Oral & Maxillofacial Surgery Fifth Year

1. (Oral!Cancer!1)!
!ORAL!CANCER:!A!Silent!Killer!
Dr. Adel I. Abdelhady
!Assistant!Professor!Oral!!Surgery!
College!of!Den5stry,!Dammam!University!
!

2. Introduc7on!
• Cancer!of!the!oral!cavity!in!Saudi!Arabia!is!not!an!uncommon!
disease!!
• It!account!for!more!than!25%!of!all!malignancies,!in!the!
Southern!region,!it!might!reach!up!to!35%!!
• In!males,!it!is!third!in!frequency!following!lung!and!prostate!
cancer!
• In!females,!it!is!second!following!breast!cancer!!

3. Introduc7on!
• The!spectrum!of!malignant!tumours!to!affect!the!
oral!cavity!vary!widely!and!includes:!
– Surface(epithelium(
• Squamous!cell!carcinoma!over!90%!
– Glandular(epithelium(
• Adenocarcinomas!in!females!
• Mucoepidermoid!carcinomas!in!males!
– Mesenchymal(5ssues(
• Lymphomas,!Sarcomas!are!very!rare!

4. Introduc7on!
Surface(Epithelium
• 1K!Squamous!cell!Carcinoma!
• Undifferen5ated!carcinoma!
• Differen5ated!carcinoma!
• Adenoid!squamous!
carcinoma!
• Verrucous!carcinoma!
• 2K!Basal!cell!carcinoma!
• 3K!Malignant!Melanoma
!!
!!

5. Introduc7on!
Glandular(epithelium(
(1K!Adenocarcinoma!
!2K!Mucoepidermoid!
carcinoma!
!3K!Adenoid!cys5c!carcinoma!
!4K!Acinic!cell!carcinoma!
!5K!Undifferen5ated!
carcinoma! !!

6. Introduc7on!
• Acquired)capability)of)cancer)cell:)
– Limitless!replica7ve!poten7al!
– Evading!apoptosis!
– SelfJsufficiency!in!growth!signal!
– Insensi7ve!to!an7growth!signals!
– Sustained!angiogenesis!
– Tissue!invasion!and!metastasis!

7. Cancer—Pathophysiology!

8. Squamous!Cell!Carcinomas!!
• More!than!90%!of!cancers!of!the!oral!cavity!and!
oropharynx!are!squamous!cell!carcinomas!!
• Squamous!cells!are!flat,!scaleJlike!cells!that!normally!
form!the!lining!of!the!oral!cavity!and!oropharynx.!!
• Invasive!squamous!cell!carcinoma!means!that!the!
cancer!cells!have!spread!beyond!this!layer!into!
deeper!layers!of!the!oral!cavity!or!oropharynx.!!

9. E7ology!&!Risk!Factors!
! Tobacco:!About!90%!of!people!with!oral!
cavity!and!oropharyngeal!cancer!use!tobacco!!
! Alcohol:!Drinking!alcohol!strongly!increases!a!
smoker's!risk!of!developing!oral!cavity!and!
oropharyngeal!cancer.!!
! Ultraviolet!light:!More!than!30%!of!pa7ents!
with!cancers!of!the!lip!have!outdoor!
occupa7ons!associated!with!prolonged!
exposure!to!sunlight.!!
! Irrita5on:!LongJterm!irrita7on!to!the!lining!of!
the!mouth!caused!by!poorly!fi[ng!dentures!!

10. E7ology!&!Risk!Factors!
! Poor!nutri5on:!A!diet!low!in!fruits!and!vegetables!is!
associated!with!an!increased!risk!!
! Mouthwash:!Some!studies!have!suggested!that!
mouthwash!with!a!high!alcohol!content!!
! Human!papillomavirus!(HPV)!infec5on:!!
! Immune!system!suppression:!
! Age:!The!likelihood!of!developing!oral!and!
oropharyngeal!cancer!increases!with!age,!especially!
aer!age!35.!!
! Gender:!Oral!and!oropharyngeal!cancer!is!twice!as!
common!in!men!as!in!women,!Oral!cancer!is!the!sixth!
most!common!cancer!among!men.!

11. E7ology!&!Risk!Factors!
– Chemicals:!
• Asbestos,!NickelKChromate,!in!nasal!and!paranasal!sinuses!
tumours!
• Wood!dust!in!Adenocarcinoma!of!the!nose!
– Dietary!factors:!
• Vitamin!A!deficiency!
• Vitamin!B!deficiency,!PateresonKKelly!syndrome!
– Radia7on!exposure!
– Viruses:!!
•
•
•
•
Human!Papilloma!Virus!HPV!
EpsteinKBarr!Virus!EBV!
Human!Immunodeficiency!!Virus!HIV!
Hepa55s!virus!

12. • The!overall!survival!rate!for!oral!cancer!in!the!general!
!
popula7on!is!52%,!a!survival!rate!worse!than!
prostate,!uterine,!breast,!bladder,!cervical!and!colon!
cancers!
• A!5Jyear!survival!rate!for!African!American!men!with!
oral!cancer!is!approximately!34%.!With!early!
detec7on!and!treatment,!the!5Jyear!survival!rate!can!
increase!up!to!85%.!
• Even!though!Oral!cancer!is!typically!a!disease!of!older!
people!(60J70),!usually!because!of!their!longer!
exposure!to!the!risk!factors,!it!does!occur!in!younger!
individuals.!

13. Tobacco!&!Alcohol!
• We!know!that!tobacco!and!alcohol!can!
damage!cells!in!the!lining!of!the!oral!cavity!
and!oropharynx,!and!that!cells!in!this!layer!
must!grow!more!rapidly!to!repair!this!
damage.!!
• Many!of!the!chemicals!found!in!tobacco!
cause!damage!to!DNA,!which!contains!the!
cell's!instruc7ons!for!repair!and!growth.!!

14. Tobacco!&!Alcohol!
! Tobacco when kept in
! Scien7sts!are!not!sure!
mouth leaches out
whether!alcohol!directly!
carcinogens, which
damages!DNA,!but!they!
act on oral mucosa
have!shown!that!
causing neoplastic
alcohol!increases!
changes.
penetra7on!of!many!
! Habit of smoking is
DNAJdamaging!
also equally
dangerous.
chemicals!into!cells!!
!

15. !
!Chemicals!In!Chewing!Tobacco!And!Snuff
!
Includes:!
! Nuclear!waste!
! Cancer!causing!agents!
! Car!baeery!chemicals!
! Cyanide!(a!type!of!poison)!
! Arsenic!
! Lead!
! Formaldehyde!(normally!used!to!embalm!
!!!corpses)!‫!ﲢﻨﻴﻂ!اﳉﺜﺚ‬

16. Epidemiology!
• Incidence:!
• Global!incidence!of!cancer!is!10!million,!with!6!million!
deaths!(Sikora,!1999).!!
• Each!year,!oral!cancer!kills!more!people!in!the!US!than!
does!cervical!cancer,!malignant!melanoma,!or!Hodgkin's!
disease.!
• Oral!cancer!more!common!than!cervical!cancer!(Ries!et!
al.,!1998).!!
• Worldwide,!oral!cancer!is!the!sixth!most!common!cancer,!
represen7ng!about!5.5!%!of!all!malignancies!and!
approximately!2%!of!all!cancer!deaths.!
• However,!the!worldwide!incidence!of!oral!cancer!varies!
(India!and!Brazil!=!40%).!!!

17. Oral!Cavity!Cancer:!
Approximately!50%!of!pa7ents!diagnosed!with!oral!cancer!will!
ul7mately!die!of!their!disease!
! Annual!incidence!31,000!Americans;!350,000!worldJwide!
! Sixth!most!common!cancer!worldJwide!
! One!pa7ent!dies!from!oral!cancer!every!hour!in!the!U.S.!
! High!mortalityJ!50%!live!less!than!5!years!following!diagnosis!
! Disease!of!middleJage!and!elderly!males!95%!over!40;!66%!
males!
! Known!risk!factors:!alcohol!and!tobacco;!viruses!(HPV?)!
! Incidence!relates!to!socioJeconomical!factors!
! 90+%!squamous!cell!carcinomas!
! Frequent!lymph!node!metastasis!
! Mul7ple!primaries!

18. • Site:!
!Oral!cancers!usually!involve!the!tongue!sides!
and!ventral!surfaces,!lips,!floor!of!the!mouth,!
so!palate,!tonsils,!salivary!glands,!or!back!of!
the!throat.!!
• Age!and!Gender:!
!More!than!90%!of!oral!and!pharyngeal!
cancers!occur!in!individuals!over!45!(<10%!!!!!!
12.3%)!years!of!age;!males!are!more!likely!
than!females!to!develop!them!(2!:!1!!!!!!!!1.3!:!
1)!

