Oral Cancer

1. Management of Oral Cancer
Group A.

2. Objectives.
1. Clinical staging of oral cancer.
2. Clinical diagnostic methods and procedures - Biopsy taking (brush,
punch and incisional), Radiography and other scans.
3. Treatment options – Analgesics and therapy, Chemotherapy,
Radiotherapy, Surgery & Complications of cancer therapy, and
management.
4. Prognosis.
5. Prevention.
6. Supportive and Rehabilitative care.
7. Referral for specialized care.

3. 1. Staging of Oral Cancer.
• The American Joint Committee on Cancer (AJCC) has developed Tumor-
Nodes-Metastasis (TNM) staging system of cancer, which reflects the
prognosis, thus influencing treatment strategy.
• T is the size of the primary tumor, N indicates the presence of regional
lymph nodes, and M indicates distant metastasis.
• The most common site of spread is to the lungs, liver and bones.
• The staging system for OSCC combines the T, N, and M to classify lesions as
stages 1 through 4.
• The AJCC classification is principally a clinical description of the disease.
• Many clinicians combine an imaging-based assessment of the size, lymph
nodes, and metastasis with the AJCC clinical staging.

4. T categories.
• TX: Primary tumor cannot be assessed; information not known
• T0: No evidence of primary tumor
• Tis: Carcinoma in situ. This means the cancer is still within the
epithelium (the top layer of cells lining the oral cavity and
oropharynx) and has not yet grown into deeper layers.
• T1: Tumor is 2 cm (about ¾ inch) across or smaller
• T2: Tumor is larger than 2 cm across, but smaller than 4 cm (about 1
½ inch)
• T3: Tumor is larger than 4 cm across. For cancers of the oropharynx,
T3 also includes tumors that are growing into the epiglottis.

5. T categories.
• T4a: Tumor is growing into nearby structures. This is known
as moderately advanced local disease.
• For oral cavity cancers: the tumor is growing into nearby structures,
such as the bones of the jaw or face, deep muscle of the tongue, skin
of the face, or the maxillary sinus.
• For lip cancers: the tumor is growing into cortical bone, the inferior
alveolar nerve, the floor of the mouth, or the skin of the chin or nose.
• For oropharyngeal cancers: the tumor is growing into the larynx, the
tongue muscle, the hard palate, or the jaw.

6. T categories.
• T4b: The tumor has grown through nearby structures and into deeper
areas or tissues. This is known as very advanced local disease. Any of the
following may be true:
• The tumor is growing into other bones, such as the pterygoid plates and/or
the skull base (for any oral cavity or oropharyngeal cancer).
• The tumor surrounds the internal carotid artery (for any oral cavity or
oropharyngeal cancer).
• For lip and oral cavity cancers: the tumor is growing into an area called the
masticator space.
• For oropharyngeal cancers: the tumor is growing into a muscle called
the lateral pterygoid muscle.
• For oropharyngeal cancers: the tumor is growing into the nasopharynx (the
area of the throat that is behind the nose).

7. N categories.
• NX: Nearby lymph nodes cannot be assessed; information not known
• N0: The cancer has not spread to nearby lymph nodes
• N1: The cancer has spread to one lymph node on the same side
(ipsilateral) of the head or neck as the primary tumor; this lymph
node is no more than 3 cm (about 1¼ inch) across

8. N categories.
• N2 includes 3 subgroups:
• N2a: The cancer has spread to one lymph node on the same side as the
primary tumor; the lymph node is larger than 3 cm across but no larger
than 6 cm (about 2 ½ inches). (Single ipsilateral)
• N2b: The cancer has spread to 2 or more lymph nodes on the same side as
the primary tumor, but none are larger than 6 cm across. (Multiple
ipsilateral).
• N2c: The cancer has spread to one or more lymph nodes on both sides of
the neck or on the side opposite the primary tumor, but none are larger
than 6 cm across.(bilateral or contralateral)
• N3: The cancer has spread to a lymph node that is larger than 6 cm across

9. M categories.
• MX: Distant mestastasis cannot be assesed
• M0: No distant spread
• M1: The cancer has spread to distant sites outside the head and neck
region (for example, the lungs)

10. Stage Grouping.
• Once the T, N, and M categories have been assigned, this information
is combined by a process called stage grouping to assign an overall
stage of 0, I, II, III, or IV.
• Stage IV is further divided into A, B, and C.

