Oral Cancer Management

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

1. ORAL CANCER
MANAGEMENT
Dr. Tun Ngwe, AP, DOMS
University of Dental Medicine, Yangon
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2. Oral Squamous cell carcinoma
Incidence
Sixth most common cancer worldwide
Third in developing countries
Fifth most common in Myanmar
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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
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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

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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
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7. 7
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N
Ulcer - lateral border
of the post 3
rd
of the
tongue
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Growth
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9. SCC Retromolar trigone
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10. Skin involvement SCC ( maxilla ) gingival
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11. SCC buccal with skin involvement
T
N
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12. SCC buccal mucosa SCC ( mandible )gingival
T
N
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13. SCC mandible
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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
 
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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
 
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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
TxPrimary tumour cannot be assessed
ToNo evidence of primary tumour
TisCarcinoma in situ
T1Tumour 2cm or less in greatest dimension
T2Tumour more than 2 cm but not more than 4 cm in
greatest dimension
T3Tumour 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. T
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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
T
N
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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
T
N
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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.
T
N
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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
MoNo distant metastasis
M1Distant 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 0Tis No Mo
Stage IT1 No Mo
Stage II T2 No Mo
Stage IIIT3 No Mo
 T1,2,3 N1 Mo
Stage IVT4 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%
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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
38
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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.
40
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N
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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 )
44
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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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N
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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

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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
T
N
Mandibulectomy
A
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48. Marginal resection - indicated where tumour has invaded or is in
close proximity to periosteum , the bone is uninvolved clinically or radiologically
T
N
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49. Segmental resection
T
N
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A
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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
T
N
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51. HEMI-MADIBULECTOMY - RESECTION OF A TUMOUR
BY REMOVAL OF THE TOTAL PART OF THE INVOLVED BONE
T
N
51
A
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52. Maxillectomy through Weber fergusson’s approach
T
N
52
A
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53. 53
T
N
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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
T
N
54
A
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55. Hemimaxillectomy
Specimens for biopsy – maxilla with
primary tumour and regional nodes
T
N
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A
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56. T
N
56
Post op
A
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57. Radical / extended - total maxillectomy including orbital
contents enbloc ( eye exenteration )
T
N
57
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58. GLOSSECTOMY - TONGUE RESECTION
local excision
partial glossectomy
hemiglossectomy
58
T
N
A
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59. Pre-op (wide excision ) Post-op
T
N
59
A
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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 )

60
T
N
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61. Composite resection –
 resection of a tumor with bone, adjacent soft tissue
and contiguous lymph node channels.
A
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61
T
N

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
A
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62
T
N

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
oLevel VI- perithyroid, delphian, tracheo-
oesophageal and anteriosuperior
mediastinum areas
oLevel VII- around mediastinum
T
N
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64. Nodal – sublevels
I A & IB – anterior belly of the
digastric
IIA & IIB – spinal acessory nerve
VA & VB – omohyoid muscle
T
N
64
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65. 65
T
N
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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
T
N
A
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67. CT – assessment of the nodal status
T
N
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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
T
N
68
A
u
g
u
s
t

3
,

2
0
1
8

69. 69
T
NSpinal acessory nerve
was preserved
FND type ?
A
u
g
u
s
t

3
,

2
0
1
8

70. T
N
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
A
u
g
u
s
t

3
,

2
0
1
8

71. TREATMENT OPTIONS FOR N0
-elective surgery
 -elective R/T
 -neck investigation ( CT or MRI)
 -wait and see
 
71
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

76. Soft tissue defect
primary closure ( for only small defect)
graft ( skin – FTG , STG )
flaps ( local, distant and free flap )
76
T
N
A
u
g
u
s
t

