Presented by :

dr shabeel pn

INTRODUCTION Tobacco is responsible for a significant amount of

morbidity & mortality among middle aged adults. India has one of the highest rates of oral cancer in the

world. Tobacco-related cancers - 1/2 of all cancers - men & 1/4

th among women. Oral cancer - 1/3rd total cancer ; 90% - tobacco

chewers. Men are affected 2-3 times than women due to higher use

of alcohol & tobacco and higher exposure to sunlight . Tongue & intra-oral cancer - equal in both as chewing

tobacco among women is common. Effects of tobacco use, heavy alcohol consumption , and

poor diet together explain over 90% of head & neck cancers.

What Is Smokeless Tobacco?

Smokeless tobacco / spit tobacco / chewing tobacco. Mainly two forms: snuff and chewing tobacco. Snuff - users "pinch" or "dip" between their lower

lip and gum. Chewing tobacco - users put between their cheek

and gum. The tobacco juice is sucked and chewed - nicotine -

absorbed into the bloodstream through the oral tissues.

No need to swallow.

Consumption

Chewed : gutkha, pan, mawa, mainpuri tobacco, khaini, zarda

Applied on gums and teeth : mishri, gudhaku, bajjar, tooth paste

Inhaled : snuff

TYPES

• Gutkha• Khaini • Mainpuri tobacco• Mawa• Mishri• Paan• Snuff• Zarda

gutkhA Leads to Oral sub-mucous fibrosis (SMF). Main component - arecanut along with tobacco.

KHAINI Paste of tobacco + slaked lime & is used with arecanut.

Mixed with the thumb to make the mixture alkaline-premolar

region of mandibular groove.

MAINPURI TOBACCO Tobacco+ slaked lime + finely cut arecanut + camphor

+ cloves. Mainly-Uttar Pradesh. High incidence of oral cancer & leukoplakia.

MAWA Gujarathi preparation made from shavings of

arecanut, tobacco and slaked lime. Sold by tobacco vendors in cellophane papers

tied like a small ball.

Mixed & chewed excessively and kept in mandibular groove- causes oral cancer.

MISHRI Prepared by roasting tobacco on a hot metal plate-

black-powdered-used with catechu. Used to clean teeth. Common in women –leads to low birth wt. babies .

PAN (BETEL QUID) WITH TOBACCO

Most common-ancient habit. Betel leaf + arecanut + slaked lime + catechu. Arecanut-vital component-drastically affects oral

health. Contains nitrosamines-carcinogenic. Pan masala - mainly contains tobacco - causes oral

cancer.

SNUFF Finely powdered air-cured & fire-cured

tobacco leaves. Used orally/nasally. Carried in a metal container-a twig is dipped

into it-placed in oral vestibule. Causes oral squamous cell carcinoma.

ZARDA

Tobacco leaves + lime+spices – boiled in water.

Residual tobacco –dried & coloured.

CONSTITUENTS OF TOBACCO

Polycyclic aromatic hydrocarbons Nicotine carcinogenesis Nitrosamine Phenol tumour promotion&

irritation Benzopyrene Carbon monoxide - impaired oxygen transport Formaldehyde & oxides of N - toxicity

EFFECTS OF TOBACCO Oral cancer Cracking & bleeding lips & gums. Receding gums –tooth falls out. Increased heart rate, high B.P, irregular

heartbeats - greater risk of heart attacks. When pregnant women smoke, carbon

monoxide and nicotine passes into their lungs and bloodstream, reducing the oxygen supply to their unborn baby leading to: - asthma attacks, chest infections and colds in later life- premature birth- underweight birth.

Oral cancer refers to cancer of the mouth , lips, tongue, floor & roof of the mouth, cheek & the gums.

Cancer from chewing tobacco does not remain in the mouth itself & it spreads to the stomach,esophagus & bladder.

