evaluation & treatment of the dental patient for cancerous & precancerous lesions mac...

Evaluation & Treatment of the Dental patient for Cancerous & PrecancerousLesions

Mac Whitesides DMD, MMSc. Atlanta, GA Doctormac@mindspring.com

Oral SCCAUSA

•3 % of all cancers•43,000 new cases •8,260 deaths•6th most common malignancy

Georgia•680 new cases•190 deaths

*usually detected early*usually detected by dental professionals

Oral Precancerous Lesions

1. Leukoplakia: white plaque that can not be described otherwise

ETI: tob, trauma, tertiary syphlitic glossitis CLINCAL: most common oral precancer (85%)

*5th to 6th decade*M>>F * lip vermillion > BM >Mn. Gingvia >

tongue > oral floor > HP > SP* more common & more likely to undergo malignant transformation in males > 40 yrs* Early, Moderate, Severe

Oral Precancerous Lesions Leukoplakia TX: remove any etiologic agent

observe for two weeksbiopsy if suspicious

PROG:SCCA much more common in pts with Leukoplakia vs. without•90-95% benign•if have dysplasia or CA in situ also,then more likely to become malignant

Oral Precancerous Lesions

2. Erythroplakia: red plaque that can not be described otherwise*FOM > SP > RTMP > tongue

*less common than Leukoplakia, but more likely to be malignant

Oral SCCA

Presentation:irregular, indurated, painful, painless, erythroplakia-like;leukoplakia-like, ulcerative, exophytic, or benignAge: 5th to 9th decadeGrades: CA in situ, mild, moderate, severe dysplasiaLocation: Tongue > FOM > Buccal Mucosa >

Alveolar Mucosa > Palate

Risk Factors

•TOB•ETOH •age•family Hx •previous Hx of oral SCCA

•race•syphilis•poor oral hygiene•Betel Nut

Oral SCCA

It is evident therefore that no man shouldventure upon snuff who is not sure thathe is not so far liable to a cancer: and no man can be sure of that.

John Hill 1761

40 yo w male: SCCA

40 yo w male: SCCA 1 wk post Bx

68 yo male: SCCA

Verrucous Carcinoma • an exophytic, well-differentiated form of SCCA ETI:TOB, Trauma, Viral CLINICAL:7% of all SCCA

7th to 8th decades, M> FBM> Gingiva> other sites

TX: Surgical removal PROGNOSIS: 75% five year survival rate

Oral Lesions 1. Detection 2. Inspection 3. Evaluation 4. Suspicion

Treatment1. Radiation2. Chemotherapy3. Surgery4. Combination

StagingT = Primary Tumor SizeN = Node InvolvementM = Metastasis

Prognosis•State at Diagnosis•Location of Primary Tumor•Metastasis

SCCA

•effective in treating T1 or T2 lesions•delivered in divided doses to maximize effect on tumor & minimize effect on normal tissue•delivered in 1.8 to 2.0 Gy per day, max at 5000 to 6000 GyHyperfractionation: deliver < 2.0 Gy BID

advantage: net 10 to 15 % increase in dose, with less effect on normal tissue

Acceleration: 2.0 Gy BIDadvantage: counteracts tumor cell re-population

Side Effects: Xerostomia, Tissue Fibrosis, Caries,Osteomyelitis

Radiation

Chemotherapy

•Treats macroscopic, microscopic,and metastatic disease

•Used with XRT, SurgeryTherapy: Combination, Neoadjuvant, Adjuvant, PalliativeAgents: Cisplatin, Carboplatin, Fluoroucil, MethotrexateSide Effects: Xerostomia, Caries, Infections, Alopecia, Bone marrow toxicity, Nausea,

Vomiting, Mucosal toxicity

SurgeryPrimary Site•1 cm margin of non diseased tissue•Defect: local, rotational, free flaps, distraction osteogenesis•Post op: Chemo/XRT ???

Regional•SCCA has invaded neck•Primary resection & neck dissection

(radical vs modified radical)•Post op: Chemo/ XRT ???

Antioxidants

•Naturally occurring substances that interact with free radicals to decreases cellular damage•Retinoids, beta-carotene, ascorbic acid,

alpha-tocopherol•Clinical trials have not clearly proven their efficacy

Lichen Planus

1. Reticular : usually asymptomatic, typically bilateral irregularly shaped white plaques ( Wickham’s straie )on BM ( location may change with time )

2. Erosive : painful & debilitating, may involve entire oral cavity atrophic & ulcerated patches with white halo

• most common dermatologic disease to affect oral cavity• W > M ; middle age adults

ETI : unknown , ? Immune systemCLINICAL :

Tx : flucinonide ointment & Orabaseclobetasol & OrabaseSteroids, Cyclosporine, Retinoids, Aloe

PROGNOSIS; good, 1 to 5 % SCCA

Audit of Clinical Information & Diagnosis Supplied to Pathologist following Bx of SCCA

University of Maryland Medical Systems

Mac Whitesides DMD, MMSc

MSDA: vol. 38, no. 2 Sept. 1995 p.63-65

Objective :Attempt to compare & correlate cases that have the histopathologic diagnosis of oral SCCA with the data submitted by the clinicianto the oral pathologist

vs

Classification of Malignancies

SCCA 85 Verrucous 4

Sarcomas 6 BCCA 4

SGT 5 Lymphoma 1

Met. Tumors 5 Myeloma 1

Clinical Factors on Bx FormClinical Factors on Bx Form

Race 82/85 = 96 %Age 80/85 = 94 %Site of Lesion 80/85 = 94 %Duration of Lesion 55/85 = 65 %Size of Lesion 49/85 = 58 %Tob use 27/85 = 32 %ETOH use 19/85 = 22 %Presence of Pain 6/85 = 7 %

Clinical Factors Vs Correct Diagnosis

Clinical Hx Number Clinical Diagnosis Grade Cases M NM %

Excellent 17 16 1 94

Good 44 41 3 93

Fair 14 11 3 79

Poor 10 8 2 80

Drmac@bellsouth.net

Dr. Mac Whitesides1100 Lake Hearn DriveSte 160Atlanta GA 30342