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Cancer that forms in tissues of the oral cavity (the mouth) or the oropharynx (the part of the throat at the back of the mouth). (NCI) Oral cancer and precancerous lesions are neoplastic conditions that are caused by local chemical or mechanical irritants or may be of unknown etiology.(WHO1987) Oral cancer is classified under the rubrics 140(lip),141(tongue),143(gingiva),144(floor of mouth)and145(other parts of mouth)

According to the World Health Report 2004, cancer accounted for 7.1 million deaths in 2003, and it is estimated the overall number of new cases will rise by 50% in the next 20 years. Characteristics of cancer cells:




Oropharyngeal cancer is more common in developing than developed countries. Age adjusted incidence rates 8th most common cancer worldwide Population Age: older age group(5th-6th decade)
based registered entries



Sex: more common in men


3.5 2.2 8.8

Oral cavity
2.4 7.3

0.6 -

Oral cavity
8.0 0.9 5.1

Incident rates Risk factors (47% of Indians aged 15yrs/> use tobacco in one form /other) An increased risk is seen in those who chew than those who smoke.

Barshi Bhopal

Chennai Mumbai

5.1 5.7

6.4 5.7

6.0 4.2

Site: Lip cancer is most common in fair skinned races. Intraoral- In western countries ,most commonly affects the lateral borders of the tongue and the floor of the mouth, followed by the buccal mucosa, mandibular alveolus, retromolar region and soft palate. In the high-risk areas of south Asia, the buccal, retromolar and commissural mucosa are the most prone sites.


Until 1964, no info on cancer occurrence in India 1982- National Cancer Registry Program by Indian council of medical research . # highlighting magnitude and common sites of cancer in india # planing the National Cancer Control Program
CANCER REGISTRIES Population based Bombay Chennai Bhopal New Delhi Bangalore Barshi Hospital based Chandigarh Dibrugarh Trivandrum Bangalore Chennai Mumbai


multi factorial
Host immunity Metabolism Angiogenesis Chronic inflammation Genetic susceptibility

Established Risk Factors

Smoking tobacco Chewing tobacco/oral snuff Chewing betel quid (paan), especially if tobacco is included Heavy consumption of alcohol Precancerous lesion/condition

Predisposing Factors
Dietary deficiencies(vitamins A, C,Eand Fe) Faimilial or genetics Viral infections Sunlight immune suppression Dental trauma

most known etiological factor
*WHO report on global consumption of tobacco (1U=1 million)

700 600 500 400 300 200 100 0 DEVELOPED DEVELOPING


According to National Epidemiological survey of drug and alcohol conducted in 25 states in India (2002),55.8% of males aged 12-60yrs currently use tobacco. National Epidemiological Oral Health Survey and Fluoride Mapping of DCI (1994)- 2324%,more males, across age groups reported smoking tobacco.

Tobacco Preparations
Tobacco is derived from species of plant of genus Nicotina of potato family. Tobacco leaves flue-curing/fire-curing/sun-curing tobacco In india tobacco is used in various ways : Smoked tobacco - most popular, rural( Bidi-0.15g-0.25g coarsely ground tobacco) Urban area ( Cigarette-1g finely cut tobacco) Reverse smoking- smoked with lighted end inside mouth ,found among females in Vishakapattanamand Srikakulam(AP) Temperature of palate-58C ,it causes palatal patches(0.12% malignant change)

Smoking habits in India

1) Bidi: 0.2-0.3g sundried tobacco flakes rolled in rectangular piece of temburni leaf. Nicotine content is 1.7-3mg and Tar is 45-50mg. 2 ) Chillum : conical clay pipe used for smoking with coarsely cut tobacco pieces and glowing charcoal 3) Chutta(shruttu/cigar): cylindrical,cured tobacco wrapped in dried tobacco leaf. 4) Cigarettes: 1g suncured /artificially cured tobacco is covered with paper and treated with sugars and flavoring agents.Nicotine content:1-1.4mg,Tar:19-27 mg 5) Dhumti: rolled leaf of tobacco inside jackfruit leaf ,used in reverse smoking 6)Gudakhu: paste of powdered tobacco,molasses and other ingredients ( women ,Bihar) 7) Hookah : tobacco smoke drawn in water in the base of hookah ( mughal culture ) 8) Hookli : clay pipe with mouth piece and bowl ( Gujarat )

