(Oral!Cancer!1)!

!ORAL!CANCER:!A!Silent!Killer!
Dr. Adel I. Abdelhady

!Assistant!Professor!Oral!!Surgery!
College!of!Den...
Introduc7on!
•  Cancer!of!the!oral!cavity!in!Saudi!Arabia!is!not!an!uncommon!
disease!!
•  It!account!for!more!than!25%!of...
Introduc7on!
•  The!spectrum!of!malignant!tumours!to!affect!the!
oral!cavity!vary!widely!and!includes:!
–  Surface(epitheli...
Introduc7on!
Surface(Epithelium
•  1K!Squamous!cell!Carcinoma!
•  Undifferen5ated!carcinoma!
•  Differen5ated!carcinoma!
•  ...
Introduc7on!
Glandular(epithelium(
(1K!Adenocarcinoma!
!2K!Mucoepidermoid!
carcinoma!
!3K!Adenoid!cys5c!carcinoma!
!4K!Aci...
Introduc7on!
•  Acquired)capability)of)cancer)cell:)
–  Limitless!replica7ve!poten7al!
–  Evading!apoptosis!
–  SelfJsuffici...
Cancer—Pathophysiology!
Squamous!Cell!Carcinomas!!
•  More!than!90%!of!cancers!of!the!oral!cavity!and!
oropharynx!are!squamous!cell!carcinomas!!
•...
E7ology!&!Risk!Factors!
!  Tobacco:!About!90%!of!people!with!oral!
cavity!and!oropharyngeal!cancer!use!tobacco!!
!  Alcoho...
E7ology!&!Risk!Factors!
! Poor!nutri5on:!A!diet!low!in!fruits!and!vegetables!is!
associated!with!an!increased!risk!!
! Mou...
E7ology!&!Risk!Factors!
–  Chemicals:!

•  Asbestos,!NickelKChromate,!in!nasal!and!paranasal!sinuses!
tumours!
•  Wood!dus...
•  The!overall!survival!rate!for!oral!cancer!in!the!general!
!
popula7on!is!52%,!a!survival!rate!worse!than!
prostate,!ute...
Tobacco!&!Alcohol!
•  We!know!that!tobacco!and!alcohol!can!
damage!cells!in!the!lining!of!the!oral!cavity!
and!oropharynx,...
Tobacco!&!Alcohol!
!  Tobacco when kept in
! Scien7sts!are!not!sure!
mouth leaches out
whether!alcohol!directly!
carcinoge...
!

!Chemicals!In!Chewing!Tobacco!And!Snuff

!

Includes:!
! Nuclear!waste!
! Cancer!causing!agents!
! Car!baeery!chemicals!...
Epidemiology!

• Incidence:!
•  Global!incidence!of!cancer!is!10!million,!with!6!million!
deaths!(Sikora,!1999).!!
•  Each...
Oral!Cavity!Cancer:!
Approximately!50%!of!pa7ents!diagnosed!with!oral!cancer!will!
ul7mately!die!of!their!disease!
!  Annu...
•  Site:!
!Oral!cancers!usually!involve!the!tongue!sides!
and!ventral!surfaces,!lips,!floor!of!the!mouth,!
so!palate,!tonsi...
Ae5ology!
! !Generally,!there!is!no!single!cause,!!which!is!

responsible!for!all!neoplasms.!
• Tobacco!x5!risk!factors!
c...
Precancerous)lesions)!
!
•  1.Oral leucoplakia
•  It is characterized by
white patch on the
buccal mucosa or any
place in ...
27Erythroplakia)
!
•  This!is!characterized!by!red!
velvety!patch!which!is!not!
associated!with!any!
trauma!or!inflamma7on....
Two!lesions!that!could!be!precursors!to!cancer!are!
!
leukoplakia!(white!lesions)!and!erythroplakia!(red!
lesions).!Althou...
3.Oral sub mucous fibrosis!
•  This condition is
characterized by limited
opening of mouth and
burning sensation on
eating...
Carcinogenesis!
•  The!mucosa!is!thought!to!be!
primed!to!develop!malignant!
tumours!by!exposure!to!repeated!
carcinogenic...
Field change & arising of a further tumour
Primary!Lesion!of!the!previous!pa7ent!
Metasta7c!Carcinoma!In!Jaws!
•  1.! ! Metastasis! in! jaws! or! (rarely)! oral! so_! 5ssues,!
especially!from!cancer!of:!
...
Metasta7c!Carcinoma!In!Jaws!
! Metastasis!is!a!feature!of!malignancy;!by!defini7on,!
benign)neoplasm)never)metastasize!!
! ...
Invasion!
Invasion!is!the!direct!extension!of!a!
malignant!neoplasm!into!the!
surrounding!7ssues;!the!term!implies!
that!c...
Theories!Of!Invasion!
Three! theories! about! invasion! exist! (Pauli,! B.! U.! and!

!!

Knudson,!W.,!1988):

(1)!The!Mec...
Theories!of!invasion!
(2)!The!Enzyma5c!Theory,!!

which!assumes!the!produc7on!of!ly7c!enzymes!that!
destroy!the!contacts!b...
Theories!of!invasion!
(3)!The!migratory!theory:!
! ! It!originates!from!the!idea!that!tumour!cells!become!

mobile! and! m...
!
The!most!common!sites!
of!the!oral!cancer!is!the!
tongue!and!the!floor!of!
the!mouth.!The!other!
common!sites!are!
buccal...
Featured)Which)Demand)Careful)
ConsideraCon)From)Examiner)Are))
1JChronic!ulcer!or!fissures!with!no!apparent!cause,!or!
one...
!

5JSigns!of!involvement!of!adjacent!nerves!producing!persistent!
pain,!anesthesia!of!part,!or!paralysis!of!muscles.!

6J...
!  9JAn!abscess!with!no!apparent!cause!which!

!!
!
may!be!a!necro7c!neoplasm!
!  10JAnaemia!with!no!obvious!cause!
!  11J...
!Warning!Symptoms!&!Signs!Of!Oral!Cancer!
! a!sore!in!the!mouth!that!does!not!heal!
(most!common!symptom)!!
! pain!in!the!...
!!Symptoms!&!Signs!Of!Oral!Cancer!
! Difficulty!chewing!or!swallowing!!
! Difficulty!moving!the!jaw!or!tongue!!
! Swelling!of!...
Signs!and!Symptoms!
•  It!can!go!unno7ced,!it!can!be!painless!
•  It!may!appear!as!a!white!or!red!patch!of!7ssue!in!the!
m...
Presenta7on!of!oral!carcinoma!
How!to!Detect!and!Diagnose!Oral!Cancer!
! Many!cancers!of!the!oral!cavity!and!oroJ
pharynx!can!be!found!early,!during!rou7...
What!You!Can!Do?!
•  EXAMINE!your!pa7ents!at!each!visit!
•  TAKE!A!HISTORY!of!their!alcohol!and!
tobacco!use!!
•  INFORM!y...
Preven5ve!instruc5ons!to!your!pa5ent!
• 
• 
• 
• 

Stop!smoking!(this!includes!cigareees,!cigars!and!pipes)!!
Stop!the!use...
Instruc7ons!to!the!Pa7ent!
•  You!should!always!contact!
your!doctor!or!den7st!
immediately!if!you!no7ce!the!
following!sy...
Management!of!oral!cancer!
•  The!management!of!oral!cancer!has!undergone!
radical!change!in!the!last!10!years!and!con7nue...
Examina7on!and!diagnos7c!methods!
•  Health!history!
•  History!of!the!lesion!
•  Clinical!examina7on!
•  Radiographic!exa...
Rou7ne!head!and!neck!examina7on!!
The!examina7on!is!conducted!with!the!pa7ent!
seated.!Any!intraoral!prostheses!(dentures!...
Oral!Cavity!Screening!
•  screening,!which!involves!the!examina7on!of!
the!oral!cavity!as!a!whole!and!not!just!your!
teeth...
!
A!thorough!oral!screening!also!includes,!!!examina7on!
of!the!nasopharynx!and!larynx,!and!involves!manually!
feeling!the...
• 

!
Diagnosis!
Ini7ally!oral!cancer!may! ! •  Diagnosis!is!established!by!

be!asymptoma7c!but!a!
check!up!of!a!small!
u...
The!ExtraKoral!Examina5on!
•  The!extraJoral!assessment!includes!
an!inspec7on!of!the!face,!head,!
and!neck.!The!face,!ear...
!
Lips!
•  Begin!examina7on!by!
observing!the!lips!with!the!
pa7ent's!mouth!both!
closed!and!open.!Note!the!
color,!texture!...
Surgical!anatomy!
•  The(Lip:(
–  Covered!with!nonKkera5nized!
stra5fied!squamous!epithelium!
which!is!transparent,!appear!...
Surgical!anatomy!The(Lip(
–  Lympha7c!drainage:!
•  Mucosal!and!cutaneous!systems.!
•  Lower!lip:!
–  One!medial!trunk!whi...
Surgical!anatomy!The(Lip(
•  Age!and!sex:!

–  The!sixth!decade!and!Male!:!female!
ra5o!is!80:1!

•  93%!affect!the!lower!l...
!
IntraKoral!examina5on!!

• 

!
!
!
Labial!Mucosa!With!the!

pa7ent's!mouth!par7ally!
open,!visually!examine!the!
labial!...
Buccal Mucosa
Retract!the!buccal!mucosa.!Examine!first!
the!right!then!the!le!buccal!mucosa!
extending!from!the!labial!comm...
Surgical!anatomy!!
•  The!buccal!mucosa:!
–  Covered!with!nonJkera7nizing!
stra7fied!squamous!
epithelium!with!mul7ple!
min...
Gingiva
•  First,!examine!the!buccal!and!labial!
aspects!of!the!gingiva!and!alveolar!
ridges!(processes)!by!star7ng!with!t...
Tongue!
•  With!the!pa7ent's!tongue!at!rest,!
and!mouth!par7ally!open,!inspect!
the!dorsum!of!the!tongue!for!any!
swelling...
Posterior!of!the!Tongue!
•  With!the!aid!of!mouth!mirrors,!
inspect!the!right!and!le!lateral!
margins!of!the!tongue.!
•  G...
Surgical!anatomy!
•  The(tongue:(
–  Specialized!kera7nized!epithelium!
with!collec7on!of!minor!salivary!
gland!and!muscle...
Ventral surface of the tongue and
floor of the mouth
•  Then!examine!the!ventral!
surface.!Palpate!the!tongue!
to!detect!g...
Surgical!anatomy!The(tongue(
•  A!disease!of!the!middle!age!and!
elderly!with!equal!sex!incidence!
•  85%!occurs!in!the!la...
Surgical!anatomy!The(tongue(
(

Lymph!drainage:!

Tip!of!the!tongue:!
To!the!submental!lymph!nodes!–!to!the!lower!
deep!ce...
Bimanual!mouth!floor!examina7on!
•  Bimanually!palpate!the!
floor!of!the!mouth!for!
any!abnormali7es.!All!
mucosal!or!facial...
Hard!and!so_!palate!
•  With!the!mouth!wide!open!and!
the!pa7ent's!head!7lted!back,!
gently!depress!the!base!of!the!
tongu...
Tongue!and!cheek!carcinoma!
SCC of the body of the mandible
Intra-oral photograph

* CT Scan (Bony invasion)
Factors!describes!the!degree!of!
malignancy!
•  The!degree!of!histological!differen7a7on!of!
Malignant!neoplasm!are!histolo...
Most!common!routes!of!!
spread!of!oral!carcinoma!
•  1JLocal!spread!is!achieved!by!direct!invasion!
and!infiltra7on!of!adja...
Test!for!metasta7c!workJup!of!oral!
cancer!
•  1J!Blood!and!biochemical!profile!
•  2JChest!xJray,!liver!ultrasound(abdomin...
Quiz!????!Management!
•  The!lesion!should!be!reJbiopsied.!Tissue!
sampling!should!be!obtained!from!mul7ple!
sites!of!the!lesion.!
•  If!this!ac...
Assessment!
•  Clinical(Examina5on:(

– Tumours,!when!first!seen,!are!almost!
always!confined!to!the!head!and!neck!with!
no!...
Assessment!
•  Whether!to!treat!or!
not!depend!on:!
–  the!age!
–  the!health!status!of!
the!pa5ent!!
–  advance!stage!
– ...
Assessment!
•  Full!assessment!will!lead!to!
one!of!the!following!
conclusions:!
–  Pa5ent!is!poten5ally!
curable!
–  Prim...
Assessment!
• 

The!pa7ent!general!condi7on:!

