Signs and symptoms
On biopsy, the three exophytic masses turned out to be oral carcinomas, while the surrounding hyperkeratotic area showed histologic features of oral lichen planus.
Skin lesion, lump, or ulcer that do not resolve in 14 days located:
- On the tongue, lip, or other mouth areas
- Usually small
- Most often pale colored, may be dark or discolored
- Early sign may be a white patch (leukoplakia) or a red patch (erythroplakia) on the soft tissues of the mouth
- Usually painless initially
- May develop a burning sensation or pain when the tumor is advanced
- Behind the wisdom tooth
- Even behind the ear
Additional symptoms that may be associated with this disease:
Oncogenes are activated as a result of mutation of the DNA. Risk factors that predispose a person to oral cancer have been identified in epidemiological (epidemiology) studies.
Around 75 percent of oral cancers are linked to modifiable behaviors such as tobacco use and excessive alcohol consumption. Other factors include poor oral hygiene, irritation caused by ill-fitting dentures and other rough surfaces on the teeth, poor nutrition, and some chronic infections caused by bacteria or viruses. If oral cancer is diagnosed in its earliest stages, treatment is generally very effective.
Oral cancer often presents as a non-healing ulcer (shows no sign of healing after 2 weeks). In the US oral cancer accounts for about 8 percent of all malignant growths. Men are affected twice as often as women, particularly men older than
Oral leukoplakia on the buccal mucosa. Overall, leukoplakia carries a risk of transformation to squamous cell carcinoma that ranges from almost 0% to about 20%, which may occur in 1–30 years.
A premalignant (or precancerous) lesion is defined as “a benign, morphologically altered tissue that has a greater than normal risk of malignant transformation.” There are several different types of premalignant lesion that occur in the mouth. Some oral cancers begin as white patches (leukoplakia), red patches (erythroplakia) or mixed red and white patches (erythroleukoplakia or “speckled leukoplakia”). Other common premalignant lesions include oral lichen planus (particularly the erosive type), oral submucous fibrosis and actinic cheilitis. In the Indian subcontinent oral submucous fibrosis is very common. This condition is characterized by limited opening of mouth and burning sensation on eating of spicy food. This is a progressive lesion in which the opening of the mouth becomes progressively limited, and later on even normal eating becomes difficult. It occurs almost exclusively in India and Indian communities living abroad. The overall prevalence of oral potentially malignant disorders in the Middle East was 2.8%. Lichen planus/lichenoid lesions were the most common lesions (1.8%) followed by leukoplakias (0.48%), chronic hyperplastic candidiosis (0.38%), and erythroplakia (0.096%). Smoking, alcohol, and age were the main identifiable risk factors.
Oral cancer in a 40-year-old male smoker
In a study of Europeans, smoking and other tobacco use was associated with about 75 percent of oral cancer cases,caused by irritation of the mucous membranes of the mouth from smoke and heat of cigarettes, cigars, and pipes. Tobacco contains over 60 known carcinogens, and the combustion of it, and by-products from this process, is the primary mode of involvement. Use of chewing tobacco or snuff causes irritation from direct contact with the mucous membranes.
Tobacco use in any form by itself, and even more so in combination with heavy alcohol consumption, continues to be an important risk factor for oral cancer. However, due to the current trends in the spread of HPV16, as of early 2011 the virus is now considered the primary causative factor in 63% of newly diagnosed patients.
Some studies in Australia, Brazil and Germany pointed to alcohol-containing mouthwashes as also being etiologic agents in the oral cancer risk family. The claim was that constant exposure to these alcohol-containing rinses, even in the absence of smoking and drinking, leads to significant increases in the development of oral cancer. However, studies conducted in summarize that alcohol-containing mouth rinses are not associated with oral cancer. In a March 2009 brief, the American Dental Association said “the available evidence does not support a connection between oral cancer and alcohol-containing mouthrinse”. A 2008 study suggests that acetaldehyde (a breakdown product of alcohol) is implicated in oral cancer, but this study specifically focused on abusers of alcohol and made no reference to mouthwash. Any connection between oral cancer and mouthwash is tenuous without further investigation.
