The lipsCheeksAlveolar ridgeTongueRoof of mouthFloor of mouth Salivary glandsPillars of the fauces

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.

Aetiology

Carcinogens: the p53 tumour suppressor gene mutationViruses: human papilloma virus, Epstein-Barr virusSmoking Alchol Family history of first degree relativeMolecular genetics: Regulation of the cell cycle is under the control of over

40 genes which include proto-oncogenes and tumour suppressor genes.

Classification of malignant neoplasm in oral cavity

Primary carcinomaOf a surfaceOf a gland usually salivary glandsRare intra-bony of the jaws:Arising in a cyst liningKrompecher carcinoma arising from residual odontogenic epithelium

Secondary carcinoma:Centrally in the medullary cavity of the jaw bonesOn the surface of the mucosa-malignant cell from sputum grafted on

to raw area.In lymph nodes from a head and neck primary lesion

Primary sarcoma:- centrally in the tissues:-1. In the jaws osteogenic sarcoma

Reticulum cell scrcomaEwing's tumourlymphosarcoma

2. In the musclesFibrosarcomaLeiomyosarcoma Rhabdomyosarcoma

ReticulasesUsually in the cheekCentrally in the jawsHodgkin's diseaseLeukaemic deposits

Staging of malignancy

The benefits of staging:Planning therapyAid to prognosisComparison of resultEpidemiology

The principle staging classification:1.American Joint Vommitte on cancer (AJCC)2.Union Internationale Contre le cancer (UICC)

The TNM system is based on the assessment of 3 components:T:- the extent of primary tumourN:-the presence or absence and extent of regional lymph node

metastasesM:- the presence or absence of distant metastases

There are 2 classifications of TNM systemClinical cTNM Pathological pTNM

The extent of primary tumour (T) as follow:To: when there is no evidence of primary tumourTis: when the primary tumour is non invasive or carcinoma in situTx: when a primary tumour can not be assessedT1: tumour 2cm or less in greatest dimensionT2: tumour more than 2 cm but no more than 4 cm in greatest dimensionT3 tumour more than 4 cm in greatest dimensionT4:adjacent structures e.g. through cortical bone, inferior alveolar nerve.

Floor of mouth, skine of face

The clinical finding regarding regional cervical lymphadenopaty (N) as:No: no palpable adenopathyNx: the node can not assessedN1: metastases in a single ipsilateral lymph node 3 cm or less in greatest

dimensionN2: is subdivided into 3 sectionsN2a: metastases in a single ipsilateral lymph node more than 3 cm but not

more than 6 cm in greatest dimensionN2b: metastases in a multiple ipsilateral lymph node not more than 6 cm in

greatest dimensionN2c: metastases in a multiple bilateral or contralateral lymph node not more

than 6 cm in greatest dimensionN3: is any lymphatic spread more than 6 cm in greatest dimension

The distant metastesis (M) is indicated by:Mo: no distant metastasesM1: presence distant metastases and subdivided to pulmonary (PUL), hepatic

(HEP), brain (BRA)

stageTNM

0TisNoMo

IT1NoMo

IIT2NoMo

IIIT3T2T1

NoN1N1

MoMoMo

IVAT4T4

Any T

NoN1N2

MoMoMo

IVBAny TN3Mo

IVCAny TAny NM1

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 .

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.

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.

Irritation: Long-term irritation to the lining of the mouth caused by poorly fitting dentures.

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.

Poor nutrition: a diet low in fruits and vegetable is associated with an increase risk of getting oral malignancy.

Mouthwash: Some studies have suggested that mouthwash with high alcohol content.

Viral infection: Scientists also are studying whether infections with certain viruses (such as the human papilolmavirus ) are linked to oral malignancy.

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.

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.

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 heal3. Bleeding in the mouth4. Loose teeth5. Difficulty or pain when swallowing6. Difficulty wearing dentures7. Persistent lump or thickening in the cheek8. Increased salivation9. A lump in the neck10. An earache

Symptoms of carcinoma of the oral cavity

Early symptomsThe 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.

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 infectedwhen 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.

Late symptomspain 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.

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.

Carcinoma of the lipCarcinoma 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.

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.

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.

25% of patients have suffered from syphilis and 5% have had leucoplakia, other precancwrous lesions as:

Superficial glossitisPapillomaFissures tongueNon-specific ulcers

58% lie near the lateral margin, 2-4% on the dorsum, 7-15% on the tip, and the posterior third 21-33%.

The appearances of carcinoma of the tongue:The ulcerative typePapillary typeThe flat noduleA malignant fissure as syphilitic fissuringScirrhous or atrophic

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.

Carcinoma of the gingiva

Carcinoma of the floor of mouthCarcinoma of the floor of mouth it is usually a typical malignant ulcer extending to the alveolar process and tongue.

The cheek lesion is often warty and proliferative due to denture irritation and, where teeth are present, from periodontal abscess.

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.

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.

The symptom secondary infection causes pain and dysphagia, and death frequently occurs following erosion of the carotid artery.

Carcinoma of maxillary antrumThe 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

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.

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.

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.

Management of oral malignancy

Diagnosis of oral malignancyClinical 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.

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.

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.

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 beganthe size of the tumorwhether the malignancy has spread.

SurgeryRadiation therapyChemotherapyImmunotherapyGene therapya combination of treatments.