–  Assessed!with!full!inves7ga7on!and!classified!for!
performance!status!
1....
Assessment!
•  Examina5on:!
–  Think!in!term!of!T!Staging,!delineate!its!border!by!
inspec7on!and!palpa7on!
–  Record!and!...
Assessment!
•  Staging!of!cancer:!
– Subdividing!the!malignant!lesion!into!
groups!with!similar!behavior!
•  Act!as!a!guid...
Staging)TNM)
•  Primary(Tumour:(
– Indicated!by!the!leeer!T!and!the!suffix!1,2,!3!
or!4!represent!more!advancing!disease!
• ...
Staging!
•  Lymph!node:!

–  Is!used!to!describe!progressive!lymph!node!
involvement!
–  NxJ!Regional!lymph!node!cannot!be...
Staging!
•  Distant!metastasis:!
–  M0!–!No!metastases!present!
–  M1!–!Metastases!clinically!demonstrable!
•  MX!–!Metast...
Staging!
•  TNM!Staging:!
–  Stage!I:!T1,!N0,!M0!
–  Stage!II:!T2,!N0,!M0!
–  Stage!III:!T3,!N0,!M0!
!!
!!!!!T1,!2!or!3,!N...
Staging!
Stage!I!!
•  compromise!nega7ve!nodes!and!operable!primary!

Stage!II!!
•  operable!primary!with!operable!nodes!
...
(Oral!Cancer!2)!

!ORAL!CANCER:!A!Silent!Killer!
Dr. Adel I. Abdelhady

!Assistant!Professor!Oral!!Surgery!
College!of!Den...
!

BIOPSY!
Defini7on:!
! Removal!of!!7ssue!from!living!beings!for!
macroscopic!examina7on!,microscopic!!!
! !!!analysis,!bacterial!ana...
BIOPSY!
INDICATIONS!!
1.To!determine!the!nature!of!lesion!which!does!not!
readily!respond!to!conserva7ve!&!simple!therapy.!
2.To!d...
Contraindica7ons:!
Rela5ve!contraindica5ons:!
1.In!cases!of!inflammatory!lesions!may!be!due!to!
allergy!,viral!,fungal,!or!...
!Absolute!contraindica5ons!!!
•  B)!Absolute!contraindica5ons:!
1.Pulsa7le!vascular!lesions.!e.g.!angiosarcoma.!
2.Pigment...
ARMAMENTERIUM:!
1.Mouth!mirror!&!probe,!
colourless!an7sep7c!
agent.!
2.LA!&!syringe.!
3.Surgical!scalpel.!
4.Long!pointed...
Points!must!be!considered!to!ensure!
obtaining!proper!specimen!!
1.Do!not!paint!the!surface!of!the!area!to!be!biopsied!
wi...
TYPES!OF!BIOPSY!!
1.Excisional!biopsy!
2.Incisional!biopsy!
3.Punch!biopsy!
4.Needle/trephine/drill!
5.Aspira7on!biopsy!
6...
•  !!Illustra7on!of!excisional!biopsy!of!so!7ssue!lesion.!A,!
Surface!view.!Ellip7c!incision!is!made!around!lesion!.!A,!
S...
•  A,!!Illustra7on!showing!desirability!of!obtaining!deep!

specimen!rather!than!broad!and!shallow!specimen!when!
incision...
!

!  !!Illustra7on!demonstra7ng!

desirability!of!obtaining!
more!than!one!incisional!
biopsy!if!characteris7cs!of!
lesio...
!
•  Illustra7on!showing!use!of!
trac7on!suture!placed!
through!specimen.!While!
lesion!is!incised,!trac7on!
suture!is!use...
!
•  !!Illustra7on!showing!
principles!used!in!
closing!an!ellip7c!biopsy!
wound.!Mucosa!should!
be!undermined!bluntly!
wi...
EXCISIONAL!BIOPSY!!
*Defini7on:!Total!excision!of!a!small!lesion!!
!!!!!!!!!!!!!!!!!!for!microscopic!study!is!called!!
!!!!...
Method!!
•  Give!LA!which!should!not!be!closer!than!2cm!
from!the!site.!
•  Stabilize!the!lesion!via!the!suture.!
•  Incis...
INCISIONAL!BIOPSY!!
Defini7on:!!
Some!lesions!are!too!large!to!!excise!ini7ally!
without!having!established!diagnosis!or!ar...
Method!
•  Administer!LA.!
•  Iden7fy!the!apparent!junc7on!between!normal!
7ssue!&!the!lesion!select!the!specimen!across!r...
PUNCH!BIOPSY:!
!

•  A!surgical!instrument!is!used!to!punch!out!a!
representa7ve!por7on!of!7ssue.!
•  Since!resul7ng!speci...
Needle/trephine/drill!biopsy:!
•  Use!:!to!biopsied!
deepJseated!fibroJ
osseous!!lesions.!
•  The!resul7ng!
specimen!is!sma...
Aspira7on!biopsy!!
•  Use!–!Applicable!to!many!cys7c!!&!!!fluctuant!lesions!
MethodJ!!
!Clean!the!7ssue!over!the!proposed!a...
How!do!I!prevent!oral!cancer!?!
Stopping!all!the!habits!of!tobacco!consump7on.!Stopping!means!complete!stop!to!the!habit.!...
MISJDiagnosis!
•  1JInadequate!oral!examina7on!
•  2JInnocuons!appearance!of!mucosa!
•  3JLow!index!of!suspicion(
•  4JLac...
Treatment!plan!is!based!on:!
!
Staging!of!disease!using!TNM!classifica7on!
!
T = Tumour size
!
N = Nodal status
!
M = Metas...
Introduc7on!
•  Prognos5c(Indicators:!
–  Sex:!Poor!prognosis!in!females!
–  General!condi5on!&!health!status!of!pa5ent!
–...
Treatment!plan!is!based!on:!
• 

coJmorbid!condi7ons!

Medical
Dental
Speech
Nutrition
Psychosocial
Socioeconomic
Treatment!Op7ons!
Primary surgery

+/J!
Adjuvant
Radiotherapy

+/J!
Concurrent
Chemotherapy

OR!

Primary Radiotherapy

+/...
Dental!Management!
Will!involve!:!
!
General!Den7st!
!

Hygienist!
Dental!Assistant!
Recep7on!Staff!
Dental!Consulta7on!!
•  Clinical!examina7on!
• char7ng!(odontogram)!
• visual!(other!lesions?)!
• palpa7on!
Dental!Consulta7on!!
•  Diagnoses!
– Dental!
•  Caries!
•  Periodontal!disease!
•  Other!Pathology!

– Medical!
•  coJmorb...
Dental!Consulta7on!(cont.)!
•  Treatment!Plan!based!on:!
– prognosis!of!individual!teeth!
– past!dental!history!(complianc...
Dental!Treatment!
•  Must!be!done!immediately!
!
–  !no!delay!in!radiotherapy!

– !cancer!is!progressing!!!
!
Dental!Treatment!
•  Extrac7ons!
– abscesses,!gross!caries!
– advanced!periodontal!disease!
– heavily!restored!teeth!w/!po...
Chronic!Sequelae!
•  Problems!with!xerostomia!!
– increased!trauma!risk!
• !so!7ssues!very!dry!!
• !easily!injured!
!
!
Chronic!Sequelae!
•  Problems!with!xerostomia!!
– thick!secre7ons!
• !change!in!mucous:serous!ra7o!
• !increased!“gag”!
• ...
Chronic!Sequelae!
•  Problems!with!xerostomia!!
– difficulty!swallowing!
• H2O!with/between!meals!!
– chronic!Candidiasis!
Distant Metastasis
Normal lung

Secondary SCC
SCC!of!Lower!Lip!in!a!pipe!smoker!(78Years)!
SCC!of!lateral!border!of!the!tongue!
SCC!in!FOM!
Metasta7c!carcinoma!in!jaws!
•  Metastasis! in! jaws! or! (rarely)! oral! so!
7ssues,!especially!from!cancer!of:!
• Breast...
Referrals!for!biopsy!
•  Health!of!pa7ent!!
•  surgical!difficulty!
•  Poten7al!for!malignancy!
Types!of!biopsy!
• 
• 
• 
• 
• 
• 
• 

Incisional!biopsy!
Punch!biopsy!!
Excisional!biopsy!
Drill!biopsy!
Oral!cytology!!
...
So!7ssue!biopsy!technique!and!surgical!
principles!
1. 
2. 
3. 
4. 
5. 
6. 

Anesthesia!
Tissue!stabiliza7on!
Haemostasis!...
Management!
•  Aer!a!defini7ve!diagnosis!has!been!made!and!the!
cancer!has!been!staged,!treatment!may!begin.!
•  Treatment!...
Nutri7onal!Implica7ons!of!Cancer!
Therapy!
•  Chemotherapy!
! !—Taste!abnormali7es,!diarrhea,!cons7pa7on!
•  Radia7on!ther...
Factors!affec7ng!the!decision!
•  Aggressiveness!of!lesion!
•  Anatomic!loca7on!of!lesion!
•  Dura7on!of!lesion!
•  Reconst...
Treatment!
1.  Early!stages!(I!and!II)!of!SCC!treated!with!surgery!or!
radia7on!(FiveJyear!survival!rates!are!similar!for!...
2.  Advanced!stages!(III!and!IV)!treated!with!a!
combina7on!of!surgery!and!radia7on!
therapy,!although!this!increases!the!...
Surgical!management!of!oral!cancer!!
•  Basic!surgical!goals!are:!
! Eradica7on!of!pathologic!condi7on:!
! The!primary!les...
Mul7ple!carcinomas!
Resected!mandible!&!composite!gra_!

!Primary!tumour!with!submandibular!!!!!!!!!!!!!!!!!!!!!!!!!Forearm!composite!gra!!!!!...
Massive!surgery!for!invasive!!
oral!cancer:!Floor!&!mandible!
Alveolar!SSC!
Alveolar!SSC!1!
Mandibulectomy!and!reconstruc7on!plate!
Maxillary!Carcinoma:!antrum!&!orbit!!
Melanoma!
Radiotherapy!
•  Tumour!cells!are!more!suscep7ble!to!ionizing!radia7on!!
•  Radia7on!can!be!delivered!by:!
!  Implanta7on!...
RADIOTHERAPY!
•  The!use!of!ionising!radia7on!to!cure!disease!or!
make!the!symptoms!of!a!disease!less!severe!
i.e.!palliate.!
•  Radioth...
•  External!beam!radiotherapy:!
!!!!!!!!!J!Directed!through!skin!to!tumor.!
!!!!!!!!!J!Use!shielding.!
•  Brachytherapy!
!...
•  Direct!effects:!
!!!!!!!!these!result!from!damage,!mainly!to!DNA,!
by!the!high!energy!of!radia7on.!This!can!cause!
chang...
•  Indirect!effects:!
!!!!!!!!these!result!from!ionisa7on!of!water!and!
forma7on!of!toxic,!free!radicals!and!
obstruc7on!of...
!
!
• 
• 
• 
• 
• 
• 

!

MUCOSITIS!
FUNGAL!INFECTION!
XEROSTOMIA!
RAMPANT!CARIES!
DIFFICLUTY!WITH!SPEECH!AND!MASTICATION!...
•  Results!in!epithelial!thinning,!erosion!and!
ulcera7on.!!
•  Affects!nonJkera7nized!mucosa!first.!
•  Usually!presents!wi...
•  Early!signs:!!

!!!!!J!whitening!of!mucosa!!
!!!!!J!mucosal!erythema!
!!!!!J!Can!cause!dysphagia!

•  Late!signs:!

!!!...
•  Reassure!the!pa7ent!of!the!limited!7me!
period!of!this!side!effect.!
•  Give!symptoma7c!relief:!
!!!!!!!!J!CXD!mouthwash...
•  Avoidance!of!certain!food,!drinks!to!relieve!
discomfort:!
!!!!!!!!J!Hard!and!spicy!foods.!
!!!!!!!!J!Strongly!flavoured...
•  Pa7ent!undergoing!radiotherapy!may!have!
altera7on!in!the!normal!flora.!
•  Bacterial,!viral!and!fungal!infec7ons!can!oc...
•  Preven7on:!
!!!!!!!J!intensive!oral!hygiene!instruc7on!prior!to!
treatment,!regular!follow!up.!!

