NEOPLASIA OF THE ORAL CAVITY The anatomical contents of the oral cavity include the upper and lower

alveolus, teeth, lips and the anterior two-thirds of the tongue. Virtually all oral cavity cancers are of the malignant squamous cell variety. Adenoid cystic carcinoma can arise from minor salivary glands but is rare. Premalignant lesions in the oral cavity include leucoplakia and erythroplakia. In virtually all neoplasia of the oral cavity one or more of several aetiological factors are present. Smoking and alcohol abuse are very common. Chronic dental infection, e.g. caries, may result in malignant change, as may lesions seen in tertiary syphilis. Carcinoma of the lip Carcinoma of the lip is common in outdoor workers and in regions close to the equator, presumably due to the effects of ultraviolet light. Tobacco smokers show a higher incidence of lip cancer. Historically, smoking a clay pipe was the major cause. Clinical features The lower lip, perhaps due to its greater size, is most frequently affected. Dyskeratosis usually manifests as a white patch on the lip, termed “actinic cheilitis”. Included in the differential diagnosis is keratoacanthoma, syphilis and tuberculosis. A biopsy will confirm the diagnosis. Management A lip shave and advancement of the vermilion is performed in actinic cheilitis. Any neoplastic lesion requiring less than a third of the lip to be excised can be removed by modified V incision and primary closure. Larger tumours will require local skin flaps for reconstruction. Radical neck dissection will be necessary if metastatic nodal disease is present. Radiotherapy in small early lesions also produces excellent results, and control may be achieved using the argon laser. Carcinoma of the tongue The incidence of tongue cancer is diminishing due to improvements in dental hygiene and the fall in popularity of chewing tabacco. The lateral border of the tongue is the commonest site affected. Clinical features A persistent ulcer, usually painless, is the common presentation. If allowed to grow, the lesion will ultimately cause tongue fixation and invade the mandible. The patient will then experience difficulty in chewing, swallowing and speech. About a third of patients will have a metastatic neck gland at presentation, which may be on the contralateral side of the neck due to the decussating nature of the lymphatic drainage in this area. The diagnosis is confirmed by biopsy. Management Treatment of small lesions without neck metastases is by either surgery or radiotherapy. A wedge excision may be emlpoyed, but implanted radium needles can produce the same cure rate. Larger lesions will require a partial glossectomy, resection of the mandible and neck dissection.

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2 . Treatment of adenoid cystic carcinoma is surgery. an illfitting denture may be the presenting symptom. Any defect in the hard palate can be occluded with a dental obturator. Early small lesions may be successfully excised and primarily sutured. Biopsy is mandatory for tissue diagnosis and prior to embarking on major surgery. The lesion may be ulcerative or exophytic. Carcinoma of the hard palate Squamous carcinoma is rare in this site. Clinical features Dysphagia or odynophagia ( pain on swallowing) are common symptoms. An orthopantogram or CT may reveal bone erosion of the mandible. A biopsy will confirm the diagnosis. Management Radiotherapy is usually not offered as a primary form of treatment as any subsequent excision has a high risk of producing osteoradionecrosis of irradiated bone. The former cancer tends to extend along the perineural spaces of the greater palatine nerves and may spread into the cranium. Mandibular reconstruction is also feasible. Wider resection will require skin grafting. Most lesions will have already invaded the periosteum and bone of the mandible.Carcinoma of floor of mouth Squamous carcinoma at this site tends to present late. In the elderly. In the latter case the contiguous spread may be as far posteriorly as the skull base. A radical neck dissection will be required as the presence of nodal disease is almost universal. as are benign minor salivary gland tumours. which are usually incurable due to invasion of the pterygoid muscle region. There may also be referred otalgia. Radiotherapy should be used in extensive lesions. the soft tissue defect is reconstructed using either a pedicled or free flap. possibly followed by postoperative radiotherapy. Pain is usually a major feature and signifies deep invasion. Most lesions will have spread to bone and the adjacent floor of mouth. After surgical excision. Treatment is along similar lines to that of carcinoma of the floor of mouth. Adenoid cystic carcinoma is not uncommon. The mandible is either invaded directly by tumor or via the inferior dental nerve canal. Carcinoma of the alveolar ridge The lower alveolar ridge is most commonly affected. probably resulting from metaplastic change induced by betel nut chewing. Carcinoma of the buccal lining The buccal lining is a very common site for cancer on the Indian subcontinent.

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