Authors: Kambarji B. M.Sc. Oral Surgery specialist at United Nations, Zafar B. M. BDS, MFDSRCSENG, FFDRCSI OSOM Boyle Dental Centre, Ireland
ABSTRACT: This article aims to disseminate dental general practitioners, oral and maxillofacial surgeons the clinical features of squamous cell carcinoma of the oral cavity. Early detection of oral cancer greatly increases the chances for successful treatment. There are two major components of early detection of oral cancer: education to promote early diagnosis and screening.
Recognizing possible warning signs of cancer and taking prompt action leads to early diagnosis. Increased awareness of possible warning signs of oral cancer, among physicians, nurses and other health care providers as well as among the general public, can have a great impact on the disease. Some early signs of oral cancer include lumps, sores that fail to heal, abnormal bleeding, pain when chewing or swallowing, and chronic hoarseness. Early diagnosis of oral cancer is a key to better quality of life and a better survival
Most cancers of the oral cavity are oral squamous cell carcinomas (OSCC). Tobacco, alcohol and betel use are main risk factors for oral cancer as well as many potentially malignant lesions (PML). The main high-risk groups are older adult males who use tobacco and alcohol.
It is expected that early diagnosis of PML can reduce mortality. Early diagnosis of OSCC can speed proceeding to treatment and can improve the prognosis. This requires patients to seek an oral and dental examination at an early stage.
Conventional oral examination (COE) is the standard method of revealing PML and OSCC, confirming the clinical suspicion by biopsy and histopathological examination. Histopathology has for many years been the gold standard in the diagnosis of OSCC; however, it is a rather slow process, requiring several days to fix, embed and stain the biopsy specimen before results can be available. It is subject to interpretation of pathologists, and although it can detect cellular changes, it can only detect molecular changes if special techniques are employed.
This review outlines the signs and symptoms of oral cancer and potentially malignant lesions, which often resemble less serious conditions more commonly found in the mouth and discusses the available and developing adjuncts for detection and diagnosis of oral cancer. All such techniques require more multicenter cross-sectional/¬longitudinal controlled trials in high-risk patients and low risk populations with histologic outcomes.
Etiology of Oral Cancer:
Epidemiologic studies established associations between a number of environmental factors and oral cancer. The most important among these factors are tobacco and alcohol. Separately these two factors increase the risk of oral cancer. On using both, the risks of developing oral cancer are multiplied. Most cases of oral carcinomas can be attributed to certain life-style risk factors and are thus preventable. The most important are using tobacco and drinking alcohol to excess. For some populations, regular areca nut and betel quid use is relevant.
Amongst younger patient, known risk factors are absent, producing a challenge for research into their aetiology (Lleweyn et al. 2001). Human Papillomavirus. HPV infection is emerging as a likely cause of oral cancer and particularly of the oro-pharynx in this age group.
The tobacco use-smoked or in smokeless forms- is far and away the most important risk factor of the oral cancer. Over 75% of the mouth and pharyngeal cancers are directly attributed to smoking (and alcohol) use. Within Europe, smoking cigarettes is the most commonly encountered risk factor, bit rolled up non-filter cigarettes have higher risk factors. Smokeless tobacco products also could cause mouth and pancreatic cancer (Warnakulasuriya,200¬4).
The risk of oral cancer increases with the amount of tobacco consumed per day, and the number of years of consumption. All tobacco products are carcinogenic (IARC,2012), and there is no evidence to suggest that replacing smoking with another tobacco product is harmless.
The international Agency on Research for Cancer (IARC) recently reviewed the published evidence for 27 cancer sites and found that of all of the risk sites, the mouth and pharynx had the highest cancer risk among alcohol misusers. Excessive consumption of alcohol is the second most important factor, it acts synergistically with tobacco so that the combined damage is more than multiplied.
-Human Papillomavirus HPV
Human papillomavirus (HPV) associated oropharyngeal and base of tongue cancers constitute an important subgroup of head and Neck cancers (HNC). Particularly among a high proportion of young people diagnosed with tongue base and oropharyngeal cancers (OPC) human papillomavirus (HPV) is an emerging risk factor. HPV is detectable in approximately a quarter of all HNC and aparticularly higher prevalence (~40%) is noted in OPCs.