11. Stage Grouping.
Stage O
• Tis, N0, M0: Carcinoma in situ. The cancer is only growing in the
epithelium, the outer layer of oral or oropharyngeal tissue (Tis). It has
not yet grown into a deeper layer or spread to nearby structures,
lymph nodes (N0), or distant sites (M0).
Stage I
• T1, N0, M0: The tumor is 2 cm (about ¾ inch) across or smaller (T1)
and has not spread to nearby structures, lymph nodes (N0), or distant
sites (M0).

12. Stage Grouping.
Stage II
• T2, N0, M0: The tumor is larger than 2 cm across but smaller than 4
cm (T2) and has not spread to nearby structures, lymph nodes (N0),
or distant sites (M0).

13. Stage Grouping.
Stage III
• One of the following applies:
• T3, N0, M0: The tumor is larger than 4 cm across (T3), but it hasn’t
grown into nearby structures or spread to the lymph nodes (N0) or
distant sites (M0).
OR
• T1 to T3, N1, M0: The tumor is any size and hasn’t grown into nearby
structures (T1 to T3). It has spread to one lymph node on the same
side of the head or neck, which is no larger than 3 cm across (N1). The
cancer hasn’t spread to distant sites (M0).

14. Stage Grouping.
Stage IV A
• One of the following applies:
• T4a, N0 or N1, M0: The tumor is growing into nearby structures (T4a). It
can be any size. It has either not spread to the lymph nodes (N0) or has
spread to one lymph node on the same side of the head or neck, which is
no larger than 3 cm across (N1). The cancer hasn’t spread to distant sites
(M0).
OR
• T1 to T4a, N2, M0: The tumor is any size and may or may not grow into
nearby structures (T1 to T4a). It has not spread to distant sites (M0). It has
spread to one of the following:

15. Stage Grouping.
Stage IV B.
• One of the following applies:
• T4b, any N, M0: The tumor is growing into deeper areas and/or
tissues (very advanced local disease - T4b). It may (or may not) have
spread to lymph nodes (any N). It has not spread to distant sites (M0).
OR
• Any T, N3, M0: The tumor is any size and it may or may not have
grown into other structures (any T). It has spread to one or more
lymph nodes larger than 6 cm across (N3), but it hasn’t spread to
distant sites (M0).

16. Stage Grouping.
Stage IV C
• Any T, Any N, M1: The tumor is any size (any T), and it may or may not
have spread to lymph nodes (any N). It has spread to distant sites
(M1), most commonly the lungs.

19. 2. Diagnostic Aids and Procedures.
• Early detection of potentially malignant and malignant lesions is a
continuing goal.
• Patient history, thorough head and neck and intraoral examinations, is a
prerequisite.
• There should be a high index of suspicion, esp of a solitary lesion present
for over 3 weeks.
• The whole oral mucosa should be examined as there may be widespread
dysplastic mucosa(‘field change’) or a second neoplasm, and the cervical
lymph nodes must be examined.
• Frank tumors should be inspected and palpated to determine the extent of
spread.

20. Diagnostic Aids and Procedures.
Examination under GA may be indicated for patients with;
• Tumors in the posterior tongue
• Tumors where the margins cannot be readily defined.
• An enlarged cervical node but no visible primary neopasm
• Any suggestion of a second primary tumor(SPT) who may then need
panendoscopy of larynx, pharynx and oesophagus.

21. Diagnostic Aids and Procedures.
• When deciding which investigations to undertake, 3 principles should
be adhered to;
• Confirm the diagnosis histopathologically and determine if there is malignant
disease elsewhere.(involvement of bone,muscles or nodes;metastases;other
primary tumours)
• Ensure that the patient is as prepared as possible for the major surgery
required i.e. consent, GA, potential blood loss and ability to metabolize drugs.
• Address any potential dental or oral problems preoperatively, to avoid later
complications such as osteoradionecrosis.

22. Diagnostic Aids and Procedures.
• The definitive test for diagnosis remains tissue biopsy.
• Several aids to the oral examination have been suggested in the past,
including light technologies, vital tissue staining using toluidine blue
(TB), and computer-assisted cytology of oral brush biopsy specimens.
• Additional markers based on blood of saliva samples are under
investigation.

23. Diagnostic Aids and Procedures.
• Several aids to the oral examination have been suggested in the past,
including light technologies, vital tissue staining using toluidine blue
(TB), and computer-assisted cytology of oral brush biopsy specimens.
• Additional markers based on blood of saliva samples are under
investigation.