19. Ae5ology!
! !Generally,!there!is!no!single!cause,!!which!is!
responsible!for!all!neoplasms.!
• Tobacco!x5!risk!factors!
compare!to!nonJsmoker,!
more!than!20!cig.!
Increased!risk!fac.!By!6!
folds!
• Alcohol!
• Chronic!irrita7on!dental!
Carcinogens!! factors!
• Radia7on!
• Chemicals!
• Diet!
• Immunity!
• Hereditary!
• HPV!&!syphilis!
Risk!groups:!
• Male!
• Old!age!
Combina5on!! • Smoker!and!drinker!
• Occupa7on!
• Viral!infected!pa7ents!
• Low!vit.!A,C,&!iron!lead!to!
increase!risk!of!cancer!
• Vit.!A!treat!leukoplakia!
• Atrophy!of!oral!mucosa!make!
suscep7ble!to!local!
carcinogens!

20. Precancerous)lesions)!
!
• 1.Oral leucoplakia
• It is characterized by
white patch on the
buccal mucosa or any
place in the mouth and
is adjacent to the place
where the tobacco quid
is kept. The less likely
place is floor of the
mouth and tongue
although 93% of
leucoplakia at this
sites turn malignant!

21. 27Erythroplakia)
!
• This!is!characterized!by!red!
velvety!patch!which!is!not!
associated!with!any!
trauma!or!inflamma7on.!It!
may!present!with!or!
without!leucoplakia.!This!
lesion!is!easily!missed!out!
but!is!considered!to!have!
great!malignancy!poten7al.!

22. Two!lesions!that!could!be!precursors!to!cancer!are!
!
leukoplakia!(white!lesions)!and!erythroplakia!(red!
lesions).!Although!less!common!than!leukoplakia,!
erythroplakia!and!lesions!with!erythroplakic!
components!have!a!much!greater!poten7al!for!
becoming!cancerous.!!
Any!white!or!red!lesion!that!does!not!resolve!itself!in!
two!weeks!should!be!reevaluated!and!considered!for!
biopsy!to!obtain!a!defini7ve!diagnosis.!

23. 3.Oral sub mucous fibrosis!
• This condition is
characterized by limited
opening of mouth and
burning sensation on
eating of spicy food.
This is a progressive
lesion in which the
opening of the mouth
becomes progressively
limited, and later on
even normal eating
becomes difficult.

24. Carcinogenesis!
• The!mucosa!is!thought!to!be!
primed!to!develop!malignant!
tumours!by!exposure!to!repeated!
carcinogenic!insults!which!cause!
mucosal!altera7ons.!
• !These!altera7ons!may!include:!
• Chromosome!altera7ons,!!
• Gene!muta7ons,!!
• Other!molecular!abnormali7es!
• Field!canceriza7on!

26. Field change & arising of a further tumour

27. Primary!Lesion!of!the!previous!pa7ent!

29. Metasta7c!Carcinoma!In!Jaws!
• 1.! ! Metastasis! in! jaws! or! (rarely)! oral! so_! 5ssues,!
especially!from!cancer!of:!
•
•
•
•
•
•
Breast!!
Lung!!
Prostate!
Thyroid!
Kidney!
Stomach!!

30. Metasta7c!Carcinoma!In!Jaws!
! Metastasis!is!a!feature!of!malignancy;!by!defini7on,!
benign)neoplasm)never)metastasize!!
! Tumor!emboli!are!carried!by!lymph!or!blood!to!
distant!sites!oen!forming!secondary!tumor!colonies!
(metasta7c!colonies,!or!metastases)!
! Although!most!malignant!neoplasm!acquire!the!ability!
to!metastasize,!at!least!one,!the!basal!cell!carcinoma,!
doesn't.!This!very!common!skin!cancer!shows!
anaplasia!and!invasion,!but!rarely!metastasizes.!
!

31. Invasion!
Invasion!is!the!direct!extension!of!a!
malignant!neoplasm!into!the!
surrounding!7ssues;!the!term!implies!
that!cells!are!s7ll!aeached!to!the!
main!tumor!mass.!

32. Theories!Of!Invasion!
Three! theories! about! invasion! exist! (Pauli,! B.! U.! and!
!!
Knudson,!W.,!1988):
(1)!The!Mechanical!Theory:!!
! whereby! the! tumour! mass! is! rapidly! increasing! by!
permanent! cycling! and! prolifera7on,! so! that! the!
surrounding! 7ssues! are! at! first! compressed! by! the!
growing! mechanical! pressure,! and! later,! the! normal!
cells! separate! to! give! way! to! the! invading! front! of!
tumour!cells.!

33. Theories!of!invasion!
(2)!The!Enzyma5c!Theory,!!
which!assumes!the!produc7on!of!ly7c!enzymes!that!
destroy!the!contacts!between!normal!cells!and,!in!part,!
destroy!the!cells!themselves!par7cularly!the!ECM!.!

34. Theories!of!invasion!
(3)!The!migratory!theory:!
! ! It!originates!from!the!idea!that!tumour!cells!become!
mobile! and! migrate! into! the! surrounding! normal!
7ssue.! ! ! Malignant! cells! may! detach! from! the! main!
tumor!mass,!enter!the!surrounding!7ssues,!penetrate!
basement! membranes,! and! enter! thinJwalled!
lympha7cs,! capillaries,! or! venules.! Malignant! cells!
within!these!vessels!are!known!as!"tumor!emboli."!
• As!Pauli!and!Knudson!have!carefully!discussed,!these!
mechanisms!are!interdependent!and!must!act!in!coJ
ordina7on!to!enable!tumour!cells!to!spread!from!the!
primary!tumour!to!distant!sites.!!

35. !
The!most!common!sites!
of!the!oral!cancer!is!the!
tongue!and!the!floor!of!
the!mouth.!The!other!
common!sites!are!
buccal!ves7bule,!buccal!
mucosa,!gingiva!and!
rarely!hard!and!so!
palate.!Cancer!of!buccoJ
pharyngeal!mucosa!is!
common!in!smokers.!

36. Featured)Which)Demand)Careful)
ConsideraCon)From)Examiner)Are))
1JChronic!ulcer!or!fissures!with!no!apparent!cause,!or!
ones!which!do!not!respond!to!simple!treatment!
! 2JSwelling!with!no!apparent!cause,!but!no!marked!
edema!or!redness!
! 3JRapid!and!unexpected!loosening!of!a!group!of!
teeth,!irregular!bone!destruc7on!seen!
radiographically!
! 4JSigns!of!infiltra7on,!such!as!tethering!of!an!organ!
or!lump!or!limita7on!of!normal!movement!of!the!part!
!

37. !
5JSigns!of!involvement!of!adjacent!nerves!producing!persistent!
pain,!anesthesia!of!part,!or!paralysis!of!muscles.!
6JRepeated,!small!hemorrhages!from!a!par7cular!part!
7JSigns!of!obstruc7on!of!related!ducts!!salivary!ducts!
8JEnlarged!lymph!nodes!without!surrounding!edema!and!no!
obvious!cause!

38. ! 9JAn!abscess!with!no!apparent!cause!which!
!!
!
may!be!a!necro7c!neoplasm!
! 10JAnaemia!with!no!obvious!cause!
! 11JSwea7ng,!malaise,!and!toxicity!not!due!to!
an!obvious!infec7on!!
! 12Jdifficulty!chewing!or!swallowing,!ear!pain,!
difficulty!moving!the!jaw!or!tongue,!
hoarseness,!numbness!of!the!tongue!or!other!
areas!of!the!mouth,!or!swelling!of!the!jaw!that!
causes!dentures!to!fit!poorly.!!!

39. !Warning!Symptoms!&!Signs!Of!Oral!Cancer!
! a!sore!in!the!mouth!that!does!not!heal!
(most!common!symptom)!!
! pain!in!the!mouth!that!doesn't!go!away!
(also!very!common)!!
! a!persistent!lump!or!thickening!in!the!
cheek!!
! a!persistent!white!or!red!patch!on!the!
gums,!tongue,!tonsil,!or!lining!of!the!
mouth!!
! a!sore!throat!or!a!feeling!that!something!
is!caught!in!the!throat!that!doesn't!go!
away!!

40. !!Symptoms!&!Signs!Of!Oral!Cancer!
! Difficulty!chewing!or!swallowing!!
! Difficulty!moving!the!jaw!or!tongue!!
! Swelling!of!the!jaw!that!causes!dentures!
to!fit!poorly!or!become!uncomfortable!!
! Loosening!of!the!teeth!or!pain!around!the!
teeth!or!jaw!!
! Voice!changes!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
! A!lump!or!mass!in!the!neck!!
! Weight!loss!!
! Persistent!bad!breath!!