•  Treatment:!
!!!!!!...
" NB:!do!not!use!Nysta7n!and!CXD!

simultaneously!!because!of!inhibitory!effect!on!
each!other.!Separate!by!1!hour.!!
•  Most!severe!if!bilateral!salivary!glands!are!
exposed!to!radia7on!
•  Results!in!acinar!cell!atrophy!and!necrosis,!
cha...
!
!

!

•  Symptoma7c!relief:!
!!!!!!!!J!Frequent!sips!of!water/!milk!and!avoid!
sugary!drinks.!
!!!!!!!J!Saliva!subs7tute...
•  Typically!affects!the!gingival!1/3!and!incisal!/!
cusp!7ps!of!teeth.!
•  Not!limited!to!teeth!within!radia7on!field.!
•  ...
•  preJradia7on!OHI,!diet!counseling!and!
treatment!of!any!ac7ve!caries.!
•  regular!follow!up!during!Treatment.!
•  Treat...
•  Caused!by!fibrosis!of!mas7catory!muscles!!
•  Jaw!exercises!limit!the!extent!of!trismus!but!
will!not!cure!it!aer!it!has...
•  Radia7on!effects!on!bone:!
!!!!!!!Hypovascularity,!Hypocellularity!and!Hypoxia!leading!
to!poor!ability!to!repair!and!re...
Non!healing!wound!

Hypovascular,!hypoxia,!hypocellular!!!
!
!

irradia7on!

3H’s!

Tissue!breakdown!
• 
• 
• 
• 
• 
• 
• 
• 

So!diet.!
Adjustment/removal!of!any!trauma7c!denture.!
Provide!analgesia.!
Stop!smoking!and!alcoh...
•  PreJirradia7on!management.!
•  During!irradia7on!management.!
•  PostJirradia7on!management.!
•  If!head!and!neck!radia7on!is!scheduled!the!following!
recommenda7ons!should!be!considered:!
!!!!!J!construct!protec7ng!...
• 
• 
• 
• 
• 
• 

Maintain!the!op7mal!oral!heath.!
Mucosa!and!salivary!gland!protec7on.!
Smoking!and!alcohol!should!be!di...
•  Management!of!oral!complica7ons.!
•  Keep!op7mal!oral!hygiene.!
•  Topical!fluorid!applica7on!by!mean!of!custom!
carrier...
•  What!is!the!management!of!post!radia7on!
pa7ent!who!needs!tooth!extrac7on?!
!!!!J!four!months!aer!comple7on!of!therapy,...
!
•  What!is!the!HBO!protocol!for!prophylac7c!use!
before!teeth!extrac7on!in!irradiated!pa7ents?!
!!!!!!!this!protocol!con...
!
•  What!is!the!protocol!for!implant!placement!in!
the!irradiated!pa7ent?!
!!!!!!J!strict!oral!hygiene!before!and!aer!imp...
!
•  Radiotherapy!can!affect!all!oral!and!perioral!
7ssues.!
•  Preven7on!management!of!disease!prior!to!
radia7on!treatmen...
Chemotherapy!
•  Used!only!in!cases!IV!with!poor!prognosis!
•  Currently!used!agents!include:!
• 
• 
• 
• 

!

cispla7n,!!...
Emerging!Therapies!
ReJevalua7on!of!the!role!of!surgery!for!distant!
metasta7c!oral!cancer!has!shown!a!possible!role!
for!...
Recurrence!and!Second!primaries!
Treatment!delay!
Morbidity!of!cancer!therapy!
•  Surgery:!
• 
• 
• 
• 

Quality!of!life!
Func7on!
Esthe7c!
Cost!of!rehabilita7on!

•  Radio...
Osteoradionecrosis!
Radia7on!Mucosi7s!!
Cancer!pa7ent!and!Quality!of!life!!
•  Every!Oral!cancer!pa7ent!has!to!be!seen!by!
specialist!of!the!following:!
•  Speech...
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
Oral cancer
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Oral cancer

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Oral & Maxillofacial Surgery
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Oral cancer