24. Tissue Biopsy.
• The main types of biopsy to be use will be brush, punch and incisional
biopsy.
Oral cytology
• Oral brush cytology uses a special brush to collect epithelial cells.
Indications- Oral brush cytology may be a good tool for "monitoring"
patients with chronic mucosal changes, such as leukoplakia, lichen planus,
post irradiation, and patients with a history of oral cancer who require
long- term surveillance of their ongoing mucosal changes.
• The greatest advantage in oral cytology is that it is a chair side test It takes
only seconds to perform, Rather than simply "observing" a suspicious
lesion, one can readily obtain a sample of cells for analysis.
• All oral lesions with abnormal brush cytology results, that is "positive"
or"atypical," require surgical biopsy and histologic evaluation.

26. Punch
Biopsy.

27. Skin punch
biopsy.
Tongue
punch biopsy.

28. Tissue Biopsy.
Incisional Biopsy
• An incisional biopsy is a biopsy that samples only a particular or
representative part of the lesion.
Indications.
• If the area under investigation appears difficult to excise because of its
extensive size (i.e., larger than 1 cm in diameter), hazardous location, or
whenever the clinician suspects malignancy, incisional biopsy is indicated.
Principles.
1.The material should be taken from the edge of the lesion to include some normal
tissue.
2.However, care must be taken to include an adequate amount of abnormal tissue.
3.It is much better to take a deep, narrow biopsy rather than a broad, shallow one,
because superficial changes may be quite different from those deeper in the tissue

30. Tissue Biopsy.
Aspirational biopsy
• Aspiration biopsy is the use of a needle and syringe to penetrate a
lesion for aspiration of its contents.
• Done for two reasons:
• To determine content of lesion( fluid or air)
• To remove cellular material for diagnostic examination.
• Tissue can be acquired for histopathology by using fine-needle
aspiration (FNA) or core needle biopsy (CNB).

31. Tissue Biopsy.
• Open biopsy of enlarged lymph nodes is not recommended; in such
cases, FNA biopsy should be considered.
• FNA/CNB also may aid in the evaluation of suspicious masses in other
areas of the head and neck, including masses that involve salivary
glands, tongue, and palate, or when there is contraindication for
conventional biopsy (e.g., thrombocytopenia).
• Ultrasound may assist in guiding FNA/CNB.

33. Tissue Biopsy.
Excisional Biopsy.
• An excisional biopsy implies removal of the entire lesion at the time the surgical
diagnostic procedure is performed.
• The entire lesion made available for pathologic examination, and complete excision may
constitute definitive treatment.
Indications.
• Excisional biopsy should be used with smaller lesions (less than 1 cm in diameter) that on
clinical examination appear to be benign.
• Any lesion that can be removed completely without mutilating the patient is best treated
by excisional biopsy. Pigmented and small vascular lesions should also be removed in
their entirety.
Principles.
• The entire lesion, along with 2 to 3 mm of normal-appearing surrounding tissue, is
excised.

35. Toluidine Blue.
• Vital staining with TB may be used as an adjunctive aid in assessing
potentially malignant oral mucosal lesions.
• TB is a metachromatic dye, which has an affinity to bind with DNA.
• TB can be applied directly to suspicious lesions or used as an oral
rinse.
• Positive retention of TB (particularly in areas of leukoplakia,
erythroplakia, and uptake in a peripheral pattern of an ulcer) may
indicate the need for biopsy or assist in identifying the site of biopsy.
• False-positive dye retention may occur in inflammatory and ulcerative
lesions, but false- negative retention is uncommon.

36. Toluidine Blue.
• TB has been suggested as a diagnostic tool in potentially malignant
oral lesions at risk of progressing to squamous cell cancer, where it
may provide guidance for the selection for the biopsy site and
accelerates the decision to biopsy.
• In postradiotherapy follow-up, the retention of TB may assist in
distinguishing nonhealing ulcers and persistent or recurrent disease.
• It is used as an adjunctive marking aid in combination with a
chemiluminescence light device.

37. Toluidine blue stain applied to
lesion shown, with stain retained on
the areas of erythroplakia.
Subsequentbiopsy diagnosed as
squamous cell carcinoma. The more
superior area of leukoplakia stained
with toluidine blue also diagnosed
as squamous cell carcinioma, and
would likely not have been
diagnosed without toluidine blue,
which led to change in the
surgical treatment to include this
site in the resection

38. Visualization Adjunctive Tools.
• Chemiluminescent devices generate light based on chemical
reactions. The suspected area of mucosa appears brighter.
• Other products generate fluorescent light using a LED source,
sometimes combined with optical filtration of a viewfinder, to
enhance natural tissue fluorescence. When using the fluorescence
light, the suspected area shows loss of fluorescence, which appears
dark.
• These products are promoted to assist the practitioner in discovering
mucosal abnormalities, specifically oral potentially malignant
disorders and evaluate margins of resection site.

