6. The clinical examination done by systemic way, there is little chance of
a malignant lesion being overlooked.
Difficulty can only arise if the lesion is exceptionally small or if it lies in
an anatomically inaccessible area.
However, the diagnosis of malignant neoplasm arising within the
mandible or the maxillae is more difficult in early stage of the disease.
7.
8. Aetiology
Carcinogens: the p53 tumour suppressor gene mutation
Viruses: human papilloma virus, Epstein-Barr virus
Smoking
Alchol
Family history of first degree relative
Molecular genetics: Regulation of the cell cycle is under the control of over
40 genes which include proto-oncogenes and tumour suppressor genes.
9. Classification of malignant neoplasm in oral cavity
Primary carcinoma
Of a surface
Of a gland usually salivary glands
Rare intra-bony of the jaws:
Arising in a cyst lining
Krompecher carcinoma arising from residual odontogenic epithelium
10. Secondary carcinoma:
Centrally in the medullary cavity of the jaw bones
On the surface of the mucosa-malignant cell from sputum grafted on
to raw area.
In lymph nodes from a head and neck primary lesion
11. Primary sarcoma:- centrally in the tissues:-
1. In the jaws osteogenic sarcoma
Reticulum cell scrcoma
Ewing's tumour
lymphosarcoma
2. In the muscles
Fibrosarcoma
Leiomyosarcoma
Rhabdomyosarcoma
13. Staging of malignancy
The benefits of staging:
Planning therapy
Aid to prognosis
Comparison of result
Epidemiology
14. The principle staging classification:
1.American Joint Vommitte on cancer (AJCC)
2.Union Internationale Contre le cancer (UICC)
15. The TNM system is based on the assessment of 3 components:
T:- the extent of primary tumour
N:-the presence or absence and extent of regional lymph node
metastases
M:- the presence or absence of distant metastases
16. There are 2 classifications of TNM system
Clinical cTNM
Pathological pTNM
17. The extent of primary tumour (T) as follow:
To: when there is no evidence of primary tumour
Tis: when the primary tumour is non invasive or carcinoma in situ
Tx: when a primary tumour can not be assessed
T1: tumour 2cm or less in greatest dimension
T2: tumour more than 2 cm but no more than 4 cm in greatest dimension
T3 tumour more than 4 cm in greatest dimension
T4:adjacent structures e.g. through cortical bone, inferior alveolar nerve.
Floor of mouth, skine of face
18. The clinical finding regarding regional cervical lymphadenopaty (N) as:
No: no palpable adenopathy
Nx: the node can not assessed
N1: metastases in a single ipsilateral lymph node 3 cm or less in greatest
dimension
N2: is subdivided into 3 sections
N2a: metastases in a single ipsilateral lymph node more than 3 cm but not
more than 6 cm in greatest dimension
N2b: metastases in a multiple ipsilateral lymph node not more than 6 cm in
greatest dimension
N2c: metastases in a multiple bilateral or contralateral lymph node not more
than 6 cm in greatest dimension
N3: is any lymphatic spread more than 6 cm in greatest dimension
19. The distant metastesis (M) is indicated by:
Mo: no distant metastases
M1: presence distant metastases and subdivided to pulmonary (PUL), hepatic
(HEP), brain (BRA)
20.
21. stage T N M
0 Tis No Mo
I T1 No Mo
II T2 No Mo
III T3
T2
T1
No
N1
N1
Mo
Mo
Mo
IVA T4
T4
Any T
No
N1
N2
Mo
Mo
Mo
IVB Any T N3 Mo
IVC Any T Any N M1
22. Rick factors for oral malignancy
Tobacco: Tobacco use accounts for most oral cancers, about 90% of people
with oral cavity and oropharyngeal cancer use tobacco. Smoking cigarettes,
cigars, or pipes; using chewing tobacco; and dipping snuff are all linked to oral
cancer. The use of other tobacco products (such as bidis and kreteks) may also
increase the risk of oral cancer. Heavy smokers who use tobacco for a long time
are most at risk. The risk is even higher for tobacco users who drink alcohol
heavily. In fact, three out of four oral malignancy occur in people who use
alcohol, tobacco, or both alcohol and tobacco.
Quitting tobacco reduces the risk of oral malignancy. Also, quitting reduces the
chance that a person with oral malignancy will get a second cancer in the head
and neck region.
People who stop smoking can also reduce their risk of malignancy of the lung,
larynx, pancreas, bladder and esophagus .