Smokeless Tobacco
Paan chewing most common Uses:- aids digestion, appetite, strengthens gums, sweetens breath, colors oral structure, alertness, induces euphoria and anti-helmenthic. Association of betel quid and oral cancer ( Balram, Trivandrum 1895)
pH alteration Rough oral mucosa Discoloration Lesion


Khaini Sun-dried tobacco+slaked lime+arecanut ( Maharshtra) Mixture placed in premolar region of mandibular groove Mainpuri tobacco Tobacco + slaked lime + arecanut + camphor + cloves ( Uttar Pradesh ) High prevalence of oral cancer and leukoplakia

Mawa Arecanut +tobacco + slaked lime Mixture is chewed as a ball and transferred to mandibular groove Mishri Roasted tobacco +/- catechu Paan Betel leaf +arecanut+ lime +catechu + cardamom + cinnamon + coconut + cloves + sugar + tobacco wrapped in betel leaf Snuff Air-cured and fire_cured tobacco leaves Used orally / nasally Bajar ( Gujarat )-twig is dipped and applied over tooth and gingiva Zarda Colored residual tobacco leaf boiled with lime and spices

Gutka Crushed beetel nut + tobacco + sweet flavourings Pan masala Betel leaf + lime+ arecanut + clove + cardamom + mint + tobacco

Constituents in Tobacco
There are 43 known carcinogens in tobacco smoke
NICOTINE Most toxic ( lethal dose -30-60mg) It causes addiction by triggering dopamine that is associated with feelings of pleasure Physiological effects-increase HR,BP and platelet stickiness( CAD) Carcinogenic activity :it enables formation of potent carcinogens ( nitrosamines)

TAR Particulate matter inhaled It condense to form sticky brown sub ( stain teeth ,fingers and lungs tissues ) Organic(volatile/semi-volatile) + Inorganic (N2,O2,H2,CO2,CO) Carcinogen Benzopyrene (polycyclic aromatic compound ) CARBON MONOXIDE Odorless , tasteless gas which interferes with uptake of O2 in lungs and release from blood to tissues Heavy smokers O2 levels,15 % CAD myocardial oxygenation, increasing platelet stickiness, atherosclerosis Pregnant smokers low weight babies due to decreased O2

Very high level Initiate lung damage leading to emphysema

Direct deleterious effect on cilia in lung Interferes with cleansing and accumulates toxins

30 metals (Ni,Cd,As,Cr,Pb) Carcinogenic-arsenic , chromium,nickel,cadmium

Polonium-210 and potassium 40 carcinogenic

Health consequences of tobacco use

Delays oral wound healing Promotes periodontal disease Halitosis Oral infections Smoking oropharyngeal cancer, cancer in esophagus ,stomach, uterine cervix and lungs,cardiovascular disease,COPD,emphysem and chronic bronchitis Smokeless tobacco- oral and esophageal cancer ( paan) exposure to non-smokers: respiratory infections ( women and children ) Smoking is major risk factor for TB in India Pregnant smokers lower weight babies and infant with congenital cleft lip / palate Men-reduced fertility and sexual impotence

Independent risk factor for oral cancer. Synergestic effect Alcohol + Tobacco
Effects of carcinogens of tobacco

Dehydrating effects of alcohol

Increasing mucosal permeability


Plummer-Vinson syndrome , a manifestation of iron deficiency anemia attributes to carcinogenesis. Decreased levels of copper, zincand manganese deplete antioxidants increase tumor-enhancing free radicals Decreased levels of serum retinol Ascorbic acid and Vit E prevents conversion of amines to nitrosamines Beta carotene protects against cancer ( carrot,spinach,lettuce ) Red chilli consumption increases cancer risk

