oral tumors dr. omnia sultan. what is a tumor ? a tumor is simply a swelling or lump a neoplasm is a...

ORAL TUMORS

Dr. Omnia Sultan

WHAT IS A TUMOR ?

•A tumor is simply a swelling or lump

•A Neoplasm is a progressive uncontrolled proliferation of cells

HYPERTROPHY VS HYPERPLASIA

Hypertrophy is an increase in cell size without an increase in cell

number .

Physiological

Muscle hypertrophy

due to exercise

Pathological

left ventricle of the heart

due to hypertensio

n

Hyperplasia is an increase in cell

number without an increase in cell

size

Physiological

Hypercementosis

Pathological

Denture fissuratum

CLASSIFICATION OF ORAL TUMORS

According to tissue of

origin

Odontogenic

Epithelial e.g.. Ameloblastoma

Mesenchymal e.g. odontogenic

myxoma Mixed e.g.

compound & complex odontome

Non-odontogeni

c

From lining epithelium or

various tissue of the oral cavity. e.g.

fibroma

According to clinical behavior • Benign tumors • Malignant tumors

BENIGN VS MALIGNANT TUMORS

Benign tumors

•Slow growth•Grow by expansion•Usually has fibrous capsule and well demarcated.•usually of small size

Malignant tumors

•Rapid growth•Grow by invasion (infiltration)•No capsule and poorly demarcated•usually of large size

BENIGN VS MALIGNANT TUMORS

Benign tumors

•Recurrence is rare•Well differentiated•Never metastasize•Show little atypia & few mitosis•Good prognosis

Malignant tumors

•Recurrence is often•Poorly differentiated•Commonly metastasize•Striking atypia & frequent mitosis•Poor prognosis

EXAMINATION & DIAGNOSIS OF ORAL TUMORS

• History• Clinical Examination• Radiographic Examination • Laboratory investigations • Biopsy• Tumor markers

HISTORY

Health History:• Existing medical problem may affect the dentist treatment• The lesion under investigation may be the oral manifestation of a significant systemic condition e.g. Leukemia, agranulocytosis

HISTORY

History of the specific lesion:•Duration • Change in size • Change in character • Symptoms associated with the lesion • Associated constitutional symptoms • Possible causes

CLINICAL EXAMINATION1.The anatomic location of the mass: determine which tissues are contributing to the lesiondetermine the nature of the lesion and in the differential diagnosis

CLINICAL EXAMINATION

2. The physical character of the lesion


3. The size and shape of the lesion:They are important physical character and should be recorded for future reference4.The surface of the lesion:It may be smooth, lobulated or ulcerated.


5. The color of the lesion:It may be bluish, red, white or pigmented. It is considered as an important diagnostic feature


6. The consistency of the lesion:As being soft (lipoma), firm (fibroma), or hard (osteoma) or (tori).


7. Presence of fluctuation:It indicates fluid within the mass.8. Presence of pulsation:a pulsatile quality indicates a vascular component ( e.g. aneurysm)A Thrill is a name given to the palpable vibration accompanying a pulsation.While a Bruit is the audible murmur heard with the stethoscope.

CLINICAL EXAMINATION 9. Lymph node examination:A through regional lymph node examination should be done and before any biopsy.Five characters of the nodes should be recorded:• Location.• Size.• Tenderness (painful versus non painful).• Degree of fixation (movable, matted, fixed).• Texture (soft, hard or firm).


Radiographic Examination:For lesion within or adjacent the bone.The radiographic appearance frequently gives clues to the true nature of a lesion.

We may use: Plain radiography.Computerized tomography (CT) scan.Magnetic resonance image (MRI.).Radionuclide imaging or scintigraphy. Ultrasonography.PET scan


Laboratory Investigation:they play an important role as in case of brown nodes of hyperparathyroidism. Serum levels of calcium, phosphorus, and alkaline phosphatase should be done to identify this metabolic abnormality.


Biopsy:it is the removal of tissue from a living individual for diagnostic examination. It is the most diagnostic and definitive procedure.

BIOPSYTypes of biopsy:1. Incisional biopsy.