  1. 1. (Oral!Cancer!1)! !ORAL!CANCER:!A!Silent!Killer! Dr. Adel I. Abdelhady !Assistant!Professor!Oral!!Surgery! College!of!Den5stry,!Dammam!University! !
  2. 2. Introduc7on! •  Cancer!of!the!oral!cavity!in!Saudi!Arabia!is!not!an!uncommon! disease!! •  It!account!for!more!than!25%!of!all!malignancies,!in!the! Southern!region,!it!might!reach!up!to!35%!! •  In!males,!it!is!third!in!frequency!following!lung!and!prostate! cancer! •  In!females,!it!is!second!following!breast!cancer!!
  3. 3. Introduc7on! •  The!spectrum!of!malignant!tumours!to!affect!the! oral!cavity!vary!widely!and!includes:! –  Surface(epithelium( •  Squamous!cell!carcinoma!over!90%! –  Glandular(epithelium( •  Adenocarcinomas!in!females! •  Mucoepidermoid!carcinomas!in!males! –  Mesenchymal(5ssues( •  Lymphomas,!Sarcomas!are!very!rare!
  4. 4. Introduc7on! Surface(Epithelium •  1K!Squamous!cell!Carcinoma! •  Undifferen5ated!carcinoma! •  Differen5ated!carcinoma! •  Adenoid!squamous! carcinoma! •  Verrucous!carcinoma! •  2K!Basal!cell!carcinoma! •  3K!Malignant!Melanoma !! !!
  5. 5. Introduc7on! Glandular(epithelium( (1K!Adenocarcinoma! !2K!Mucoepidermoid! carcinoma! !3K!Adenoid!cys5c!carcinoma! !4K!Acinic!cell!carcinoma! !5K!Undifferen5ated! carcinoma! !!
  6. 6. Introduc7on! •  Acquired)capability)of)cancer)cell:) –  Limitless!replica7ve!poten7al! –  Evading!apoptosis! –  SelfJsufficiency!in!growth!signal! –  Insensi7ve!to!an7growth!signals! –  Sustained!angiogenesis! –  Tissue!invasion!and!metastasis!
  7. 7. Cancer—Pathophysiology!
  8. 8. Squamous!Cell!Carcinomas!! •  More!than!90%!of!cancers!of!the!oral!cavity!and! oropharynx!are!squamous!cell!carcinomas!! •  Squamous!cells!are!flat,!scaleJlike!cells!that!normally! form!the!lining!of!the!oral!cavity!and!oropharynx.!! •  Invasive!squamous!cell!carcinoma!means!that!the! cancer!cells!have!spread!beyond!this!layer!into! deeper!layers!of!the!oral!cavity!or!oropharynx.!!
  9. 9. E7ology!&!Risk!Factors! !  Tobacco:!About!90%!of!people!with!oral! cavity!and!oropharyngeal!cancer!use!tobacco!! !  Alcohol:!Drinking!alcohol!strongly!increases!a! smoker's!risk!of!developing!oral!cavity!and! oropharyngeal!cancer.!! !  Ultraviolet!light:!More!than!30%!of!pa7ents! with!cancers!of!the!lip!have!outdoor! occupa7ons!associated!with!prolonged! exposure!to!sunlight.!! !  Irrita5on:!LongJterm!irrita7on!to!the!lining!of! the!mouth!caused!by!poorly!fi[ng!dentures!!
  10. 10. E7ology!&!Risk!Factors! ! Poor!nutri5on:!A!diet!low!in!fruits!and!vegetables!is! associated!with!an!increased!risk!! ! Mouthwash:!Some!studies!have!suggested!that! mouthwash!with!a!high!alcohol!content!! ! Human!papillomavirus!(HPV)!infec5on:!! ! Immune!system!suppression:! ! Age:!The!likelihood!of!developing!oral!and! oropharyngeal!cancer!increases!with!age,!especially! aer!age!35.!! ! Gender:!Oral!and!oropharyngeal!cancer!is!twice!as! common!in!men!as!in!women,!Oral!cancer!is!the!sixth! most!common!cancer!among!men.!
  11. 11. E7ology!&!Risk!Factors! –  Chemicals:! •  Asbestos,!NickelKChromate,!in!nasal!and!paranasal!sinuses! tumours! •  Wood!dust!in!Adenocarcinoma!of!the!nose! –  Dietary!factors:! •  Vitamin!A!deficiency! •  Vitamin!B!deficiency,!PateresonKKelly!syndrome! –  Radia7on!exposure! –  Viruses:!! •  •  •  •  Human!Papilloma!Virus!HPV! EpsteinKBarr!Virus!EBV! Human!Immunodeficiency!!Virus!HIV! Hepa55s!virus!
  12. 12. •  The!overall!survival!rate!for!oral!cancer!in!the!general! ! popula7on!is!52%,!a!survival!rate!worse!than! prostate,!uterine,!breast,!bladder,!cervical!and!colon! cancers! •  A!5Jyear!survival!rate!for!African!American!men!with! oral!cancer!is!approximately!34%.!With!early! detec7on!and!treatment,!the!5Jyear!survival!rate!can! increase!up!to!85%.! •  Even!though!Oral!cancer!is!typically!a!disease!of!older! people!(60J70),!usually!because!of!their!longer! exposure!to!the!risk!factors,!it!does!occur!in!younger! individuals.!
  13. 13. Tobacco!&!Alcohol! •  We!know!that!tobacco!and!alcohol!can! damage!cells!in!the!lining!of!the!oral!cavity! and!oropharynx,!and!that!cells!in!this!layer! must!grow!more!rapidly!to!repair!this! damage.!! •  Many!of!the!chemicals!found!in!tobacco! cause!damage!to!DNA,!which!contains!the! cell's!instruc7ons!for!repair!and!growth.!!
  14. 14. Tobacco!&!Alcohol! !  Tobacco when kept in ! Scien7sts!are!not!sure! mouth leaches out whether!alcohol!directly! carcinogens, which damages!DNA,!but!they! act on oral mucosa have!shown!that! causing neoplastic alcohol!increases! changes. penetra7on!of!many! !  Habit of smoking is DNAJdamaging! also equally dangerous. chemicals!into!cells!! !
  15. 15. ! !Chemicals!In!Chewing!Tobacco!And!Snuff ! Includes:! ! Nuclear!waste! ! Cancer!causing!agents! ! Car!baeery!chemicals! ! Cyanide!(a!type!of!poison)! ! Arsenic! ! Lead! ! Formaldehyde!(normally!used!to!embalm! !!!corpses)!‫!ﲢﻨﻴﻂ!اﳉﺜﺚ‬
  16. 16. Epidemiology! • Incidence:! •  Global!incidence!of!cancer!is!10!million,!with!6!million! deaths!(Sikora,!1999).!! •  Each!year,!oral!cancer!kills!more!people!in!the!US!than! does!cervical!cancer,!malignant!melanoma,!or!Hodgkin's! disease.! •  Oral!cancer!more!common!than!cervical!cancer!(Ries!et! al.,!1998).!! •  Worldwide,!oral!cancer!is!the!sixth!most!common!cancer,! represen7ng!about!5.5!%!of!all!malignancies!and! approximately!2%!of!all!cancer!deaths.! •  However,!the!worldwide!incidence!of!oral!cancer!varies! (India!and!Brazil!=!40%).!!!
  17. 17. Oral!Cavity!Cancer:! Approximately!50%!of!pa7ents!diagnosed!with!oral!cancer!will! ul7mately!die!of!their!disease! !  Annual!incidence!31,000!Americans;!350,000!worldJwide! !  Sixth!most!common!cancer!worldJwide! !  One!pa7ent!dies!from!oral!cancer!every!hour!in!the!U.S.! !  High!mortalityJ!50%!live!less!than!5!years!following!diagnosis! !  Disease!of!middleJage!and!elderly!males!95%!over!40;!66%! males! !  Known!risk!factors:!alcohol!and!tobacco;!viruses!(HPV?)! !  Incidence!relates!to!socioJeconomical!factors! !  90+%!squamous!cell!carcinomas! !  Frequent!lymph!node!metastasis! !  Mul7ple!primaries!
  18. 18. •  Site:! !Oral!cancers!usually!involve!the!tongue!sides! and!ventral!surfaces,!lips,!floor!of!the!mouth,! so!palate,!tonsils,!salivary!glands,!or!back!of! the!throat.!! •  Age!and!Gender:! !More!than!90%!of!oral!and!pharyngeal! cancers!occur!in!individuals!over!45!(<10%!!!!!! 12.3%)!years!of!age;!males!are!more!likely! than!females!to!develop!them!(2!:!1!!!!!!!!1.3!:! 1)!
  19. 19. Ae5ology! ! !Generally,!there!is!no!single!cause,!!which!is! responsible!for!all!neoplasms.! • Tobacco!x5!risk!factors! compare!to!nonJsmoker,! more!than!20!cig.! Increased!risk!fac.!By!6! folds! • Alcohol! • Chronic!irrita7on!dental! Carcinogens!! factors! • Radia7on! • Chemicals! • Diet! • Immunity! • Hereditary! • HPV!&!syphilis! Risk!groups:! • Male! • Old!age! Combina5on!! • Smoker!and!drinker! • Occupa7on! • Viral!infected!pa7ents! • Low!vit.!A,C,&!iron!lead!to! increase!risk!of!cancer! • Vit.!A!treat!leukoplakia! • Atrophy!of!oral!mucosa!make! suscep7ble!to!local! carcinogens!
  20. 20. Precancerous)lesions)! ! •  1.Oral leucoplakia •  It is characterized by white patch on the buccal mucosa or any place in the mouth and is adjacent to the place where the tobacco quid is kept. The less likely place is floor of the mouth and tongue although 93% of leucoplakia at this sites turn malignant!
  21. 21. 27Erythroplakia) ! •  This!is!characterized!by!red! velvety!patch!which!is!not! associated!with!any! trauma!or!inflamma7on.!It! may!present!with!or! without!leucoplakia.!This! lesion!is!easily!missed!out! but!is!considered!to!have! great!malignancy!poten7al.!
  22. 22. Two!lesions!that!could!be!precursors!to!cancer!are! ! leukoplakia!(white!lesions)!and!erythroplakia!(red! lesions).!Although!less!common!than!leukoplakia,! erythroplakia!and!lesions!with!erythroplakic! components!have!a!much!greater!poten7al!for! becoming!cancerous.!! Any!white!or!red!lesion!that!does!not!resolve!itself!in! two!weeks!should!be!reevaluated!and!considered!for! biopsy!to!obtain!a!defini7ve!diagnosis.!
  23. 23. 3.Oral sub mucous fibrosis! •  This condition is characterized by limited opening of mouth and burning sensation on eating of spicy food. This is a progressive lesion in which the opening of the mouth becomes progressively limited, and later on even normal eating becomes difficult.
  24. 24. Carcinogenesis! •  The!mucosa!is!thought!to!be! primed!to!develop!malignant! tumours!by!exposure!to!repeated! carcinogenic!insults!which!cause! mucosal!altera7ons.! •  !These!altera7ons!may!include:! •  Chromosome!altera7ons,!! •  Gene!muta7ons,!! •  Other!molecular!abnormali7es! •  Field!canceriza7on!
  25. 25. Field change & arising of a further tumour
  26. 26. Primary!Lesion!of!the!previous!pa7ent!
  27. 27. Metasta7c!Carcinoma!In!Jaws! •  1.! ! Metastasis! in! jaws! or! (rarely)! oral! so_! 5ssues,! especially!from!cancer!of:! •  •  •  •  •  •  Breast!! Lung!! Prostate! Thyroid! Kidney! Stomach!!
  28. 28. Metasta7c!Carcinoma!In!Jaws! ! Metastasis!is!a!feature!of!malignancy;!by!defini7on,! benign)neoplasm)never)metastasize!! ! Tumor!emboli!are!carried!by!lymph!or!blood!to! distant!sites!oen!forming!secondary!tumor!colonies! (metasta7c!colonies,!or!metastases)! ! Although!most!malignant!neoplasm!acquire!the!ability! to!metastasize,!at!least!one,!the!basal!cell!carcinoma,! doesn't.!This!very!common!skin!cancer!shows! anaplasia!and!invasion,!but!rarely!metastasizes.! !
  29. 29. Invasion! Invasion!is!the!direct!extension!of!a! malignant!neoplasm!into!the! surrounding!7ssues;!the!term!implies! that!cells!are!s7ll!aeached!to!the! main!tumor!mass.!
  30. 30. Theories!Of!Invasion! Three! theories! about! invasion! exist! (Pauli,! B.! U.! and! !! Knudson,!W.,!1988): (1)!The!Mechanical!Theory:!! ! whereby! the! tumour! mass! is! rapidly! increasing! by! permanent! cycling! and! prolifera7on,! so! that! the! surrounding! 7ssues! are! at! first! compressed! by! the! growing! mechanical! pressure,! and! later,! the! normal! cells! separate! to! give! way! to! the! invading! front! of! tumour!cells.!
  31. 31. Theories!of!invasion! (2)!The!Enzyma5c!Theory,!! which!assumes!the!produc7on!of!ly7c!enzymes!that! destroy!the!contacts!between!normal!cells!and,!in!part,! destroy!the!cells!themselves!par7cularly!the!ECM!.!
