Copyright (c) Dr. Tun Ngwe University of Dental Medicine, Yangon

1. ORAL CANCER
MANAGEMENT
Dr. Tun Ngwe, AP, DOMS
University of Dental Medicine, Yangon
1
TNAugust3,2018

2. Oral Squamous cell carcinoma
 Incidence
 Sixth most common cancer worldwide
 Third in developing countries
 Fifth most common in Myanmar
2
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3.  Survival rates
 Five year survival – 30-40%
 the more the disease free interval the better the
prognosis
 observed rate – proportion of patients alive in a
period of time after diagnosis
 relative rate – which adjusts the cancer survival
rates taking into account death expected from
other cause
3
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4. Aetiology
 Oral cancer is a multifactorial disease
 Social habits ; tobacco (smoking) , alcohol(spirit),
betel quid ( smokeless tobacco)
 Infections ; bacterial (tertiary syphilis )
 fungal (candidial leukoplakia)
 viral ( herpes , papilloma , HIV )
 Extrinsic factors ; ill fitting prosthesis (sharp) , spices
 atinic radiation ( sunlight)
 industrial hazards ( chemical )
 Instrinsic factors; (susceptibility)
 genetic
 nutritional defiencies ( Fe,folate,B12)
 immunodeficiency? suppression

4
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5.
CLINICAL PRESENTATION OF ORAL SCC
 Depend on the site of the lesion, duration, stage
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6.  Early lesion – asymptomatic
 Persistent ulceration /Ch ulcer ( Marjolin’s ulcer –
SCC occasionally occurs in a Ch. Ulcer or in a
scar ) , swelling , discolouration , induration ,
fixation
 Advanced or late lesion - ulcerated lesion -
exophytic, infiltrative
 Emergencies - bleeding ( erosion of vessel) , sepsis,
air way obstruction etc.
 Enlarge neck node with occult primary
Occult primary – presents as metastatic SCC in
cervical nodes but without evidence of primary
lesion
6
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7. 7
TN
 Ulcer - lateral border
of the post 3rd
of the
tongue
August3,2018

8. 8
TN
 Growth
August3,2018

9. SCC Retromolar trigone
TN
9
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10. Skin involvement SCC ( maxilla ) gingival
TN
10
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11. SCC buccal with skin involvement
TN
11
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12. SCC buccal mucosa SCC ( mandible )gingival
TN
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13. SCC mandible
13
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14. ULCER
 irregular shape
 indurated based
 rough, nodular, warty, hemorrhagic floor
 crater like, raised rolled everted edge
 in association with
 pain - involvement of nerve, invasion, infection
 excessive mobility of teeth adjacent to lesion
 altered sensation – paresthesia
 poor motor function - palsy
 trismus (retro trigone)
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15. COMMON SITE
 Tongue
 Buccal mucosa
 Gingiva
 Floor of the mouth
 Palate
 Lip
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16. INTERNATIONAL CLASSIFICATION OF DISEASE
– WHO 1977
ORAL CANCER
 ICD- O
 140 – lip
 141 – tongue post. to vallate papillae
 141- 1 to 141- 4 – ant. 2/3 , tip, lat, dorsum, ventral
 143 – upper alveolar ridge
 143 – 1 – lower alveolar ridge
 144 – floor of the mouth
 145 – buccal mucosa
 145 – 2- hard palate
 146- Oropharynx
 147 - Nasopharynx
 148 - Hypopharynx
 16
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17. MANAGEMENT OF A PATIENT WITH ORAL
CANCER
 JCC - Joint Cancer Clinic
 before treatment –Tx plan individually
 during treatment – supportive therapy
 after completing each type of treatment –life long
follow up
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18.  Multidisplinaries – Oral & Maxillofacial Surgeon,
 Radio – oncologist
 Medical- oncologist
 Nutritionist
 Prosthodontist
 Multimodalities – combined treatment
 Surgery
 Radiotherapy
 Chemotherapy
 18
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19.  TNM staging of oral cancer
 Union Internationale Contre le Cancer ( UICC )
1987
 American Joint Committee on Cancer ( AJCC )
1988
 Purpose ; Standard communicable description ,
planning of treatment , assessment of prognosis ,
comparison of treatment result between different
centres , as well as different treatment protocols
in one centre