41. Signs!and!Symptoms!
• It!can!go!unno7ced,!it!can!be!painless!
• It!may!appear!as!a!white!or!red!patch!of!7ssue!in!the!
mouth,!or!a!small!indurated!ulcer!
• May!be!or!not!accompanied!with!relevant!
lymphadenopathy!
• It!is!important!to!have!a!biopsy!for!any!sore!or!
discolored!area!in!the!pa7ent’s!mouth,!which!does!
not!heal!within!14!days!!

43. Presenta7on!of!oral!carcinoma!

44. How!to!Detect!and!Diagnose!Oral!Cancer!
! Many!cancers!of!the!oral!cavity!and!oroJ
pharynx!can!be!found!early,!during!rou7ne!
screening!examina7ons!by!a!doctor!or!den7st,!
or!by!selfJexamina7on.!!

45. What!You!Can!Do?!
• EXAMINE!your!pa7ents!at!each!visit!
• TAKE!A!HISTORY!of!their!alcohol!and!
tobacco!use!!
• INFORM!your!pa7ents!of!the!associa7on!between!
tobacco!use,!alcohol!use,!and!oral!cancer!!
• FOLLOWKUP!to!make!sure!a!defini7ve!diagnosis!is!
obtained!
• Have!a!biopsy!from!any!non!responding!lesions!

46. Preven5ve!instruc5ons!to!your!pa5ent!
•
•
•
•
Stop!smoking!(this!includes!cigareees,!cigars!and!pipes)!!
Stop!the!use!of!chewing!tobacco!and!snuff!!
Do!not!drink!alcohol!at!all!!
Maintain!good!oral!hygiene!J!this!includes!regular!brushing,!
flossing!and!regular!checkups!and!cleanings!at!the!den7st's!
office.!!
• If!you!spend!7me!outside,!protect!yourself!from!the!
damaging!rays!of!the!sun.!Wearing!a!wide!hat!will!offer!extra!
protec7on!to!your!face.!!
• If!you!are!aware!of!anything!that!causes!frequent!irrita7on!
to!the!inside!of!your!mouth,!take!measures!to!prevent!this!
irrita7on.!!
• Examine!the!inside!of!your!mouth!regularly.!!

47. Instruc7ons!to!the!Pa7ent!
• You!should!always!contact!
your!doctor!or!den7st!
immediately!if!you!no7ce!the!
following!symptoms!in!
yourself!or!a!loved!one:!
• A!sore!or!lesion!in!the!mouth!
that!does!not!heal!within!two!
weeks.!!
• A!lump!or!thickening!in!the!
cheek.!!
• A!white!or!red!patch!on!the!
gums,!tongue,!tonsil,!or!
lining!of!the!mouth.!!
• A!sore!throat!or!a!feeling!
that!something!is!caught!
in!the!throat.!!
• Difficulty!chewing!or!
swallowing!dysphagia!or!
painful!of!swallowing!
• Difficulty!moving!the!jaw!
or!tongue.!!!
• Numbness!of!the!tongue!
or!other!area!of!the!
mouth.!!
• Swelling!of!the!jaw!that!
causes!dentures!to!fit!
poorly!or!become!
uncomfortable.!!

48. Management!of!oral!cancer!
• The!management!of!oral!cancer!has!undergone!
radical!change!in!the!last!10!years!and!con7nues!to!
evolve!rapidly.!
• Discoveries!in!molecular!biology,!diagnos7c!
techniques,!surgery,!radia7on!therapy!and!medical!
oncology!have!altered!many!tradi7onal!concepts!
• Of!all!the!procedures!available!to!control!oral!cancer,!
none!has!affected!survival!as!much!as!has!early!
detec7on.!.!

49. Examina7on!and!diagnos7c!methods!
• Health!history!
• History!of!the!lesion!
• Clinical!examina7on!
• Radiographic!examina7on:!Head!and!Neck!CT,!MRI!for!
the!primary!lesion!and!lymph!nodes!by!FNA!and!PER.!
• Laboratory!inves7ga7on:!
• Blood,!enzymes,!electrolytes,!biopsies!

50. Rou7ne!head!and!neck!examina7on!!
The!examina7on!is!conducted!with!the!pa7ent!
seated.!Any!intraoral!prostheses!(dentures!or!
par7al!dentures)!are!removed!before!star7ng!the!
examina7on.!The!extraoral!and!periJoral!7ssues!
are!examined!first,!followed!by!the!intraoral!
7ssues.!
!

51. Oral!Cavity!Screening!
• screening,!which!involves!the!examina7on!of!
the!oral!cavity!as!a!whole!and!not!just!your!
teeth.!Besides!a!visual!examina7on!of!all!the!
7ssues!in!your!mouth,!your!doctor!will!feel!the!
floor!of!your!mouth!and!por7ons!of!the!back!
of!your!throat!with!his!fingers,!in!the!search!
for!abnormali7es.!!

52. !
A!thorough!oral!screening!also!includes,!!!examina7on!
of!the!nasopharynx!and!larynx,!and!involves!manually!
feeling!the!neck!for!swollen!lymph!nodes,!and!other!
abnormali7es!such!as!hardened!masses.!!
Doctor!will!also!check!the!mouth!for!white!patches,!red!
patches,!ulcera7ons,!lumps,!loose!teeth,!and!review!
your!dental!xJrays!for!abnormali7es.!Be!sure!to!tell!the!
doctor!if!you!have!been!a!tobacco!user!in!any!form.!
Tobacco!use!is!implicated!in!more!than!75%!of!all!oral!
cancers!

53. •
!
Diagnosis!
Ini7ally!oral!cancer!may! ! • Diagnosis!is!established!by!
be!asymptoma7c!but!a!
check!up!of!a!small!
ulcera7ve!lesion!from!a!
professional!is!
recommended.!
• !But!pa7ents!normally!
presents!when!pain!and!
discomfort!is!
predominant!and!then!
the!prognosis!becomes!
poor.!
!
many!ways!like!applying!dyes!
like!toluidine!blue!which!may!
give!false!posi7ve!results!in!
inflammatory!lesion!but!never!
false!nega7ve,!using!X!rays!and!
scans!to!see!the!extension!of!
the!lesion!and!the!bony!
involvement!and!the!most!
confirmatory!test!is!biopsy!of!
the!lesion!and!its!histoJ
pathological!examina7on!

54. The!ExtraKoral!Examina5on!
• The!extraJoral!assessment!includes!
an!inspec7on!of!the!face,!head,!
and!neck.!The!face,!ears,!and!neck!
are!observed,!no7ng!any!
asymmetry!or!changes!on!the!skin!
such!as!crusts,!fissuring,!growths,!
and/or!color!change.!!
• The!regional!lymph!node!areas!are!
bilaterally!palpated!to!detect!any!
enlarged!nodes,!and!if!detected,!
their!mobility!and!consistency.!!
• A!recommended!order!of!examina7on!
includes!these!regions:!
• Preauricular!!
• Submandibular!!
• Anterior!Cervical!!
• Posterior!Auricular!!
• Posterior!Cervical!

55. !

58. Lips!
• Begin!examina7on!by!
observing!the!lips!with!the!
pa7ent's!mouth!both!
closed!and!open.!Note!the!
color,!texture!and!any!
surface!abnormali7es!of!
the!upper!and!lower!
vermilion!borders.!

59. Surgical!anatomy!
• The(Lip:(
– Covered!with!nonKkera5nized!
stra5fied!squamous!epithelium!
which!is!transparent,!appear!red,!and!
contain!no!hair,!sebaceous!gland!or!
pigments!
– On!the!vermilion!border!it!closely!
cover!the!orbicularis!oris!muscle!but!
on!the!lingual!side!mucous!gland!is!
present!within!the!muscle!and!
mucosa!
– The!epithelium!is!2!mm!away!from!
the!muscle,!ulcera5ve!lesions!will!be!
fixed!early!in!the!disease!!!

60. Surgical!anatomy!The(Lip(
– Lympha7c!drainage:!
• Mucosal!and!cutaneous!systems.!
• Lower!lip:!
– One!medial!trunk!which!drain!the!inner!third!of!the!lip!into!
the!submental!group!
– Two!lateral!trunk!which!drain!the!outer!twoJthird!into!the!
submandibular!lymph!nodes!
– Anastomosis!account!for!bilateral!metastases!
• Upper!lip:!
– Drain!into!the!periauricular,!paro7d,!submandibular!and!
submental!lymph!nodes!

61. Surgical!anatomy!The(Lip(
• Age!and!sex:!
– The!sixth!decade!and!Male!:!female!
ra5o!is!80:1!
• 93%!affect!the!lower!lip!with!
squamous!cell!carcinoma,!
exophy7c!type!!
• 5%!in!the!upper!lip!and!commonly!
basal!cell!carcinoma,!commoner!
in!females!
– Solar!exposure,!more!radia5on!on!
the!lower!lip!
– Commoner!in!fair!complexion!
– Smoker!mainly!pipe!
– In!the!upper!lip,!SCC!metastasizes!
earlier!than!lower!lip!!