Infection with human papillomavirus (HPV), particularly type 16 (there are over 180 types), is a known risk factor and independent causative factor for oral cancer. (Gillison et al. Johns Hopkins) A fast-growing segment of those diagnosed does not present with the historic stereotypical demographics. Historically that has been people over 50, blacks over whites 2 to 1, males over females 3 to 1, and 75% of the time people who have used tobacco products or are heavy users of alcohol. This new and rapidly growing sub population between 30 and 50 years old, is predominantly nonsmoking, white, and males slightly outnumber females. Recent research from multiple peer-reviewed journal articles indicates that HPV16 is the primary risk factor in this new population of oral cancer victims. HPV16 (along with HPV18) is the same virus responsible for the vast majority of all cervical cancers and is the most common sexually transmitted infection in the US. Oral cancer in this group tends to favor the tonsil and tonsillar pillars, base of the tongue, and the oropharynx. Recent data suggest that individuals that come to the disease from this particular etiology have a significant survival advantage, as the disease responds better to radiation treatments than tobacco etiology disease.
Hematopoietic stem cell transplantation
Patients after hematopoietic stem cell transplantation (HSCT) are at a higher risk for oral squamous cell carcinoma. Post-HSCT oral cancer may have more aggressive behavior with poorer prognosis, when compared to oral cancer in non-HSCT patients. This effect is supposed to be owing to the continuous lifelong immune suppression and chronic oral graft-versus-host disease.
Histopathologic appearance of a well differentiated squamous cell carcinoma specimen. Hematoxylin-eosin stain
Early diagnosis of oral cancer patients would decrease mortality and help to improve treatment. Oral surgeons and dentists are the early diagnosers that diagnose these patients in early stages. Health providers, dentists, and oral surgeons shall have high knowledge and awareness that would help them to provide better diagnosis for oral cancer patients. An examination of the mouth by the health care provider, dentist, oral surgeons shows a visible and/or palpable (can be felt)lesion of the lip, tongue, or other mouth area. The lateral/ventral sides of the tongue are the most common sites for intraoral SCC. As the tumor enlarges, it may become an ulcer and bleed. Speech/talking difficulties, chewing problems, or swallowing difficulties may develop. A feeding tube is often necessary to maintain adequate nutrition. This can sometimes become permanent as eating difficulties can include the inability to swallow even a sip of water. The doctor can order some special investigations which may include a chest x-ray, CT or MRI scans, and tissue biopsy.
There are a variety of screening devices that may assist dentists in detecting oral cancer, including the Velscope, Vizilite Plus and the identafi 3000. There is no evidence that routine use of these devices in general dental practice saves lives. However, there are compelling reasons to be concerned about the risk of harm this device may cause if routinely used in general practice. Such harms include false positives, unnecessary surgical biopsies and a financial burden on the patient. While a dentist, physician or other health professional may suspect a particular lesion is malignant, there is no way to tell by looking alone – since benign and malignant lesions may look identical to the eye. A non-invasive brush biopsy (BrushTest) can be performed to rule out the presence of dysplasia (pre-cancer) and cancer on areas of the mouth that exhibit an unexplained color variation or lesion. The only definitive method for determining if cancerous or precancerous cells are present is through biopsy and microscopic evaluation of the cells in the removed sample. A tissue biopsy, whether of the tongue or other oral tissues and microscopic examination of the lesion confirm the diagnosis of oral cancer or precancer. There are six common species of bacteria found at significantly higher levels in the saliva of patients with oral squamous cell carcinoma (OSCC) than in saliva of oral-free cancer individuals. Three of the six, C. gingivalis, P. melaninogenica, and S. mitis, can be used as a diagnostic tool to predict more than 80% of oral cancers.