  32. 32. Theories!of!invasion! (3)!The!migratory!theory:! ! ! It!originates!from!the!idea!that!tumour!cells!become! mobile! and! migrate! into! the! surrounding! normal! 7ssue.! ! ! Malignant! cells! may! detach! from! the! main! tumor!mass,!enter!the!surrounding!7ssues,!penetrate! basement! membranes,! and! enter! thinJwalled! lympha7cs,! capillaries,! or! venules.! Malignant! cells! within!these!vessels!are!known!as!"tumor!emboli."! •  As!Pauli!and!Knudson!have!carefully!discussed,!these! mechanisms!are!interdependent!and!must!act!in!coJ ordina7on!to!enable!tumour!cells!to!spread!from!the! primary!tumour!to!distant!sites.!!
  33. 33. ! The!most!common!sites! of!the!oral!cancer!is!the! tongue!and!the!floor!of! the!mouth.!The!other! common!sites!are! buccal!ves7bule,!buccal! mucosa,!gingiva!and! rarely!hard!and!so! palate.!Cancer!of!buccoJ pharyngeal!mucosa!is! common!in!smokers.!
  34. 34. Featured)Which)Demand)Careful) ConsideraCon)From)Examiner)Are)) 1JChronic!ulcer!or!fissures!with!no!apparent!cause,!or! ones!which!do!not!respond!to!simple!treatment! !  2JSwelling!with!no!apparent!cause,!but!no!marked! edema!or!redness! !  3JRapid!and!unexpected!loosening!of!a!group!of! teeth,!irregular!bone!destruc7on!seen! radiographically! !  4JSigns!of!infiltra7on,!such!as!tethering!of!an!organ! or!lump!or!limita7on!of!normal!movement!of!the!part! ! 
  35. 35. ! 5JSigns!of!involvement!of!adjacent!nerves!producing!persistent! pain,!anesthesia!of!part,!or!paralysis!of!muscles.! 6JRepeated,!small!hemorrhages!from!a!par7cular!part! 7JSigns!of!obstruc7on!of!related!ducts!!salivary!ducts! 8JEnlarged!lymph!nodes!without!surrounding!edema!and!no! obvious!cause!
  36. 36. !  9JAn!abscess!with!no!apparent!cause!which! !! ! may!be!a!necro7c!neoplasm! !  10JAnaemia!with!no!obvious!cause! !  11JSwea7ng,!malaise,!and!toxicity!not!due!to! an!obvious!infec7on!! ! 12Jdifficulty!chewing!or!swallowing,!ear!pain,! difficulty!moving!the!jaw!or!tongue,! hoarseness,!numbness!of!the!tongue!or!other! areas!of!the!mouth,!or!swelling!of!the!jaw!that! causes!dentures!to!fit!poorly.!!!
  37. 37. !Warning!Symptoms!&!Signs!Of!Oral!Cancer! ! a!sore!in!the!mouth!that!does!not!heal! (most!common!symptom)!! ! pain!in!the!mouth!that!doesn't!go!away! (also!very!common)!! ! a!persistent!lump!or!thickening!in!the! cheek!! ! a!persistent!white!or!red!patch!on!the! gums,!tongue,!tonsil,!or!lining!of!the! mouth!! ! a!sore!throat!or!a!feeling!that!something! is!caught!in!the!throat!that!doesn't!go! away!!
  38. 38. !!Symptoms!&!Signs!Of!Oral!Cancer! ! Difficulty!chewing!or!swallowing!! ! Difficulty!moving!the!jaw!or!tongue!! ! Swelling!of!the!jaw!that!causes!dentures! to!fit!poorly!or!become!uncomfortable!! ! Loosening!of!the!teeth!or!pain!around!the! teeth!or!jaw!! ! Voice!changes!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ! A!lump!or!mass!in!the!neck!! ! Weight!loss!! ! Persistent!bad!breath!!
  39. 39. Signs!and!Symptoms! •  It!can!go!unno7ced,!it!can!be!painless! •  It!may!appear!as!a!white!or!red!patch!of!7ssue!in!the! mouth,!or!a!small!indurated!ulcer! •  May!be!or!not!accompanied!with!relevant! lymphadenopathy! •  It!is!important!to!have!a!biopsy!for!any!sore!or! discolored!area!in!the!pa7ent’s!mouth,!which!does! not!heal!within!14!days!!
  40. 40. Presenta7on!of!oral!carcinoma!
  41. 41. How!to!Detect!and!Diagnose!Oral!Cancer! ! Many!cancers!of!the!oral!cavity!and!oroJ pharynx!can!be!found!early,!during!rou7ne! screening!examina7ons!by!a!doctor!or!den7st,! or!by!selfJexamina7on.!!
  42. 42. What!You!Can!Do?! •  EXAMINE!your!pa7ents!at!each!visit! •  TAKE!A!HISTORY!of!their!alcohol!and! tobacco!use!! •  INFORM!your!pa7ents!of!the!associa7on!between! tobacco!use,!alcohol!use,!and!oral!cancer!! •  FOLLOWKUP!to!make!sure!a!defini7ve!diagnosis!is! obtained! •  Have!a!biopsy!from!any!non!responding!lesions!
  43. 43. Preven5ve!instruc5ons!to!your!pa5ent! •  •  •  •  Stop!smoking!(this!includes!cigareees,!cigars!and!pipes)!! Stop!the!use!of!chewing!tobacco!and!snuff!! Do!not!drink!alcohol!at!all!! Maintain!good!oral!hygiene!J!this!includes!regular!brushing,! flossing!and!regular!checkups!and!cleanings!at!the!den7st's! office.!! •  If!you!spend!7me!outside,!protect!yourself!from!the! damaging!rays!of!the!sun.!Wearing!a!wide!hat!will!offer!extra! protec7on!to!your!face.!! •  If!you!are!aware!of!anything!that!causes!frequent!irrita7on! to!the!inside!of!your!mouth,!take!measures!to!prevent!this! irrita7on.!! •  Examine!the!inside!of!your!mouth!regularly.!!
  44. 44. Instruc7ons!to!the!Pa7ent! •  You!should!always!contact! your!doctor!or!den7st! immediately!if!you!no7ce!the! following!symptoms!in! yourself!or!a!loved!one:! •  A!sore!or!lesion!in!the!mouth! that!does!not!heal!within!two! weeks.!! •  A!lump!or!thickening!in!the! cheek.!! •  A!white!or!red!patch!on!the! gums,!tongue,!tonsil,!or! lining!of!the!mouth.!! •  A!sore!throat!or!a!feeling! that!something!is!caught! in!the!throat.!! •  Difficulty!chewing!or! swallowing!dysphagia!or! painful!of!swallowing! •  Difficulty!moving!the!jaw! or!tongue.!!! •  Numbness!of!the!tongue! or!other!area!of!the! mouth.!! •  Swelling!of!the!jaw!that! causes!dentures!to!fit! poorly!or!become! uncomfortable.!!
  45. 45. Management!of!oral!cancer! •  The!management!of!oral!cancer!has!undergone! radical!change!in!the!last!10!years!and!con7nues!to! evolve!rapidly.! •  Discoveries!in!molecular!biology,!diagnos7c! techniques,!surgery,!radia7on!therapy!and!medical! oncology!have!altered!many!tradi7onal!concepts! •  Of!all!the!procedures!available!to!control!oral!cancer,! none!has!affected!survival!as!much!as!has!early! detec7on.!.!
  46. 46. Examina7on!and!diagnos7c!methods! •  Health!history! •  History!of!the!lesion! •  Clinical!examina7on! •  Radiographic!examina7on:!Head!and!Neck!CT,!MRI!for! the!primary!lesion!and!lymph!nodes!by!FNA!and!PER.! •  Laboratory!inves7ga7on:! •  Blood,!enzymes,!electrolytes,!biopsies!
  47. 47. Rou7ne!head!and!neck!examina7on!! The!examina7on!is!conducted!with!the!pa7ent! seated.!Any!intraoral!prostheses!(dentures!or! par7al!dentures)!are!removed!before!star7ng!the! examina7on.!The!extraoral!and!periJoral!7ssues! are!examined!first,!followed!by!the!intraoral! 7ssues.! !
  48. 48. Oral!Cavity!Screening! •  screening,!which!involves!the!examina7on!of! the!oral!cavity!as!a!whole!and!not!just!your! teeth.!Besides!a!visual!examina7on!of!all!the! 7ssues!in!your!mouth,!your!doctor!will!feel!the! floor!of!your!mouth!and!por7ons!of!the!back! of!your!throat!with!his!fingers,!in!the!search! for!abnormali7es.!!
  49. 49. ! A!thorough!oral!screening!also!includes,!!!examina7on! of!the!nasopharynx!and!larynx,!and!involves!manually! feeling!the!neck!for!swollen!lymph!nodes,!and!other! abnormali7es!such!as!hardened!masses.!! Doctor!will!also!check!the!mouth!for!white!patches,!red! patches,!ulcera7ons,!lumps,!loose!teeth,!and!review! your!dental!xJrays!for!abnormali7es.!Be!sure!to!tell!the! doctor!if!you!have!been!a!tobacco!user!in!any!form.! Tobacco!use!is!implicated!in!more!than!75%!of!all!oral! cancers!
  50. 50. •  ! Diagnosis! Ini7ally!oral!cancer!may! ! •  Diagnosis!is!established!by! be!asymptoma7c!but!a! check!up!of!a!small! ulcera7ve!lesion!from!a! professional!is! recommended.! •  !But!pa7ents!normally! presents!when!pain!and! discomfort!is! predominant!and!then! the!prognosis!becomes! poor.! ! many!ways!like!applying!dyes! like!toluidine!blue!which!may! give!false!posi7ve!results!in! inflammatory!lesion!but!never! false!nega7ve,!using!X!rays!and! scans!to!see!the!extension!of! the!lesion!and!the!bony! involvement!and!the!most! confirmatory!test!is!biopsy!of! the!lesion!and!its!histoJ pathological!examina7on!
  51. 51. The!ExtraKoral!Examina5on! •  The!extraJoral!assessment!includes! an!inspec7on!of!the!face,!head,! and!neck.!The!face,!ears,!and!neck! are!observed,!no7ng!any! asymmetry!or!changes!on!the!skin! such!as!crusts,!fissuring,!growths,! and/or!color!change.!! •  The!regional!lymph!node!areas!are! bilaterally!palpated!to!detect!any! enlarged!nodes,!and!if!detected,! their!mobility!and!consistency.!! • A!recommended!order!of!examina7on! includes!these!regions:! • Preauricular!! • Submandibular!! • Anterior!Cervical!! • Posterior!Auricular!! • Posterior!Cervical!
  52. 52. !
  53. 53. Lips! •  Begin!examina7on!by! observing!the!lips!with!the! pa7ent's!mouth!both! closed!and!open.!Note!the! color,!texture!and!any! surface!abnormali7es!of! the!upper!and!lower! vermilion!borders.!
  54. 54. Surgical!anatomy! •  The(Lip:( –  Covered!with!nonKkera5nized! stra5fied!squamous!epithelium! which!is!transparent,!appear!red,!and! contain!no!hair,!sebaceous!gland!or! pigments! –  On!the!vermilion!border!it!closely! cover!the!orbicularis!oris!muscle!but! on!the!lingual!side!mucous!gland!is! present!within!the!muscle!and! mucosa! –  The!epithelium!is!2!mm!away!from! the!muscle,!ulcera5ve!lesions!will!be! fixed!early!in!the!disease!!!
  55. 55. Surgical!anatomy!The(Lip( –  Lympha7c!drainage:! •  Mucosal!and!cutaneous!systems.! •  Lower!lip:! –  One!medial!trunk!which!drain!the!inner!third!of!the!lip!into! the!submental!group! –  Two!lateral!trunk!which!drain!the!outer!twoJthird!into!the! submandibular!lymph!nodes! –  Anastomosis!account!for!bilateral!metastases! •  Upper!lip:! –  Drain!into!the!periauricular,!paro7d,!submandibular!and! submental!lymph!nodes!
  56. 56. Surgical!anatomy!The(Lip( •  Age!and!sex:! –  The!sixth!decade!and!Male!:!female! ra5o!is!80:1! •  93%!affect!the!lower!lip!with! squamous!cell!carcinoma,! exophy7c!type!! •  5%!in!the!upper!lip!and!commonly! basal!cell!carcinoma,!commoner! in!females! –  Solar!exposure,!more!radia5on!on! the!lower!lip! –  Commoner!in!fair!complexion! –  Smoker!mainly!pipe! –  In!the!upper!lip,!SCC!metastasizes! earlier!than!lower!lip!!
  57. 57. ! IntraKoral!examina5on!! •  ! ! ! Labial!Mucosa!With!the! pa7ent's!mouth!par7ally! open,!visually!examine!the! labial!mucosa!and!sulcus!of! the!maxillary!ves7bule!and! frenum!and!the!mandibular! ves7bule.!! •  Observe!the!color,!texture,! and!any!swelling!or!other! abnormali7es!of!the! ves7bular!mucosa!and! gingiva.! ! !!
  58. 58. Buccal Mucosa Retract!the!buccal!mucosa.!Examine!first! the!right!then!the!le!buccal!mucosa! extending!from!the!labial!commissure! and!back!to!the!anterior!tonsillar!pillar.!! Note!any!change!in!pigmenta7on,!color,! texture,!mobility!and!other!abnormali7es! of!the!mucosa,!making!sure!that!the! commissures!are!examined!carefully!and! are!not!covered!by!the!retractors!during! the!retrac7on!of!the!cheek.!
  59. 59. Surgical!anatomy!! •  The!buccal!mucosa:! –  Covered!with!nonJkera7nizing! stra7fied!squamous! epithelium!with!mul7ple! minor!salivary!glands! –  It!is!7ght!over!the!buccinator! muscle!and!fixed!to!the!upper! and!lower!sulci! –  Lympha7c!drainage:! •  The!submandibular!lymph! nodes!to!the!lower!deep! cervical!chain!