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20. PROGNOSTIC INDICATORS
 T – size of presenting tumour
 the larger the primary the more compromised
condition for surgery will be ,the greater chance
for nodal metastasis
 Stage I & II are considered early and associated
with best prognosis and highly curable by
Surgery or R/T.
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21. T - PRIMARY TUMOUR SIZE
 Tx Primary tumour cannot be assessed
 To No evidence of primary tumour
 Tis Carcinoma in situ
 T1 Tumour 2cm or less in greatest dimension
 T2 Tumour more than 2 cm but not more than 4 cm in
greatest dimension
 T3 Tumour more than 4 cm in greatest dimension
 T4 Tumour invades adjacent structures (e.g through
cortical bone into deep extrinsic muscle of tongue,
maxillary sinus, skin)
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22. N – LYMPH NODE METASTASIS
 regional spread of cancer
 lymph nodes of the neck are efficient barrier to the spread
of the cancer
 early stage – no nodal involvement – 50% chance of 5 year
survival
 positive node reduces the 5yr survival rate by half
 bilateral and contralateral nodes(N2c) – grave sign
 high number and level of positive nodes – poor prognosis
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23. TN
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24.  malignant nodes – size greater than 1.5cm
 10 – 30% of malignant nodes are clinically undetected on
physical examination ( pitfalls ) due to deep location ,
nodal conglomerates may mistaken for a single node
 Accuracy of nodal staging ; CT( 90-95% ) , Physical
examination (75%)
 Necrosis regardless of size and presence of extracapsular
spread - poor prognosis
 Extracapsular spread is found in 60% of positive node,
becoming more frequently when the nodes are > 3cm
 Skip area in the neck are common
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25. N - REGIONAL LYMPH NODE
NX REGIONAL LYMPH NODES CANNOT BE ASSESSED
No No regional lymph node
metastasis
N1 Metastasis in single
ipsilateral lymph node, 3cm or less
in greatest dimension
TN
25
August3,2018

26. N2a Metastasis in single
ipsilateral lymph node more than 3
cm but not more than 6 cm in greatest
dimension
N2b Metastasis in multiple
ipsilateral lymph nodes, none more
than in 6 cm in greatest dimension
TN
26
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27. N2c Metastasis in multiple bilateral
or contralateral lymph nodes, none
more than in 6 cm in greatest
dimension
N3 Metastasis lymph node more
than 6 cm in greatest dimension.
TN
27
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28. 28
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29. M – DISTANCE METASTASIS , DISTANT
SPREAD OF CANCER
 late dissemination most commonly to lung, liver
and bone,
 grave prognosis
 does not happen very often ( less than 10%)
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30. M- DISTANT METASTASIS
 Mx - Presence of distant metastasis cannot be assessed
 Mo No distant metastasis
 M1 Distant metastasis
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31.  cTNM - clinical staging based on preoperative
assessment
 pTNM – pathological staging based on
postoperative assessment including
histopathologic data