Ultraviolet radiation : Fair-skinned individuals are more susceptible Imp etiology of scc of vermillion border of lip Fungal infection : Hyphae of Candida albicans in outer epi layer in oral red and white lesions and in oral cancer They may be secondary invaders / risk factors Dysplastic candidial lesions are more prone to transformation to oral cancer Trauma and dental irritation From jagged teeth and dentures Poor oral hygiene


Viruses: Human herpes virus 1 may increase risk of oral cancer Herpes simplex virus type 1 and HIV have been associated with scc Genetic factors Expression and stability of gene is affected Loss of heterozygosity Suppression of tumor suppressor genes : 3p (FHIT ) 9p( CDKN2A ) 17p (TP53 )


Definition Precancerous lesion 'a morphologically altered tissue in which cancer is more likely to occur than in its apparently normal counterpart' -WHO 1978. Precancerous condition 'the generalized state of the body, which is associated with a significantly increased risk of cancer'- WHO 1978

Definition a predominantly white lesion of the oral mucosa that cannot be characterized as any other definable lesion ;some oral leukoplakia will transform into cancer (Axell et al , 1996 ) The global prevalence of leukoplakia has been reported to be about 2.6% Etiology Smoking Spirits Spices Sharp tooth edge Syphilis Vit defeciency, endocrine disturbances Virus Blood grp A and active radiation Related to fresh tobacco that contacts the oral mucosa

Site : buccal mucosa,commisures, tongue , alveolar mucosa ,floor of mouth , lips , gingiva , hard and soft palate Clinical types a) Homogenous :white ,well demarcated plaque with an identical reaction pattern throughout the entire lesion b) Non homogenous : may have patches / plaque intermixed with red tissue elements .due to red and white areas it is also called erythroleukoplakia. Precancerous nature : leukoplakia may be persistent ,regress spontaneously , recur/progress to oral cancer . Regression 40% of cases Malignant change 1-20% Lesion cracks, bleeds / erosion is present malignant

Definition Lesions of oral mucosa that present as bright red velvety patch which cannot be characterized clinically / pathologically as due to any condition Global prevalence 0.02-0.1% It has been associated with reverse smoking

Smokers palate / stomatitis nicotina is reaction of palatal mucosa Diffuse white palate numerous excrescenes having red dots , usually corresponding to minor salivary glands Global prevalence 0.1-0.2% Etiology : high temperature due to smoking


Precancerous condition Global prevalence 2.5 million individuals in India 5 % women + 2% men Etiology : Betel nut tobacco Chillies Nutritional deficiencies Genetic susceptibility Autoimmunity Collagen disorders and blood grp A Betel nut : constant irritant ,tannins ppt proteins and damage mucosa ,phenol cause burning sensation, arecoline stimulate fibroblast proliferation and collagen synthesis

Clinical Aspects
Characteristic : palpable fibrous bands Site : buccal mucosa , retromolar areas and around rima oris tongue ( devoid of papillae and smooth ) Trismus , tongue mobility reduces if affected Initial symptoms : burning sensation aggravated by spicy food followed by hyper salivation / dryness, blanching due to decreased vascularity

Definition Oral lichen planus is a chronic mucocutaneous condition in which mucosal and skin manifestations occur independently ,concurrently / sequentially Etiology : cell-mediated ,immunologically induced destruction of basal cell layer of epithelium Global prevalence : 0.5-2.2% GRINSPANS SYNDROME : predisposes to development of scc

Lichen planus


Diabetes mellitus

Clinical Aspects
1. Keratotic white lines that cannot be eliminated by stretching/ rubbing Site : most buccal mucosa Symptoms : burning sensation with pain / asymptomatic Histologic types : Reticular : common ,criss-crossing white striae giving white lacey like appearance Papular : initial ,small white dots, which intermingle to form reticular type Plaque-like: homo well-demarcated white plaque which may / may not be surrounded by striae Erythematous : homo red area Ulcerative : disabling form , ulcers surrounded by erythematous zone displaying white striae, may have burning sensation on food intake

2. 3.
4. 5.