40. Cytology.
• Cytology of the oral mucosa is used to assess cellular morphology.
• The brush is designed to sample the entire thickness of the oral epithelium.
• Originally, the cytobrush was combined with a computer-assisted analysis
of the cytologic sample, assessing the cell morphology and keratinization.
• The final diagnosis was made by a pathologist based on the standard
histomorphologic criteria.
• Further developments in cytology include molecular evaluation of
exfoliated cells for molecular markers of dysplasia or carcinoma to improve
the diagnostic and prognostic value.

41. Molecular Analysis.
• Molecular markers obtained from tissue specimens have been
suggested to assist with detection and evaluation of cancerous
lesions.
• Including c-erbB2, Cyclin D1, p53 etc.

42. Imaging.
• Routine radiology, computed tomography (CT), nuclear scinti
scanning, magnetic resonance imaging, and ultrasonography can
provide evidence of bone involvement or can indicate the extent of
some soft tissue lesions.
• The selection of the appropriate imaging modality is dependent on
the type and location of the suspected tumor.
• Jaw radiography (often rotating pantomography)
• Chest radiography or CT. Important as preanaesthetic check,esp in pts
with known pulmonary or airways disease or to demonstrate second
primary tumours or mets to lungs or hilar lymph nodes, ribs or
vertebrae

43. Imaging.
• MRI or CT of the primary site, the head and neck, and suspected sites
of distant mets and MRI scans of the neck to delineate the extent of
cervical node mets.
• MRI is used to determine;
• Tumour spread
• Bone involvement
• Nodal metastases.

44. Periapical radiograph
demonstrating bone
destruction in the furcation of
the first molar tooth and
associated resorption of
the root. A subsequent biopsy
specimen demonstrated
squamous cell carcinoma,
which was diagnosed as a
primary intra-alveolar lesion.

45. Other Investigations.
• Electrocardiography
• Blood tests
• Full blood picture & haemoglobin
• Blood for grouping & cross-matching
• Urea and electrolytes
• Liver function tests

46. Other Investigations.
In selected cases other investigations may be indicated;
• Bronchoscopy, if chest xray reveals any lesions
• Endoscopy of the upper git, if there is a history of tobacco use.
• Gastrocopy, if a PEG(perendoscopic gatrostomy) is to be used for
feeding.
• Liver ultrasound, if there is hepatomegaly or abnormal liver function.
• Doppler duplex flow studies, in planning radial free forearm flaps
• Angiography, in planning lower limb free flaps.

47. 3. Management.
• Principle objective of treatment is to cure the patient.
• Choice of treatment depends on cell type and degree of differentiation,
the site and size of the primary lesion, lymph node status, the presence of
local bone involvement, the ability to achieve adequate surgical margins,
and the presence or absence of metastases.
• Treatment decisions are also impacted by appraisal of the ability to
preserve oropharyngeal function, including speech, swallowing, and
esthetics, as well as the medical and mental status of the patient.
• Furthermore, the support available to the patient throughout therapy, a
thorough assessment of the potential complications of each therapy, the
experience of the oncologist team, and the personal preferences and
cooperation of the patient all influence the operative decisions.

48. Management.
Patient communication
• Patient communication and information are important aspects in
management.
• You must leave discussion of actual treatment and prognosis to the
specialist concerned, as only they are in a position to give accurate
facts.
• If a cancer diagnosis has been established, it is reasonable to discuss
with the patient,their partner and relatives that;

49. Management.
• Tumours differ in their degree of malignancy
• Their tumour has been detected at an early stage(hopefully)
• Treatment is continually improving
• You have referred them to the best possible centre for treatment.
• The oncological team will provide fuller detaills of treatment options.

50. Management.
Treatment planning.
• Cancer treatment and planning decisions are based on;
• Tumour size,nodal status,mets
• The site of the tumour
• Wishes of the pt
• Social circumstances
• Co-existent medical conditions.
• It involves a multidiscipinary team(MDT) that includes a range of specialities:
surgeons, anaesthetists, oncologists, nursing staff, dental staff, nutritionists,
speech and physiotherapists.

51. Management.
Treatment planning.
• The MDT should plan the cancer treatment and also plan to avoid
postoperative complications.
• Concerns regarding restorative and surgical interventions required
before cancer treatment including osseointergrated implants and jaw
reconstruction should be handled in the planning phase.
• As much dental treatment as possible should be completed before
starting cancer treatment.

