Oral premalignant and

malignant conditions
Dr. B R Joshi
 Anatomy
• Oral Cavity = Mouth
– Lips, inside lining of the lips and cheeks, the teeth, the gums, the front
two-thirds of the tongue, the floor of the mouth below the tongue,
the bony roof of the mouth (hard palate), and the area behind the
wisdom teeth.

• Oropharynx ( base of tongue, soft palate, tonsils , tonsillar pillars, and the
back wall of the throat.)
 Premalignant lesions
– Leucoplakia (3-6% malignant transformation esp. Nodular)
– Erythroplakia (17 times more malignant)
– Chronic hyperplastic candidiasis high risk lesion

– Oral submucous fibrosis (malignant transformation rate of

0.5%)
– Syphilitic glossitis medium risk lesion
– Patersion –kelly syndrome
– Lichen planus (reported transformation rate of 0.5-3%)
– Discoid lupus erythromatous low risk
– Diskeratosis congenita
Leukoplakia
 Any white patch or plaque that cannot be characterized clinically or
pathologically.
 Small or large white lesion.
 Smooth or wrinkled

 2.4% malignant transformation at 10 years

Erythroplakia
 Presents as bright red plaque which cannot be
characterized clinically or pathologically as any
other recognizable condition.
 Irregular outline
 Surface may be nodular
 17 times higher risk
Chronic hyperplastic candidiasis
 Result of invasion of lesion by candida albicans
 Produces dense plaque of leukoplakia
 Mainly involved commisures of the mouth
 High incidence of malignant transformation
 6 weeks topical antibiotics or 2 weeks
systemic antifungal treatment
Oral submucous fibrosis:
 Fibrous band form beneath the oral mucosa
 Scaring produces contracture, resulting in
limited in mouth opening
 Associated with pan masala areca nut.
 Treatment is intralesional steroid or surgical
excision and grafting.
 Oral cancer
Epidemiology
• 40% of all malignancy in India (2-4% in west)
• Male predominance
• 1.5 million people alive with oral cancer at a
time
• In Asia Pan, gutkha, and reverse smoking
• Currently 20% death due to distant metastasis
• Systemic disease at early stage
 Etiological Factors
• Premalignant condition of oral cavity
• Tobacco
• Alcohol
• Marijuana
• Syphilis
• Poor oral hygiene
• Sharp tooth
• Spices
• Vitamin –A deficiency
• Viruses
• Genetic
 Clinical features of oral cancer
• Persistent oral swelling for>4 weeks.
• Mouth ulceration for > 4 weeks
• Sore tongue
• Difficulty in swallowing
• Jaw or facial swelling
• Painless neck lump
• Unexplained tooth mobility
• Trismus
• Otalgia
 Investigations
Biopsy:
• Mandatory before planning treatment can be
done under local anesthesia.
• Biopsy should be deep and include a portion
of the normal adjoining mucosa.
• In verrucous variety the basement membrane
is intact and deep biopsy mandatory.
Imaging:
• An orthopantomogram (OPG) to assess mandibular
involvement. Intra-oral X-rays may supplement OPG.
• CT (Computed tomography) : extent of involvement of the
mandible, malignant infiltration and cervical nodal disease.
CT is indicated in patients with:
1. Trismus
2. lesions abutting the mandible where marginal
mandibulectomy is planned
3. To evaluate the clinically N0 neck and
4. In patients with large nodes to look for carotid artery
involvement.
• Magnetic resonance imaging (MRI) is useful
in detecting the soft tissue and perineural
involvement. In cases with carcinoma of the
tongue excellent definition of the extent of
the disease.
• Ultrasound neck
In clinically No neck, is cheap, quick and no
radiation exposure, useful for ultrasound
guided aspiration of the lymph nodes.
 Staging
• Tx - Primary tumor not assessable
• T0 - No evidence of primary tumor
• Tis - Carcinoma in situ
• T1 - Tumor 2 cm or less in greatest dimension
• T2 – Tumor >2 cm but <4 cm in greatest
dimension
• T3 - Tumor >4 cm in greatest dimension
• T4 - Tumor invading adjacent structures,
through the cortical bone, into the deep
(extrinsic) muscles of tongue, maxillary sinus,
or facial skin
 Regional lymph nodes
• NX - Regional lymph node status not assessable
• N0 - No regional lymph node metastases
• N1 - Metastases in a single ipsilateral lymph node, 3 cm or
less in greatest dimension
• N2a - Metastases in a single ipsilateral lymph node >3 cm but
<6 cm in greatest dimension
• N2b - Metastases in multiple ipsilateral lymph nodes,
<6 cm in greatest dimension
• N2c - Metastases in bilateral or contralateral lymph nodes,
none <6 cm in greatest dimension
• N3 - Metastases in a lymph node >6 cm in greatest dimension
• MX - Distant metastasis not assessable
• M0 - No distant metastasis
• M1 - Distant metastasis
 TNM Staging
Stages are defined as follows:
• Stage 0 - Tis N0 M0
• Stage 1 - T1 N0 M0
• Stage 2 - T2 N0 M0
• Stage 3 - T3 N0 M0; T1, T2, or T3 N1 M0
• Stage 4 - Any T any N M1
 Treatment
Goals of Treatment of Oral Cancer :  
1) Eradication of Primary Tumor

