Oral Cancer

In detail about the GINGIVOBUCCAL COMPLEX CANCER
ANATOMY of Oral Cavity, Tonge, GBC.are well explained in detail.
RISK FACTORS
PREMALIGNANT LESIONS
PREMALIGNANT CONDITIONS

1. ORAL CANCER By : Dr. VALLURI MUKESH KRISHNA

2. INTRODUCTION GINGIVOBUCCAL COMPLEX CANCER

3. India has one of the highest incidence in the world. Oral cancer rank no.1 in males and 3 in females. 12% in males and 8% in females of all cancers. 4

4. GINGIVOBUCCAL COMPLEX CANCER Buccal Mucosa & Gingiva are involved Indian Oral Cancer Due to keeping Tobacco in Gingivobuccal Sulcus Indian Oral Cancer

5. ANATOMY ORAL CAVITY

6. ORAL CAVITY Consists of 1. Lips 2. The Floor of the Mouth 3. Anterior 2/3 rd of the Tongue 4. Buccal Mucosa 5. Upper & Lower Alveolar Ridges 6. Hard Palate 7. Retromolar Trigone

7. ORAL CAVITY ( Mouth ) The entire oral cavity is lined with mucous membrane tissue. The oral cavity consists of the following two areas: 1. The VESTIBULE is the space between the teeth and the inner mucosal lining of the lips and checks. 2. The ORAL CAVITY PROPER is the space contained within the upper and lower dental arches.

8. Extends from the LIPS to the OROPHARYNGEAL ISTHMUS. Its ROOF consists of the HARD and SOFT PALATES . The FLOOR is formed mainly of soft tissues, which include MUSCULAR DIAPHRAGM The TONGUE The LATERAL WALLS (cheeks) are muscular and merge anteriorly with the lips surrounding the oral fissure ORAL FISSURE ( The Anterior Opening Of The Oral Cavity ). OROPHARYNGEAL ISTHMUS opens into the oral part of the pharynx ( Posterior Aperture Of The Oral Cavity )

9. SLIT LIKE SPACE between the CHEEKS and the GUMS Superiorly and inferiorly limited by the reflection of MUCOUS MEMBRANE from LIPS and CHEEK onto the GUMS. The lateral wall of the vestibule is formed by the CHEEK. A. VESTIBULE

10. It is the cavity within the ALVEOLAR MARGINS of the MAXILLA and the MANDIBLE Its ROOF is formed by the HARD PALATE ANTERIORLY and the SOFT PALATE POSTERIORLY Its FLOOR is formed by the MYLOHYOID MUSCLE . The ANTERIOR 2/3RD OF THE TONGUE lies on the floor. B. ORAL CAVITY PROPER

11. Made up of 3 Structures : 1. A MUSCULAR DIAPHRAGM , which fills the u-shaped gap between the Left and Right sides of the Body of the MANDIBLE and is composed of the paired MYLOHYOID MUSCLES ; 2.Two cord-like GENIOHYOID MUSCLES above the diaphragm , which run from the MANDIBLE in front to the HYOID BONE behind ; 3.The TONGUE , which is Superior to the Geniohyoid muscles. Also present in the floor of the oral cavity proper are salivary glands and their ducts. FLOOR of Oral Cavity

12. MUSCLES of the FLOOR of ORAL CAVITY Muscles Origin Insertions Innervation Function Mylohyoid Mylohyoid line of mandible Median fibrous raphe and adjacent part of hyoid bone Nerve to mylohyoid from the inferior alveolar branch of mandibular nerve [V3] Supports & elevates floor of oral cavity; depresses mandible when hyoid is fixed; elevates & pulls hyoid forward when mandible is fixed Geniohyoid Inferior mental spines of mandible Body of hyoid bone C1 Elevates & pulls hyoid forward when mandible is fixed; depresses mandible when hyoid is fixed

13. Sensory ROOF : by GREATER PALATINE and NASOPALATINE nerves (branches of Maxillary Nerve ) FLOOR : by LINGUAL nerve (branch of Mandibular Nerve ) CHEEK : by BUCCAL nerve (branch of Mandibular Nerve ) Motor Muscle in the cheek ( BUCCINATOR ) and the lip ( ORBICULARIS ORIS ) are supplied by the branches of the FACIAL NERVE NERVE SUPPLY of Oral Cavity