Ultra-violet light is an important etiologic factor in lip cancer particularly in fair skinned individuals. Lip cancer is more common in outdoor workers who live in sunny climates.
The most common presentations of squamous cell carcinoma of the oral mucosa are a red patch, a combined white and red patch, a white patch or an ulceration or erosion. Oral cancer ulcers are frequently described as having indurated base, everted borders and necrotic center and are fixed to surrounding tissues. Verrucous carcinoma presents as a cauliflower-like mass that might occur at any site in the oral cavity. Carcinoma of the verrucous type may offer a better prognosis than deeply ulcerated lesions of similar size.
Examination for Oral Cancer:
The oral mucosa can be easily inspected and therefore oral cancer should be detected at a very early stage. However, delay often occurs between the time of onset of signs or symptoms and diagnosis. This delay often results from the clinician’s failure to suspect the malignant nature of the lesion or is unfamiliar with the different forms in which oral malignant and premalignant lesions present themselves.
It is a very important that a methodical approach to examination of oral mucosa should be adopted by all dentists. A thorough examination of the oral mucosa of lips, tongue, and alveolar mucosa, floor of the mouth, palate, cheek and oropharynx should be routinely carried out for every patient presenting at a dental office.
Since oral cancer in early stages is painless, it is not likely that the patient will seek dental consultation for an early cancerous lesion. The more likely scenario is a patient seeking consultation for a painful carious lesion, periodontal condition or routine check up and the cancerous or precancerous lesion is discovered as incidental finding.
Screening & Examination
A thorough, systematic examination of the mouth and neck need only take a few minutes and can detect these cancers at an early and curable, stage. Our goal is to discover oral, head and neck cancers early, before patients present complaining of pain, a mass, bleeding, otalgia, or dysphagia. Errors in diagnosis are most often ones of omission, and therefore the importance of a systematic approach to the oral, head and neck cancer examination cannot be overstated.
While taking the patient’s history it is helpful to note any facial asymmetry, masses, skin lesions, facial paralysis, swelling or temporal wasting. Inspection of the lips, both moving and at rest, can also be performed while first meeting the patient. Again, look for any asymmetry or gross lesions on the lips. Listening in an important part of this examination. The sound of one’s voice and speech are important in consideration of the location of tumors as a “hot potato” voice may signal the presence of an oropharyngeal tumor whereas a raspy, hoarse voice could be the first sign of a laryngeal neoplasm. Throughout this oral, head and neck cancer examination, it is helpful to remember to look, listen, AND feel every site that is being examined.
Early biopsy is the key in the management of oral cancer. There is strong evidence that early diagnosis makes significance difference in the outcome of oral cancer. Biopsy should be correlated with the physical examination and clinical presentation.
Biopsy is a simple procedure which can be performed under local anesthesia. Any unexplained or persistent (lasting more than three weeks) lesion should be biopsied. In biopsy the clinician takes a piece of sampled tissue for histopathological examination, interpretation and diagnosis. Two incisions forming an ellipse at the surface and converging to form a V at the base of the lesion provides a good specimen and leaves a wound that is easy to close by suturing. The specimen should include pathologic and normal tissue. The lesion could be present in the form of white, red or mixed red and white lesion. The lesion could be present in the form of ulcer, lump or non healing socket.
The dental clinician should be able to indentify, diagnose and investigate any suspected lesion. It is important for the clinician to be aware of different procedures in regard to biopsy.
Biopsy could be incisional or excisional based on the size and location of the lesion. It can be performed with scalpel or punch. OralCDx brush biopsy is another significant adjunct diagnostic technique available to the clinician in the diagnosis of oral cancer. Toluidine blue staining is significant in the early diagnosis of dysplasia and early detection can be done with the help of toluidine blue staining.
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Pictures are reposted from Making oral cancer screening a routine part of your patient care, Part 2
Linda Douglas, RDH http://www.nature.com/vital/journal/v9/n2/full/vital1486.htm