Oral Cancer

 A new tissue growth on the lip, gum, tongue, floor of mouth and unspecified parts of the mouth, with uncontrolled growth of cells that have no physiological use.

 Incidence

·    40% of all cancers in South Asia, 10-15% of all cancers in Nepal (hospital-based finding)

·   Cancer of mouth and pharynx ranks as the 5th commonest site of cancer in developing countries and 8^th in developed countries. In Nepal, over 2000 new cases of cancer and 600 deaths reported annually, with a distribution of 5:1 for male: female.

·    Age related disease with 98% of patients over 40 years of age

·    Is relatively common in younger people in developing countries

 Warning Signs

·       Ulcers that persist after 2-3 weeks, usually painless

·       Red lesions (Erythroplakia)

·       White lesions (Leukoplakia)

·       Mixed red and white lesions (Speckled leukoplakia)

·       Submucous fibrosis: lips and cheeks become immobile resulting in trismus

Pain is usually a late feature when the lesion becomes superinfected or when in contact with spicy food.

Additional features

·       Lump or thickening in the oral soft tissues

·       Soreness or a feeling that something is caught in the throat

·       Referred pain to the ear

·       Difficulty moving the jaw or tongue

·       Hoarseness in voice

·       Numbness of the tongue or other areas of the mouth

·       Swelling of the jaw that causes dentures to fit poorly or become uncomfortable

Risk Factors

1.     Tobacco Chewing (paan)

·       Betel quid only: the longer the quid is kept in mouth, the higher the risk

·       Smoking only (cigarettes/bidi): Reverse smoking is associated with higher risks. In Nepal, overall prevalence of daily smoking was reported to be 64% in 2000. In 1990, 9.4% of male smokers and 1.6% of female smokers were reported to have smoked 20 cigarettes per day, from which 93% had started smoking before the age of 20. From 1990 to 2000 per capita consumption of cigarettes has increased from 580 to 626 cigarettes.

·       Betel quid with tobacco

·       Betel quid and smoking

·       Betel quid with tobacco and smoking

2.     Alcohol: second major risk factor for oral cancer.  Synergistic effect of alcohol and tobacco.

3.     Khaini, gutka (paanparag), surtti

4.     Suparri (betel nut)

5.     Diet: deficiencies in vitamins A, vitamins C, iron and other trace elements may

               predispose individual to develop cancer (one of the possible reasons why

               highest incidence rates are in the poorest countries).

6.     Exposure to sunlight: risk factor for lip cancer

7.     Other factors: Immunological disorders, fungal and viral infections, poor oral hygiene, ill-fitting dentures, jagged teeth.

Preventive Measures

1.     Avoid risk behaviours, mentioned above

2.     Have nutritious diet, that includes green vegetables, fresh fruits, dairy products, meat and fish

3.     At least decrease the use or modify risk behaviours: e.g. in the case of betel-quid chewing, not to sleep with quid in mouth or rinse mouth after chewing.

4.     Quit risk habits

Risk falls dramatically with the cessation of tobacco use, with 30% reduction in risk for those stopping smoking from 1-9 years, 50% reduction for those stopping smoking more than 9yrs and after 10 years, it is believed that there is no greater risk than one who has never smoked.

Early detection is equally important. Survival rate of small cancers less than 2cm is 76%, while that of larger lesions is only 19%. Therefore, health workers should thoroughly examine their patient's mouths regularly and inform the patients about the risk factors. They should enable individuals to examine their own mouths.

Extra -oral Signs

This includes:

·       Examination of the face, head and neck for any asymmetry and changes in skin such as crusts, growths and /or colour change.

·       Palpation of regional lymph nodes and if present, their mobility and consistency.

Intra-oral Signs

The recommended order of examination is as follows:

Lips: Any changes in colour, texture or surface abnormalities in both upper and lower lips must be noted.

Labial mucosa: Colour, texture, swelling or any other abnormalities of the vestibular mucosa, gingiva and frenum must be observed in both the arches.

Buccal mucosa: The buccal mucosa must be retracted and any changes in colour, texture, mobility or any other abnormalities of the mucosa must be carefully examined.

Gingiva: The buccal, labial, palatal and lingual aspects of the gingiva and alveolar ridge must be examined systematically starting from the upper right quadrant to the lower right quadrant.

Tongue: The following areas of the tongue must be examined for any swelling, ulceration, growths, coating or changes in size, colour or texture.

·       dorsum of the tongue,

·       the papillae,

·       the right and left margins of the tongue,

·       the ventral surface of the tongue.

In addition, the tongue should be protruded to check for any abnormality in mobility or positioning.

Floor of mouth: With the tongue elevated, the floor of the mouth should be examined for any changes in colour or texture, swelling or other surface abnormalities.

Palate: Both the hard and the soft palate must be examined, with the patient's head tilted back and the mouth wide open. The base of the tongue should be depressed with a mouth mirror for good vision.

If suspicious lesions intra-orally or extra-orally are detected, the patient should be referred to the nearest hospital for a biopsy of the lesion.