1.Presented by : dr shabeelpn

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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-1/3 rd 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.

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What Is Smokeless Tobacco?

Smokeless tobacco / spit tobacco / chewing tobacco.

Mainlytwo forms:snuff andchewing 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 -absorbedinto the bloodstream through the oral tissues.

No need to swallow.

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Consumption

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

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

Inhaled : snuff

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TYPES

Gutkha

Khaini

Mainpuri tobacco

Mawa

Mishri

Paan

Snuff

Zarda

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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.

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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.

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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 .

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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.

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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.

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ZARDA

Tobacco leaves + lime+spices boiled in water.

Residual tobacco dried & coloured.

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CONSTITUENTS OF TOBACCO

Polycyclic aromatic hydrocarbons

Nicotinecarcinogenesis

Nitrosamine

Phenoltumour promotion& irritation

Benzopyrene

Carbon monoxide-impaired oxygen transport

Formaldehyde & oxides ofN-toxicity

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EFFECTS OF TOBACCO

Oral cancer

Cracking & bleeding lips & gums.

Receding gums tooth falls out.

Increasedheartrate, 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.

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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.

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ETIOLOGY & RISK FACTORS

• • Genetic factors

• • Dental factors

• • Occupational risks

• • Tobacco use

• • Alcohol

• • Mouthwash

• • Viral & fungal infections

• • Diet & nutrition

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CLASSIFICATION OF ORAL CANCEROUS LESIONS

Benign tumours-Epithelial origin

Papilloma

Squamous acanthoma

Pigmentedcellular nevus

Premalignant lesions-Epithelial origin

Leukoplakia

Leukodema

Erythroplakia

Intraepithelial carcinoma

Oral submucous fibrosis

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Malignant tumours-epithelial origin

Basal cell carcinoma

Epidermoid carcinoma

Carcinoma of lip, tongue, floor of mouth, gingiva, buccalmucosa, palate, maxillary sinus

Verrcous carcinoma

Adenoid squamous cell carcinoma

Malignant melanoma

Benign tumours- connective tissue origin

Fibroma

Giant cell fibroma

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Peripheral central ossifying granuloma

Lipoma

Hemangioma

Myxoma

Chondroma

Codmans tumour

Osteomas

Malignant tumours ofconnective tissue

Fibrosarcoma

Kaposissarcoma

Ewings sarcoma

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Chondro/Osteosarcoma

Non-Hodkins lymphoma

Burkitts lymphoma

Multiple myleoma

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RED & WHITE / PRECANCEROUSLESIONS

• Leukoplakia

• Erythroplakia

• Oral lesions- tobacco/alcohol

• Carcinoma-in-situ

• Bowens disease

• Oral submucousfibrosis

• Actinic keratosis

• Discoid lupus erythematosis

• Dyskeratosis congenita

• Lichen planus

• Lichenoid reactions

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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 /smokers palate

• Tobacco-associated

• Idiopathic leukoplakia

EPIDEMIOLOGY :

• Highestprevalence in Ernakulam

LEUKOPLAKIA 25.

ETIOLOGY:

• S moking

• S pirits

• S pices

• S epsis

• S harp tooth edge

• S yphilis

CLINICAL FEATURES:

• Age : after 30yrs.

• Strong male predominance.

• Site:buccal mucosa,commissures,tongue,alveolar mucosa,etc

• Yellowish-whitechanges tobrownish-yellow.

• Types:

• • Homogenous

• • Ulcerated

• • Nodular

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Resembles early leukoplakia

Opaque appearance of buccal mucosa grayish white

Common in occlusal line bicuspid&molar region.

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• Erythroplasia of Queyrat

• • Red patch

• • Rare-most imp. precancerous lesion.

• • More dangerous than its white kin.

• • Bright red velvety plaques cannot becharacterized clinically/pathologically as dueto any other condition.

• • No sex predilection.

• • Occur in 6 th &7 thdecades.

• • • ETIOLOGY & CLINICAL FEATURES:

• • • • Smoking & alcohol abuse-same.

• • Types:

• • • Homogenous

• • • Granular/Speckled

ERYTHROPLAKIA 28.

Malignant transformations:

• Preleukoplakia

• Leukodema

• Smokers palate

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ORAL SUBMUCOSIS FIBROSIS (OSF)

• Chronic,progressive,scarring disease.

• A chronic mucosal condition affecting any part of the oral mucosa characterizedby 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 - 25yrs.

• • Site buccal mucosa.

• • Presence of palpable fibrous bands.

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• 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.

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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.

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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.

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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.

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Clinical features:

• • Mainly-ulcerated & indurated margin

• • Occurs as carcinoma of lip , tongue, floor of mouth, gingiva,etc.

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Carcinoma in situ

• • Intra-epithelial carcinoma.

• • Cancer which involves only the place in which it began & that has not spread.

• • Early - stage tumour. eg: Bowens disease.

• • Common site- floor of mouth , tongue , lips.

• • More common in males /elderly.

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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 3 rd & 4 thdecades.

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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 WICKHAMS STRIAE.

• Association of lichen planus, diabetes & vascular hypertension -triad -GRINSPANS SYNDROME.

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FORMS OF LICHEN PLANUS

• • Reticular form

• • Plaque form

• • Erosive form

• • Annular & Linear form

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STAGING OF CANCER

TNMCLASSIFICATION - 3 mainparameters:

T- extentof theprimary tumour

N- condition of regionallymph nodes.

M- absence/presence of distantmetastasis.

New parameters:P- Pathology&

S- Site of the tumour

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T- primary tumour

Tx primary tumour cannot be assessed

To no evidence ofprimary tumour

Tis-carcinoma in situ

T1 tumour 2cm / less in greatestdimension

T2 tumour>2cm but not more than 4cm in greatest dimension

T3 tumour >4cm in greatest dimension

T4 tumour invades adjacentstructures

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 ingreatest dimension

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

N2a metastasis in a single ipsilateral lymph node ,>3cm ,butnot >6cm in greatest dimension

N2c -metastasis in bilateral / contralaterallymph 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 -distantmetastasis

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PREVENTION & CONTROL OF ORAL CANCER

• 3wellknown 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

• • Awareness

• • Initiation /Experimentation

• • Habituation

• • Maintenance / Dependence

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References:

• Essentials of Preventive and CommunityDentistry-3 rdedition- Soben Peter.

• Shafers textbook of Oral Pathology 6 thedition

• Indian Dentist Research and Review.

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