ETIOLOGY & RISK FACTORS

Genetic factors Dental factors Occupational risks Tobacco use Alcohol Mouthwash Viral & fungal infections Diet & nutrition

CLASSIFICATION OF ORAL CANCEROUS LESIONS

Benign tumours-Epithelial originPapillomaSquamous acanthomaPigmented cellular nevus

Premalignant lesions-Epithelial originLeukoplakiaLeukodemaErythroplakiaIntraepithelial carcinomaOral submucous fibrosis

Malignant tumours-epithelial originBasal cell carcinomaEpidermoid carcinomaCarcinoma of lip, tongue, floor of mouth,

gingiva, buccal mucosa, palate, maxillary sinusVerrcous carcinomaAdenoid squamous cell carcinomaMalignant melanoma

Benign tumours - connective tissue originFibromaGiant cell fibroma

Peripheral central ossifying granulomaLipomaHemangiomaMyxomaChondromaCodman’s tumourOsteomas

Malignant tumours of connective tissueFibrosarcomaKaposis sarcomaEwings sarcoma

Chondro/Osteosarcoma

Non-Hodkins lymphomaBurkitt’s lymphomaMultiple myleoma

RED & WHITE / PRECANCEROUS LESIONS Leukoplakia Erythroplakia Oral lesions- tobacco/alcohol Carcinoma-in-situ Bowen’s disease Oral submucous fibrosis Actinic keratosis Discoid lupus erythematosis Dyskeratosis congenita Lichen planus Lichenoid reactions

Leukokeratosis/white patch formed by keratinization/ thickening of the mucosa.

Most common malignant lesion of the oral mucosa. Raised white part of the oral mucosa measuring 5cm / more which cannot

be scraped off & which cannot be attributed to any other diagnosable diseases.

Definable white lesions: Hyperplastic candidiasis Hairy leukoplakia Tobacco-induced /smoker’s palate Tobacco-associated Idiopathic leukoplakia

EPIDEMIOLOGY :

Highest prevalence in Ernakulam

LEUKOPLAKIA

ETIOLOGY: Smoking Spirits Spices Sepsis Sharp tooth edge Syphilis

CLINICAL FEATURES:

Age: after 30yrs. Strong male predominance. Site: buccal mucosa,commissures,tongue,alveolar

mucosa,etc Yellowish-white changes to brownish-yellow.

Types: Homogenous Ulcerated Nodular

Resembles early leukoplakia Opaque appearance of buccal mucosa

–grayish white Common in occlusal line –

bicuspid&molar region.

Erythroplasia of Queyrat “Red –patch” Rare-most imp. precancerous lesion. More dangerous than its white kin. Bright red velvety plaques –cannot be characterized

clinically/pathologically as due to any other condition.

No sex predilection. Occur in 6th&7th decades.

ETIOLOGY & CLINICAL FEATURES: Smoking & alcohol abuse-same.

Types: Homogenous Granular/Speckled

ERYTHROPLAKIA

Malignant transformations: Preleukoplakia Leukodema Smoker’s palate

ORAL SUBMUCOSIS FIBROSIS (OSF) Chronic,progressive,scarring disease. A chronic mucosal condition affecting any

part of the oral mucosa characterized by mucosal rigidity of varying intensity due to fibro - elastic transformation of the juxta – epithelial connective tissue layer.

Etiology: Pan chewing Clinical features:

Onset is incidious - 2–5yrs. Site – buccal mucosa. Presence of palpable fibrous bands.

Cheek mucosa & tongue become fibrosed-loses its elasticity.

Opening of mouth – restricted Blanching of oral mucosa - impaired vascularity. Difficult to tolerate both spicy & hot foods. Pain on palpation at areas of submucosal fibrotic

bands.

Epidemiology: Prevalent in Ernakulam- Kerala.

BASAL CELL CARCINOMA Most common malignancy. Common site – exposed surface of skin,

face,scalp. Age – middle-aged/elderly People with fair complexion-high rate.

Etiology: UV radiation-shorter wavelength-more Chronic sun exposure X-ray exposure / arsenic.