62. !
IntraKoral!examina5on!!
•
!
!
!
Labial!Mucosa!With!the!
pa7ent's!mouth!par7ally!
open,!visually!examine!the!
labial!mucosa!and!sulcus!of!
the!maxillary!ves7bule!and!
frenum!and!the!mandibular!
ves7bule.!!
• Observe!the!color,!texture,!
and!any!swelling!or!other!
abnormali7es!of!the!
ves7bular!mucosa!and!
gingiva.!
!
!!

63. Buccal Mucosa
Retract!the!buccal!mucosa.!Examine!first!
the!right!then!the!le!buccal!mucosa!
extending!from!the!labial!commissure!
and!back!to!the!anterior!tonsillar!pillar.!!
Note!any!change!in!pigmenta7on,!color,!
texture,!mobility!and!other!abnormali7es!
of!the!mucosa,!making!sure!that!the!
commissures!are!examined!carefully!and!
are!not!covered!by!the!retractors!during!
the!retrac7on!of!the!cheek.!

64. Surgical!anatomy!!
• The!buccal!mucosa:!
– Covered!with!nonJkera7nizing!
stra7fied!squamous!
epithelium!with!mul7ple!
minor!salivary!glands!
– It!is!7ght!over!the!buccinator!
muscle!and!fixed!to!the!upper!
and!lower!sulci!
– Lympha7c!drainage:!
• The!submandibular!lymph!
nodes!to!the!lower!deep!
cervical!chain!

65. Gingiva
• First,!examine!the!buccal!and!labial!
aspects!of!the!gingiva!and!alveolar!
ridges!(processes)!by!star7ng!with!the!
right!maxillary!posterior!gingiva!and!
alveolar!ridge!and!then!move!around!
the!arch!to!the!le!posterior!area.!Drop!
to!the!le!mandibular!posterior!gingiva!
and!alveolar!ridge!and!move!around!the!
arch!to!the!right!posterior!area.!!
• Second,!examine!the!palatal!and!lingual!
aspects!as!had!been!done!on!the!facial!
side,!from!right!to!le!on!the!palatal!
(maxilla)!and!le!to!right!on!the!lingual!
(mandible).!

66. Tongue!
• With!the!pa7ent's!tongue!at!rest,!
and!mouth!par7ally!open,!inspect!
the!dorsum!of!the!tongue!for!any!
swelling,!ulcera7on,!coa7ng!or!
varia7on!in!size,!colour,!or!
texture.!!
• Also!note!any!change!in!the!
paeern!of!the!papillae!covering!
the!surface!of!the!tongue!and!
examine!the!7p!of!the!tongue.!
! !The!pa7ent!should!then!protrude!
the!tongue,!and!the!examiner!
should!note!any!abnormality!of!
mobility!or!posi7oning.!

67. Posterior!of!the!Tongue!
• With!the!aid!of!mouth!mirrors,!
inspect!the!right!and!le!lateral!
margins!of!the!tongue.!
• Grasping!the!7p!of!the!tongue!with!
a!piece!of!gauze!will!assist!full!
protrusion!and!will!aid!examina7on!
of!the!more!posterior!aspects!of!the!
tongue's!lateral!borders.!

68. Surgical!anatomy!
• The(tongue:(
– Specialized!kera7nized!epithelium!
with!collec7on!of!minor!salivary!
gland!and!muscle!fibres!
– The!interlacing!muscle!fibres!form!
an!easy!pathway!for!cancer!
spread!and!the!constant!
movement!of!the!tongue!
disseminates!the!disease!widely!
• Excision!should!be!wide!with!2!cm!
safe!margin!

69. Ventral surface of the tongue and
floor of the mouth
• Then!examine!the!ventral!
surface.!Palpate!the!tongue!
to!detect!growths.!
• With!the!tongue!s7ll!
elevated,!inspect!the!floor!of!
the!mouth!for!changes!in!
color,!texture,!swellings,!or!
other!surface!abnormali7es.!

70. Surgical!anatomy!The(tongue(
• A!disease!of!the!middle!age!and!
elderly!with!equal!sex!incidence!
• 85%!occurs!in!the!lateral!border!of!
the!anterior!2/3,!!while!7p,!
dorsum!and!ventral!surface!are!
rarely!involved!
• The!lesion!may!be!infiltra7ve!
(small!on!the!outside!but!
palpa7on!shows!deep!invasion)!or!
exophy7c!and!usually!of!the!wellJ
differen7ated!type!

71. Surgical!anatomy!The(tongue(
(
Lymph!drainage:!
Tip!of!the!tongue:!
To!the!submental!lymph!nodes!–!to!the!lower!
deep!cervical!chains!
The!anterior!2/3:!
the!lower!deep!cervical!chains!–!juguloK
omohyoid!nodes!
Suprahyoid(block(dissec5on(of(no(value(
The!posterior!1/3:!
drain!to!the!upper!deep!cervical!chains!
The!5p!and!middle!part!of!the!tongue!have!
rich!bilateral!capillary!network!but!less!in!
the!lateral!margins!
The!UKshaped!floor!of!the!mouth!drain!to!the!
submandibular!lymph!nodes!
Bilateral!drainage!from!the!anterior!part!of!
the!U!

72. Bimanual!mouth!floor!examina7on!
• Bimanually!palpate!the!
floor!of!the!mouth!for!
any!abnormali7es.!All!
mucosal!or!facial!7ssues!
that!seem!to!be!
abnormal!should!be!
palpated.!

73. Hard!and!so_!palate!
• With!the!mouth!wide!open!and!
the!pa7ent's!head!7lted!back,!
gently!depress!the!base!of!the!
tongue!with!a!mouth!mirror.!
First!inspect!the!hard!and!then!
the!so!palate.!
• Examine!all!so!palate!and!
oropharyngeal!7ssues.!

74. Tongue!and!cheek!carcinoma!

75. SCC of the body of the mandible
Intra-oral photograph
* CT Scan (Bony invasion)

76. Factors!describes!the!degree!of!
malignancy!
• The!degree!of!histological!differen7a7on!of!
Malignant!neoplasm!are!histologically!
classified!as:!
• 1JWell!differen7ated!
• 2J!Moderately!differen7ated!
• 3J!Poorly!differen7ated!

77. Most!common!routes!of!!
spread!of!oral!carcinoma!
• 1JLocal!spread!is!achieved!by!direct!invasion!
and!infiltra7on!of!adjacent!stractures.!
• 2JPerineural!invasion!!
• 3JRegional!spread!to!the!neck!lymph!nodes!
occurs!via!lympha7c!route!
• 4JSpread!to!distal!organs!follows!the!
hematogenous!route!

78. Test!for!metasta7c!workJup!of!oral!
cancer!
• 1J!Blood!and!biochemical!profile!
• 2JChest!xJray,!liver!ultrasound(abdominoJ
pelvic!sonar),!bone!scan!
• 3J!CT!and!MRI!
• 4J!PanJendoscopy!

79. Quiz!????!Management!

80. • The!lesion!should!be!reJbiopsied.!Tissue!
sampling!should!be!obtained!from!mul7ple!
sites!of!the!lesion.!
• If!this!ac7on!does!not!solve!the!diagnos7c!
problem!,!a!second!opinion!from!another!
pathologist!might!be!appropriate!before!any!
final!treatment!decision!is!reached!!

81. Assessment!
• Clinical(Examina5on:(
– Tumours,!when!first!seen,!are!almost!
always!confined!to!the!head!and!neck!with!
no!distant!metastasis!
– Head!and!neck!tumours!are!rarely!
irremovable,!all!structures!can!be!removed!
with!the!tumour!in!con7nuity!and!repaired!
later!!
• The!majority!of!cases!are!poten5ally!treatable!!!

82. Assessment!
• Whether!to!treat!or!
not!depend!on:!
– the!age!
– the!health!status!of!
the!pa5ent!!
– advance!stage!
– local!disease!!

83. Assessment!
• Full!assessment!will!lead!to!
one!of!the!following!
conclusions:!
– Pa5ent!is!poten5ally!
curable!
– Primary!tumour!is!curable!
but!pa5ent!develop!
another!illness!
– Pa5ent!is!incurable!and!
should!not!be!treated!

84. Assessment!
•
The!pa7ent!general!condi7on:!
– Assessed!with!full!inves7ga7on!and!classified!for!
performance!status!
1. Grade)0 !Fully!ac7ve!without!restric7on!
2. Grade)1 !Ambulatory!but!restricted!in!!!!
physically!strenuous!ac7vity!
3. Grade)2 !Ambulatory!but!unable!to!carry!out!
any!work!ac7vity!
4. Grade)3 !Confined!to!bed!but!capable!of!
limited!self!care!
5. Grade)4 !Confined!to!bed!and!unable!to!carry!
out!any!self!care!
!
!
!
!
!
!Karnofsky(Status(

85. Assessment!
• Examina5on:!
– Think!in!term!of!T!Staging,!delineate!its!border!by!
inspec7on!and!palpa7on!
– Record!and!draw!the!lesion!from!different!angles!
using!normal!anatomical!landmarks!
– The!status!of!teeth!should!be!assessed!as!
causa7ve!and!if!radiotherapy!is!to!considered!!