Can occur as carcinoma of lip , mouth , floor of mouth , buccal mucosa , gingiva , palate , maxilary sinus Clinical features : it appears as red , white / mixed lesion , a change in surface texture / presence of mass / ulceration Lesion flat / elevated / ulcerated / non ulcerated and minimally palpable / indurated Loss of function involving tongue speech, swallowing and diet Lymphatic spread submandibular and digastric nodes , upper cervical and remaining nodes of cervical chain


Anatomical extent of cancer is determined T- Size of primary tumor N-Status of cervical nodes M-Presence / absence of metastasis T Primary tumour
TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ T1 Tumour 2 cm or less in greatest dimension T2 Tumour more than 2 cm but not more than 4 cm in greatest dimension T3 Tumour more than 4 cm in greatest dimension T4a (lip) Tumour invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin (chin or nose) T4a (oral cavity) Tumour invades through cortical bone, into deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, or skin of face T4b (lip and oral cavity) Tumour invades masticator space, pterygoid plates, or skull base; or encases internal carotid artery

N - Regional Lymph Nodes NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2 Metastasis as specified in N2a, 2b, 2c below N2a Metastasis in a 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 6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3 Metastasis in a lymph node more than 6 cm in greatest dimension M Distant metastasis MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis

Stage Grouping

Stage 0 Stage I Stage II Stage III

Tis T1 T2 T1, T2 T3

N0 N0 N0 N1 N0, N1 N2

M0 M0 M0 M0 M0 M0

Stage IVA

T1, T2, T3


N0, N1, N2


Stage IVB

Any T T4b

N3 Any N Any N

M0 M0 M1

Stage IVC

Any T

Vital staining Toluidine blue (TB) staining- simple ,inexpensive uses a blue dye - highlight abnormal areas of mucosa. TB - metachromatic nuclear stain( stains nuclear material of malignant lesions but not normal mucosa) method (a) the patient rinsing the mouth with 1% acetic acid for 20 seconds followed by a similar rinse with water twice for 20 seconds (b) rinsing the mouth with 5-10 cc. 1% toluidine blue solution; and (c) rinsing with 1% acetic acid solution (5 oz.) for about 1 minute followed by a water rinse. TB -higher sensitivity to detect carcinoma in situ (CIS) and OSCC False- 8-10% of cases associated with keratotic lesions and the regenerating edges of ulcers and erosions. clinical appearance -the nuclear uptake of TB, related to genetic changes molecular changes of early carcinogenesis.

Biomarkers molecular markers -TSG p53 protein expression, chromosomal polysomy (DNA ploidy) and changes ( loss of heterozygozity) in chromosomes available markers-cell proliferation (Ki-67 antigen)and apoptosis (Bax, Bcl-2 :decreases significantly in dysplastic and early invasive lesions ) Ki-67 expression: increases sharply in initial stages of OSCC, but significantly decreases in later aggressive tumor behavior and worse prognosis : E-cadherin expression,54,55 laminin and decreased tumor cell transmembrane proteo- glycan syndecan-1.5 DNA ploidy measurement of nuclear DNA content. measure of gross genetic damage Aneuploidy cancers. Measured with automated image cytometry of nuclei obtained from routinely processed tissue samples

Brush biopsy uses a small nylon brush to gather cytology samples then sent for computer scanning and analysis (Oral CDx) to identify and display individual cells abnormal cells from the computer display followed with a conventional incisional biopsy. Controversial: false negative results Optical systems Interaction of light -changes in tissue structure and metabolism. Optical spectroscopy- detect changes about the histological and biochemical characteristics of tissue. identification of cellular and molecular abnormalities Early detection -use of a dilute acetic acid rinse and observation under a chemi- luminescent light enhanced by the use of fluorescence.