14. Parasympathetic fibers & Taste Branches of the FACIAL NERVE [VII], which join and are distributed with branches of the TRIGEMINAL NERVE [V]; Sympathetic fibers From SPINAL CORD LEVEL T1 , synapse in the SUPERIOR CERVICAL SYMPATHETIC GANGLION , and are distributed along branches of the TRIGEMINAL NERVE [V]

15. All muscles of the tongue are innervated by the HYPOGLOSSAL NERVE [XII], Except the PALATOGLOSSUS muscle; vagus nerve [X]. Muscles of the soft palate are innervated by the vagus nerve [X] Except for the tensor veli palatini ; branch from the mandibular nerve [V3]. The muscle, mylohyoid, that forms the floor of the oral cavity is also innervated by the mandibular nerve [V3].

16. ANATOMY TONGUE

17. APEX OF TONGUE : Directed anteriorly and sits immediately behind the incisor teeth. Triangular in shape & blunt. ROOT OF TONGUE : is attached to the mandible and the hyoid bone. TONGUE

18. The superior surface of the oral part of the tongue is covered by hundreds of papillae: 1. FILIFORM PAPILLAE are small cone-shaped projections of the mucosa that end in one or more points; 2. FUNGIFORM PAPILLAE are rounder in shape and larger than the filiform papillae, and tend to be concentrated along the margins of the tongue; 3. VALLATE PAPILLAE , the largest of the papillae, which are blunt-ended cylindrical papillae in invaginations in the tongue's surface-there are only about 8 to 12 vallate papillae in a single v-shaped line immediately anterior to the terminal sulcus of tongue; 4. FOLIATE PAPILLAE are linear folds of mucosa on the sides of the tongue near the terminal sulcus of tongue. PAPILLAE of the TONGUE

19. The bulk of the tongue is composed of muscle. The tongue is completely divided into a left and right half by a median sagittal septum composed of connective tissue. This means that all muscles of the tongue are paired. There are INTRINSIC and EXTRINSIC lingual muscles. Except for the palatoglossus , which is innervated by the vagus nerve [X], all muscles of the tongue are innervated by the hypoglossal nerve [XII]. MUSCLES of the TONGUE

20. The intrinsic muscles of the tongue originate and insert within the substance of the tongue. They are : SUPERIOR LONGITUDINAL, INFERIOR LONGITUDINAL, TRANSVERSE, VERTICAL MUSCLES 1. Intrinsic Muscles

21. Extrinsic muscles of the tongue originate from structures outside the tongue and insert into the tongue. There are 4 major extrinsic muscles on each side : GENIOGLOSSUS HYOGLOSSUS STYLOGLOSSUS PALATOGLOSSUS. 2. Extrinsic Muscles

22. LINGUAL ARTERY : is the major ARTERY to the tongue. It originates from the External Carotid Artery . Also supplies the sublingual gland, gingiva, and oral mucosa in the floor of the oral cavity. DORSAL and DEEP LINGUAL VEINS : They accompany the lingual arteries in anterior parts of the tongue, but become separated posteriorly by the hyoglossus muscles. It joins the Internal Jugular Vein in the neck. VASCULAR Supply of the TONGUE

23. GLOSSOPHARYNGEAL NERVE [IX] : Taste and general sensation from the pharyngeal part of the tongue. LINGUAL NERVE : General sensory innervation from the anterior two-thirds or oral part of the tongue. FACIAL NERVE [VII] : Taste from the oral part of the tongue is carried into the central nervous system. HYPOGLOSSAL NERVE [XII] : All muscles of the tongue are innervated by the hypoglossal nerve [XII] except for the Palatoglossus Muscle , which is innervated by the VAGUS NERVE [X] . INNERVATION of the TONGUE

24. LYMPHATIC DRAINAGE of the TONGUE

25. ANATOMY GINGIVOBUCCAL COMPLEX

26. Buccal Mucosa Extends from Upper Alveolus to Lower Alveolus & Comissure in front to Retromolar Trigone behind

27. Gingiva The part of oral mucosa that covers the alveolar processes of jaws It has 4 parts 1. Gingival Sulcus 2. Free Gingiva 3. Interdental Gingiva 4. Attached Gingiva

28. Retromolar Trigone Triangle-shaped area of mucosa posterior to last mandibular molar that covers anterior surface of lower ascending ramus of mandible.