2. Excisional biopsy.

3. Aspiration biopsy.

4. Drill biopsy.

5. Punch.

6. Frozen section biopsy.7. Exfoliative cytology & Brush biopsy ( for early detection of oral

carcinoma)

8. Fine needle aspiration cytology.

BIOPSY

• Indications of Biopsy:1. If there is a cause related to a lesion and we remove it

but no regression of the lesion within 2 weeks 2. If there is no cause related to a lesion with no response

to treatment 3. If suspect malignancy ( e.g., rapid growth, ulceration,

color changes, or fissuring),

BIOPSY•Contraindications of biopsy:

1. Vascular lesions e.g. hemangioma (as the incisional biopsy may lead to severe bleeding, which may endanger the patient life

2. Melanoma (as malignant cells have fast tendency to metastasis through the blood vessels).

BIOPSY

BIOPSY3. Aspiration biopsy:• Aspiration biopsy is the use of a needle and syringe to penetrate a lesion for aspiration of it’s contents• It is carried out for all lesions thought to contain fluid. • Any radiolucency in the jaws bone should be aspirated before surgical intervention to rule out a vascular lesion which could result in life– threatening hemorrhage if incised.

BIOPSY• The material obtained by aspiration can be submitted to

pathologic examination, chemical analysis, and/or microbiologic culturing. • Aspiration is carried out using an 18 gauge needle

connected to a 5 or 10 ml syringe.

Disadvantages of aspiration biopsy microscopic examination is difficult and inaccurate due to insufficient sample (cytology).

BIOPSYResults of aspiration: Air: (Max. sinus \ Traumatic bone cyst). Pus: ( Abscess \ Infected cyst). Yellowish (creamy white) material: (OKC). Straw yellow colored fluid with cholesterol crystals:

(Periodontal or dentigerous cyst). Blood: (vascular tumor \ Aneurysmal bone cyst). Sticky clear mucous or viscous fluid: ( Mucocele\ Ranula). No aspirate with difficulty to pull plunger of the syringe: (solid mass \ latent bone cyst).

BIOPSY4.Drill biopsy:• It has been used for obtaining

samples from deeply seated lesions. • Ellis biopsy drill fits on a

straight hand-piece is used for central fibro-osseous lesions of the jaws.

BIOPSY5. Punch biopsy:• This is performed with a punch type

forceps which punches or bites out a portion of tissue. • It is indicated in inaccessible areas

(larynx and oropharynx).• The sample is liable to be bruised or

damaged.

6. Frozen section biopsyThis is performed during surgery to attain immediate information (within 30 min).

BIOPSY7. Exfoliative cytology & Brush biopsy• It is carried out by scraping the lesion

repeatedly and firmly by a spatula or tongue depressor. • The cells obtained are immediately smeared on

a glass slide, fixed and stained. • Then the cellular characteristics, are examined

under the microscope. • Cytological examination is less valuable in oral

tumors. • when large areas of mucosal changes must be

monitored for dysplastic change, cytology may be helpful (as in post radiation changes)

BIOPSY

8.Fine needle aspiration cytology: It is considered an added diagnostic modality for oral tumors specially in the salivary gland region. It also can be used anywhere in the body. This modality has the advantage of being simple, speedy, atraumatic, cheap and with minimal risk of complications.

BIOPSY

• A fine disposable needle of gauge 18-23 is used with a 3-10 CC disposable plastic syringe• The needle is introduced into the

lesion and moved in all direction to collect cells from the lesion.• The obtained cells are smeared on

a glass slide, fixed , stained, and examined under the microscope.

SURGICAL MANAGEMENT OF ORAL NEOPLASMS

Goals:• Remove the entire lesion and leave no cells that could

proliferate and cause a recurrence of the tumor.• dealing with the residual defects resulting from the

surgical excision of the tumor.


Types of Surgical Operations Used for the Removal of Oral Neoplasms:

1. Surgical excision or enucleation.2. Enbloc or marginal resection.3. Partial resection (discontinuity resection), as hemi-

mandibulectomy.4. Total resection, as total-mandibulectomy or total

maxillectomy.5. Composite resection (bone & soft tissue).


1.Excision or enucleation• It is local removal of the tumor at it’s boundaries. • Used for benign tumor with no tendency for recurrence it may be used for:• Most of odontogenic tumor as adontoma, ameloblastic

fibroma, cementoblastoma and ossifying fibroma. • Benign soft tissue lesion of oral mucosa as fibromas,

pyogenic granuloma, peripheral giant cell granuloma and papilloma.