23. Alcohol: People who drink alcohol are more likely to develop oral
malignancy than people who don't drink. The risk increases with the
amount of alcohol that a person consumes. The risk increases even
more if the person both drinks alcohol and uses tobacco.
24. Sun: Malignancy of the lip can be caused by exposure to the sun, more
than 30% of patients with cancers of the lip have outdoor occupations
associated with prolonged exposure to sunlight. The risk of malignancy
of the lip increases if the person also smokes.
26. A personal history of head and neck malignancy: People who have had head
and neck malignancy are at increased risk of developing another primary
head and neck malignancy. Smoking increases this risk.
27. Poor nutrition: a diet low in fruits and vegetable is associated with an increase
risk of getting oral malignancy.
29. Viral infection: Scientists also are studying whether infections with certain
viruses (such as the human papilolmavirus ) are linked to oral malignancy.
30. Immune system suppression
Age: The likelihood of developing oral and oropharyngeal cancer
increases with age, especially after age 35.
Gender: Oral and oropharyngeal cancer is twice as common in men as in
women.
31. Inherited:
Defective DNA repair mechanism as xeroderma pigmentosa, ataxia
telangiectasia, bloom syndrome, fanconi syndrome,
Tumor suppressor gene (p53) defect as Li Fraumeni syndrome.
Relationship between ABO blood groups and oral cancer. The people with
blood group A had 1.046 times higher risk of developing oral cancer as
compared with other blood group.
Allergies have heightened immunity had a 19% lower of HNSCC.
32.
33.
34.
35.
36. 1. Patches in the mouth that are:
a/ White patches (leukoplakia) are the most common. White patches
sometimes become malignant.
b. Mixed red and white patches (erythroleukoplakia) are more likely than
white patches to become malignant.
c. Red patches (erythroplakia) are brightly colored, smooth areas that
often become malignant.
2. A sore on in the mouth that won't heal
3. Bleeding in the mouth
4. Loose teeth
5. Difficulty or pain when swallowing
6. Difficulty wearing dentures
7. Persistent lump or thickening in the cheek
8. Increased salivation
9. A lump in the neck
10. An earache
Symptoms of carcinoma of the oral cavity
37.
38. Early symptoms
The early stage may be painless, especially when they are sited towards the
back of the oral cavity.
Carcinoma of the lip usually noticed by the patient as a painless lump or ulcer.
The carcinoma of the anterior part of the mouth may first discovered by the
patient's tongue probing the lesion.
39. In the posterior part of the mouth symptoms are usually slight until the:
lesion has reached a diameter of 2-3 cm
until it becomes infected
when pain and swelling supervene, which may cause difficulty in
deglutition. Pain and tenderness only develop when a malignant ulcer
becomes secondarily infected or if the lesion involves a sensory nerve
until the tumour has metastasized to the regional lymph nodes and a
hard lump in the neck.
40. Late symptoms
pain due to secondary infection or involvement of the nerve in the region.
Excessive salivation.
Difficulty in deglutition.
Difficulty in speech.
Haemorrhage which usually manifests as blood stained saliva.
41.
42. Neoplasm arising within the bone
The early symptoms is:
Painless swelling involve both labial/buccal and lingual/palatal sulci.
If the teeth are present they may become loose and painful abscess.
If the patient edentulous a previously satisfactory denture may no longer fit
and may be displaced or produce localized denture hyperplasia or
granuloma.
Anaesthesia of the upper or lower lip is quite common.
43. Carcinoma of the lip
Carcinoma of the vermilion border is most common in male between 50-
70 year olds.
The patients tend to have dirty, jagged, stained teeth.
The malignancy arise at a site irritated fractured tooth.
Hot tobacco may lead irritation and leukoplastic change.
The incidence of carcinoma increase in occupations as if patient to
intense solar radiation, when the patient give a history of blistering
cheilitis due to sunlight.
44. The lower lip is affected in 93%, upper lip 5%, while 2% at the angle of mouth.
Sometimes a growth occurs on the upper lip at appoint opposite the lower lip due
to direct implantation of cells.
The early symptoms is small, painless, scabbing ulcer. If untreated spreads to the
cheek, gingiva, and jaw.
The most lymph nodes affected by metastases are submental, submandibular,
and upper jugular groups.
Differential diagnosis from molluscum pseudo-carcinomatosum.
45. Carcinoma of the tongue
The anterior two third of the tongue affects male nine time than fimale, while
the posterior third affects the sexes equally, the age over 60 years.