  60. 60. Gingiva •  First,!examine!the!buccal!and!labial! aspects!of!the!gingiva!and!alveolar! ridges!(processes)!by!star7ng!with!the! right!maxillary!posterior!gingiva!and! alveolar!ridge!and!then!move!around! the!arch!to!the!le!posterior!area.!Drop! to!the!le!mandibular!posterior!gingiva! and!alveolar!ridge!and!move!around!the! arch!to!the!right!posterior!area.!! •  Second,!examine!the!palatal!and!lingual! aspects!as!had!been!done!on!the!facial! side,!from!right!to!le!on!the!palatal! (maxilla)!and!le!to!right!on!the!lingual! (mandible).!
  61. 61. Tongue! •  With!the!pa7ent's!tongue!at!rest,! and!mouth!par7ally!open,!inspect! the!dorsum!of!the!tongue!for!any! swelling,!ulcera7on,!coa7ng!or! varia7on!in!size,!colour,!or! texture.!! •  Also!note!any!change!in!the! paeern!of!the!papillae!covering! the!surface!of!the!tongue!and! examine!the!7p!of!the!tongue.! !  !The!pa7ent!should!then!protrude! the!tongue,!and!the!examiner! should!note!any!abnormality!of! mobility!or!posi7oning.!
  62. 62. Posterior!of!the!Tongue! •  With!the!aid!of!mouth!mirrors,! inspect!the!right!and!le!lateral! margins!of!the!tongue.! •  Grasping!the!7p!of!the!tongue!with! a!piece!of!gauze!will!assist!full! protrusion!and!will!aid!examina7on! of!the!more!posterior!aspects!of!the! tongue's!lateral!borders.!
  63. 63. Surgical!anatomy! •  The(tongue:( –  Specialized!kera7nized!epithelium! with!collec7on!of!minor!salivary! gland!and!muscle!fibres! –  The!interlacing!muscle!fibres!form! an!easy!pathway!for!cancer! spread!and!the!constant! movement!of!the!tongue! disseminates!the!disease!widely! •  Excision!should!be!wide!with!2!cm! safe!margin!
  64. 64. Ventral surface of the tongue and floor of the mouth •  Then!examine!the!ventral! surface.!Palpate!the!tongue! to!detect!growths.! •  With!the!tongue!s7ll! elevated,!inspect!the!floor!of! the!mouth!for!changes!in! color,!texture,!swellings,!or! other!surface!abnormali7es.!
  65. 65. Surgical!anatomy!The(tongue( •  A!disease!of!the!middle!age!and! elderly!with!equal!sex!incidence! •  85%!occurs!in!the!lateral!border!of! the!anterior!2/3,!!while!7p,! dorsum!and!ventral!surface!are! rarely!involved! •  The!lesion!may!be!infiltra7ve! (small!on!the!outside!but! palpa7on!shows!deep!invasion)!or! exophy7c!and!usually!of!the!wellJ differen7ated!type!
  66. 66. Surgical!anatomy!The(tongue( ( Lymph!drainage:! Tip!of!the!tongue:! To!the!submental!lymph!nodes!–!to!the!lower! deep!cervical!chains! The!anterior!2/3:! the!lower!deep!cervical!chains!–!juguloK omohyoid!nodes! Suprahyoid(block(dissec5on(of(no(value( The!posterior!1/3:! drain!to!the!upper!deep!cervical!chains! The!5p!and!middle!part!of!the!tongue!have! rich!bilateral!capillary!network!but!less!in! the!lateral!margins! The!UKshaped!floor!of!the!mouth!drain!to!the! submandibular!lymph!nodes! Bilateral!drainage!from!the!anterior!part!of! the!U!
  67. 67. Bimanual!mouth!floor!examina7on! •  Bimanually!palpate!the! floor!of!the!mouth!for! any!abnormali7es.!All! mucosal!or!facial!7ssues! that!seem!to!be! abnormal!should!be! palpated.!
  68. 68. Hard!and!so_!palate! •  With!the!mouth!wide!open!and! the!pa7ent's!head!7lted!back,! gently!depress!the!base!of!the! tongue!with!a!mouth!mirror.! First!inspect!the!hard!and!then! the!so!palate.! •  Examine!all!so!palate!and! oropharyngeal!7ssues.!
  69. 69. Tongue!and!cheek!carcinoma!
  70. 70. SCC of the body of the mandible Intra-oral photograph * CT Scan (Bony invasion)
  71. 71. Factors!describes!the!degree!of! malignancy! •  The!degree!of!histological!differen7a7on!of! Malignant!neoplasm!are!histologically! classified!as:! •  1JWell!differen7ated! •  2J!Moderately!differen7ated! •  3J!Poorly!differen7ated!
  72. 72. Most!common!routes!of!! spread!of!oral!carcinoma! •  1JLocal!spread!is!achieved!by!direct!invasion! and!infiltra7on!of!adjacent!stractures.! •  2JPerineural!invasion!! •  3JRegional!spread!to!the!neck!lymph!nodes! occurs!via!lympha7c!route! •  4JSpread!to!distal!organs!follows!the! hematogenous!route!
  73. 73. Test!for!metasta7c!workJup!of!oral! cancer! •  1J!Blood!and!biochemical!profile! •  2JChest!xJray,!liver!ultrasound(abdominoJ pelvic!sonar),!bone!scan! •  3J!CT!and!MRI! •  4J!PanJendoscopy!
  74. 74. Quiz!????!Management!
  75. 75. •  The!lesion!should!be!reJbiopsied.!Tissue! sampling!should!be!obtained!from!mul7ple! sites!of!the!lesion.! •  If!this!ac7on!does!not!solve!the!diagnos7c! problem!,!a!second!opinion!from!another! pathologist!might!be!appropriate!before!any! final!treatment!decision!is!reached!!
  76. 76. Assessment! •  Clinical(Examina5on:( – Tumours,!when!first!seen,!are!almost! always!confined!to!the!head!and!neck!with! no!distant!metastasis! – Head!and!neck!tumours!are!rarely! irremovable,!all!structures!can!be!removed! with!the!tumour!in!con7nuity!and!repaired! later!! •  The!majority!of!cases!are!poten5ally!treatable!!!
  77. 77. Assessment! •  Whether!to!treat!or! not!depend!on:! –  the!age! –  the!health!status!of! the!pa5ent!! –  advance!stage! –  local!disease!!
  78. 78. Assessment! •  Full!assessment!will!lead!to! one!of!the!following! conclusions:! –  Pa5ent!is!poten5ally! curable! –  Primary!tumour!is!curable! but!pa5ent!develop! another!illness! –  Pa5ent!is!incurable!and! should!not!be!treated!
  79. 79. Assessment! •  The!pa7ent!general!condi7on:! –  Assessed!with!full!inves7ga7on!and!classified!for! performance!status! 1.  Grade)0 !Fully!ac7ve!without!restric7on! 2.  Grade)1 !Ambulatory!but!restricted!in!!!! physically!strenuous!ac7vity! 3.  Grade)2 !Ambulatory!but!unable!to!carry!out! any!work!ac7vity! 4.  Grade)3 !Confined!to!bed!but!capable!of! limited!self!care! 5.  Grade)4 !Confined!to!bed!and!unable!to!carry! out!any!self!care! ! ! ! ! ! !Karnofsky(Status(
  80. 80. Assessment! •  Examina5on:! –  Think!in!term!of!T!Staging,!delineate!its!border!by! inspec7on!and!palpa7on! –  Record!and!draw!the!lesion!from!different!angles! using!normal!anatomical!landmarks! –  The!status!of!teeth!should!be!assessed!as! causa7ve!and!if!radiotherapy!is!to!considered!!
  81. 81. Assessment! •  Staging!of!cancer:! – Subdividing!the!malignant!lesion!into! groups!with!similar!behavior! •  Act!as!a!guide!to!appropriate!treatment!! •  Act!as!a!guide!to!prognosis! •  Permits!more!reliable!comparison!of!results! – Primary(site:( » Histological!type,!size!and!extend!of!the!primary! – Node(metastasis( – Haematogenous((metastasis(
  82. 82. Staging)TNM) •  Primary(Tumour:( – Indicated!by!the!leeer!T!and!the!suffix!1,2,!3! or!4!represent!more!advancing!disease! • T1(–!tumour!2!cm!or!less! • T2!–!tumour!more!than!2!but!less!than!4!cm! •  T3(–!tumour!more!than!4!cm! •  T4!–!Tumour!more!than!4!cm!with!deep!invasion!of! underlying!7ssues! – T0!–!No!evidence!of!primary!tumour! – Tis!–!Carcinoma!in!Situ! – TX!–!Extend!of!primary!tumour!cannot!be!assessed!
  83. 83. Staging! •  Lymph!node:! –  Is!used!to!describe!progressive!lymph!node! involvement! –  NxJ!Regional!lymph!node!cannot!be!assessed! –  N0J!No!Regional!lymph!node!metastasis!! •  N1!–!Metastasis!in!a!single!ipsilateral!nodes!!!>3!cm!!! •  N2!–!Single!ipsilateral!nodes!!<!!3!cm!but!!>6!cm,!or! mul7ple!clinically!posi7ve!ipsilateral!less!than!6!cm! –  N2a!–!Single!<!!3!cm!but!!>6!cm! –  N2b!–!Mul7ple!none!!<!6!cm! –  N2CJ!metastasis!in!a!bilateral!or!!contralateral!!LN! •  N3(–!Clinically!posi7ve!ipsilateral!more!than!6!cm,! Bilateral!or!contralateral! –  N3a!–!ipsilateral!more!than!6!cm! –  N3b!–!Bilateral,!each!side!staged!separately! –  N3c!–!Contralateral!only!
  84. 84. Staging! •  Distant!metastasis:! –  M0!–!No!metastases!present! –  M1!–!Metastases!clinically!demonstrable! •  MX!–!Metastases!cannot!be!assessed!
  85. 85. Staging! •  TNM!Staging:! –  Stage!I:!T1,!N0,!M0! –  Stage!II:!T2,!N0,!M0! –  Stage!III:!T3,!N0,!M0! !! !!!!!T1,!2!or!3,!N1,!M0! –  Stage!IV:!T4,!N0!or!1,!M0! !! !!!!!T1!–!4,!N2!or!3,!M0! !! !!!!!T1!–!4,!N1!–!3,!M1!!! !! ! ! ! ! !AJCC(1983(
  86. 86. Staging! Stage!I!! •  compromise!nega7ve!nodes!and!operable!primary! Stage!II!! •  operable!primary!with!operable!nodes! Stage!III! •  inoperable!due!advanced!primary!or!advanced!nodal! involvement! Stage!IV!! •  Distant!metastases!preclude!any!surgical!interven7on!!
  87. 87. (Oral!Cancer!2)! !ORAL!CANCER:!A!Silent!Killer! Dr. Adel I. Abdelhady !Assistant!Professor!Oral!!Surgery! College!of!Den5stry,!Dammam!University! !
  88. 88. ! BIOPSY!
  89. 89. Defini7on:! ! Removal!of!!7ssue!from!living!beings!for! macroscopic!examina7on!,microscopic!!! ! !!!analysis,!bacterial!analysis!!&!combina7on!of! above!is!called!!“BIOPSY!
  90. 90. BIOPSY!
  91. 91. INDICATIONS!! 1.To!determine!the!nature!of!lesion!which!does!not! readily!respond!to!conserva7ve!&!simple!therapy.! 2.To!determine!the!nature!of!the!lesion!which!is!! unknown.! 3.To!establish!the!diagnosis!where!there!is! suspecious!of!neoplasm.! 4.To!determine!nature!of!any!intraosseous!lesion! which!can’t!be!iden7fied!radiographically.! 5.To!determine!the!nature!of!all!abnormal!7ssue! removed!from!the!oral!cavity!including!cysts!&! granulomas.!
  92. 92. Contraindica7ons:! Rela5ve!contraindica5ons:! 1.In!cases!of!inflammatory!lesions!may!be!due!to! allergy!,viral!,fungal,!or!bacterial!lesion.!e.g.! candidiasis.! 2.Compromised!generalised!health!of!pa7ent.!e.g.! pa7ent!on!an7coagulant!therapy.! 3.Proximity!of!lesions!to!vital!,!anatomic,! physiologic,!neural,!vascular,!or!glandular! structures.! ! A. 
  93. 93. !Absolute!contraindica5ons!!! •  B)!Absolute!contraindica5ons:! 1.Pulsa7le!vascular!lesions.!e.g.!angiosarcoma.! 2.Pigmented!lesion!should!not!be!biopsied.! e.g.!! !!!!!!!Melanoma.! 3.Intrabony!radiolucent!lesions!should!not!be! biopsied!or!removed!without!prior! inves7ga7onal!aspira7on!
  94. 94. ARMAMENTERIUM:! 1.Mouth!mirror!&!probe,! colourless!an7sep7c! agent.! 2.LA!&!syringe.! 3.Surgical!scalpel.! 4.Long!pointed!surgical! scissors.! 5.Tissue!forceps! 6.Biopsy!punch! 7.Bone!burs! ! ! 8.Periosteal!elevator! 9.Chiesel! 10.Bow!cureee! 11.Suture!material! 12.Needle!holder! 13.Sponges! 14.Wide!mouthed!boele! with10%!neutral! buffered!formalin! !
  95. 95. Points!must!be!considered!to!ensure! obtaining!proper!specimen!! 1.Do!not!paint!the!surface!of!the!area!to!be!biopsied! with!iodine!or!other!highly!coloured!an7sep7c.! 2.Don’t!inject!LA!into!the!lesion.! 3.Use!sharp!scalpel!!to!avoid!tearing!of!7ssue.! 4.Use!care!not!to!mu7late!the!specimen!when!grasping! it!with!forceps.! 5.Fix!the!7ssue!immediately!upon!removal!in!10%! formalin!or!70%!alcohol.! 6.If!the!specimen!is!thin,!place!it!upon!a!piece!of!glazed! paper!&!drop!into!fixa7ve!which!prevents!curling!of! 7ssue.!
