Oral Cancer

DR.ZIA ABBAS

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 Oral Cancer
Definition & Incidence
Premalignant and Malignant Lesions
Clinical Features Risk Areas
Causes
Biopsy : Types , Indications &
Contraindications
Treatment & Prognosis
Pretreatment & Post Therapeutic Concerns for
the Dentists
Cancers Of Facial Skin
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 Oral Cancers
Squamous Cell Carcinoma
Malignant Melanoma
Malignancies Of Salivary Gland
Cancers Of Lymphoid Tissue
Osteosarcoma, Chondrosarcoma
Cancers Of Connective Tissues : (fibrous,
vascular, muscular, neurogenic)

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 More than 90% of cancers of the oral cavity
and oropharynx are squamous cell
carcinomas, also called squamous cell
cancer.
Squamous cell cancer begins as a collection
of abnormal squamous cells.
The earliest form of squamous cell cancer is
called carcinoma in situ meaning that the
cancer cells are present only in the lining
layer of cells called the epithelium.
Invasive squamous Cell cancer means that
the cancer cells have spread beyond this
layer into deeper layers of the oral cavity or
oropharynx.
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 The American Cancer Society estimates
about 30,200 new cases (20,000 in men and
10,000 in women) or oral cavity and
pharyngeal cancer will be diagnosed in the
United States during 2000 .
8000 patients with oral cancer die every
year in USA.

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 What are premalignant lesions?
Premalignant lesions are dysplastic
lesions that show histologic change in
epithelium characterized by a
combination of individual cell and
architectural alterations

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 Clinical appearance of
premalignant lesions:
1-Leukoplakic
2-Erythroplakic
3-Leuko-erythroplakic

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Clinical Features Of Squamous
Cell Carcinoma:
Leukoplakia
Erythroplakia
Nonhealing Ulcer
Exophytic( raised )
Indurated
Verrucous

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 Clinical Symptoms Associated
With Oral Cancer
Asymptomatic in early lesions
Parasthesia
Numbness
Pain and Pressure

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Causes Of Oral Cancer I: Main
Factors:
Tobacco (smoking, chewing)
Excessive Alcohol Consumption
Solar Radiation

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 Men are more often affected than women.

Smokers are six times more likely to get

mouth cancers, while those chewing
tobacco have a 50-fold increase in risk.

Using tobacco and alcohol together

increases the risk more than either alone.

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 II: Infections:
HPV
EBV
HIV
HSV type I &II
Candidiasis

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 III: Nutritional Deficiency
Severe Iron Deficiency
Severe Vitamin A deficiency

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 IV: Immunosuppression
HIV
Patients treated with immunosuppressive
drugs
Old age

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 V: Chronic Traumatic Injury
and Irritation
Ill fitting dentures
Sharpe edges of the teeth or restorations

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 VI : Heredity

Congenital Dyskeratosis
Cowden syndrome
Liframi syndrome etc

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 Relative Incidence of Oral
Carcinoma
Lower Lip 35%
Lateral/Ventral Tongue 25%
Floor Of Mouth 20%
Soft Palate 15%
Gingival& Alveolar Ridge 4%
Buccal Mucosa 1%

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 Squamous Cancer of the Lip is often related to
exposure to the sun, wind, and the elements.
There is a high incidence of this in farmers
ranchers, telephone linemen, fishermen, golfers,
and outdoorsmen in general.
Wood industry workers prone to adenocarcinomas
of the sinus
Dye industry worker prone to bladder carcinomas
And some folks will get this cancer without any
predisposing factor.
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Study finds increase in
oral cancer among young
adults

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 There is an increase in tongue cancers among
Americans born since the mid-1940s, especially
white males. However, they also found that
incidence of tongue cancer among older
Americans is decreasing.

While overall incidence of head and neck cancer is

stable from 1973-1997, tongue cancer cases
increased 62% from 1985 to 1997, compared with
the preceding 11 years. (Reuters Health,)

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 Cancer Of Floor Of Mouth

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 Cancer Of Soft Palate and
Retromolar Region

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 Cancer Of Gingiva and
Alveolar mucosa

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 VERRUCOUS CARCINOMA
The lesion presents as a verrucous,
exophytic, or endophytic mass that typically
develops at sites of chronic irritation and
inflammation.