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32. TNM - Staging
T1-4 N1-3 M1
 Stage 0 Tis No Mo
 Stage I T1 No Mo
 Stage II T2 No Mo
 Stage III T3 No Mo
 T1,2,3 N1 Mo
 Stage IV T4 N0,N1 M0
Any T N2,3 M0
Any T Any N M1
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33. S – SITE
 poor prognosis with more posterior region , silent
progression, difficult to visualize
 notice very late ( patient's delay)
 can be missed ( Doctor's delay)
 tumour of the tongue and FOM – highest nodal
metastasis
 tumour in the midline, then both side of the neck
can be involved.
 5 year survival rates of lip cancer ( T1 & T2)
range from 70-90%
33
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34. anterior one-third
of the tongue
drains into the
lower cervical
posterior one-
third drains to
upper cervical
area
middle one-third
can drain
bilaterally to
submandibular
triangle and the
middle jugular
cervical area
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35. P- HISTOPATHOLOGICAL GRADING
 Cytological assessment / Tumour grading
(Broader's Classification ) – C/G
 Cx /Gx Grade cannot be assessed
 C1/G1 Well differentiated ( 95% of SCC)
 C2/G2 Moderately differentiated
 C3/G3 Poorly differentiated
 C4/G4 Undifferentiated
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36.  Well differentiated – keratin pearls , masses of prickle cells
within connective tissue surrounded by basal cells and central
keratinization.the basement membrane is absent. generally have
a less aggressive than poorly diffentiated
 Moderately differentiated – Keratin pearls are sparse or absent .
Prickle cells are more pleomorphic. There are atypical mitotic
figures .
 Poorly differentiated– no keratin ,pleomorphism and
hyperchromatism are extreme .The cells cannot be recognized as
keratinocytes .
 Undiffrentiated - (Anaplasticpoor differretiated/ anaplastic – poor
prognosis
 Ca in situ - basement membrane intact
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37. D – DEPTH OF TUMOUR
 the greater the depth , the more invasion into the
subepithelial tissue , greater risk of nodal
metastasis
 < 2mm - < 8% chance of nodal metastsis
 > 8mm – 40% chance of nodal metastasis
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38. V- VELOCITY OF TUMOUR
 Aggressiveness and destructive potential of the lesion
 The ratio of the tumor cells cycling to total number of cells
in the tumor is called growth fraction
 Some rapidly growing tumor ( leukemia, lymphoma) will
have the growth fraction of 90%, whereas carcinomas and
sarcomas may be as low as 10%
 Tumor lysis syndrome can occur in rapidly growing bulky
chemosensitive tumours and cause hyperuricemic,
hypocalcemia, hypokalemia and hyperphoshatemia – renal
failure
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39. A/S – AGE/SEX
 extreme of age - inability to tolerate the prolong
surgery and GA
 highly aggressive disease in younger patients
( lymphoma)
 advanced age – unfit , compromised medical
condition
 sex- male has poor prognosis , habits ( smoke/
smokeless tobaco,
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40. Other
 recurrent local / regional
 multiple cancer
 multicentric
 perineural involvement of the tumour
 tumour attached to the carotid artery
 continued tumour growth during treatment with
C/T & R/T etc.
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41. TREATMENT
 general consideration
 aimed at curing disease without undue complications
 decision based on STNMP , age, coexisting disease, life
expectancy of the patient
 patient acceptance ( autonomy )
 counseling , consent

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42. OBJECTIVES OF SURGICAL
ONCOLOGY ;

 To excise the entire neoplastic lesion
 To remove an adequate margin of adjacent
normal tissue
 To remove of all potential channels of likely
metastasis
 To promote rapid healing and rapid restoration
of function
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43. ELIGIBLE CRITERIA – ECOG – EASTERN CO-
OPERATIVE ONCOLOGY GROUP
 Performance status of operable case
 Adequate bone marrow – Hb >10Gm% , WBC >
4000 / micro gm , PC > 100,000 / micro gm
 Renal – Creatinine < 1.5 mgm/dl , Creat
.clearance 60ml/min ( function )
 Hepatic – Bilirubin < 2mgm/dl
 Laboratory investigation - full blood examination
, clotting , U&E , urianalysis , LFT , Lung
function test , CXR , ECG

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44. SURGICAL TREATMENT TO PRIMARY SITE
 Curative
Local control - Tumour ablation
 eradication of disease
 tumours of limited radiosensitivity ( eg. Melanoma ,
salivary t/m , R/T induced malignancy , where previous
R/T has been ineffective )
 tumour is removed in single piece completely . If the
tumour is breached , fragmented or removed in pieces then
the operation is deemed a failure
 three dimensional marginal clearance (frozen section )
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45.  Primary surgery - undertaken in cancers which have not
been previously treated with surgery
 Secondary surgery ( Salvage surgery) – in cases
where previous treatment has had limited success. In
residual disease following radiation or surgery and for the
management of necrosis following R/T
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46.  Palliative – provides clinical benefit in the
absence of cure
 Debulking ( Cytoreductive) – without curative intent ,
reduction of tumour mass, which may improve the ability to
control residual disease in selected advanced cancer
 subsequent treatment C/T or R/T to be more effective and
response
 Increase survival
 Emergency –
 Hemorrhage due to perforation of major vessels and
destruction of vital organs
 Airway obstruction
 46
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47. removal of a tumour by
incising through uninvolved
tissue around the tumour
(En bloc resection)
a , b – marginal – preserving
at the inferior margin
of symphysis ( middle third
alveolus ) – anterior to
mental foramen
of lateral third of alveolus –
whole length of intrabony
inferior alveolar canal is
resected from madibular to
mental foramen in
anticapicipation of neural
spread of tumour
c , d – segmental - resection
of a tumour by removing full
thickness portion of the jaw ,
segmental between mental
foramen , of body and part of
assending ramus, posterior
border preserved to enable
functional reconstruction
( continuity defect )
47
TN
Mandibulectomy
August3,2018

