ORAL CANCER

Nader A. Al-Aizari

Oral cancer is arguably the most serious condition that dental providers may encounter in their practice. The relatively poor prognosis associated with oral cancer highlights the importance of the dental team’s awareness of the disease.

Oral cancer is generally classified into cancers of the oral cavity and of the oropharynx. The oral cavity includes the lips, buccal mucosa, gingiva, hard palate, floor of mouth and anterior 2/3s of the tongue, whereas the oropharynx consists of the posterior 1/3 of the tongue, soft palate, tonsils and posterior pharyngeal wall.

Human oral cancer is the sixth largest group of malignancies worldwide. Seventy percent of oral cancers appear from premalignant lesions. About 94% of oral cancers are squamous cell carcinoma, a malignancy derived from the surface epithelial cells that line the oral cavity and oropharynx.

Etiology oral cancer is a multifactorial disease Risk factors :
ü

Tobacco use (single biggest risk factor). About 80% of OSCC patients have a history of smoking tobacco and a person’s risk of developing OSCC increases with heavier daily use and longer duration of use.

ü Smokeless tobacco (chewing tobacco. Tobacco and alcohol appear to have a synergistic effect. and their combined use increases a person’s risk for OSCC ü . the risk of alcohol and tobacco in combination is well established. While it is unclear whether alcohol abuse alone can cause cancer. Excessive alcohol consumption. moist snuff and dry snuff) has also been implicated in OSCC.

They include leukoplakia. nicotine stomatitis and tobacco pouch keratosis. lichen planus.ü ü ü Genetic Inflammation Preneoplasia: There are clinically apparent oral premalignant lesions of oral cancer. and submucous fibrosis Immunosuppression ü . erythroplakia.

A different type of radiation. ü . Xirradiation.Radiation to the head and neck: Long-term exposure to ultraviolet radiation is the primary causative factor in SCC of the lip vermillion. X-irradiation generates cellular abnormalities in the area of exposure that cause a dose dependent increased risk of developing another primary malignancy in the future. is a common treatment for many malignancies and other diseases.

Importantly. particularly type 16. Infection with human papillomavirus (HPV). ü Infection by tumor-producing (oncogenic) viruses is an independent risk factor for many different types of cancers. is a known risk factor and independent causative factor for oral cancer. there is no association between oral cancers and the small amount of radiation generated by routine dental radiographs. .

Available information suggests that qat chewing should be considered one of the possible confounding risk factors for oral cancer specific to individuals who practise qat chewing along with tobacco use.ü Qat: There is not enough evidence in the literature that qat chewing alone is carcinogenic or plays an independent direct role in the development of head and neck cancers. .

numbness. sore throat or the sensation of something “caught” in the throat. Other potential signs and symptoms include pain. The most common symptom is a non-healing sore or ulcer. a persistent lump or thickened area. . a persistent red or white patch. which can result in a delay in the patient seeking care. dysphagia.Clinical Features and Diagnosis • • Early OSCCs are often asymptomatic.

radiating from the lesion to the ipsilateral ear • Lump q . nodularity and fixation to underlying tissues. and is elevated and hard on palpation. When the lesion is large the patient often has severe pain. • Ulceration The ulceration has an irregular floor and margins.Advanced stages The classic features of oral malignancy include ulceration.

• Ø Ø Ø Ø Less common presentations Paraesthesia or numbness of the chin. . Delayed healing after a dental extraction A lump with abnormal supplying blood vessels Weight loss. These advanced cases can be associated with neck metastases.

The high risk sites for OSCC Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level .

which can be a helpful diagnostic clue. Many OSCCs are associated with an adjacent leukoplakia. speckled red and white.Clinical appearance of OSCC can be Ø Ø Ø Ø Ø Exophytic (growing outward) or Endophytic (growing inward). the most . OSCCs are characteristically firm on palpation. in many cases. The color of OSCC can be white. and may have an ulcerated surface. red or.

Oral squamous cell carcinoma on the gingiva Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level .

Oral squamous cell carcinoma on the alveolar ridge Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level .

Oral squamous cell carcinoma on the tongue Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level .

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should lead to less damage from cancer treatments and to a better prognosis. Distinguishes ‘‘screening” (application of a test to evaluate presence of the disease in asymptomatic individuals who apparently do not suffer from it) from ‘‘detection of cases” (application of a particular procedure to patients with an identified lesion). in which oral health professionals should play a leading role.Early diagnosis of oral cancer Ø Is a priority public health objective. Ø Ø .