52. Management.
• Treatment options include:
1. Surgery.
2. Radiotherapy.
3. Chemotherapy.

53. Management.
• Surgery and radiation are used with curative intent in the treatment
of oral cancer.
• Chemotherapy and targeted therapy are used together with the
principal therapeutic modalities of radiation and surgery and is now
considered the benchmark for management of advanced disease.
• Either surgery or radiation may be used for T1 and T2 lesions;
however, combined radiation and chemotherapy with or without
surgery is usually employed for more advanced disease

54. Management.
• OSCC is treated largely by surgery and/or radiotherapy to control the
primary tumour and mets in the draining cervical lymph nodes.
• Lip cancer is treated mainly surgically.
• Intraoral cancers <4cm in diameter may be treated effectively by surgery or
radiotherapy.
• T1 tumours are managed surgically
• T2 tumours are managed surgically. However, tumours of the lateral margin
of tongue may be treated by radiotherapy using external beam plus
radioactive iridium implants.The treatment must include treatment of the
lymph nodes in the neck hence the treatment of choice is surgery(tumour
excision with radical neck dissection) plus radiotherapy.

55. Management.
• T3 tumours are generally treated by surgery followed by radiotherapy
if there is extracapsular spread or multiple lymph node
involvement.(tumour excision with radical neck dissection) plus
radiotherapy.
• T4 may be treated with chemo-radiotherapy. Drugs used include
cisplatin, fluorouracil(5-Fu),taxanes and methotrexate.
• TPF is a common regimen(taxane platinum, 5-Fu)

56. Analgesics and therapy.
• Pain at diagnosis of head and neck cancer is common and is usually
described as low-grade discomfort.
• Acute pain following radiotherapy and surgery is universal. Neurologic
pain states, including neuropathic pain and neuralgia-like pain, may
require the use of centrally acting medications, including
antidepressants and anticonvulsants.
• Chronic pain management approaches, including counseling,
relaxation therapy, imagery, biofeedback, hypnosis, and
transcutaneous nerve stimulation, may be needed. Pain associated
with musculoskeletal syndromes is reviewed in the section entitled
“Mandibular Dysfunction.

57. Analgesics and therapy.
TOPICAL AGENTS FOR THE ORAL MUCOSA
• Topical anesthetics are used for mucositis pain, producing a short period of mucosal
anesthesia (up to half an hour), but may sting with application on damaged mucosa and
affect taste and gag reflex. Topical anesthetics are often mixed with coating and
antimicrobial agents such as milk of magnesia, diphenhydramine, or nystatin; however,
these mixes have not been subjected to controlled studies, and effectiveness,
acceptance, and tolerability are variable.
• Topical doxepin, a tricyclic antidepressant, produces analgesia for 4 hours or longer
following a single application in cancer patients. In addition to extended duration of pain
relief, burning does not accompany topical application on damaged mucosa.
• Topical morphine has been shown to be effective for relieving pain, although there is
concern about dispensing large volumes of the medication.
• Topical fentanyl prepared as lozenges provides relief from oral mucositis pain.
• Topical coating agents have been promoted for use in patients with mucositis. Sucralfate
may have a role to play in pain management

58. Analgesics and therapy.
SYSTEMIC AGENTS
• The WHO Pain Management Ladder has
been recommended for managing pain in
cancer patients. Modification of the WHO
ladder is recommended to add topical
therapy before and during use of systemic
agents and to move from non-opioid
analgesics to powerful opioids at
sufficient dose and frequency to control
pain, and with adjuvant therapy.
• Analgesics, when required, should be
provided on a regularly scheduled or
time-contingent basis, not on an as-
needed basis, as improved pain control
can be achieved using lower total doses
of analgesics.

59. Surgery.
Surgery is indicated for
(1) early or localized oral cancer.
(2) tumors involving bone, and when the side effects of surgery are
expected to be less significant than those associated with radiation.
(3) tumors that lack sensitivity to radiation.
(4) recurrent tumor in areas that have previously received
radiotherapy.
(5) in palliative cases to reduce the bulk of the tumor and to promote
drainage from a blocked cavity (e.g., antrum).

60. Surgery.
Principles of surgery.
• Remove the whole tumour
• Ablative surgery excises the cancer with atleast a 2cm margin of clinically
normal tissue.
• Radical neck resection-removes the internal jugular vein, lymphatics,
accessory nerve, cervical sensory nerves, the sternomastoid, omohyoid and
often digastric muscles.
• Functional neck dissection preserves such vital structures.

61. Surgery.
• Retain as much normal anatomy and function as possible.
• Permit normal breathing-tracheostomy may be necessary.
• Support feeding through an NG tube or PEG.
• Reconstruct to produce acceptable function and cosmetics.