86. Assessment!
• Staging!of!cancer:!
– Subdividing!the!malignant!lesion!into!
groups!with!similar!behavior!
• Act!as!a!guide!to!appropriate!treatment!!
• Act!as!a!guide!to!prognosis!
• Permits!more!reliable!comparison!of!results!
– Primary(site:(
» Histological!type,!size!and!extend!of!the!primary!
– Node(metastasis(
– Haematogenous((metastasis(

87. Staging)TNM)
• Primary(Tumour:(
– Indicated!by!the!leeer!T!and!the!suffix!1,2,!3!
or!4!represent!more!advancing!disease!
• T1(–!tumour!2!cm!or!less!
• T2!–!tumour!more!than!2!but!less!than!4!cm!
• T3(–!tumour!more!than!4!cm!
• T4!–!Tumour!more!than!4!cm!with!deep!invasion!of!
underlying!7ssues!
– T0!–!No!evidence!of!primary!tumour!
– Tis!–!Carcinoma!in!Situ!
– TX!–!Extend!of!primary!tumour!cannot!be!assessed!

88. Staging!
• Lymph!node:!
– Is!used!to!describe!progressive!lymph!node!
involvement!
– NxJ!Regional!lymph!node!cannot!be!assessed!
– N0J!No!Regional!lymph!node!metastasis!!
• N1!–!Metastasis!in!a!single!ipsilateral!nodes!!!>3!cm!!!
• N2!–!Single!ipsilateral!nodes!!<!!3!cm!but!!>6!cm,!or!
mul7ple!clinically!posi7ve!ipsilateral!less!than!6!cm!
– N2a!–!Single!<!!3!cm!but!!>6!cm!
– N2b!–!Mul7ple!none!!<!6!cm!
– N2CJ!metastasis!in!a!bilateral!or!!contralateral!!LN!
• N3(–!Clinically!posi7ve!ipsilateral!more!than!6!cm,!
Bilateral!or!contralateral!
– N3a!–!ipsilateral!more!than!6!cm!
– N3b!–!Bilateral,!each!side!staged!separately!
– N3c!–!Contralateral!only!

89. Staging!
• Distant!metastasis:!
– M0!–!No!metastases!present!
– M1!–!Metastases!clinically!demonstrable!
• MX!–!Metastases!cannot!be!assessed!

90. Staging!
• TNM!Staging:!
– Stage!I:!T1,!N0,!M0!
– Stage!II:!T2,!N0,!M0!
– Stage!III:!T3,!N0,!M0!
!!
!!!!!T1,!2!or!3,!N1,!M0!
– Stage!IV:!T4,!N0!or!1,!M0!
!!
!!!!!T1!–!4,!N2!or!3,!M0!
!!
!!!!!T1!–!4,!N1!–!3,!M1!!!
!!
!
!
!
!
!AJCC(1983(

91. Staging!
Stage!I!!
• compromise!nega7ve!nodes!and!operable!primary!
Stage!II!!
• operable!primary!with!operable!nodes!
Stage!III!
• inoperable!due!advanced!primary!or!advanced!nodal!
involvement!
Stage!IV!!
• Distant!metastases!preclude!any!surgical!interven7on!!

93. (Oral!Cancer!2)!
!ORAL!CANCER:!A!Silent!Killer!
Dr. Adel I. Abdelhady
!Assistant!Professor!Oral!!Surgery!
College!of!Den5stry,!Dammam!University!
!

94. !
BIOPSY!

95. Defini7on:!
! Removal!of!!7ssue!from!living!beings!for!
macroscopic!examina7on!,microscopic!!!
! !!!analysis,!bacterial!analysis!!&!combina7on!of!
above!is!called!!“BIOPSY!

96. BIOPSY!

97. INDICATIONS!!
1.To!determine!the!nature!of!lesion!which!does!not!
readily!respond!to!conserva7ve!&!simple!therapy.!
2.To!determine!the!nature!of!the!lesion!which!is!!
unknown.!
3.To!establish!the!diagnosis!where!there!is!
suspecious!of!neoplasm.!
4.To!determine!nature!of!any!intraosseous!lesion!
which!can’t!be!iden7fied!radiographically.!
5.To!determine!the!nature!of!all!abnormal!7ssue!
removed!from!the!oral!cavity!including!cysts!&!
granulomas.!

98. Contraindica7ons:!
Rela5ve!contraindica5ons:!
1.In!cases!of!inflammatory!lesions!may!be!due!to!
allergy!,viral!,fungal,!or!bacterial!lesion.!e.g.!
candidiasis.!
2.Compromised!generalised!health!of!pa7ent.!e.g.!
pa7ent!on!an7coagulant!therapy.!
3.Proximity!of!lesions!to!vital!,!anatomic,!
physiologic,!neural,!vascular,!or!glandular!
structures.!
!
A.

99. !Absolute!contraindica5ons!!!
• B)!Absolute!contraindica5ons:!
1.Pulsa7le!vascular!lesions.!e.g.!angiosarcoma.!
2.Pigmented!lesion!should!not!be!biopsied.!
e.g.!!
!!!!!!!Melanoma.!
3.Intrabony!radiolucent!lesions!should!not!be!
biopsied!or!removed!without!prior!
inves7ga7onal!aspira7on!

101. ARMAMENTERIUM:!
1.Mouth!mirror!&!probe,!
colourless!an7sep7c!
agent.!
2.LA!&!syringe.!
3.Surgical!scalpel.!
4.Long!pointed!surgical!
scissors.!
5.Tissue!forceps!
6.Biopsy!punch!
7.Bone!burs!
!
!
8.Periosteal!elevator!
9.Chiesel!
10.Bow!cureee!
11.Suture!material!
12.Needle!holder!
13.Sponges!
14.Wide!mouthed!boele!
with10%!neutral!
buffered!formalin!
!

102. Points!must!be!considered!to!ensure!
obtaining!proper!specimen!!
1.Do!not!paint!the!surface!of!the!area!to!be!biopsied!
with!iodine!or!other!highly!coloured!an7sep7c.!
2.Don’t!inject!LA!into!the!lesion.!
3.Use!sharp!scalpel!!to!avoid!tearing!of!7ssue.!
4.Use!care!not!to!mu7late!the!specimen!when!grasping!
it!with!forceps.!
5.Fix!the!7ssue!immediately!upon!removal!in!10%!
formalin!or!70%!alcohol.!
6.If!the!specimen!is!thin,!place!it!upon!a!piece!of!glazed!
paper!&!drop!into!fixa7ve!which!prevents!curling!of!
7ssue.!

103. TYPES!OF!BIOPSY!!
1.Excisional!biopsy!
2.Incisional!biopsy!
3.Punch!biopsy!
4.Needle/trephine/drill!
5.Aspira7on!biopsy!
6.Exfolia7ve!cytology!

104. • !!Illustra7on!of!excisional!biopsy!of!so!7ssue!lesion.!A,!
Surface!view.!Ellip7c!incision!is!made!around!lesion!.!A,!
Surface!view.!Ellip7c!incision.!B,!Side!view,!Incision!is!made!
deep!enough!to!remove!lesion!completely.!C,!End!view.!
Incision!are!made!convergent!to!depth!of!wound.!If!excision!is!
made!in!this!way,!closure!will!be!facilitated.!!

105. • A,!!Illustra7on!showing!desirability!of!obtaining!deep!
specimen!rather!than!broad!and!shallow!specimen!when!
incisional!biopsy!is!performed.!If!malignant!cells!are!present!
only!at!base!of!lesion,!broad!and!shallow!biopsy!might!not!
obtain!these!diagnos7c!cells.!!
• B,!Illustra7on!showing!desirability!of!obtaining!incisional!
biopsy!at!margin!of!so!7ssue!lesion.!Junc7on!of!lesion!with!
normal!7ssue!frequently!provides!pathologist!with!more!
diagnos7c!informa7on!than!if!biopsy!were!taken!only!from!
center!of!lesion.!!

106. !
! !!Illustra7on!demonstra7ng!
desirability!of!obtaining!
more!than!one!incisional!
biopsy!if!characteris7cs!of!
lesion!differ!from!one!area!
to!another.!!
! Frequently!one!area!of!
lesion!appears!histologically!
different!from!another!(A).!
When!obtaining!biopsy!on!
buccal!or!labial!mucosa,!
incision!is!usually!carried!to!
depth!of!musculature!(B).!!