Saliva-based oral cancer diagnostics Exfoliative cell samples -to detect genetic alterations in the oral epithelium ,to detect microsatellite alterations Promoter hypermethylation patterns of TSG p16, O6-methylguanine-DNAmethyltransferase and death-associated protein kinase messenger ribo-nucleic acid (mRNA) testing from saliva Salivary soluble CD44 (solCD44) levels were found significantly raised in cancer High salivary counts - Capnocytophaga gingivalis,Prevotella melaninogenica and Streptococcus mitis have been found in patients with OSCC Biopsy CT scan / ultrasound / MRI

Other potential future diagnostic technologies Laser-induced fluorescence spectroscopy Light-induced fluorescence spectroscopy Elastic scattering spectroscopy Raman spectroscopy Photoacoustic imaging Photon fluorescence Orthogonal polarization spectral (OPS) imaging Quantum dots Optical coherence tomography (OCT) Trimodal spectroscopy Doppler Nuclear magnetic resonance spectroscopy Chromoendoscopy Narrow band imaging (NBI Immunophotodiagnostic techniques


Surgery Surgery (including the use of lasers) involves removing just the affected tissue. Surgery is sometimes followed by chemotherapy or radiotherapy treatment Non-surgical treatments Radiotherapy Chemotherapy - anti-cancer drugs are used to destroy cancer cells Biological therapy - special manufactured monoclonal antibodies (cetuximab) are used to block areas on the surface of cancer cells that can trigger growth.


LEVELS OF PREVENTION PREVENTIVE SERVICES SERVICES PROVIDED BY INDIVIDUAL PRIMARY Health promotion -Periodic visits to dental clinic -Demand for preventive measures -Dental health education programs -Promotion of research efforts -Lobby efforts Patient education Specific protection Avoidance of known irritants SECONDARY Early diagnosis and treatment -Self examination and referral -Utilization of dental services TERTIARY Disability limitation Utilization of dental services Rehabilitation Utilization of dental services


Avoidance of known irritants

-Periodic screening and referral -Provision of dental services

Provision of dental services

Provision of dental services


Removal of known irritants

-complete examination -Biopsy -Complete excision

Chemotherapy -Radiotherapy -Surgery

prosthodontics -plastic surgery -speech therapy

REGIONAL CANCER CENTRE MEDICAL COLLEGE HOSPITAL Health Promotion/Home Care/Early Detection/ Pain Relief/Palliative Care/ Treatment of common cancers/Training of medical officers/paramedical personnel Health Promotion/Home Care/Early Detection/Pain Relief/Palliative Care/Comprehensive Cancer treatment/ Organise screening programmes/Cytology training/ Basic and applied research/Training of all categories of personnel/Cancer Registries/Epidemiology

DISTRICT HOSPITAL TALUK HOSPITAL/SUB DISTRICT HOSPITAL Health Promotion/Home Care/ Early Detection/Pain Relief/ Palliative Care/Treatment of common cancers

Health Promotion/Home Care/Early Detection/Pain Relief/Palliative Care

The Crete Declaration on Oral Cancer Prevention 2005

10th International Congress on Oral Cancer which took place 19-24 April 2005 in Crete, Greece initiative to analyse the evidence on oral cancer and the implications for prevention and public health programmes. 57 countries emphasized that oral health is an integral part of general health and wellbeing. neglected burden of oral cancer -developing countries with low availability of prevention programmes and services for oral health. In particular, the following areas of work should be strengthened: provision of systematic epidemiological information on prevalences of oral cancer and cancer risks in countries, particularly in the developing world. promotion of research into understanding biological, behavioural and psychosocial factors in oral cancer, emphasizing the inter-relationship between oral health and general health integrating oral cancer information into national health surveillance systems which record chronic diseases and common risk factors

dissemination of information on oral cancer, prevention and care through every possible means of communication active involvement of oral health professionals in oral cancer prevention through control of risk factors such as tobacco, alcohol and diet training of primary health workers in screening and provision of first-level care in oral cancer access to health facilities and provision of systems for early detection and intervention, oral health care and health promotion for the improvement of quality of life of people affected by oral cancer. The participants support the efforts of the WHO Oral Health Programme aiming at coordination and inter-country sharing of experiences in prevention and oral health care of people affected by oral cancer.