62. Surgery.
Surgery may fail due to:
• Incomplete excision
• Tumour seeding in the wound
• Unrecognized lymphatic or hematogenous spread
• Neural invasion
• Perineural spread

63. Surgery.
Advantages.
• Complete tumour and lymph node excision with full histological examination.
• Removal of involved bone.
• Use for radio-resistant tumours.
Disadvantages
• It is mutilating for very large tumours
• Possibility of perioperative mortality and morbidity although modern techniques
have significantly decreased these and the aesthetic and functional defects.
• Adequate surgical margins are required but may not be attainable due to the size
and the location of the tumor and limited information on the molecular status of the
margins.
• Surgery results in a sacrifice of structure and associated postsurgery fibrosis, which
may have important esthetic and functional considerations.

64. Deformity after tumour
resection

65. Surgery.
Complications.
• Carotid artery infection and rupture.
• Salivary fistula
• Issues with speech, swallowing, chewing and neurologic dysfunction

66. Surgery.
Advancements.
• Surgical excision of dysplastic and malignant lesions can be
accomplished with laser therapy.
• Such therapy for these lesions is generally well tolerated and usually
decreases the period of hospitalization and may have similar
outcomes as traditional surgical interventions.
• However, laser therapy has the disadvantage of limiting the
assessment of the margins for histopathologic confirmation.

67. Surgery.
• New approaches to reconstruction like;
• Vascularized flaps
• Free microvascular reconstruction
• Neurologic anastomoses of free grafts
• Reconstruction with the use of osseointergrated implants offers the
ability to provide stable prostheses and enhanced esthetic and
functional results.

68. Radiation Therapy.
• May be administered as the sole treatment modality for primary oral
cancers without obvious lymph node involvement and also for
inoperable tumors.
• Radiation therapy may be administered with intent to cure, as a single
modality, as part of a combined radiation surgery and/or
chemotherapy management, or for palliation.

69. Radiation Therapy.
Techniques.
• Interstitial therapy (brachytherapy; plesiotherapy) uses a radiation
source close to tumour and is suitable only for small tumours less
than 2cm and in certain sites.
• External beam radiation(teletherapy).Uses supervoltage radiation
which penetrates and is not particularly absorbed by bone and the
dose is fractionated in order to increase the differential effect on the
tumour

70. Radiation Therapy.
• Radiation kills cells by interaction with water molecules in the cells,
producing charged molecules that interact with biochemical
processes in the cells and by causing direct damage to DNA. The
affected cells may die or remain incapable of division.
• OSCCs are considered radiosensitive, and early lesions are highly
curable.
• Exophytic and well-oxygenated tumors are more radiosensitive,
whereas large invasive tumors with small growth fractions are
generally less responsive.

71. Radiation Therapy.
• Radical radiotherapy is intended to cure, the total dose is high, the
course of therapy is prolonged and early and late radiation effects are
common.
• In palliative care, radiation may provide symptomatic relief from pain,
bleeding, ulceration and oropharyngeal obstruction.
• Hyperfractionation of radiation(twice-daily dose)is used more
extensively as chronic complications appear to be reduced although
acute complications are more severe.

72. Radiation Therapy.
• To achieve therapeutic effects, radiation therapy is delivered in daily
fractions for a planned number of days.
• The more differentiated the tumour, the less rapid is the response to
radiotherapy.
• SCC limited to the mucosa is highly curable with radiotherapy than
the one that has spread to bone.
• The biologic effect of radiation depends on the dose per fraction, the
number of fractions per day, the total treatment time, the total dose
of radiation, and the radiation used (e.g., electron, neutron, proton).

73. Radiation Therapy.
Advantages.
• Radiation therapy has the advantage of treating the disease in situ and
avoiding the need for the removal of tissue and may be the treatment of
choice for many T1 and T2 tumors, particularly in the base of the tongue
and oropharynx.
• Radiation may be administered to a localized lesion by using implant
techniques (brachytherapy) or to a region of the head and neck by using
external beam radiation.
• Technical advances such as intensity-modulated radiotherapy (IMRT),
newer faster forms of image-guided IMRT (image-guided radiotherapy
[IGRT]), and proton beam therapy reduce the size of the high-dose field of
irradiation and limit the exposure of adjacent vital structures, including the
salivary glands.

74. Radiation Therapy.
• Has the potential to eradicate well- oxygenated tumor cells at the
periphery of a tumor and to manage subclinical regional disease.
• GA is not needed.
• Salvage surgery is still available if radiotherapy fails.