107. !
• Illustra7on!showing!use!of!
trac7on!suture!placed!
through!specimen.!While!
lesion!is!incised,!trac7on!
suture!is!use!to!li!
specimen!from!wound!
bed.!Suture!can!then!be!
7ed!and!le!aeached!to!
lesion!to!iden7fy!margin!
of!specimen.!!

108. !
• !!Illustra7on!showing!
principles!used!in!
closing!an!ellip7c!biopsy!
wound.!Mucosa!should!
be!undermined!bluntly!
with!scissors!to!width!of!
original!ellipse!in!each!
direc7on.!This!allows!
approxima7on!of!
wound!margins!without!
tension.!!

109. EXCISIONAL!BIOPSY!!
*Defini7on:!Total!excision!of!a!small!lesion!!
!!!!!!!!!!!!!!!!!!for!microscopic!study!is!called!!
!!!!!!!!!!!!!!!!!!“excisional!biopsy”.!
Use!!!!!!!!:!Lesions!smaller!than!1cm!in!!diameter.!!

110. Method!!
• Give!LA!which!should!not!be!closer!than!2cm!
from!the!site.!
• Stabilize!the!lesion!via!the!suture.!
• Incise!mucosa!around!the!base!of!the!lesion!in!
an!ellip7cal!shape.!
• Place!specimen!immediately!in!a!fixa7ve.!
• Close!the!wound!using!suture.!

112. INCISIONAL!BIOPSY!!
Defini7on:!!
Some!lesions!are!too!large!to!!excise!ini7ally!
without!having!established!diagnosis!or!are!of!
such!a!nature!that!excision!would!be!
inadvisable!!in!such!instances!a!small!sec7on!is!
removed!for!examina7on!called!incisional!!or!
diagnos7c!biopsy.!
Use!!!!!!!:!For!large!lesions!!!

113. Method!
• Administer!LA.!
• Iden7fy!the!apparent!junc7on!between!normal!
7ssue!&!the!lesion!select!the!specimen!across!region.!
• Stabilize!the!specimen!with!a!suture.!
• Dissect!the!specimen!from!the!edge!of!the!lesion!&!
include!a!margin!of!apparently!normal!7ssue.!
• The!specimen!should!include!representa7ve!area!of!
the!lesion.!
• Place!the!specimen!immediately!in!a!prescribed!
specimen!boele!containing!10%!formalin.!
• Close!surgical!site!by!sutures.!

115. PUNCH!BIOPSY:!
!
• A!surgical!instrument!is!used!to!punch!out!a!
representa7ve!por7on!of!7ssue.!
• Since!resul7ng!specimen!is!oen!damaged!!
!!!by!the!procedure!so!biopsy!by!scalpel!is!
preffered.!

116. Needle/trephine/drill!biopsy:!
• Use!:!to!biopsied!
deepJseated!fibroJ
osseous!!lesions.!
• The!resul7ng!
specimen!is!smaller!
may!be!nonJ
representa7ve!&!
again!oen!
damaged!by!the!
procedures!so!they!
are!not!oen!used.!

117. Aspira7on!biopsy!!
• Use!–!Applicable!to!many!cys7c!!&!!!fluctuant!lesions!
MethodJ!!
!Clean!the!7ssue!over!the!proposed!aspira7on!site.!
JInject!LA!solu7on!over!the!lesion.!
JSelect!a!wide!bore!needle!&!10!ml!syringe.!
JPenetrate!7ssue!&!aspirate!fluid.!
JTransfer!the!aspirate!into!a!screw!top!specimen!boele.!
!

119. How!do!I!prevent!oral!cancer!?!
Stopping!all!the!habits!of!tobacco!consump7on.!Stopping!means!complete!stop!to!the!habit.!
Reducing!the!consump7on!of!tobacco!does!not!reduce!your!risk!of!cancer.!But!stopping!
certainly!reduces!the!risk.!!
!
Is!tobacco!the!only!cause!of!oral!cancer!?!
Tobacco!is!the!major!cause!of!oral!cancer!but!certainly!not!the!only!cause.!Their!are!other!
causes!like!poor!oral!hygiene,!chronic!trauma!from!sharp!tooth!or!an!ill!fi[ng!dentures.!Their!
are!other!agents!like!some!viruses!which!are!thought!to!cause!or!expedite!the!effect!of!tobacco!
in!causing!oral!cancer.!
!
Why!is!that!not!all!people!consuming!tobacco!have!oral!cancer!?!
Their!are!many!factors!like!gene7c!make!of!the!person,!his!diet!and!many!unknown!factors!that!!
increases!or!decreases!the!suscep7bility!of!person!of!!having!oral!cancer.!But!one!thing!is!certain!
that!tobacco!consump7on!increases!your!suscep7bility!by!almost!8!7mes.!That!means!a!person!
consuming!tobacco!is!more!prone!to!have!oral!cancer!or!other!tobacco!related!problems.!!
!
Who!is!more!suscep7ble!to!oral!cancer!?!
Anybody!consuming!tobacco!is!suscep7ble!to!oral!cancer.!Differences!in!gene7cs!have!not!been!
iden7fied!in!rela7on!to!risk!and!survival.!That!means!a!Caucasian!or!a!mongoloid,!Black!race!all!
are!equally!prone!to!oral!cancer!if!they!consume!tobacco.!!!
!
Dr!Suwas!Darvekar!

120. MISJDiagnosis!
• 1JInadequate!oral!examina7on!
• 2JInnocuons!appearance!of!mucosa!
• 3JLow!index!of!suspicion(
• 4JLack!of!experience)

121. Treatment!plan!is!based!on:!
!
Staging!of!disease!using!TNM!classifica7on!
!
T = Tumour size
!
N = Nodal status
!
M = Metastases
!
!!!!!!!!!!Eg.!T3N2M0!laryngeal!carcinoma!!

122. Introduc7on!
• Prognos5c(Indicators:!
– Sex:!Poor!prognosis!in!females!
– General!condi5on!&!health!status!of!pa5ent!
– T!stage!
– Number!of!histologically!posi5ve!nodes!!
– Surgical!margin!status!
– Type!of!therapy!and!blood!transfusion!!

123. Treatment!plan!is!based!on:!
•
coJmorbid!condi7ons!
Medical
Dental
Speech
Nutrition
Psychosocial
Socioeconomic

124. Treatment!Op7ons!
Primary surgery
+/J!
Adjuvant
Radiotherapy
+/J!
Concurrent
Chemotherapy
OR!
Primary Radiotherapy
+/J!
Concurrent
Chemotherapy
+/J!
Surgery for Salvage

125. Dental!Management!
Will!involve!:!
!
General!Den7st!
!
Hygienist!
Dental!Assistant!
Recep7on!Staff!

126. Dental!Consulta7on!!
• Clinical!examina7on!
• char7ng!(odontogram)!
• visual!(other!lesions?)!
• palpa7on!

127. Dental!Consulta7on!!
• Diagnoses!
– Dental!
• Caries!
• Periodontal!disease!
• Other!Pathology!
– Medical!
• coJmorbidi7es!

128. Dental!Consulta7on!(cont.)!
• Treatment!Plan!based!on:!
– prognosis!of!individual!teeth!
– past!dental!history!(compliance)!
– sequelae!and!poten7al!complica7ons!
from!radiotherapy!
– LONG!TERM!RISKS!!

129. Dental!Treatment!
• Must!be!done!immediately!
!
– !no!delay!in!radiotherapy!
– !cancer!is!progressing!!!
!

130. Dental!Treatment!
• Extrac7ons!
– abscesses,!gross!caries!
– advanced!periodontal!disease!
– heavily!restored!teeth!w/!poor!OH!
!
Must!have!2!weeks!healing!prior!to!
start!of!radiotherapy!!!!

131. Chronic!Sequelae!
• Problems!with!xerostomia!!
– increased!trauma!risk!
• !so!7ssues!very!dry!!
• !easily!injured!
!
!

132. Chronic!Sequelae!
• Problems!with!xerostomia!!
– thick!secre7ons!
• !change!in!mucous:serous!ra7o!
• !increased!“gag”!
• !difficulty!wearing!dentures!
!

133. Chronic!Sequelae!
• Problems!with!xerostomia!!
– difficulty!swallowing!
• H2O!with/between!meals!!
– chronic!Candidiasis!

137. Distant Metastasis
Normal lung
Secondary SCC

138. SCC!of!Lower!Lip!in!a!pipe!smoker!(78Years)!

139. SCC!of!lateral!border!of!the!tongue!

140. SCC!in!FOM!

141. Metasta7c!carcinoma!in!jaws!
• Metastasis! in! jaws! or! (rarely)! oral! so!
7ssues,!especially!from!cancer!of:!
• Breast!!
• Lung!!
• Prostate!
• Thyroid!
• Kidney!
• Stomach!!

