis. Int J Oncol 2004;108:741-9.
    Pubmed CrossRef
  23. Kaplan I, Hirshberg A, Shlomi B, Platner O, Kozlovsky A, Ofec R, Schwartz-Arad D. Histopathological Diagnosis in Peri-Implantitis. Clinical Implant Dentistry and Related Research 2015;17:e126-e33.
    Pubmed CrossRef

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