75. Radiation therapy.
Disadvantages
• Subsequent surgery is more difficult and hazardous and survival
further reduced.
• Failure is probably because of repopulation and hypoxia.
• Cure is uncommon for large tumours.
• Adverse effects are common.

76. Radiation Therapy.
Complications
1. Mucositis-widespread oral erythema, ulceration and soreness.
2. Salivary changes: xerostomia, which predisposes to caries,
candidiasis and bacterial acute ascending sialadenitis
3. Trismus arises because of reduced vascularity from the endarteritis
obliterans following radiotherapy leading to fibrosis in the muscles
of mastication and surrounding tissues.

77. Radiation Therapy.
4. Osteoradionerosis (ORN) is potentially the most serious complication
and follows endarteritis obliterans.
Mandible is more prone to ORN than the maxilla due to its high
density and poor vascularity.
The initiating factor is often trauma such as tooth extraction, oral
infection or ulceration from an appliance.
Presentation is of exposed bone in an irradiated mouth,with or
without external sinuses, pain and pathological fracture.
NB : The late complications of radiotherapy are due to effects on
vascular, connective, and slowly proliferating parenchymal tissues.

78. Radiation erythema and hair loss

79. Chemotherapy.
Cytotoxic Chemotherapy.
• Chemotherapy may be used as induction therapy prior to local
therapies, concurrent chemoradiotherapy (CCRT), and adjuvant
chemotherapy after local treatment.
• The objective of induction chemotherapy is to promote initial tumor
reduction and to provide early treatment of micrometastases.
• The principal agents that have been studied alone or in combination
in head and neck cancer are taxol and derivatives, platinum
derivatives (cisplatin and carboplatin), 5-fluorouracil, and
hydroxyurea.

80. Chemotherapy.
• CCRT protocols are now the standard of care for stage 3 and 4 as
primary therapy and for disease with poor prognostic findings
following surgery including close margin and vascular invasion by
tumor.
• CCRT, is associated with potential local toxicities, such as mucositis.
• Nausea, vomiting, and bone marrow suppression may also occur.

81. Chemotherapy.
Targeted therapy.
• Dental medicine has evolved and is now applying certain drugs in
what is termed targeted therapy. The drugs act as adjuncts or
replacements for older agents. The EGFR antibody, cetuximab
(Erbitux®, ImClone, New York, NY) has become the first new
chemotherapeutic accepted by the FDA for head and neck SCC in
decades.

82. Chemotherapy.
Combined Protocols.
• Cytotoxics and targeted therapy may be used in combination.

85. Photodynamic therapy.
• Photodynamic therapy applies light over a tissue that initially
absorbed exogenous sensitizer. The sensitizing agent may be
delivered systemically or topically and then after it selectively
accumulates in target tissue. The subsequent light delivery to the
target tissue results in cellular destruction.
• Complications associated with this mode of treatment is small.

86. Gene Therapy.
• Still under research.
• Main objective is reversing dysplasia in oral epithelial lesions.
• p53 gene, currently being targeted.

87. Immunotherapy.
• Immunotherapy offers the potential for additional approaches to
management, alone or in combination with other therapies.
• Based on an analysis of a gene expression profile in matched tumor
and normal fibroblast cell lines, a number of proteins have been
detected that might be potential targets for immunotherapy in
individuals with head and neck cancer.

88. 4. Prognosis.
Prognostic indicators for oral cancers include:
• Tumour factors:
• grade: well-differentiated OSCC have better prognosis.
• stage: and depth of infiltration, size of tumour and presence of metastases adversely
affect prognosis. Thus the prognosis for stage I tumours is around 85% 5-year
survival, but this figure plummets to 10% in stage IV tumours.
• Thickness: deep tumours have a worse prognosis.
• site: prognosis is better where the cancer does not involve the floor of mouth,
posterior tongue or maxilla.
• Lymph node factors: (invasion, capsular rupture, nodal site, number of
involved nodes). Nodal involvement decreases cure rates by around 50%.

89. Prognosis.
• Patient factors:
• The prognosis is usually worse for:
• male gender: possibly because of the somewhat later presentation of males for
treatment, or because of associated medical problems. Many male patients with oral
cancer are heavy smokers and drinkers, and some have cirrhosis and nutritional defects.
• habits: chronic alcohol consumption and tobacco smoking associate with a poor
prognosis.
• age: the poor general health of some aged patients may limit their resistance to the
disease or its treatment.
• Treatment factors:
• quality of surgical margins: if excision margins are tumour-free, prognosis is
better.