  96. 96. TYPES!OF!BIOPSY!! 1.Excisional!biopsy! 2.Incisional!biopsy! 3.Punch!biopsy! 4.Needle/trephine/drill! 5.Aspira7on!biopsy! 6.Exfolia7ve!cytology!
  97. 97. •  !!Illustra7on!of!excisional!biopsy!of!so!7ssue!lesion.!A,! Surface!view.!Ellip7c!incision!is!made!around!lesion!.!A,! Surface!view.!Ellip7c!incision.!B,!Side!view,!Incision!is!made! deep!enough!to!remove!lesion!completely.!C,!End!view.! Incision!are!made!convergent!to!depth!of!wound.!If!excision!is! made!in!this!way,!closure!will!be!facilitated.!!
  98. 98. •  A,!!Illustra7on!showing!desirability!of!obtaining!deep! specimen!rather!than!broad!and!shallow!specimen!when! incisional!biopsy!is!performed.!If!malignant!cells!are!present! only!at!base!of!lesion,!broad!and!shallow!biopsy!might!not! obtain!these!diagnos7c!cells.!! •  B,!Illustra7on!showing!desirability!of!obtaining!incisional! biopsy!at!margin!of!so!7ssue!lesion.!Junc7on!of!lesion!with! normal!7ssue!frequently!provides!pathologist!with!more! diagnos7c!informa7on!than!if!biopsy!were!taken!only!from! center!of!lesion.!!
  99. 99. ! !  !!Illustra7on!demonstra7ng! desirability!of!obtaining! more!than!one!incisional! biopsy!if!characteris7cs!of! lesion!differ!from!one!area! to!another.!! ! Frequently!one!area!of! lesion!appears!histologically! different!from!another!(A).! When!obtaining!biopsy!on! buccal!or!labial!mucosa,! incision!is!usually!carried!to! depth!of!musculature!(B).!!
  100. 100. ! •  Illustra7on!showing!use!of! trac7on!suture!placed! through!specimen.!While! lesion!is!incised,!trac7on! suture!is!use!to!li! specimen!from!wound! bed.!Suture!can!then!be! 7ed!and!le!aeached!to! lesion!to!iden7fy!margin! of!specimen.!!
  101. 101. ! •  !!Illustra7on!showing! principles!used!in! closing!an!ellip7c!biopsy! wound.!Mucosa!should! be!undermined!bluntly! with!scissors!to!width!of! original!ellipse!in!each! direc7on.!This!allows! approxima7on!of! wound!margins!without! tension.!!
  102. 102. EXCISIONAL!BIOPSY!! *Defini7on:!Total!excision!of!a!small!lesion!! !!!!!!!!!!!!!!!!!!for!microscopic!study!is!called!! !!!!!!!!!!!!!!!!!!“excisional!biopsy”.! Use!!!!!!!!:!Lesions!smaller!than!1cm!in!!diameter.!!
  103. 103. Method!! •  Give!LA!which!should!not!be!closer!than!2cm! from!the!site.! •  Stabilize!the!lesion!via!the!suture.! •  Incise!mucosa!around!the!base!of!the!lesion!in! an!ellip7cal!shape.! •  Place!specimen!immediately!in!a!fixa7ve.! •  Close!the!wound!using!suture.!
  104. 104. INCISIONAL!BIOPSY!! Defini7on:!! Some!lesions!are!too!large!to!!excise!ini7ally! without!having!established!diagnosis!or!are!of! such!a!nature!that!excision!would!be! inadvisable!!in!such!instances!a!small!sec7on!is! removed!for!examina7on!called!incisional!!or! diagnos7c!biopsy.! Use!!!!!!!:!For!large!lesions!!!
  105. 105. Method! •  Administer!LA.! •  Iden7fy!the!apparent!junc7on!between!normal! 7ssue!&!the!lesion!select!the!specimen!across!region.! •  Stabilize!the!specimen!with!a!suture.! •  Dissect!the!specimen!from!the!edge!of!the!lesion!&! include!a!margin!of!apparently!normal!7ssue.! •  The!specimen!should!include!representa7ve!area!of! the!lesion.! •  Place!the!specimen!immediately!in!a!prescribed! specimen!boele!containing!10%!formalin.! •  Close!surgical!site!by!sutures.!
  106. 106. PUNCH!BIOPSY:! ! •  A!surgical!instrument!is!used!to!punch!out!a! representa7ve!por7on!of!7ssue.! •  Since!resul7ng!specimen!is!oen!damaged!! !!!by!the!procedure!so!biopsy!by!scalpel!is! preffered.!
  107. 107. Needle/trephine/drill!biopsy:! •  Use!:!to!biopsied! deepJseated!fibroJ osseous!!lesions.! •  The!resul7ng! specimen!is!smaller! may!be!nonJ representa7ve!&! again!oen! damaged!by!the! procedures!so!they! are!not!oen!used.!
  108. 108. Aspira7on!biopsy!! •  Use!–!Applicable!to!many!cys7c!!&!!!fluctuant!lesions! MethodJ!! !Clean!the!7ssue!over!the!proposed!aspira7on!site.! JInject!LA!solu7on!over!the!lesion.! JSelect!a!wide!bore!needle!&!10!ml!syringe.! JPenetrate!7ssue!&!aspirate!fluid.! JTransfer!the!aspirate!into!a!screw!top!specimen!boele.! !
  109. 109. How!do!I!prevent!oral!cancer!?! Stopping!all!the!habits!of!tobacco!consump7on.!Stopping!means!complete!stop!to!the!habit.! Reducing!the!consump7on!of!tobacco!does!not!reduce!your!risk!of!cancer.!But!stopping! certainly!reduces!the!risk.!! ! Is!tobacco!the!only!cause!of!oral!cancer!?! Tobacco!is!the!major!cause!of!oral!cancer!but!certainly!not!the!only!cause.!Their!are!other! causes!like!poor!oral!hygiene,!chronic!trauma!from!sharp!tooth!or!an!ill!fi[ng!dentures.!Their! are!other!agents!like!some!viruses!which!are!thought!to!cause!or!expedite!the!effect!of!tobacco! in!causing!oral!cancer.! ! Why!is!that!not!all!people!consuming!tobacco!have!oral!cancer!?! Their!are!many!factors!like!gene7c!make!of!the!person,!his!diet!and!many!unknown!factors!that!! increases!or!decreases!the!suscep7bility!of!person!of!!having!oral!cancer.!But!one!thing!is!certain! that!tobacco!consump7on!increases!your!suscep7bility!by!almost!8!7mes.!That!means!a!person! consuming!tobacco!is!more!prone!to!have!oral!cancer!or!other!tobacco!related!problems.!! ! Who!is!more!suscep7ble!to!oral!cancer!?! Anybody!consuming!tobacco!is!suscep7ble!to!oral!cancer.!Differences!in!gene7cs!have!not!been! iden7fied!in!rela7on!to!risk!and!survival.!That!means!a!Caucasian!or!a!mongoloid,!Black!race!all! are!equally!prone!to!oral!cancer!if!they!consume!tobacco.!!! ! Dr!Suwas!Darvekar!
  110. 110. MISJDiagnosis! •  1JInadequate!oral!examina7on! •  2JInnocuons!appearance!of!mucosa! •  3JLow!index!of!suspicion( •  4JLack!of!experience)
  111. 111. Treatment!plan!is!based!on:! ! Staging!of!disease!using!TNM!classifica7on! ! T = Tumour size ! N = Nodal status ! M = Metastases ! !!!!!!!!!!Eg.!T3N2M0!laryngeal!carcinoma!!
  112. 112. Introduc7on! •  Prognos5c(Indicators:! –  Sex:!Poor!prognosis!in!females! –  General!condi5on!&!health!status!of!pa5ent! –  T!stage! –  Number!of!histologically!posi5ve!nodes!! –  Surgical!margin!status! –  Type!of!therapy!and!blood!transfusion!!
  113. 113. Treatment!plan!is!based!on:! •  coJmorbid!condi7ons! Medical Dental Speech Nutrition Psychosocial Socioeconomic
  114. 114. Treatment!Op7ons! Primary surgery +/J! Adjuvant Radiotherapy +/J! Concurrent Chemotherapy OR! Primary Radiotherapy +/J! Concurrent Chemotherapy +/J! Surgery for Salvage
  115. 115. Dental!Management! Will!involve!:! ! General!Den7st! ! Hygienist! Dental!Assistant! Recep7on!Staff!
  116. 116. Dental!Consulta7on!! •  Clinical!examina7on! • char7ng!(odontogram)! • visual!(other!lesions?)! • palpa7on!
  117. 117. Dental!Consulta7on!! •  Diagnoses! – Dental! •  Caries! •  Periodontal!disease! •  Other!Pathology! – Medical! •  coJmorbidi7es!
  118. 118. Dental!Consulta7on!(cont.)! •  Treatment!Plan!based!on:! – prognosis!of!individual!teeth! – past!dental!history!(compliance)! – sequelae!and!poten7al!complica7ons! from!radiotherapy! – LONG!TERM!RISKS!!
  119. 119. Dental!Treatment! •  Must!be!done!immediately! ! –  !no!delay!in!radiotherapy! – !cancer!is!progressing!!! !
  120. 120. Dental!Treatment! •  Extrac7ons! – abscesses,!gross!caries! – advanced!periodontal!disease! – heavily!restored!teeth!w/!poor!OH! ! Must!have!2!weeks!healing!prior!to! start!of!radiotherapy!!!!
  121. 121. Chronic!Sequelae! •  Problems!with!xerostomia!! – increased!trauma!risk! • !so!7ssues!very!dry!! • !easily!injured! ! !
  122. 122. Chronic!Sequelae! •  Problems!with!xerostomia!! – thick!secre7ons! • !change!in!mucous:serous!ra7o! • !increased!“gag”! • !difficulty!wearing!dentures! !
  123. 123. Chronic!Sequelae! •  Problems!with!xerostomia!! – difficulty!swallowing! • H2O!with/between!meals!! – chronic!Candidiasis!
  124. 124. Distant Metastasis Normal lung Secondary SCC
  125. 125. SCC!of!Lower!Lip!in!a!pipe!smoker!(78Years)!
  126. 126. SCC!of!lateral!border!of!the!tongue!
  127. 127. SCC!in!FOM!
  128. 128. Metasta7c!carcinoma!in!jaws! •  Metastasis! in! jaws! or! (rarely)! oral! so! 7ssues,!especially!from!cancer!of:! • Breast!! • Lung!! • Prostate! • Thyroid! • Kidney! • Stomach!!
  129. 129. Referrals!for!biopsy! •  Health!of!pa7ent!! •  surgical!difficulty! •  Poten7al!for!malignancy!
  130. 130. Types!of!biopsy! •  •  •  •  •  •  •  Incisional!biopsy! Punch!biopsy!! Excisional!biopsy! Drill!biopsy! Oral!cytology!! Aspira7on!biopsy! Fine!needle!aspira7on! biopsy! •  Sen7nel!node!biopsy! •  Brush!biopsy!
  131. 131. So!7ssue!biopsy!technique!and!surgical! principles! 1.  2.  3.  4.  5.  6.  Anesthesia! Tissue!stabiliza7on! Haemostasis! Incision! Handling!of!7ssue! Iden7fica7on!of! surgical!margins! 7.  Specimen!care! !Surgical!closure! !Biopsy!data!sheet! 10. !Hard!7ssue! 8.  9.  •  •  •  •  ! Aspira7on!biopsy! !Mucoperiosteal!flaps! Osseous!window! Removal!of!specimen!
  132. 132. Management! •  Aer!a!defini7ve!diagnosis!has!been!made!and!the! cancer!has!been!staged,!treatment!may!begin.! •  Treatment!of!oral!cancers!is!ideally!a!mul7disciplinary! approach!involving!the!efforts!of:!! •  •  •  •  •  •  surgeons,!! radia7on!oncologists,!! chemotherapy!oncologists,!! dental!prac77oners,!! nutri7onists,!! rehabilita7on!and!restora7ve!specialists.!!
  133. 133. Nutri7onal!Implica7ons!of!Cancer! Therapy! •  Chemotherapy! ! !—Taste!abnormali7es,!diarrhea,!cons7pa7on! •  Radia7on!therapy! ! !—Fa7gue,!loss!of!appe7te,!skin!changes! •  Surgery! !—Fa7gue,!pain,!loss!of!appe7te! •  Immunotherapy! ! !—Flulike!symptoms,!decreased!food!intake!
  134. 134. Factors!affec7ng!the!decision! •  Aggressiveness!of!lesion! •  Anatomic!loca7on!of!lesion! •  Dura7on!of!lesion! •  Reconstruc7ve!efforts! •  Reconstruc7on!of!jaws!aer!removal!of!oral! tumours! •  Histopathologic!diagnosis! •  Presence!and!degree!of!metastasis! •  RadioJsensi7vity!and!chemoJsensi7vity! •  Age!and!condi7on!of!the!pa7ent! •  Experience!of!the!clinicians! •  Wishes!of!the!pa7ent.!
  135. 135. Treatment! 1.  Early!stages!(I!and!II)!of!SCC!treated!with!surgery!or! radia7on!(FiveJyear!survival!rates!are!similar!for!both! modali7es).! !A!decision!is!made!on!the!basis!of:! •  •  •  •  the!tumour's!site!and!size,!! histological!findings,!! the!pa7ent’s!wishes! the!advice!of!the!mul7disciplinary!team.! 2.  Advanced!stages!(III!and!IV)!treated!with!a! combina7on!of!surgery!and!radia7on!therapy,! although!this!increases!the!complica7ons!and! morbidity.!
  136. 136. 2.  Advanced!stages!(III!and!IV)!treated!with!a! combina7on!of!surgery!and!radia7on! therapy,!although!this!increases!the! complica7ons!and!morbidity.! 3.  Chemotherapy!is!added!in!order!to:! •  decrease!the!possibility!of!metastasis,!! •  sensi7ze!the!malignant!cells!! •  !radia7on,!or!for!those!pa7ents!who!have!confirmed! distant!metastasis!of!the!disease.!