Clinical features: Age – after 40yrs Sex –male:female=3:2 More in fair skin individuals , rare in dark. Common in middle – third of face. Does not arise in the oral mucosa –arrives

by invasion & infiltration from a skin surface.

Begins as a small, elevated papule –ulcerates-heals-crusts down-develops a rolled border.

EPIDERMOID CARCINOMA /SQUAMOUS CELL CARCINOMA

Most common malignant neoplasm of oral cavity.

Etiology:

Tobacco Alcohol Syphilis Nutritional deficiencies Sunlight Trauma , sepsis Viruses-EBV,CMV, immunocompromised.

Clinical features: Mainly-ulcerated & indurated margin Occurs as carcinoma of lip , tongue, floor of

mouth, gingiva,etc.

Carcinoma in situ Intra-epithelial carcinoma. Cancer which involves only the place in which it

began & that has not spread. Early - stage tumour. eg: Bowen’s disease. Common site- floor of mouth , tongue , lips. More common in males /elderly.

DISCOID LUPUS ERYTHEMATOSIS( DLE)

• A chronic , scarring , atrophy producing, photosensitive dermatosis.

• Red-atrophic , white - keratotic , red - telangiectatic zones provide a characteristic appearance.

• Sites - cheeks, gingiva, labial mucosa, lip.• Age – 3rd& 4th decades.

LICHEN PLANUS /LICHEN RUBBER PLANUS

Common mucocutaneous disease. Affects skin /mucosa /both. Causes bilateral white striations, papules/plaques on the buccal

mucosa, tongue & gingiva.

Epidemiology:Prevalent in Ernakulam.

Clinical features:• Common site in oral cavity – buccal mucosa.• Affects all racial groups/older people.• Flat papules covered by grayish white lines –WICKHAM’S

STRIAE.• Association of lichen planus, diabetes & vascular

hypertension -triad - GRINSPAN’S SYNDROME.

FORMS OF LICHEN PLANUSReticular formPlaque formErosive formAnnular & Linear form

STAGING OF CANCER TNM CLASSIFICATION- 3 main

parameters: T - extent of the primary tumour N - condition of regional lymph

nodes. M - absence/presence of distant

metastasis. New parameters: “P” - Pathology & “S” - Site of the

tumour

‘T’- primary tumour Tx – primary tumour cannot be assessed To – no evidence of primary tumour Tis - carcinoma in situ T1 – tumour 2cm / less in greatest dimension T2 – tumour >2cm but not more than 4cm in

greatest dimension T3 – tumour >4cm in greatest dimension T4 – tumour invades adjacent structures ‘N’ – regional lymph nodes Nx – regional lymph nodes cannot be assessed N0 – no lymph nodes N1 – metastasis in a single ipsilateral lymph

node,3cm/less in greatest dimension

N2 – metastasis in a single ipsilateral lymph node, >3cm but not >6cm in greatest dimension,or in multiple ipsilateral lymph nodes , none >6cm in greatest dimension

N2a – metastasis in a single ipsilateral lymph node ,>3cm ,but not >6cm in greatest dimension

N2c - metastasis in bilateral / contralateral lymph nodes, none >6cm in greatest dimension

N3 – metastasis in a lymph node >6cm in greatest dimension

M – distant metastasis Mx – presence of distant metastasis cannot be assessed M0 - no distant metastasis M1 - distant metastasis

PREVENTION & CONTROL OF ORAL CANCER 3 well–known approaches to public health:

Regulatory / legal approach Service approach Educational approach

Regulatory approach :Health – warning displays.Ban on tobacco advertisements.

Service approach :Active search for the disease & its treatment.

Educational approach :4 stages –

AwarenessInitiation /ExperimentationHabituationMaintenance / Dependence

References: Essentials of Preventive and

Community Dentistry -3rd edition- Soben Peter.

Shafer’s textbook of Oral Pathology – 6th edition

Indian Dentist Research and Review.