142. Referrals!for!biopsy!
• Health!of!pa7ent!!
• surgical!difficulty!
• Poten7al!for!malignancy!

143. Types!of!biopsy!
•
•
•
•
•
•
•
Incisional!biopsy!
Punch!biopsy!!
Excisional!biopsy!
Drill!biopsy!
Oral!cytology!!
Aspira7on!biopsy!
Fine!needle!aspira7on!
biopsy!
• Sen7nel!node!biopsy!
• Brush!biopsy!

144. So!7ssue!biopsy!technique!and!surgical!
principles!
1.
2.
3.
4.
5.
6.
Anesthesia!
Tissue!stabiliza7on!
Haemostasis!
Incision!
Handling!of!7ssue!
Iden7fica7on!of!
surgical!margins!
7. Specimen!care!
!Surgical!closure!
!Biopsy!data!sheet!
10. !Hard!7ssue!
8.
9.
•
•
•
•
!
Aspira7on!biopsy!
!Mucoperiosteal!flaps!
Osseous!window!
Removal!of!specimen!

145. Management!
• Aer!a!defini7ve!diagnosis!has!been!made!and!the!
cancer!has!been!staged,!treatment!may!begin.!
• Treatment!of!oral!cancers!is!ideally!a!mul7disciplinary!
approach!involving!the!efforts!of:!!
•
•
•
•
•
•
surgeons,!!
radia7on!oncologists,!!
chemotherapy!oncologists,!!
dental!prac77oners,!!
nutri7onists,!!
rehabilita7on!and!restora7ve!specialists.!!

146. Nutri7onal!Implica7ons!of!Cancer!
Therapy!
• Chemotherapy!
! !—Taste!abnormali7es,!diarrhea,!cons7pa7on!
• Radia7on!therapy!
! !—Fa7gue,!loss!of!appe7te,!skin!changes!
• Surgery!
!—Fa7gue,!pain,!loss!of!appe7te!
• Immunotherapy!
! !—Flulike!symptoms,!decreased!food!intake!

148. Factors!affec7ng!the!decision!
• Aggressiveness!of!lesion!
• Anatomic!loca7on!of!lesion!
• Dura7on!of!lesion!
• Reconstruc7ve!efforts!
• Reconstruc7on!of!jaws!aer!removal!of!oral!
tumours!
• Histopathologic!diagnosis!
• Presence!and!degree!of!metastasis!
• RadioJsensi7vity!and!chemoJsensi7vity!
• Age!and!condi7on!of!the!pa7ent!
• Experience!of!the!clinicians!
• Wishes!of!the!pa7ent.!

149. Treatment!
1. Early!stages!(I!and!II)!of!SCC!treated!with!surgery!or!
radia7on!(FiveJyear!survival!rates!are!similar!for!both!
modali7es).!
!A!decision!is!made!on!the!basis!of:!
•
•
•
•
the!tumour's!site!and!size,!!
histological!findings,!!
the!pa7ent’s!wishes!
the!advice!of!the!mul7disciplinary!team.!
2. Advanced!stages!(III!and!IV)!treated!with!a!
combina7on!of!surgery!and!radia7on!therapy,!
although!this!increases!the!complica7ons!and!
morbidity.!

150. 2. Advanced!stages!(III!and!IV)!treated!with!a!
combina7on!of!surgery!and!radia7on!
therapy,!although!this!increases!the!
complica7ons!and!morbidity.!
3. Chemotherapy!is!added!in!order!to:!
• decrease!the!possibility!of!metastasis,!!
• sensi7ze!the!malignant!cells!!
• !radia7on,!or!for!those!pa7ents!who!have!confirmed!
distant!metastasis!of!the!disease.!

151. Surgical!management!of!oral!cancer!!
• Basic!surgical!goals!are:!
! Eradica7on!of!pathologic!condi7on:!
! The!primary!lesion!(surgical!excision!with!safety!margin).!
(If!bone!involved!marginal!or!segmental!resec7on!is!indicated)!
! The!secondary!lesion!(neck!dissec7on:!radical,!selec7ve,!
supraomohyoid)!
! Func7onal!rehabilita7on!of!pa7ent!using:!flaps,!gras,!
Implants,!as!well!as!gaining!speech!therapy,!physical!therapy,!
psychological!therapy.!!

152. Mul7ple!carcinomas!

153. Resected!mandible!&!composite!gra_!
!Primary!tumour!with!submandibular!!!!!!!!!!!!!!!!!!!!!!!!!Forearm!composite!gra!!!!!!!!
glands!(LN!&!SG).!

154. Massive!surgery!for!invasive!!
oral!cancer:!Floor!&!mandible!

155. Alveolar!SSC!

156. Alveolar!SSC!1!

157. Mandibulectomy!and!reconstruc7on!plate!

158. Maxillary!Carcinoma:!antrum!&!orbit!!

159. Melanoma!

160. Radiotherapy!
• Tumour!cells!are!more!suscep7ble!to!ionizing!radia7on!!
• Radia7on!can!be!delivered!by:!
! Implanta7on!of!the!radioac7ve!material!into!the!tumour!
! Use!of!external!xJray!generators!
• Radia7on!therapy!can!be!delivered!by!two!mechanisms:!
! Frac7ona7on!
! Mul7ple!ports!
• Using!directed!radia7on!and!intensity!modulated!radia7on!therapy!(IMRT)!
(focused!to!the!target)!and!accelerated!and!HyperJfrac7ona7on!regimens!
(higher/more!frequent!doses!are!used)!
• Preven7on!of!xerostomia!by!shielding!the!paro7d!gland!and!using!directed!
radiotherapy!and!using!pilocarpine!during!and!aer!radia7on.!

161. RADIOTHERAPY!

163. • The!use!of!ionising!radia7on!to!cure!disease!or!
make!the!symptoms!of!a!disease!less!severe!
i.e.!palliate.!
• Radiotherapy!is!used!mainly!to!damage!or!
destroy!prolifera7ng!cells.!
• The!faster!the!cellular!turnover,!the!more!
suscep7ble!the!7ssue!to!the!damaging!effects!
of!radia7on.!!

164. • External!beam!radiotherapy:!
!!!!!!!!!J!Directed!through!skin!to!tumor.!
!!!!!!!!!J!Use!shielding.!
• Brachytherapy!
!!!!!!!!!J!inject!source!of!radia7on,!
delivered!by!close!contact!with!
!!!!the!tumor,!then!ac7vate!it.!

165. • Direct!effects:!
!!!!!!!!these!result!from!damage,!mainly!to!DNA,!
by!the!high!energy!of!radia7on.!This!can!cause!
changes!in!DNA!structure!resul7ng!in!point!
muta7on!or!chromosomal!breaks.!
!!!!J!The!effects!may!be!
1. Arrest!the!mito7c!division!
2. Cells!death!by!apoptosis!

166. • Indirect!effects:!
!!!!!!!!these!result!from!ionisa7on!of!water!and!
forma7on!of!toxic,!free!radicals!and!
obstruc7on!of!vessels!which!affects!on!the!
7ssues!supplied.!

167. !
!
•
•
•
•
•
•
!
MUCOSITIS!
FUNGAL!INFECTION!
XEROSTOMIA!
RAMPANT!CARIES!
DIFFICLUTY!WITH!SPEECH!AND!MASTICATION!
OSTEORADIONECROSIS!

168. • Results!in!epithelial!thinning,!erosion!and!
ulcera7on.!!
• Affects!nonJkera7nized!mucosa!first.!
• Usually!presents!within!1J2!weeks!and!
increases!in!severity!to!a!maximum!at!4!weeks.!

169. • Early!signs:!!
!!!!!J!whitening!of!mucosa!!
!!!!!J!mucosal!erythema!
!!!!!J!Can!cause!dysphagia!
• Late!signs:!
!!!!!J!Reflect!hypovascularity!and!hyaliniza7on!of!
collagen.!
!!!!!J!Can!be!compounded!by!impaired!mucosal!
defense!and!onset!of!opportunis7c!infec7on!

170. • Reassure!the!pa7ent!of!the!limited!7me!
period!of!this!side!effect.!
• Give!symptoma7c!relief:!
!!!!!!!!J!CXD!mouthwash.!
!!!!!!!!J!Oral!cooling.!
!!!!!!!!J!Sucralfate!!!!!!!!!!!!!!!!!!!coa7ng!agent.!
!!!!!!!!J!topical!anesthesia.!

171. • Avoidance!of!certain!food,!drinks!to!relieve!
discomfort:!
!!!!!!!!J!Hard!and!spicy!foods.!
!!!!!!!!J!Strongly!flavoured!toothpaste.!
!!!!!!!!J!Alcohol!and!tobacco.!
!!!!!!!!J!Carbonated!and!acidic!drinks.!
!!!!!!!!J!Sweets.!
!!!!!!!!J!Hot!drinks.!