3
,

2
0
1
8

77. FREE GRAFT ( SKIN – FTG , STG )
T
N
77
A
u
g
u
s
t

3
,

2
0
1
8

78. FTG
T
N
78
A
u
g
u
s
t

3
,

2
0
1
8

79. STG
T
N
79
A
u
g
u
s
t

3
,

2
0
1
8

80. Harvesting from the donor site
T
N
80
A
u
g
u
s
t

3
,

2
0
1
8

81. Localflap
T
N
81
A
u
g
u
s
t

3
,

2
0
1
8

82. T
N
82
A
u
g
u
s
t

3
,

2
0
1
8

83. T
N
83
A
u
g
u
s
t

3
,

2
0
1
8

84. Distant flap
T
N
84
A
u
g
u
s
t

3
,

2
0
1
8

85. Micro-surgery – Free flap
T
N
85
A
u
g
u
s
t

3
,

2
0
1
8

86. Hard tissue defect
bone – cortical , cancellous
alloplastic ( nonbiological
materials – titanium ,
urethane , silicone ,
osseointegrated implants )
T
N
86
A
u
g
u
s
t

3
,

2
0
1
8

87. T
N
87
A
u
g
u
s
t

3
,

2
0
1
8

88. T
N
88
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

90. 90
T
N
What can you do ?
PREVENTIONS
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

93. Betel quid
betel leave
areca nut ( alkaloid , arecoline – collagensynthesis ,
tannin and flavanoid )
lime ( irritation )
tobacco
World no tobacco day - National strategic plan
93
T
N
A
u
g
u
s
t

3
,

2
0
1
8

94. World no tobacco day – 31
st
May , Tobacco free
environment , enforcement of new law – National
strategic plan
94
T
N
A
u
g
u
s
t

3
,

2
0
1
8

95.  reduce consumption of hot stuff – chillies ,
spices
 risk - remove chronic irritation - sharp tooth,
prosthesis , regular ( 6 monthly ) check-up , oral
examination
95
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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 9
th
CN
paresthesia of sensory supply
obstructive symptoms in nasal
98
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
100
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

102. 102
T
N
A
u
g
u
s
t

3
,

2
0
1
8

103. Screening procedures
Oral examination
Toulidine blue staining T
N
103
A
u
g
u
s
t

3
,

2
0
1
8

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
104
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
106
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
107
T
N
A
u
g
u
s
t

3
,

2
0
1
8

108. White lesions
T
N
108
A
u
g
u
s
t

3
,

2
0
1
8

109. T
N
109
A
u
g
u
s
t

3
,

2
0
1
8

110. T
N
110
A
u
g
u
s
t

3
,

2
0
1
8

111. T
N
111
A
u
g
u
s
t

3
,

2
0
1
8

112. Oral submucousfibrosis
T
N
112
Before treatment After treatment
A
u
g
u
s
t

3
,

2
0
1
8

113. Intra-lesional injection
T
N
113
A
u
g
u
s
t

3
,

2
0
1
8

114. Premalignant lesion was changed to malignant lesion which
was widely excised and SSG done
T
N
114
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
 
116
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
117
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
118
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
119
T
N
A
u
g
u
s
t

3
,

2
0
1
8

120. MUCOSITIS , ORAL ULCER
pain , topical anesthesia
Tricaine , mucaine
Enziclor – Benzydamine + Chlorhexidine 0.2% ,
Quadrajel – antiseptic , analgesic , Astrigent &
Demulscent gel
antibiotics moisturizing gel
120
T
N
A
u
g
u
s
t

3
,

2
0
1
8

121. CANDIDIASIS

antifungal oral suspension - Nystatin ,
mycostatin , miconazole
121
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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.
  122
T
N
A
u
g
u
s
t

3
,

2
0
1
8

123. MAIN GOAL
CURE
IF ?
PROLONGATION OF SURVIVAL
with better quality of life
 
123
T
N
A
u
g
u
s
t

3
,

2
0
1
8

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
T
N
A
u
g
u
s
t

3
,

2
0
1
8

125. 125
T
N
A
u
g
u
s
t

3
,

2
0
1
8