48. Marginal resection - indicated where tumour has invaded or is in
close proximity to periosteum , the bone is uninvolved clinically or radiologically
TN
48
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49. Segmental resection
TN
49
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50. Mid split incision for the assessment of the mandible
Post-op- ID&MMF to promote wound
healing
Late post-op
TN
50
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51. HEMI-MADIBULECTOMY - RESECTION OF A TUMOUR
BY REMOVAL OF THE TOTAL PART OF THE INVOLVED BONE
TN
51
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52. Maxillectomy through Weber fergusson’s approach
TN
52
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53. 53
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54. PARTIAL MAXILLECTOMY
 Marginal - does not
involve the maxillary
sinus
 Segmental - growths
limited to the anterior
part of floor of the
antrum or the
alveolus of the upper
jaw
TN
54
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55. Hemimaxillectomy
Specimens for biopsy – maxilla with
primary tumour and regional nodes
TN
55
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56. TN
56
 Post op
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57.  Radical / extended - total maxillectomy including orbital
contents enbloc ( eye exenteration )
TN
57
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58. GLOSSECTOMY - TONGUE RESECTION
 local excision
 partial glossectomy
 hemiglossectomy
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59. Pre-op (wide excision ) Post-op
TN
59
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60. PAROTIDECTOMY
 superficial parotid lobectomy
 total parotidectomy with preservation of facial
nerve
 radical paroditectomy ( including facial nerve ,
partial mandibulectomy , and radical neck
dissection en bloc )

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61.  Composite resection –
 resection of a tumor with bone, adjacent soft tissue
and contiguous lymph node channels.
August3,2018
61
TN

62. NECK DISSECTION - REGIONAL
CONTROL
 lymph node invaded by SCC seldom respond to
R/T , especially > 3cm
 important to keep a band of continuity between
the neck dissection ( lymph , nerve , vessel ,
muscle etc. ) and the primary growth
 neck first, follow by tumour ablation
August3,2018
62
TN

63.  Level I - (Sub mandibular triangle)
bounded by the anterior and posterior
bellies of the digastric muscle and
inferior border of the mandibular
triangle
 Level II - (Upper jugular) Extending
from the skull base to the bifurcation of
the carotid artery or the hyoid bone
(clinical land mark)
 Level III - (Middle jugular) from the
inferior border of the level II to the
omohyoid muscle or the cricothyroid
membrane(clinical landmark)
 Level IV - (Lower jugular) from the
inferior border of level III to the clavicle
 Level V -( Posterior triangle) Bounded
by the clavicle , posterior border of the
sternocledomastoid muscle and the
trapezius muscle
nodal tissue lying around the IJV and spinal
accessory nerve
o Level VI- perithyroid, delphian, tracheo-
oesophageal and anteriosuperior
mediastinum areas
o Level VII- around mediastinum
TN
63
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64. Nodal – sublevels
I A & IB – anterior belly of the
digastric
IIA & IIB – spinal acessory nerve
VA & VB – omohyoid muscle
TN
64
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65. 65
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66.  Prophylasix / Elective to N0
 Therapeutic to N +
 Standard radical neck dissection – (Crile 1906)includes the
superficial and deep cervical fascia with its enclosed
Lymph nodes ( I-V)
+
non-lymphatic ( the sternocleidomastioid , internal jugular vein and the spinal
accessory nerve )
 Extended radical neck dissection –
all structures in a radical neck
+
lymphatic structures ( retropharyngeal , parotid or nodes in level VI or VII )
+
nonlymphatic structures ( include part or all of mandible, parotid gland, part of
mastoid tip, prevertebral fascia and musculature – digastric, hypoglossal nerve
and external carotid artery and skin)
66
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67. CT – assessment of the nodal status
TN
67
August3,2018