90. Prognosis.
Age as a prognostic indicator:
• The overall survival in younger patients is better than that of older patients.
• This could be due to:
• The more complex medical backgrounds of older patients may lead to additional systemic
complications.
• Likelihood of comorbidities in older patients may lead to poorer outcomes.
• Presence of comorbidities also limits treatment options.
• Reduced resistance to disease and treatment due to a decrease in the immune system’s
ability to initiate an effective immune response in older patients.
• Deterioration of the physical and nutritional status in older patients.
• A better vascular supply in younger patients renders effects of treatment to be widespread
and effective throughout the whole body.
• Younger patients are more energetic and have an aggressive immune system and can thus
withstand aggressive treatment increasing likelihood of treatment success.

91. Prognosis.
• Others include:
• presence of HPV (Cancers positive for HPV, particularly type 16, have a better
prognosis compared to HPV-negative tumors).
• perineural invasion.
• lymphocytic infiltrate at interface.
• underlying disease.

92. Prognosis.
• Cure rates decline rapidly if the lesion is not successfully managed
with initial therapy, and therefore, the initial approach to therapy is
critical.
• Locoregional causes of death from head and neck cancer may be due
to erosion of major vessels, erosion of the cranial base, nutritional
compromise, cachexia, and secondary infection of the respiratory
tract.

93. 5. Prevention.
• Involves interventions aimed at eliminating, eradicating, or minimizing the impact of the disease.
• Primary
Targets to reduces incidence of cancer and precancer.
• Primary prevention has focused on tobacco as a major cause of upper aerodigestive tract cancers, and
attention has been paid to strategies for tobacco cessation.
• Consumption of diets comprising fresh fruits and vegetables (balanced diet).
• Vitamin supplements have not been shown effective.
• HPV preventive vaccination, and appeal for reduction in numbers of sexual partners and reduced oral-genital
contact.
• Discourage alcohol consumption.
• Encourage good oral hygiene.
• Use of hat in sunlight for farmers
• Wearing of facemasks for factory workers involved with chemicals and metals
• Health education.
• Head and neck and oral examinations.
• Oral cancer screening in the primary dental care setting.

94. Prevention.
• Secondary
Aimed at detection of cancer at an early stage.
Early detection, esp at the precancerous stage, offers a better
prognosis with a better chance of cure.
• Public education on early signs and self examination.
• Screening.

95. Prevention.
• Tertiary
Treat late stage of disease and complications.

96. 6. Supportive and Rehabilitative care.
• Medications should not be used alone but should be part of a pain
control strategy that also includes; physical therapy, counseling,
relaxation therapy, biofeedback, hypnosis, and transcutaneous nerve
stimulation.
• Physical management of orofacial pain includes use of ice chips for
oral cooling and cold compresses.
• Alternative approaches considered to potentially affect pain in cancer
patients include biofeedback, hypnosis, relaxation, imagery, cognitive
behavioral training, acupuncture, transcutaneous nerve stimulation,
and massage therapy.

97. Supportive and Rehabilitative care
Artificial tears and saliva
• The lubricating property of methyl cellulose is of particular benefit in
the treatment of dry mouth & eyes. Solutions containing methyl
cellulose or similar cellulose derivatives are used as substitute for
tears or saliva if the natural production of these fluids is disturbed.

98. 7. Referral and Specialized care.
• What to refer- Consider an urgent referral (for an appointment within 2 weeks)
for assessment for possible oral cancer by a dentist in people who have either: A
lump on the lip or in the oral cavity, or A red or red and white patch in the oral
cavity consistent with erythroplakia or erythroleukoplakia.
• The following symptoms should also be considered when to refer patients; Ulcers
that do not heal
• Persistent lump in the mouth / throat · Persistent discomfort or pain in the mouth
• Persistent white or red patches in the mouth or throat · Difficulty in swallowing or
unintended weight loss
• Speech problems
• A lump in the neck
• Unusual bleeding or numbness in the mouth /face
• Loose teeth for no apparent reason
• Non-healing dental extraction socket(s)
head-and-neck-guidance-article-cancer.pdf (oxfordshireccg.nhs.uk)

99. Referral and Specialized care.
• Who to refer to- general dentist practitioners should refer patients
with the above symptoms to specialists i.e. oral pathologists and
specialized cancer and research hospitals and institutions.
• Management of referred patients- all the patients medical history and
information should also be included alongside with the symptoms
that warranted the referral.

100. • Healing.
• Immunity.
• Vascularity.
• Ability of the immune cells to move to site.
• Underlying disease.