Surgical excision (removal) of the tumor is usually recommended if the tumor is small enough, and if surgery is likely to result in a functionally satisfactory result. Radiation therapy with or withoutchemotherapy is often used in conjunction with surgery, or as the definitive radical treatment, especially if the tumour is inoperable. Surgeries for oral cancers include:
- Maxillectomy (can be done with or without orbital exenteration)
- Mandibulectomy (removal of the mandible or lower jaw or part of it)
- Glossectomy (tongue removal, can be total, hemi or partial). When glossectomy is performed for smaller tumors (< 4 cm), the adequacy of resection (margin status) is best assessed from the resected specimen itself. The status of the margin (positive/tumor cut through versus negative/clear margin) obtained from the glossectomy specimen appears to be of prognostic value, while the status of the margin sampled from the post-glossectomy defect is not. The method of margin sampling appears to correlate with local recurrence: preference for tumor bed/defect margins may be associated with worse local control.
- Radical neck dissection
- Mohs surgery or CCPDMA
- Combinational, e.g. glossectomy and laryngectomy done together
- Feeding tube to sustain nutrition
Owing to the vital nature of the structures in the head and neck area, surgery for larger cancers is technically demanding. Reconstructive surgery may be required to give an acceptable cosmetic and functional result. Bone grafts and surgical flaps such as the radial forearm flap are used to help rebuild the structures removed during excision of the cancer. An oral prosthesis may also be required. Most oral cancer patients depend on a feeding tube for their hydration and nutrition. Some will also get a port for the chemo to be delivered. Many oral cancer patients are disfigured and suffer from many long term after effects. The after effects often include fatigue, speech problems, trouble maintaining weight, thyroid issues, swallowing difficulties, inability to swallow, memory loss, weakness, dizziness, high frequency hearing loss and sinus damage.
Survival rates for oral cancer depend on the precise site, and the stage of the cancer at diagnosis. Overall, 2011 data from the SEER database shows that survival is around 57% at five years when all stages of initial diagnosis, all genders, all ethnicities, all age groups, and all treatment modalities are considered. Survival rates for stage 1 cancers are approximately 90%, hence the emphasis on early detection to increase survival outcome for patients. Similar survival rates are reported from other countries such as Germany.
Following treatment, rehabilitation may be necessary to improve movement, chewing, swallowing, and speech. Speech and language pathologists may be involved at this stage.
Chemotherapy is useful in oral cancers when used in combination with other treatment modalities such as radiation therapy. It is not used alone as a monotherapy. When cure is unlikely it can also be used to extend life and can be considered palliative but not curative care. Biological agents, such as Cetuximab have recently been shown to be effective in the treatment of squamous cell head and neck cancers, and are likely to have an increasing role in the future management of this condition when used in conjunction with other established treatment modalities.
Treatment of oral cancer will usually be by a multidisciplinary team, with treatment professionals from the realms of radiation, surgery, chemotherapy, nutrition, dental professionals, and even psychology all possibly involved with diagnosis, treatment, rehabilitation, and patient care.
- Postoperative disfigurement of the face, head and neck
- Complications of radiation therapy, including dry mouth and difficulty swallowing
- Other metastasis (spread) of the cancer
- Significant weight loss
Prognosis depends on stage and overall health. Grading of the invasive front of the tumor is a very important prognostic parameter
Gum Disease and Obesity
Some researchers are now suggesting that perio-dontitis may contribute to obesity by elevating C-reactive protein, which then acts as a potent inducer of inflammatory cytokines and hormones secreted by adipose tissue.26-29
Scientists have found that elevated C-reactive protein causes fat cells (adipocytes) to store more fat and burn less energy. Indeed, evidence is accumulating that there is a link between obesity, type 2 diabetes, and periodontitis. As one research team noted recently, “Obesity is a significant predictor of periodontal disease and insulin resistance appears to mediate this relationship.”28 A University of Mississippi study found, “…significant correlations between body composition and periodontal disease,” and noted this finding “strengthened arguments that periodontal disease and certain obesity-related systemic illnesses are related…”29
Periodontal Disease Linked With Cancer
The link between oral health and cancer remains somewhat controversial, largely because this information is so new. But a recently published study by researchers at the Imperial College of London and Harvard School of Public Health has shed new light on the matter. By carefully eliminating potential confounding factors, such as a patient’s history of cigarette smoking, these scientists sought to identify any statistically significant associations between oral health and the incidence of cancer. Their conclusion is chilling. “Periodontal disease was associated with a small, but significant, increase in overall cancer risk, which persisted in never-smokers,” write the collaborators, in the medical journal Lancet Oncology.19 This conclusion has profound implications. The fact that it arises from data gathered from more than 48,000 men over the course of approximately 18 years lends additional gravity to the findings.