68. FUNCTIONAL NECK DISSECTION - MODIFIED
RND
 Complete enbloc lymphadenectomy
with preservation of
sternocleidomastoid, interval
jugular vein and spinal accessory
nerve.
 Lymph nodes(I-V) + non-lymphatic
 Type I - preserve accessory nerve
 Type II- preserve accessory nerve
and internal jugular vein
 Type III - preserve accessory nerve,
internal jugular vein and
sternocleidomastoid muscle
TN
68
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69. 69
TN
Spinal acessory nerve
was preserved
FND type ?
August3,2018

70. TN
70
 spinal accessory, internal jugular
vein and sternocleidomastoid
muscle are preserved in all cases
 Supra-omohyoid neck dissection –
level I, II, III
 Extended supraomohyoid neck
dissection – removes IV in addition
to levels I, II and III
 Lateral ( Jugular ) neck dissection
– level II, III, IV
 Anterior compartment neck
dissection- level VI
 Posterolateral neck dissection –
level II, III, IV, V
SELECTIVE NECK DISSECTION
August3,2018

71. TREATMENT OPTIONS FOR N0
 -elective surgery
 -elective R/T
 -neck investigation ( CT or MRI)
 -wait and see

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72. INDICATIONS FOR ELECTIVE NECK
TREATMENT
 -more than 20-25% chance of subclinical disease
– tongue , FOM
 vigilant followup impossible
 clinical evaluation is difficult
 surgery is being performed for access and
reconstruction
 imaging suggests possible occult nodal spread

72
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73. PATIENTS WITH METASTATIC NECK
DISEASE WHO SHOULD NOT UNDERGO
SURGERY
 those with untreatable tumour
 those who are unfit for surgery , anaesthesia
 those with inoperable neck disease
 those with distance metastases


73
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74. ENLARGE NECK NODE WITH OCCULT
PRIMARY
 Occult primary – presents as metastatic SCC in cervical nodes but without
evidence of primary lesion , common – aerodigestive tract
 - may also be due to the tumour below the clavicle , lung, stomach, and
breast are common sites
 - occasionally ovary and testis – subclavicle ( rising sun)
 - Virchow's node or Troisier's sign – occult malignancy in chest and GI
 - search for primary is necessary , EUA – examination under anaesthesia
 Blind biopsy at most common site of primary – pyriform sinus , base of
tongue, nasopharynx, tonsil
 Incisional biopsy for lymph node is contraindicated due to increase
metastatic spread,
 Node biopsy make subsequent neck dissection difficult
 Prefer FNAC
74
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75. RECONSTRUCTIVE SURGERY
 Preserve adjacent healthy tissues
 Restoration of aesthetic and function – lining, cover,
support
 Reconstruction for surgical defect – hard and soft tissue
defects
 Timing – immediate ( new trend ), delayed ( old trend )
75
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76.  Soft tissue defect
 primary closure ( for only small defect)
 graft ( skin – FTG , STG )
 flaps ( local, distant and free flap )
76
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77. FREE GRAFT ( SKIN – FTG , STG )
TN
77
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78. FTG
TN
78
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79. STG
TN
79
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80. Harvesting from the donor site
TN
80
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81. Localflap
TN
81
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82. TN
82
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83. TN
83
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84. Distant flap
TN
84
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85. Micro-surgery – Free flap
TN
85
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86.  Hard tissue defect
 bone – cortical , cancellous
 alloplastic ( nonbiological
materials – titanium ,
urethane , silicone ,
osseointegrated implants )
TN
86
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87. TN
87
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88. TN
88
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89. SURVIVAL RATES
 Five year survival – 30-40%
 the more the disease free interval the better the
prognosis
 observed rate – proportion of patients alive in a
period of time after diagnosis
 relative rate – which adjusts the cancer survival
rates taking into account death expected from
other causes
89
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90. 90
TN
What can you do ?
PREVENTIONS
August3,2018