172. • Pa7ent!undergoing!radiotherapy!may!have!
altera7on!in!the!normal!flora.!
• Bacterial,!viral!and!fungal!infec7ons!can!occur!
in!the!presence!of!mucosi7s.!
• The!most!common!infec7on!is!Candida.!

173. • Preven7on:!
!!!!!!!J!intensive!oral!hygiene!instruc7on!prior!to!
treatment,!regular!follow!up.!!
• Treatment:!
!!!!!!J!If!candida!found:!
!!!!!!!!!!!!!!!!Nysta7n(sugarJfree),!Miconazole,!or!Fluconazole!
!!!!!!!J!If!the!pa7ent!is!unable!to!brush!due!to!pain,!use!
CXD!mouthwash.!

174. " NB:!do!not!use!Nysta7n!and!CXD!
simultaneously!!because!of!inhibitory!effect!on!
each!other.!Separate!by!1!hour.!!

175. • Most!severe!if!bilateral!salivary!glands!are!
exposed!to!radia7on!
• Results!in!acinar!cell!atrophy!and!necrosis,!
changes!in!the!vascular!CT!and!altered!
neurological!func7oning.!
• Serous!acini!affected!first!then!mucinous.!
• Predisposing!factor!infec7on,!candida,!and!
caries.!

176. !
!
!
• Symptoma7c!relief:!
!!!!!!!!J!Frequent!sips!of!water/!milk!and!avoid!
sugary!drinks.!
!!!!!!!J!Saliva!subs7tutes:!saliva!orthanaor!or!
methylcellulose!subs7tute.!
!!!!!!J!SugarJfree!chewing!gum!
!!!!!!J!Salivary!s7mulants!e.g.!pilocarpine!or!
cevimeline.!

177. • Typically!affects!the!gingival!1/3!and!incisal!/!
cusp!7ps!of!teeth.!
• Not!limited!to!teeth!within!radia7on!field.!
• Related!to!xerostomia!leading!to!loss!of!
remineralisa7on!poten7al,!loss!of!buffering!
capacity,!increased!acidity!and!a!change!in!
bacterial!flora.!

178. • preJradia7on!OHI,!diet!counseling!and!
treatment!of!any!ac7ve!caries.!
• regular!follow!up!during!Treatment.!
• Treat!xerostomia.!
• Use!fluoride!mouthwashes!or!gels.!

179. • Caused!by!fibrosis!of!mas7catory!muscles!!
• Jaw!exercises!limit!the!extent!of!trismus!but!
will!not!cure!it!aer!it!has!occurred;!exercise!
before!and!during!radiotherapy.!

180. • Radia7on!effects!on!bone:!
!!!!!!!Hypovascularity,!Hypocellularity!and!Hypoxia!leading!
to!poor!ability!to!repair!and!remodel!!
• Sign!and!symptom:!!
!!!!!!discomfort,!tenderness,!bad!taste,!paraesthesia!and!
anaesthes.!
• Risk!factors!for!development!of!ORN!are:!
!!!!!!!Dose,!frac7on,!volume!of!bone!exposed,!presence!of!
teeth!in!high!dose!radia7on!field,!immunodeficiency,!
smoking!and!alcohol.!

181. Non!healing!wound!
Hypovascular,!hypoxia,!hypocellular!!!
!
!
irradia7on!
3H’s!
Tissue!breakdown!

182. •
•
•
•
•
•
•
•
So!diet.!
Adjustment/removal!of!any!trauma7c!denture.!
Provide!analgesia.!
Stop!smoking!and!alcohol!consump7on!and!
ensure!good!nutri7on.!
Daily!local!irriga7on.!
Good!oral!hygiene!instruc7ons.!
HBO!as!adjunc7ve!treatment.!
Excision!of!necrosed!bone!with!1°closure!and!
appropriate!HBO!therapy.!

183. • PreJirradia7on!management.!
• During!irradia7on!management.!
• PostJirradia7on!management.!

184. • If!head!and!neck!radia7on!is!scheduled!the!following!
recommenda7ons!should!be!considered:!
!!!!!J!construct!protec7ng!shield.!
!!!!!J!good!OHI.!!
!!!!!J!extrac7on!of!nonrestorable!teeth!and!poor!prognosis.!
!!!!!J!adequate!7me!for!wound!healing!before!radia7on!
therapy.!
!!!!!J!no!bone!should!be!le!exposed!when!radiotherapy!begin.!
!!!!!J!teeth!scaling!and!prophylaxis!before!radiotherapy!to!
reduce!the!risk!of!oral!complica7ons.!
!!!!!J!restore!of!all!restorable!teeth.!

185. •
•
•
•
•
•
Maintain!the!op7mal!oral!heath.!
Mucosa!and!salivary!gland!protec7on.!
Smoking!and!alcohol!should!be!discouraged.!
Mucosi7s!management.!
Xerostomia!management.!
Trismus!may!be!improved!by!jawJopening!
exercises.!

186. • Management!of!oral!complica7ons.!
• Keep!op7mal!oral!hygiene.!
• Topical!fluorid!applica7on!by!mean!of!custom!
carrier.!
• Regular!follow!up.!

187. • What!is!the!management!of!post!radia7on!
pa7ent!who!needs!tooth!extrac7on?!
!!!!J!four!months!aer!comple7on!of!therapy,!the!
surgical!procedures!should!be!done!aer!
prophylac7c!HBO!treatment.!
!!!!J!CXD!mouthwash!prior!to!Surgery.!!
!!!!J!Minimal!trauma.!

188. !
• What!is!the!HBO!protocol!for!prophylac7c!use!
before!teeth!extrac7on!in!irradiated!pa7ents?!
!!!!!!!this!protocol!consist!of!onceJdaily!treatment!
5!day/week.!The!pa7ent!should!receive!100%!
oxygen,!20J30!consecu7ve!treatment!before!
extrac7on.!10!addi7onal!treatment!should!be!
administered!post!opera7vely.!

189. !
• What!is!the!protocol!for!implant!placement!in!
the!irradiated!pa7ent?!
!!!!!!J!strict!oral!hygiene!before!and!aer!implant!
placement.!
!!!!!!J!use!of!longest!and!widest!implant!types!and!
maximum!number!of!implants!possible.!
!!!!!!J!cessa7on!of!smoking.!
!!!!!!J!preopera7ve!HBO.!

190. !
• Radiotherapy!can!affect!all!oral!and!perioral!
7ssues.!
• Preven7on!management!of!disease!prior!to!
radia7on!treatment!can!significantly!reduce!
the!incidence!and!severity!of!poten7al!
complica7ons.!!
• •Symptoma7c!relief!and!rapid!management!
of!oral!complica7ons!is!an!important!role!of!
the!den7st,!as!part!of!the!mul7disciplinary!
team.!

192. Chemotherapy!
• Used!only!in!cases!IV!with!poor!prognosis!
• Currently!used!agents!include:!
•
•
•
•
!
cispla7n,!!
carbopla7n,!!
5Jfluorouracil!
taxanes!(paclitaxel!and!docetaxel),!!
!The!last!to!agents!are!also!used!as!radia7on!!!!!
!sensi7zers.!!
• Recent!interest!has!been!shown!in!intraJarterial!
delivery!of!chemotherapy,!which!increases!the!drug!
dose!to!the!tumor!and!decreases!systemic!toxicity.!
• Combina7on!therapy!(radioJchemoJtherapy)!
increases!the!survival.!

193. Emerging!Therapies!
ReJevalua7on!of!the!role!of!surgery!for!distant!
metasta7c!oral!cancer!has!shown!a!possible!role!
for!excision!of!pulmonary!metastases!
Reirradia7on!in!the!head!and!neck!is!being!
inves7gated,!mostly!in!the!nasopharynx!and!
larynx.!locoregional!control!has!been!improved,!
Gene!therapy!(p53,!p21),!angiosta7c!therapy!and!
enhancing!immunity,!diet!modifica7on!
Photodynamic!therapy:!light!source!and!sensi7zer!!!

194. Recurrence!and!Second!primaries!

195. Treatment!delay!

196. Morbidity!of!cancer!therapy!
• Surgery:!
•
•
•
•
Quality!of!life!
Func7on!
Esthe7c!
Cost!of!rehabilita7on!
• Radiotherapy:!
•
•
•
•
•
•
Xerostomia!
Mucosi7s!
Taste!sensa7on!!
Osteoradionecrosis!
Rampant!caries!
PreJmalignancy!!
• Chemotherapy:!
• Blood!cell!disorders!
• Alopecia!!
• mucosi7s!

197. Osteoradionecrosis!

198. Radia7on!Mucosi7s!!

199. Cancer!pa7ent!and!Quality!of!life!!
• Every!Oral!cancer!pa7ent!has!to!be!seen!by!
specialist!of!the!following:!
• Speech!therapy!
• Diet!
• Psychic!condi7on!
• Esthe7c!
• Physical!therapy!!