The research team also found significant associations among oral health status and lung, kidney, and pancreatic cancers, as well as cancers of the blood. The investigators note that their results need independent confirmation, but they offer this speculation regarding the implications of the findings: “…periodontal disease might be a marker of a susceptible immune system or might directly affect cancer risk.”19 In either case, periodontal disease takes on new significance, and appears to pose more of a threat to health than has previously been recognized.
Furthermore, a recent study by researchers at the Harvard School of Public Health tentatively concludes that periodontitis is associated with an increased risk of one of the most deadly cancers. “Compared with no periodontal disease, history of periodontal disease was associated with increased pancreatic cancer risk,” write the Harvard researchers, in the Journal of the National Cancer Institute.30
The American Dental Association agrees that “oral health is important for overall health” and indicates that salivary diagnosis may offer a key tool in health assessment. “A wide range of proteins, nucleic acids, hormones, pharmaceuticals, and pathogens can be measured in saliva, making it an excellent candidate for rapid detection and screening of biomarkers for conditions like caries, periodontal disease, osteoporosis, infectious diseases, and cancer,” it says.31
Botanical and Nutritional Agents Show Promise in Oral Hygiene
Given the potentially lethal risks of poor dental hygiene, it makes sense to utilize all the science available to prevent even the smallest problems in the mouth.
Several nutrients have shown very favorable effects when used as part of an oral hygiene program. Among these are coenzyme Q10 (CoQ10), green tea, aloe vera, and pomegranate. These claims have been verified by published research.9-11,32-35 Other beneficial ingredients for healthy teeth and gums include xylitol, lactoferrin, and folic acid.12,13,15,17
Multi-Faceted Benefits of Green Tea
Green tea is well known for its beneficial effects throughout the body, but it is also effective in the fight against dental caries and oral disease. Studies have shown that green tea catechins exert direct antibacterial activity against Streptococcus mutans, one of the key microorganisms responsible for tooth decay. Green tea also helps prevent bacteria from sticking to teeth, by inhibiting a bacterial enzyme involved in this process. It also inhibits production of amylase, an enzyme used by bacteria to break starches down into sugars, which bacteria use to fuel their own growth.34,35
Furthermore, Asian researchers showed recently that green tea reduces the invasiveness of oral cancer and decreases the production of a protein associated with oral cancer proliferation.36,37 Additionally, American researchers report that green tea arrests the growth and causes self-destruction (apoptosis) of oral carcinoma cells in the laboratory.38
In Japan, researchers conducted a study in which green tea was applied to the teeth of subjects with periodontal disease for eight weeks. Symptoms of periodontitis improved in subjects receiving green tea catechins and there was objective evidence that green tea killed a significant proportion of the bacteria causing periodontitis in these test subjects.39
Fight Oral Disease
Best known as a potent cardioprotective nutrient, CoQ10 has also been shown to improve symptoms of periodontitis when applied topically in the oral cavity.9,32,33 Japanese researchers conducted a placebo-controlled clinical trial in men with established periodontitis. After nine weeks of CoQ10 application, investigators found evidence of “significant improvements” in periodontal status, which were not seen in control subjects.9
An early study on CoQ10’s effectiveness against periodontitis impressed the study’s authors so much, they wrote, “Healing was so excellent five to seven days’ post-biopsy that the biopsy sites were difficult to locate. The healing was viewed as extraordinarily effective.”40 It has been suggested that CoQ10 benefits oral health by reducing the oxidative stress associated with low-grade inflammation of gums and bone.
Good oral and dental hygiene can help you avoid cavities and tooth decay. Below are some tips to help prevent cavities. Ask your dentist which tips are best for you.