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 Advanced Oral Cancer

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 Treatment Of Oral Cancer
Surgery
Chemotherapy
Radiation Therapy

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 Complications Associated with
Cancer treatment
Oral mucositis
Infection: viral, bacterial, and fungal
Xerostomia/salivary gland dysfunction
Functional disabilities: impaired ability
to eat, taste, swallow
Taste alterations
Nutritional compromise: poor nutrition
from eating difficulti

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 Complications Associated with
Cancer treatment
Neurotoxicity: persistent, deep aching
and burning pain that mimics a
toothache
Bleeding: oral bleeding from the
decreased platelets and clotting factors
Radiation caries
Trismus/tissue fibrosis
Osteoradionecrosis
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 The Role of Pretreatment Oral
Care
Open communication with the patient's oncologist is essential to
ensure that each provider has the information necessary to deliver
the best possible care
Identify and treat existing infections, carious and other
compromised teeth, and tissue injury or trauma.
In adults, extract teeth that may pose a future problem or are
nonrestorable to prevent later extraction-induced osteonecrosis.
Stabilize or eliminate potential sites of infection
Conduct a prosthodontic evaluation, if indicated. If a removable
prosthesis is worn, make sure that it is well adapted to the tissue
and that the patient is able to wear and clean it daily. Instruct the
patient to leave the prosthesis out of the mouth at

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 The Role of Pretreatment Oral
Care ( Con )
Perform oral surgery at least 2 weeks
before radiation therapy begins. For
patients receiving radiation treatment,
this is the best time to consider surgical
procedures. Oral surgery should be
performed at least 7 to 10 days before the
patient receives myelosuppressive
chemotherapy. Medical consultation is
indicated before invasive procedure.

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 The Role of Pretreatment Oral
Care ( Con )
Instructions for Patients Using Supplemental
Fluoride
Advise patients to
Gently brush teeth, gums, and tongue with an
extra-soft toothbrush and fluoride toothpaste
after every meal and before bed. If brushing
hurts, soften the bristles in warm water
Avoid candy, gum, and soda unless they are
sugar-free.

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 Oral Care During Cancer
Treatment
When treatment is necessary, consult the
oncologist before any dental procedure,
including dental prophylaxis.
Examine the soft tissues for inflammation
or infection and evaluate for plaque levels
and dental caries.
Review oral hygiene and oral care
protocols; prescribe antimicrobial
therapy as indicated
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 Oral Care During Cancer
Treatment ( Con )
Provide recommendations for treating dry
mouth and other complications.
- Sip water frequently.
- Suck ice chips or sugar
-free candy.
Chew sugar-free gum.
If appropriate, use a saliva substitute spray or
gel or a prescribed saliva stimulant.
Avoid glycerine swabs
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 Oral Care During Cancer
Treatment ( Con )
Take precautions to protect against
trauma
Provide topical anesthetics or analgesics
as appropriate for oral pain

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 Follow-up Oral Care
Chemotherapy
Once all complications of chemotherapy
have resolved, patients may be able to
resume their normal dental care
schedule. However, if immune function
continues to be compromised, determine
the patient's hematological status before
initiating any dental trea

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 Follow-up Oral Care (Con)
Radiation therapy
Once the patient has completed head and
neck radiation therapy and acute oral
complications have abated, evaluate the
patient regularly (every 4 to 8 weeks, for
example) for the first 6 months.
Thereafter, you can determine a schedule
based on the patient

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 Points to remember
High-dose radiation treatment carries a lifelong risk of
Osteoradionecrosis, xerostomia, and dental caries.
Because of the risk of Osteoradionecrosis, principally in
the mandible, patients should avoid invasive surgical
procedures, including extractions that involve
irradiated bone. If an invasive procedure is required,
use of antibiotics and hyperbaric oxygen
Lifelong daily fluoride application, good nutrition, and
conscientious oral hygiene are especially important for
patients with salivary gland dysfunction.

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 Points to remember (Con)
Dentures may need to be reconstructed if treatment
altered oral tissues. Some people can never wear
dentures again because of friable tissues and
xerostomia.
Dentists should closely monitor children who have
received radiation to craniofacial and dental structures
for abnormal growth and development.
Dentists should be mindful about the recurrence of
malignancies, especially in patients with oral and head
and neck cancers, and thoroughly examine all oral
mucosal tissues at recall appointments.