91. Aetiology
 Oral cancer is a multifactorial disease
 Social habits ; tobacco (smoking) , alcohol(spirit),
betel quid ( smokeless tobacco)
 Infections ; bacterial (tertiary syphilis )
 fungal (candidial leukoplakia)
 viral ( herpes , papilloma , HIV )
 Extrinsic factors ; ill fitting prosthesis (sharp) , spices
 atinic radiation ( sunlight)
 industrial hazards ( chemical )
 Instrinsic factors; (susceptibility)
 genetic
 nutritional defiencies ( Fe,folate,B12)
 immunodeficiency? suppression

91
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92. PRIMARY PREVENTION
 preventing from occurring disease
 aimed at reducing or eliminating to carcinogens
 oral health education to public/individual
 stop habit/ developing habit
 exposure to smoke ( active / passive – PAH
polycyclic aromatic hydrocarbon , precarcinogen )
 smokeless tobacco (nitroso nicotine – direct
carcinogenesis )
 alcohol , betel nut chewing
92
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93.  Betel quid
 betel leave
 areca nut ( alkaloid , arecoline – collagensynthesis ,
tannin and flavanoid )
 lime ( irritation )
 tobacco
 World no tobacco day - National strategic plan
93
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94.  World no tobacco day – 31st
May , Tobacco free
environment , enforcement of new law – National
strategic plan
94
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95.  reduce consumption of hot stuff – chillies ,
spices
 risk - remove chronic irritation - sharp tooth,
prosthesis , regular ( 6 monthly ) check-up , oral
examination
95
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96. SECONDARY PREVENTION
 screening is to identify individual without
symptoms who either already have a disease or
clearly at high risk of developing it and where
intervention could have a beneficial effect
 early detection ( awareness & suspicion ) to
identify early cases, so that treatment increases
the chance of cure , survival
 early referral to appropriate centre and
adequate treatment
96
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97. Delays
 Patient not seeking for treatment
 Fear , ignorance , geographic isolation , high
tolerance level
 Clinician not referring to specialist
 poor history and physical examination , low
index of suspicion , ignorance of S/S
97
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98. HISTORY TAKING
 personal habit - smoking, betel nut chewing, alcohol etc.
 previous cancer treatment(? recurrent)
 cancer in other part of the body (? secondary)
 patients on immunosuppressive drugs – cyclophosphamide in
renal transplant case – aerodigastric cancer
 Otalgia – deeply infiltrating tumour of posterior part of the
tongue and FOM give rise through 9th
CN
 paresthesia of sensory supply
 obstructive symptoms in nasal
98
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99. *EXAMINATION
 performance status – cachexia , facial asymmetry
Oral - systematically
 lips, lower labial sulcus and upper labial mucosa and sulcus,
commisure, buccal mucosa and sulcus, alveolar ridge, tongue,
floor of the mouth, hard and soft palate
 teeth – excessive mobility due to nonodontogenic and
nonperiodontal cause
 oral health status – necrotic foul smell
 mouth opening – trimus (? involvement of retromolar trigone)
Extraoral examination – lymphadenopathy – reactionary,
metastasis
99
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100. Oral - systematically
 lips
 lower labial mucosa &sulcus
 upper labial mucosa &sulcus
 commisure
 buccal mucosa & sulcus
 alveolar ridge
 tongue
 floor of the mouth
 hard and soft palate
TN
100
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101. The oral cavity
extends from the
skin vermilion
junction of the lips
to the junction of
the hard
and soft palate
above and to the
line of
circumvellate
papillae below .
101
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102. 102
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103. Screening procedures
 Oral examination
 Toulidine blue staining
TN
103
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104. *DEFINITIVE DIAGNOSIS BY BIOPSY
 no tumour should be treated without
confirmation of the diagnosis by histological
examination
 Types of biopsy
 incisional, needle , punched , drilled
 excisional
 cytology- FNAC , exfoliated cytology , brush biopsy
 EUA – examination under anaesthesia ( GA ) for
occult primary
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105. Suspicion of malignancy
 Lesion totally red or speckled red and white
 Ulceration
 Lesion persisted for more than 2 weeks
 Lesions exhibits rapid growth
 Lesions bleed on gentle manipulation
 Lesion and surrounding tissue firm to the touch
 Lesion feels attached to the adjacent structures
105
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106. *RECOGNITION OF COMMON ORAL
PREMALIGNANT
 premalignant lesions – a morphologically altered
tissue in which cancer is more likely to occur than in
its apparently normal counterpart
 Leukoplakia, erythroplakia
 premalignant conditions - a generalized state
associated with significantly increased risk of cancer ,
unstable epithelium
 Plummer- Vinson (Kelly-Peterson)
syndrome, tertiary syphilis, OSMF ,
erosive lichen planus
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107.  definitive prevention from malignant , epithelial
atrophy – more susceptible to carcinogen
 systemic and topical steroid, high Vit A( Retinoid
or carotenoid), C, E , antioxidant , excision
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108. White lesions
TN
108
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109. TN
109
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110. TN
110
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111. TN
111
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112. Oral submucousfibrosis
TN
112
Before treatment After treatment
August3,2018