29. RISK FACTORS ORAL CANCER

30. 1 . Tobacco 2. Alcohol 3. Areca nut/ pan masala 4. Human Papilloma Virus 5. Epstein Barr Virus 6. Plummer Vinson Syndrome 7. Poor Nutrition

31. Relative Risk factors for Oral Cancers HABIT RELATIVE RISK % None 1% Betel nut Chewing 4% Smoking only 3-6% Betel chewing + Tobacco chewing 8-15% Betel chewing + Smoking 4-25% Betel+Tobacco+smoking 20%

32. EPIDEMIOLOGICAL TRIAD 47

33. HOST FACTOR AGE ( Old Age ) SEX ( Males ) RACE ( Whites ) CUSTOMS AND HABITS ( Tobacco & Reverse Smoking ) NUTRITION AND DIET ( Vit A, Vit C Iron Deficincy ) GENETIC PREDISPOSITION OCCUPATION ( Solar & UV Radiation ) 48

34. AGENT FACTOR Tobacco Biological Virus ( HSV, EBV, HPV, Herpes Simplex ) Fungal infection. Mechanical Chemical ( Arsenic, Dyes, nickel, Aromatic amines ) Nutritional ( Saccharin and Aflatoxin, High Fats, Low Protein, Folic Acid, Vit C Deficinecy diets. ) 49

35. ENVIRONMENTAL FACTOR Ultra-violet radiation ( Ca Lips ) Occupations - farming, fishing, forestry ( risk due to prolong exposure ) Countries near tropics and equator where air is cleaner and UV rays are not trapped cancers can account for about 60% of all oral cancers. Air pollution ( Aromatic hydrocarbons ) Water and air contaminated by toxins of industries 50

36. PREMALIGNANT LESIONS ORAL CANCER

37. HIGH RISK LESIONS Erythroplakia Speckled Erythroplakia Chronic Hyperplastic Candidiasis MEDIUM RISK LESIONS Oral Submucous Fibrosis Syphilitic Glossitis Sideropenic Dysphagia LOW RISK / EQUIVOCAL RISK Oral Lichen Planus Discoid Lupus Erethematosus Discoid Keratosis Congenita

38. 1. LEUKOPLAKIA Any white patch or plaque that cannot be characterized clinically or pathologically. Small, Well Circumscribed Homogenous White Plaque. Extensive lesions involving surface of oral mucus. Smooth or Wrinkled or Fissured White ~ 5mm Cannot be scraped off

39. Cracks, Bleeding, Redness, Erosions – turning malignant. Regression in 40% of cases 1-20% become malignant – 1 to 30 years.

40. 2. ERYTHROPLAKIA Any lesion of the oral mucosa that presents as a bright red plaque which cannot be characterized clinically or pathologically as any other recognizable condition. Irregular or Nodular May coexist with Leukoplakia Eroded area with demarcation against normal appearing mucosa.

41. PREMALIGNANT CONDITIONS ORAL CANCER

42. 1. ORAL SUBMUCOUS FIBROSIS Progressive disease in which fibrous bands form beneath oral mucosa. Scarring > Contracture > Limited Mouth Opening Patho – Epithilial Fibrosis + Atrophy + Epithelial Hyperplasia & Dysplasia Associated – Pan Masala / Areca nut / Tobacco / Alochol

43. 2. CHRONIC HYPERPLASTIC CANDIDIASIS Produce dense plaques of Leukoplakia ( commissures ) Extends to Vermillion or Facial Skin High incidence of Malignant Transformation ( Candida Albicans ) Rx = Topical Antifungals X 6 Weeks or Systemic Antifungals X 2 Weeks Sx = Excision or Laser Vaporization

44. PREMALIGNANT LESIONS PREMALIGNANT CONDITIONS Leukoplakia Oral submucous fibrosis Erythroplakia Oral lichen planus Leukokeratosis nicotina palatinae Actinic keratosis Candidiasis Syphilis Carcinoma in situ Discoid lupus erythematosus Sideropenic dysphagia

45. ORAL PRECANCER – An intermediate clinical state with increased cancer risk, which can be recognized and treated with a much better prognosis than a full blown cancer. PREMALIGNANT LESION – Morphologically altered tissue in which cancer is more likely to develop than its apparently normal counterpart. PREMALIGNANT CONDITION – A generalized state associated with significantly increased risk of cancer. 62

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