2) Eradication of disease in  Cervical nodes.

3) Preservation of Form and Function

4) Prevention of Recurrence and Second Primary

tumor
 Management Of Primary Tumor
Surgery
• Tumor excision with margin of 1 cm normal
tissue
• Usually post op radiation is given
Choice Of Treatment
 Contraindications
• For surgery include
– Poor medical status,
– Patient's refusal of surgery,
– Unresectable disease (e.g., skull-base fixation and carotid
encasement), and
– Presence of distant metastases.
• For radiation therapy include
– Collagen vascular disorders
– Previous irradiation (relative contraindication) and
– Reluctance of the patient to undergo the dental
intervention frequently required to prevent
osteoradionecrosis (relative contraindication
 Carcinoma lip
• V-W shaped excision <2cms lesion
• Stepladder approach of Johnson
• Total lip shave
Advancing labial or buccal mucosal flap
 Carcinoma Tongue
• Early lesion – simple excision
• If <1/3 tongue resected no reconstruction
needed
• Residual defect allowed to granulate
• If >2cms – Hemiglossectomy
• Extensive lesion – major resection
• Tongue defect <2/3 – Radial forearm free flap
• Rim resection of mandible if tumor reaches
but not invades alveolus
• Total glossectomy – bulky flaps to prevent
pooling of food
• At least one hypoglossal nerve to be preserved
 Management of Neck
• Controversial (Diaz et al found a 26% rate of occult
nodal metastases; regional recurrence rate
decreased from 25% to 10% in those receiving neck
prophylaxis. Mishra et al found that the recurrence
rate in those having such prophylaxis was 29% versus
48%.
• Recommendation – neck treatment for tumors of T2
or worse.
• N+ neck either modified radical or radical neck
dissection
 Selective Neck Dissection
• Consists of preservation of one or more lymph
nodes groups & spinal accessory nerve, IJV &
sternocleidomastoid muscle
• For Ca cheek supraomohyoid lymph nodes i.e.
Levels I - III dissected & submandibular gland
removed
Indication T1- T4 N0
 Modified Radical Neck Dissection
Type I
– Removal of all lymph nodes groups level I - V with preservation of spinal
accessory nerve
Indications
– Operable palpable neck disease N1, 2a , 2b not involving accessory nerve
– Occasionally performed for N0 neck
Type 2
– Removal of all lymph nodes groups level I - V with preservation of spinal
accessory nerve & IJV
Indications
– Same as above particularly for a second side operation, when need for
microvascular anastomosis
Type 3
– Removal of all lymph nodes groups level I - V with preservation of spinal
accessory nerve, IJV & sternocleidomastiod muscle (type 3 also known as
comprehensive functional neck dissection)
 Classic Radical Neck Dissection
Levels I - V + SAN + IJV + SCM muscle

Indication
• Significant operable neck disease N2a 2b N3

Contraindications
• Untreatable primary tumor
• Pt unfit for major surgery
• Distant metastasis
• Inoperable neck disease i.e. involvement of CCA, ICA,
brachial plexus or skull base
 Extended Radical Neck Dissection
• Removal of all structures as in RND with
additional removal of Level VI or VII with
mandible , parotid, mastoid , digastric muscle ,
hypoglossal nerve & external carotid artery &
skin
Indication
• When neck disease invades any of the above
structures