  137. 137. Surgical!management!of!oral!cancer!! •  Basic!surgical!goals!are:! ! Eradica7on!of!pathologic!condi7on:! ! The!primary!lesion!(surgical!excision!with!safety!margin).! (If!bone!involved!marginal!or!segmental!resec7on!is!indicated)! ! The!secondary!lesion!(neck!dissec7on:!radical,!selec7ve,! supraomohyoid)! ! Func7onal!rehabilita7on!of!pa7ent!using:!flaps,!gras,! Implants,!as!well!as!gaining!speech!therapy,!physical!therapy,! psychological!therapy.!!
  138. 138. Mul7ple!carcinomas!
  139. 139. Resected!mandible!&!composite!gra_! !Primary!tumour!with!submandibular!!!!!!!!!!!!!!!!!!!!!!!!!Forearm!composite!gra!!!!!!!! glands!(LN!&!SG).!
  140. 140. Massive!surgery!for!invasive!! oral!cancer:!Floor!&!mandible!
  141. 141. Alveolar!SSC!
  142. 142. Alveolar!SSC!1!
  143. 143. Mandibulectomy!and!reconstruc7on!plate!
  144. 144. Maxillary!Carcinoma:!antrum!&!orbit!!
  145. 145. Melanoma!
  146. 146. Radiotherapy! •  Tumour!cells!are!more!suscep7ble!to!ionizing!radia7on!! •  Radia7on!can!be!delivered!by:! !  Implanta7on!of!the!radioac7ve!material!into!the!tumour! !  Use!of!external!xJray!generators! •  Radia7on!therapy!can!be!delivered!by!two!mechanisms:! !  Frac7ona7on! !  Mul7ple!ports! •  Using!directed!radia7on!and!intensity!modulated!radia7on!therapy!(IMRT)! (focused!to!the!target)!and!accelerated!and!HyperJfrac7ona7on!regimens! (higher/more!frequent!doses!are!used)! •  Preven7on!of!xerostomia!by!shielding!the!paro7d!gland!and!using!directed! radiotherapy!and!using!pilocarpine!during!and!aer!radia7on.!
  147. 147. RADIOTHERAPY!
  148. 148. •  The!use!of!ionising!radia7on!to!cure!disease!or! make!the!symptoms!of!a!disease!less!severe! i.e.!palliate.! •  Radiotherapy!is!used!mainly!to!damage!or! destroy!prolifera7ng!cells.! •  The!faster!the!cellular!turnover,!the!more! suscep7ble!the!7ssue!to!the!damaging!effects! of!radia7on.!!
  149. 149. •  External!beam!radiotherapy:! !!!!!!!!!J!Directed!through!skin!to!tumor.! !!!!!!!!!J!Use!shielding.! •  Brachytherapy! !!!!!!!!!J!inject!source!of!radia7on,! delivered!by!close!contact!with! !!!!the!tumor,!then!ac7vate!it.!
  150. 150. •  Direct!effects:! !!!!!!!!these!result!from!damage,!mainly!to!DNA,! by!the!high!energy!of!radia7on.!This!can!cause! changes!in!DNA!structure!resul7ng!in!point! muta7on!or!chromosomal!breaks.! !!!!J!The!effects!may!be! 1.  Arrest!the!mito7c!division! 2.  Cells!death!by!apoptosis!
  151. 151. •  Indirect!effects:! !!!!!!!!these!result!from!ionisa7on!of!water!and! forma7on!of!toxic,!free!radicals!and! obstruc7on!of!vessels!which!affects!on!the! 7ssues!supplied.!
  152. 152. ! ! •  •  •  •  •  •  ! MUCOSITIS! FUNGAL!INFECTION! XEROSTOMIA! RAMPANT!CARIES! DIFFICLUTY!WITH!SPEECH!AND!MASTICATION! OSTEORADIONECROSIS!
  153. 153. •  Results!in!epithelial!thinning,!erosion!and! ulcera7on.!! •  Affects!nonJkera7nized!mucosa!first.! •  Usually!presents!within!1J2!weeks!and! increases!in!severity!to!a!maximum!at!4!weeks.!
  154. 154. •  Early!signs:!! !!!!!J!whitening!of!mucosa!! !!!!!J!mucosal!erythema! !!!!!J!Can!cause!dysphagia! •  Late!signs:! !!!!!J!Reflect!hypovascularity!and!hyaliniza7on!of! collagen.! !!!!!J!Can!be!compounded!by!impaired!mucosal! defense!and!onset!of!opportunis7c!infec7on!
  155. 155. •  Reassure!the!pa7ent!of!the!limited!7me! period!of!this!side!effect.! •  Give!symptoma7c!relief:! !!!!!!!!J!CXD!mouthwash.! !!!!!!!!J!Oral!cooling.! !!!!!!!!J!Sucralfate!!!!!!!!!!!!!!!!!!!coa7ng!agent.! !!!!!!!!J!topical!anesthesia.!
  156. 156. •  Avoidance!of!certain!food,!drinks!to!relieve! discomfort:! !!!!!!!!J!Hard!and!spicy!foods.! !!!!!!!!J!Strongly!flavoured!toothpaste.! !!!!!!!!J!Alcohol!and!tobacco.! !!!!!!!!J!Carbonated!and!acidic!drinks.! !!!!!!!!J!Sweets.! !!!!!!!!J!Hot!drinks.!
  157. 157. •  Pa7ent!undergoing!radiotherapy!may!have! altera7on!in!the!normal!flora.! •  Bacterial,!viral!and!fungal!infec7ons!can!occur! in!the!presence!of!mucosi7s.! •  The!most!common!infec7on!is!Candida.!
  158. 158. •  Preven7on:! !!!!!!!J!intensive!oral!hygiene!instruc7on!prior!to! treatment,!regular!follow!up.!! •  Treatment:! !!!!!!J!If!candida!found:! !!!!!!!!!!!!!!!!Nysta7n(sugarJfree),!Miconazole,!or!Fluconazole! !!!!!!!J!If!the!pa7ent!is!unable!to!brush!due!to!pain,!use! CXD!mouthwash.!
  159. 159. " NB:!do!not!use!Nysta7n!and!CXD! simultaneously!!because!of!inhibitory!effect!on! each!other.!Separate!by!1!hour.!!
  160. 160. •  Most!severe!if!bilateral!salivary!glands!are! exposed!to!radia7on! •  Results!in!acinar!cell!atrophy!and!necrosis,! changes!in!the!vascular!CT!and!altered! neurological!func7oning.! •  Serous!acini!affected!first!then!mucinous.! •  Predisposing!factor!infec7on,!candida,!and! caries.!
  161. 161. ! ! ! •  Symptoma7c!relief:! !!!!!!!!J!Frequent!sips!of!water/!milk!and!avoid! sugary!drinks.! !!!!!!!J!Saliva!subs7tutes:!saliva!orthanaor!or! methylcellulose!subs7tute.! !!!!!!J!SugarJfree!chewing!gum! !!!!!!J!Salivary!s7mulants!e.g.!pilocarpine!or! cevimeline.!
  162. 162. •  Typically!affects!the!gingival!1/3!and!incisal!/! cusp!7ps!of!teeth.! •  Not!limited!to!teeth!within!radia7on!field.! •  Related!to!xerostomia!leading!to!loss!of! remineralisa7on!poten7al,!loss!of!buffering! capacity,!increased!acidity!and!a!change!in! bacterial!flora.!
  163. 163. •  preJradia7on!OHI,!diet!counseling!and! treatment!of!any!ac7ve!caries.! •  regular!follow!up!during!Treatment.! •  Treat!xerostomia.! •  Use!fluoride!mouthwashes!or!gels.!
  164. 164. •  Caused!by!fibrosis!of!mas7catory!muscles!! •  Jaw!exercises!limit!the!extent!of!trismus!but! will!not!cure!it!aer!it!has!occurred;!exercise! before!and!during!radiotherapy.!
  165. 165. •  Radia7on!effects!on!bone:! !!!!!!!Hypovascularity,!Hypocellularity!and!Hypoxia!leading! to!poor!ability!to!repair!and!remodel!! •  Sign!and!symptom:!! !!!!!!discomfort,!tenderness,!bad!taste,!paraesthesia!and! anaesthes.! •  Risk!factors!for!development!of!ORN!are:! !!!!!!!Dose,!frac7on,!volume!of!bone!exposed,!presence!of! teeth!in!high!dose!radia7on!field,!immunodeficiency,! smoking!and!alcohol.!
  166. 166. Non!healing!wound! Hypovascular,!hypoxia,!hypocellular!!! ! ! irradia7on! 3H’s! Tissue!breakdown!
  167. 167. •  •  •  •  •  •  •  •  So!diet.! Adjustment/removal!of!any!trauma7c!denture.! Provide!analgesia.! Stop!smoking!and!alcohol!consump7on!and! ensure!good!nutri7on.! Daily!local!irriga7on.! Good!oral!hygiene!instruc7ons.! HBO!as!adjunc7ve!treatment.! Excision!of!necrosed!bone!with!1°closure!and! appropriate!HBO!therapy.!
  168. 168. •  PreJirradia7on!management.! •  During!irradia7on!management.! •  PostJirradia7on!management.!
  169. 169. •  If!head!and!neck!radia7on!is!scheduled!the!following! recommenda7ons!should!be!considered:! !!!!!J!construct!protec7ng!shield.! !!!!!J!good!OHI.!! !!!!!J!extrac7on!of!nonrestorable!teeth!and!poor!prognosis.! !!!!!J!adequate!7me!for!wound!healing!before!radia7on! therapy.! !!!!!J!no!bone!should!be!le!exposed!when!radiotherapy!begin.! !!!!!J!teeth!scaling!and!prophylaxis!before!radiotherapy!to! reduce!the!risk!of!oral!complica7ons.! !!!!!J!restore!of!all!restorable!teeth.!
  170. 170. •  •  •  •  •  •  Maintain!the!op7mal!oral!heath.! Mucosa!and!salivary!gland!protec7on.! Smoking!and!alcohol!should!be!discouraged.! Mucosi7s!management.! Xerostomia!management.! Trismus!may!be!improved!by!jawJopening! exercises.!
  171. 171. •  Management!of!oral!complica7ons.! •  Keep!op7mal!oral!hygiene.! •  Topical!fluorid!applica7on!by!mean!of!custom! carrier.! •  Regular!follow!up.!
  172. 172. •  What!is!the!management!of!post!radia7on! pa7ent!who!needs!tooth!extrac7on?! !!!!J!four!months!aer!comple7on!of!therapy,!the! surgical!procedures!should!be!done!aer! prophylac7c!HBO!treatment.! !!!!J!CXD!mouthwash!prior!to!Surgery.!! !!!!J!Minimal!trauma.!
  173. 173. ! •  What!is!the!HBO!protocol!for!prophylac7c!use! before!teeth!extrac7on!in!irradiated!pa7ents?! !!!!!!!this!protocol!consist!of!onceJdaily!treatment! 5!day/week.!The!pa7ent!should!receive!100%! oxygen,!20J30!consecu7ve!treatment!before! extrac7on.!10!addi7onal!treatment!should!be! administered!post!opera7vely.!
  174. 174. ! •  What!is!the!protocol!for!implant!placement!in! the!irradiated!pa7ent?! !!!!!!J!strict!oral!hygiene!before!and!aer!implant! placement.! !!!!!!J!use!of!longest!and!widest!implant!types!and! maximum!number!of!implants!possible.! !!!!!!J!cessa7on!of!smoking.! !!!!!!J!preopera7ve!HBO.!
  175. 175. ! •  Radiotherapy!can!affect!all!oral!and!perioral! 7ssues.! •  Preven7on!management!of!disease!prior!to! radia7on!treatment!can!significantly!reduce! the!incidence!and!severity!of!poten7al! complica7ons.!! •  •Symptoma7c!relief!and!rapid!management! of!oral!complica7ons!is!an!important!role!of! the!den7st,!as!part!of!the!mul7disciplinary! team.!
  176. 176. Chemotherapy! •  Used!only!in!cases!IV!with!poor!prognosis! •  Currently!used!agents!include:! •  •  •  •  ! cispla7n,!! carbopla7n,!! 5Jfluorouracil! taxanes!(paclitaxel!and!docetaxel),!! !The!last!to!agents!are!also!used!as!radia7on!!!!! !sensi7zers.!! •  Recent!interest!has!been!shown!in!intraJarterial! delivery!of!chemotherapy,!which!increases!the!drug! dose!to!the!tumor!and!decreases!systemic!toxicity.! •  Combina7on!therapy!(radioJchemoJtherapy)! increases!the!survival.!
  177. 177. Emerging!Therapies! ReJevalua7on!of!the!role!of!surgery!for!distant! metasta7c!oral!cancer!has!shown!a!possible!role! for!excision!of!pulmonary!metastases! Reirradia7on!in!the!head!and!neck!is!being! inves7gated,!mostly!in!the!nasopharynx!and! larynx.!locoregional!control!has!been!improved,! Gene!therapy!(p53,!p21),!angiosta7c!therapy!and! enhancing!immunity,!diet!modifica7on! Photodynamic!therapy:!light!source!and!sensi7zer!!!
  178. 178. Recurrence!and!Second!primaries!
  179. 179. Treatment!delay!
  180. 180. Morbidity!of!cancer!therapy! •  Surgery:! •  •  •  •  Quality!of!life! Func7on! Esthe7c! Cost!of!rehabilita7on! •  Radiotherapy:! •  •  •  •  •  •  Xerostomia! Mucosi7s! Taste!sensa7on!! Osteoradionecrosis! Rampant!caries! PreJmalignancy!! •  Chemotherapy:! •  Blood!cell!disorders! •  Alopecia!! •  mucosi7s!
  181. 181. Osteoradionecrosis!
  182. 182. Radia7on!Mucosi7s!!
  183. 183. Cancer!pa7ent!and!Quality!of!life!! •  Every!Oral!cancer!pa7ent!has!to!be!seen!by! specialist!of!the!following:! •  Speech!therapy! •  Diet! •  Psychic!condi7on! •  Esthe7c! •  Physical!therapy!!

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