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 Facial Skin Cancers

Basal Cell Carcinoma

Squamous Cell Carcinoma

Malignant Melanoma

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 Basal Cell Carcinoma is the
most common skin cancer

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 Squamous Cell Carcinoma Of
The Facial Skin

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 Malignant Melanoma Of The
Facial Skin Has The Worst
Prognosis

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 Asymmetry--one half unlike the other half
Border irregular--scalloped or poorly
circumscribed border
Color varied from one area to another;
shades of tan and brown; black; sometimes
white, red or blue.
Diameter larger than 6mm as a rule
(diameter of a pencil eraser).
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 The key to reduction of death due to oral
cancer is early detection, and dentists can
play an important role!

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 How ?

1 -Thorough oral examination, and

detection of the early lesions.

2-Biopsy and histological evaluation of the

lesion.

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 When is a biopsy needed?
1-When you have a list of differential
diagnosis and you are looking for a
definitive diagnosis.
Example 1: Hyperkeratosis, Dysplasia,
SCC Example

2: Dentigerous cyst, OKC,

Ameloblastoma.
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 When is a biopsy needed?
2-In case of a non-healing ulcer:
Examples:
SCC,
Pemphigus
Pemphigoid Lupus

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 When is a biopsy
contraindicated?
1-A benign lesion with a distinct clinical
feature Examples:
Geographic tongue
Nicotine Stomatitis

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 When biopsy is contraindicated?
2-Lesions of long duration with minor
clinical change Examples:
Torus Palatinus and Mandibularis

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 When is a biopsy
contraindicated?
3-Variation of normal
Example:
Fordyce Granules
Leukedema

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 When is a biopsy
contraindicated?
4.Lesions prone to infection
Example:
Periapical Cemental dysplasia

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 When is a biopsy
contraindicated?
5-Intrabony radiolucent lesions suspected
of being vascular in nature,unless are
aspirated.
Example:
Central Hemangioma

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 Types of Biopsy
Exfoliative cytology
Fine needle aspiration
Excisional biopsy
Incisional biopsy

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 Exfoliative cytology
Diagnosis from cells that are scraped from the
surface
Advantages
Non-invasive, simple for general dentist
Disadvantages
Requires a trained cytopathologist
Reliability?
Indications
Fungal infections
Newer techniques

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 Exfoliative Cytology
If there is moderate to high index of
suspicion for malignancy definitive
biopsy specimen is indicated NOT
EXFOLIATIVE CYTOLOGY
False negatives reportedly as high as
37%!

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 Fine Needle Aspiration (FNA)
Used for deep lesions that are not easily
accessible for biopsy
A large gauge needle (typically 20g)
Aspirate is put on a glass slide and fixed
Trained cytopathologist will then interpret the
cell and cell aggregates that are aspirated
NOT always 100%reliable, but an excellent
diagnostic tool for difficult to access lesions.

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 Excisional biopsy
Whenever a lesion is small enough that
complete removal is possible without
significant morbidity
Both a therapeutic as well as a diagnostic
procedure
Generally for lesions of 1 cm or less
Additional advantage in that it does not
transect the tumor
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 Transport media
5-10% formalin
Special media for immunofluorescence
staining
One bottle per specimen, DO NOT MIX
SPECIMENS
Each container should be identified with
the patients name, clinicians name, date
and the site of the biopsy.
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 More pearls
Always have a differential diagnosis
Plan surgery ahead of time
If you confident the lesion is a malignancy,
refer to the surgeon that is likely to manage
head and neck oncology
When in doubt, biopsy or refer

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 Even more pearls
Do not cut into the specimen
Put the sample immediately into the
transport media
Take photographs
When in doubt: biopsy
If the histologic diagnosis does not seem
correct with your clinical impression,
talk to the pathologist personally
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 The first step
Discovering a lesion is the first step to
making a diagnosis
If you find yourself 10 years into practice
and you have not diagnosed any dysplasia
you are missing lesions guaranteed!!!!
Diagnosing cancer is as important as
treating caries!!!

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 How about other cancers in
oral cavity!
Salivary gland cancer
Cancers of white blood cells
Sarcomas

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 Salivary gland malignancies
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Polymorphous low grade
adenocarcinoma

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 Cancers of White Blood Cells
Hodgkin lymphoma
Non-Hodgkin malignant lymphoma
Burkits lymphoma
Multiple myeloma
Leukemia

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 Sarcomas
Osteosarcoma
Chondrosarcoma
Fibrosarcoma

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 Staging cancer
Carcinomars
TNM
TNMRP
Grading histological
Sarcomas
Tumour size
Intra or extra compartment
Grading histological
Metastasis

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