- Brush with fluoride toothpaste after eating or drinking. Brush your teeth at least twice a day and ideally after every meal, using fluoride-containing toothpaste. To clean between your teeth, floss or use an interdental cleaner. If you can’t brush after eating, at least try to rinse your mouth with water. If you have a young child, ask the dentist how much fluoride toothpaste to put on your child’s toothbrush so your child gets the cavity-fighting benefits without getting too much fluoride.
- Rinse your mouth. If your dentist feels you have a high risk of developing cavities, he or she may recommend that you use a mouth rinse with fluoride.
- Visit your dentist regularly.Get professional teeth cleanings and regular oral exams, which can help prevent problems or spot them early. Your dentist can recommend a schedule that’s best for you.
- Consider dental sealants.A sealant is a protective plastic coating that’s applied to the chewing surface of back teeth, sealing off the grooves and crannies that tend to collect food. The sealant protects tooth enamel from plaque and acid. Sealants can help both children and adults.The Centers for Disease Control and Prevention recommends sealants for all school-age children. Sealants last up to 10 years before they need to be replaced, though they need to be checked regularly to ensure they’re still intact.
- Drink some tap water. Most public water supplies have added fluoride, which has helped decrease tooth decay significantly. If you drink only bottled water that doesn’t contain fluoride, you’ll miss out on fluoride benefits.
- Avoid frequent snacking and sipping. Whenever you eat or drink beverages other than water, you help your mouth bacteria create acids that can destroy your tooth enamel. If you snack or drink throughout the day, your teeth are under constant attack.
- Eat tooth-healthy foods.Some foods and beverages are better for your teeth than others. Avoid foods that get stuck in grooves and pits of your teeth for long periods, such as chips, candy or cookies, or brush soon after eating them. However, foods such as fresh fruits and vegetables increase saliva flow, and unsweetened coffee, tea and sugar-free gum help wash away food particles.
- Consider fluoride treatments. Your dentist may recommend periodic fluoride treatments, especially if you aren’t getting enough fluoride through fluoridated drinking water and other sources.
- Ask about antibacterial treatments. If you’re especially vulnerable to tooth decay — for example, because of a medical condition — your dentist may recommend special antibacterial mouth rinses or other treatments to help cut down on harmful bacteria in your mouth.
Most dentists recommend regular checkups to identify cavities and other dental conditions before they cause troubling symptoms and lead to more-serious problems. The sooner you seek care, the better your chances of reversing the earliest stages of tooth decay and preventing its progression. If a cavity is treated before it starts causing pain, you probably won’t need extensive treatment.
Treatment of cavities depends on how severe they are and your particular situation. Treatment options include:
- Fluoride treatments. If your cavity is just getting started, a fluoride treatment may help restore your tooth’s enamel. Professional fluoride treatments contain more fluoride than the amount found in tap water, over-the-counter toothpaste and mouth rinses. Fluoride treatments may be liquid, gel, foam or varnish that’s brushed onto your teeth or placed in a small tray that fits over your teeth. Each treatment takes a few minutes.
- Fillings. Fillings, sometimes called restorations, are the main treatment option when decay has progressed beyond the earliest enamel-erosion stage. Fillings are made of various materials, such as tooth-colored composite resins, porcelain or combinations of several materials. Silver amalgam fillings contain a variety of materials, including small amounts of mercury.
- Crowns. If you have extensive decay or weakened teeth, you may need a crown — a custom-fitted covering that replaces your tooth’s entire natural crown. Your dentist will drill away all the decayed area and enough of the rest of your tooth to ensure a good fit. Crowns may be made of gold, porcelain, resin, porcelain fused to metal or other materials.
- Root canals. When decay reaches the inner material of your tooth (pulp), you may need a root canal. This is a treatment to repair and save a badly damaged or infected tooth instead of removing it. The diseased tooth pulp is removed. Medication is sometimes put into the root canal to clear any infection. Then the pulp is replaced with a filling.
- Tooth extractions. Some teeth become so severely decayed that they can’t be restored and must be removed. Having a tooth pulled can leave a gap that allows your other teeth to shift. If possible, consider getting a bridge or a dental implant to replace the missing tooth.