CT. Imaging techniques (DPT. while biopsy and histopathological examination represents the indispensable study for the detection of cases in patients with an identified lesion. and MRI) are frequently used to supplement the clinical evaluation and staging of the primary tumour .• • Conventional oral exploration (visual and palpation examination) constitutes the current gold standard for oral cancer screening.

.e. invasion across the basement membrane.Biopsy and histopathological examination Carcinoma is diagnosed when histopathological examination shows there is: • Dysplasia extending through the full thickness of the epithelium (severe dysplasia) and with. • Extension of the rete pegs into the underlying lamina propria. i.

There are also a number of techniques that may contribute to the diagnosis of oral cancer ORAL CANCER SCREENING Screening and early detection in populations at risk have been proposed to decrease both the morbidity andedit Master text styles mortality associated Click to with oral Second level cancer. ● Third level ● Fourth level ● Fifth level .

MRI) Ø Ø Ø .Main techniques that theoretically contribute to the diagnosis of oral cancer in addition to conventional oral exploration (visual and palpation examination). CBCT. biopsy and histopathology: v Ø Toluidine blue Light-based detection systems Chemiluminescence Tissue fluorescence imaging Tissue fluorescence spectroscopy Ø § § § Ø Exfoliative cytology or brush biopsy Specific blood analysis Specific saliva analysis Imaging (DPT. CT.

When applied topically or as an oral rinse.§ Toluidine blue (TB) Toluidine blue and Lugol’s iodine have been used as clinical aids to identify occult mucosal abnormalities and to demarcate the extent of a potentially malignant lesion prior to excision. Second level ● Third level ● Fourth level ● Fifth level . toluidine blue binds to DNA and can help identify malignant lesions with Click to edit Master text styles reasonable accuracy.

.Light-based detection systems Light-based detection § systems are based on the assumption that the structural and metabolic changes that take place in the mucosa during carcinogenesis give rise to distinct profiles of absorption and refraction when exposed to different types of light or energy.

multicentre controlled studies conducted principally by general dentists must be designed in order to justify its application .q Principal weaknesses of the available light-based systems for cancer detection: Low specificity They have not been found to be cost effective compared to conventional oral exploration (visual and palpation examination) The risk collectives in which they should be applied have not been clearly established The results of their use by general dentists have not been published Their effectiveness has not been evaluated for the early diagnosis of oral cancer in terms of a reduction of mortality There is little published scientific evidence.

its specificity (0–14. .ü Chemiluminescence The Vizilite is the most well known system.2%) and positive predictive value are very low. as all patients presented mucosal lesions previously detected on naked eye examination. and has been found to have a high sensitivity (100%) in a number of cross-sectional studies. However.

red lesions appear darker than surrounding tissue .Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level * Normal epithelium absorbs ViziLite illumination *Abnormal epithelium: leukoplakias appear white.

Another marketed device consists of a batterypowered light emitting diode (LED) transilluminator with an autoclavable light guide that produces diffused light .

.ü Tissue fluorescence imaging The VELscope system (Visually Enhanced Lesion Scope) detects the loss of fluorescence in visible and non-visible high-risk oral lesions such as cancers and precancers. there are no studies that have demonstrated the utility of VELscope as a diagnostic aid in malignant or premalignant lesions in low-risk patients or when used by primary care dentists. VELscope reported sensitivity values of 97–100% and specificities of 94–100% are encouraging. However. by applying direct fluorescence. This procedure has been shown to be helpful to obtain safer surgical margins in tumour excision.

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e. loss of fluorescence). In this procedure. while abnormal cells will appear dark (i.ü Tissue fluorescence spectroscopy This system consists of a small optical fiber that produces various excitation wavelengths and a spectrograph that receives the data and records it on a computer. nor can it be accomplished with a curing light . under which normal cells emit autofluorescence. Have a high sensitivity and specificity when differentiating healthy mucosa from malignant oral lesions. there is no pre-rinse or stain. normal cells appear green. A multi-use electrical metal halide light produces a particular excitation wavelength in a 50-mm circular area. Eliminates the subjective interpretation of the changes in tissue fluorescence. When viewed through a filtering scope that eliminates other wavelengths of light. Main indication is limited to the study of small lesions previously diagnosed by visual examination. This fluorescent effect cannot be observed with the naked eye.

Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level Clinical y. . ectroscop before sp th or of mou view of flo tro after spec r of mouth w of floo Clinical vie scopy.

whether naturally or artificially. . Oral cytology is useful for monitoring several sites for a large lesion and can guide the choice of sites for incisional biopsies. from the oral mucosa.§ Exfoliative cytology The study and interpretation of the characteristics of cells that flake off.

minimally invasive method of screening oral lesions should be reconsidered. Many clinicians. . rather than undertake a procedure which can be costly and not reliable at excluding neoplasia.The use of oral brush biopsy as a standardized. faced with a doubtful mucosal lesion will elect to undertake a biopsy with scalpel or punch.

Click to edit Master text styles Second level ● Third level ● Fourth level ● Fifth level The cytobrush was rolled on the glass slide. The slide must be fixed immediately with Merckofix-spray .

inhibitor of apoptosis (IAP). significantly lower iron and selenium levels have been found than in healthy controls. In patients with OSCC. squamous cell carcinoma associated antigen (SCCAA). The serum concentrations of carcinoembryonic antigen (CEA). In contrast. Annexin A1 (ANXA1) was recently identified in peripheral blood by real-time PCR and has been proposed as a potential diagnostic biomarker for OSCC. . serum copper levels were higher in patients with OSCC or precancerous lesions than in healthy controls. and cytokeratin fragments (CYFRA) have been shown to have a sensitivity of 81% for the detection of OSCC.§ Specific blood analysis Immunological and biochemical alterations in the serum help in the early diagnosis of oral cancer. Serum tumour markers for OSCC have shown only moderate degrees of sensitivity for diagnosis.

albumin. . Salivary levels of total sugar. sodium. and lactate dehydrogenase are significantly raised compared to controls with healthy mucosa. immunoglobulin G. calcium. patient-friendly tool for the diagnosis of OSCC Saliva analysis could in the Patients with OSCC have a global alteration of salivary composition.§ Specific saliva analysis future prove to be an efficient. noninvasive. protein-bound sialic acid. free sialic acid.

§ Immunohistochemical Techniques These diagnostic tests help to establish a definitive diagnosis when. by routine histopathology techniques. . a lesion appears morphologically benign or its classification is in doubt.

§ Imaging Dental panoramic tomography (DPT) Computed Tomography (CT) Magnetic Resonance Imaging (MRI) .

N involvement Distant metastasis Stage of lesion Site of lesion Histopathological differentiation Depth of invasion Adequacy of initial treatment Ø Ø Ø Ø Ø Ø Ø .Staging is dependent on: Ø Survival is dependent on: Ø Lesion size Local extension L.

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and has not metastasized to local lymph nodes .Cancer Stages • Stage I – The cancer does not span more than 2 cm. and has not metastasized (spread) to local lymph nodes • Stage II – The cancer spans between 2 and 4 cm.

. or the cancer is any size but has metastasized to a single. lymph node in the neck region ipsilateral (on the same side) to the original cancer.• Stage III –The cancer spans more than 4 cm. The cancerous lymph node does not exceed 3 cm.

local lymph nodes ipsilaterally. to local lymph nodes on one or both sides of the neck. to the same or different part of the body . and has spread: to multiple.• Stage IV – Any of the following applies: a) The cancer has spread within the oral cavity or to the lips. the local lymph nodes may or may not be involved b) The cancer measures any size. • Recurrent – The cancer returned after treatment. or to any lymph node exceeding 6 cm.) The cancer has metastasized to other body regions.

delay. or reverse malignant progression in tissues at risk for the development of invasive cancer Retinoids.CHEMOPREVENTION Is the use of natural or synthetic substances to halt. a class of chemical compounds that are related chemically to vitamin A. are the most extensively studied agents for chemoprevention of oral cancer .

. Bowman-Birk inhibitor concentrate (BBIC) derived from soybeans. curcumin . and green tea polyphenol epigallocatechin-3-gallate.Other agents that have been assessed in clinical trials to evaluate the chemoprevention activity in oral leukoplakia patients include vitamin E.

Strawberries have the potential to prevent esophageal cancer .

(COX-) 2 inhibitors and Epidermal Growth Factor Receptor (EGFR) inhibitors .Agents targeted to specific steps in the molecular progression from normal to oral premalignancy and to invasive carcinoma: q cyclooxygenase.

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