The oral hygiene is usually bad in patient with carcinoma of the tongue. The
disease is often associated with heavy drinking of alcohol due to a deficiency
of vitamin B1 which lead a precancerous mucosal atrophy.
46. 25% of patients have suffered from syphilis and 5% have had leucoplakia,
other precancwrous lesions as:
Superficial glossitis
Papilloma
Fissures tongue
Non-specific ulcers
58% lie near the lateral margin, 2-4% on the dorsum, 7-15% on the tip, and
the posterior third 21-33%.
47. The appearances of carcinoma of the tongue:
The ulcerative type
Papillary type
The flat nodule
A malignant fissure as syphilitic fissuring
Scirrhous or atrophic
48. The early symptom is a painless swelling or an ulcer.
When the lesion established, pain is severe continuous and may radiate to the
ear and referred pain to auriculotemporal region, excessive salivation, focter oris,
haemorrhage, and finally immobility of the tongue.
The life expectancy of an treated lesion about 16 months whicj lead to inhalation
bronchopneumonia, cachexia, starvation, haemorrhage and asphyxia.
Metastases are restricted to the regional glands, anterior two third metastases
are ipsilateral and bilateral if the lesion extended to the midline of the tongue.
The metastases from posterior third are bilateral.
51. Carcinoma of the floor of mouth
Carcinoma of the floor of mouth it is usually a typical malignant ulcer extending to
the alveolar process and tongue.
52. The cheek lesion is often warty and proliferative due to denture irritation and, where
teeth are present, from periodontal abscess.
53. Carcinoma of the hard palate is often papillary or ulcerative and usually spreads
extensively before it affects the bone. It is difficult to distinguish it from a carcinoma
of the maxillary sinus which spread to the palate.
54. Carcinoma of the soft palate and fauces are proliferative, fungating tumours, and it
is poor prognosis due to spread to the base of the tongue and early involvement of
the lymph node bilaterally.
55. The symptom secondary infection causes pain and dysphagia, and death frequently
occurs following erosion of the carotid artery.
56.
57.
58.
59. Carcinoma of maxillary antrum
The squamous cell carcinoma about 90-95% of antral malignancues.
The tumour infiltrates the soft tissue, destroys bone, and can ulcerate into the
mouth, pharynx, and skin of the face.
Lymphatic metastasis to the upper deep cervical nodes and rarely spread to
retropharyngeal
60. If teeth are present in relation to the floor of the sinus the they may become
loose, painful, and periostatic, and may appear as acute alveolar abscess,
anaesthesia of the cheek, or parasaethesia of the palate.
If the nasolcremal duct is occluded epiphora will ensue.
If the lesion has invaded the eye proptosed with interfered with one or more of
introrbital muscle or the nerves supply, so lead to strabismus, limitation of
ocular movements and diplopia.
61. The nostril on the affected side may be blocked, blood stained discharge pus
from the nostril.
Pain due to secondary sinusitis. Trismus may occur due to encroachment
upon the medial pterygoid muscle.
62. Malignant melanoma
It is a rare condition more frequently in male and 75% of patients are 40
years of age or over.
It presents as a raised soft, vascular, dark brown or black mass, bleeding
and ulceration are common.
When occur in the mouth it destroys adjacent bone and loosens teeth, and
may invade blood vessels and lymph channels, and 50% shows
involvement lymph node.
63. Management of oral malignancy
Diagnosis of oral malignancy
Clinical examination of the mouth and throat for red or white patches, lumps,
swelling, or other problems.
This exam includes looking carefully at the roof of the mouth, back of the
throat, and insides of the cheeks and lips, gently pulls out the tongue so it
can be checked on the sides and underneath.
The floor of the mouth and lymph nodes in the neck also are checked.
64. The investigation include:
An x-ray of the entire mouth can show whether malignancy has spread
to the jaw.
Chest X-ray and/or other bone radiography to establish secondary
metastases to bone.
CT scan an injection of dye. Tumors in the mouth, throat, neck, or
elsewhere in the body show up on the CT scan.
MRI can show whether oral malignancy has spread.
65.
66.
67.
68.
69.
70. A biopsy is essential to confirm the diagnosis and the treatment
according to the histopathology of the lesion.
HB examination, blood film, blood group are essential investigation.
71. Treatment of oral malignancy
Treatment goals to eradicate primary tumor, and LN metastasis, to maintain
function, cosmetic reconstruction.
The factors affecting choice of treatment depends mainly on: tumor, patient and
resource factor:
general health
where in the mouth or oropharynx the malignancy began
the size of the tumor
whether the malignancy has spread.