113. Intra-lesional injection
TN
113
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114. Premalignant lesion was changed to malignant lesion which
was widely excised and SSG done
TN
114
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115. TERTIARY PREVENTION
 Treatment of oral cancer – S/T , R/T , C/T
 S/T - Do what you can , when you can
 aimed at curing the disease without undue
complications ( acute or chronic , advanced and
end stage organ failure , supportive therapy )
115
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116. DENTAL MANAGEMENT –
SUPPORTIVE ROLE
 Improve and maintain O.H. (O.H status and
dentition)
 To reduce - risks for odontogenic complication
 Elimination of odontogenic infection
 To prevent - fatal infection of dental origin
 control pain
 To provide - reconstruction and / or rehabilitation
 To prevent / reduce - ORN
 To improve - quality of patient life

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117. PREVENTION OF CARIES AND
PERIO-
 keep oral cavity moist and clean.
 OHI – soft tooth brush
 M/W – avoid alcohol containing , hot and burning
M/W
 Sodiumbicarb – 1 tea spoon of baking soda in a
quart of water – 10- 15 times / day
 Fluoride – custom made carrier and 0.4%
stannous fluoride gel
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118. MAINTENANCE OF TEETH –
CONSERVE

 elimination of gross sepsis, potential source of
infection
 caries, perio, deciduous (mobile) , sites of trauma
/ irritation sharp edges - should be scheduled in
consultation with oncologist refer to dentist with
experience to treatment of cancer
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119. TEETH IN THE LINE OF FIRE
 Surgical extraction with alveoplasty and primary
closure rather than simple extraction without
primary closure
 Extraction is done usually at the time of biopsy
to R/T cases and at the time of surgery to
operable cases
 Allow epithelization – 1 to 2 wks.
 R/T delay if healing is not satisfactory
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120. MUCOSITIS , ORAL ULCER
 pain , topical anesthesia
 Tricaine , mucaine
Enziclor – Benzydamine + Chlorhexidine 0.2% ,
Quadrajel – antiseptic , analgesic , Astrigent &
Demulscent gel
 antibiotics moisturizing gel
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121. CANDIDIASIS

 antifungal oral suspension - Nystatin ,
mycostatin , miconazole
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122. PROSTHODONTIC
 proper evaluation of preexisting prosthesis
 leave out of the mouth during treatment
 upper denture only to those with cannot live
without denture
 previous edentulous with denture who needs new
one- wait at least 6 mths.
 extraction done before treatment and who need
new denture - wait at least 1 yr
 denture base and occlusal table designed - equal
distribution of load, avoid lateral forces.
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123. MAIN GOAL
CURE
IF ?
PROLONGATION OF SURVIVAL
with better quality of life
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124. References;
 Oral cancer , A synopsis of pathology and management , G.
Dimitroulis and B.S. Avery
 Oncology , L . Barr , R. Cowen , M. Nicolson
 Contemporary , Oral & Maxillofacial Surgery ,
L.J.Peterson
 Oral diseases in tropics , S.R. Prabhu , D.F. Wilson , D.K.
Daftray and N.W. Jhonson
 Surgical pathology of mouth and jaws , R.A.Cawson , J.D.
Langdon , J.W. Eveson
 Oral pathology , Clinical pathologic correlations , J.A.
Regezi , J. Sciubba
 A text book of Oral pathology , Shafer , Hine Levy
124
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125. 125
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