WHO Framework Convention On Tobacco C ontrol

For the purposes of this Convention: (a) illicit trade means any practice or conduct prohibited by law and which relates to production, shipment, receipt, possession, distribution, sale or purchase including any practice or conduct intended to facilitate such activity; (b) regional economic integration organization means an organization that is composed of several sovereign states, and to which its Member States have transferred competence over a range of matters, including the authority to make decisions binding on its Member States in respect of those matters (c) tobacco advertising and promotion means any form of commercial communication, recommendation or action with the aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly; (d) tobacco control means a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke; (e) tobacco industry means tobacco manufacturers, wholesale distributors and importers of tobacco products 1

(f) tobacco products means products entirely or partly made of the leaf tobacco as raw material which are manufactured to be used for smoking, sucking, chewing or snuffing; (g) tobacco sponsorship means any form of contribution to any event, activity or individual with the aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly;

Bloomberg Initiative to reduce tobacco use

Campaign for Tobacco-Free Kids Grants management and advocacy/legal assistance. Centers for Disease Control and Prevention (CDC) Foundation Monitoring/surveillance. Johns Hopkins Bloomberg School of Public Health Education/training. World Health Organization - Tobacco Free Initiative (WHO/TFI) Coordination mechanism at country level

World Lung Foundation (WLF) Grants management, global clearing house for tobacco ads.


Build Healthy Public Policy Tighten restriction on tobacco and alcohol advertizing and promotion Subsidize the cost of healthier choices. e.g. fruits and vegetables. Improve labeling on betel quid products. Create Supportive Environment Smoke free public spaces, e.g. cinemas Increase availability of fresh fruits and vegetables [in school canteen and tuckshop]. Develop Personal Skills Expand personal and social education in schools-life skills: empowerment, refusal and negotiation skills. etc. Incorporate tobacco and alcohol control within health promoting schools. Reorient Health Services Expand health professionals education and training in smoking cessation and alcohol control

Increase numbers and range of health promotion professional, with expertize in smoking and alcohol support. Establish evidence-based smoking and alcohol preventive services with primary care setting TOBACCO/SMOKING CESSATION The first step in treating tobacco use and dependence is to identify tobacco users. Screening for current or past tobacco use will result in tour possible responses: 1. The patient uses tobacco and is now willing to make a quit attempt. 2. The patient uses tobacco but is not now willing to make a quit attempt. 3. The patient once used tobacco but has since quit. 4. The patient never regularly used tobacco.

FOR THE PATIENT WILLING TO QUIT Given that so many tobacco users visit a dentist each year, it is important that these dentist be prepared to intervene with tobacco users who are willing to quit. The five major steps (the "5 As") to intervention are [The SA approach]: Ask Identify and document tobacco user about patient's habits Advice of consequence of smoking Assess willingness to quit Assist with cessation plant development Arrange for follow-up

FOR PATIENTS NOT WILLING TO QUIT (5 R method ) 1. Relevance: Provide information that has the greatest impact on the patients disease status, family or social situation (e.g., children and second-hand smoke), health concerns, age or gender. 2. Risks: Acute risks: shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility, increased blood carbon monoxide, bacterial pneumonia; increased risk for surgery Long-term risks: heart attacks, strokes, lung and other cancers, chronic obstructive pulmonary diseases, long-term disability and need for extended care Environmental risks: increased risks of lung cancer and heart disease in spouses; higher rate of smoking by children of tobacco users; increased risk of low birth weight babies, SIDS, asthma, middle ear disease, and respiratory infections in children of smokers

3. Rewards: Highlight benefits most relevant to the patient, such as better health, improved sense of taste and smell, money saved, good example for children, more physically fit, and reduced wrinkling and aging of skin. 4. Roadblocks: Ask the patient to identify barriers to quitting, such as withdrawal symptoms, fear of failure, weight gain, lack of support and depression. Note elements of cessation treatment, such as problem solving or pharmacotherapy. 5. Repetition: Repeat the motivational intervention each time the patient has an office visit. Let the patient know that most people make repeated attempts to quit before they are finally successful.

No tobacco day is observed on 31st May to highlight the adverse effect of tobacco on health .It has been estimated that a majority of cancer death worldwide are due to tobacco. Oral cancer is easily accessible for diagnosis . These factors coupled with finding that oral cancer is generally preceded by precancerous lesions provides an excellent opportunity for early detection and control