2. Marginal resection:It is the removal of the tumor with 1 cm of safety margin in bone without disruption of the continuity of the mandible (intact inferior border).


3.Partial resection:Removal of the tumor with safety margin is achieved by removing a full thickness portion of the jaw. The continuity of the jaw is disrupted. The defect vary from a small continuity defect to hemimandibulectomy. used when the tumor is known to be aggressive and has tendency for recurrence. E.g. ameloblastoma, myxoma & benign chondroblastoma


4. Total resection: • Is resection of a tumor by

removal of the involved bone for example maxillectomy or mandibulectomy. • It is used when an aggressive

tumor with such big size that involves the jaw.


5. Composite resection:• Is resection of a tumor with

bone, adjacent soft tissue, and contiguous lymph node channels. • It is used most commonly for

malignant tumors as malignant ameloblastoma, fibrosarcoma and carcinoma that had involved the jaw with lymph node metastases.


Factors affecting the choice of surgical operation:• Aggressiveness of the lesion.• Size of the tumor.• Confinement to the bone.• Anatomic location.• Reconstructive considerations.

AMELOBLASTOMA

AMELOBLASTOMA

Ameloblastoma is the most common epithelial odontogenic tumor. Though it accounts nearly 1% of all oral neoplasms

AMELOBLASTOMA Clinical features:• Location: About 80% in the mandible and 20% in the maxilla. • Site: The ramus – molar area is most frequently involved,

about 70% of the cases.• Gender: Males are affected more commonly than female.• Behavior: It is benign, locally invasive tumor with high

tendency for recurrence (locally malignant).• Age: It appears most commonly in third to fifth decade of life,

but cases has been reported in children as well as old individuals.• Race: No racial preference.

AMELOBLASTOMA

Signs and symptoms: • The tumor may be symptomless

and is discovered in routine radiographic examination.• It is seldom painful unless

secondarily infected. • No facial disfigurement is

noticed except when the tumor attains a large size. It attains a large size because of the painless, slow, insidious development, and often without interference with function.

AMELOBLASTOMA

• Adjacent teeth: It may cause migration and loosening of teeth as well as root resorption. • Inferior alveolar nerve: It

may cause parasthesia of the inferior alveolar nerve.

AMELOBLASTOMA

Behavior and local spread:• Ameloblastoma invades the intertrabecular spaces of

cancellous bone without accompanying resorption of the trabeculae. • It does not invade the cortical bone, although it may erode it. • ameloblastoma often extends in the cancellous bone that appears not involved radiographically or even clinically during surgery. • a good safety margin in cancellous bone is a must during

excision of these tumors which should pass the clinically and radiographically involved regions. • This practice should minimize the chances of recurrence of

the tumor.

AMELOBLASTOMA

• Although this tumor is described as “locally malignant”, it is actually benign. The term “locally invasive” is preferred and used by many authors. • It is rarely, if ever, metastasis. • Ameloblastic changes may take place in the wall of cystic lesions. • This occurs more often in association with dentigerous cysts rather than with other cyst.

AMELOBLASTOMA

Aspiration biopsy:• Reveals negative pressure

except for cystic ameloblastoma where a clear or slightly turbid albuminous fluid with few or no cholesterol crystals could be aspirated.

AMELOBLASTOMA

Radiographic Picture:• The typical picture:• A multilocular radiolucency denoting bony destruction.• In which the bone is replaced

by a number of small well defined radiolucent areas giving rise to a honey comb or soap-bubble appearance.

AMELOBLASTOMA

• Less commonly: A unilocular radiolucent area in the jaw. • The roots of the adjacent

teeth may show some resorption.

AMELOBLASTOMA

Treatment of ameloblastoma: • Is usually surgical excision with safety margins.• The selection of the method and extent of excision depends to a

large extent on: Clinical type of ameloblastoma. Location in the jaw. Size of the lesion. Age of the patient.

• No place for radiotherapy in the treatment of ameloblastoma as being radioresistant.• Chemotherapy has not been reported to be successful in it’s

management.

AMELOBLASTOMA

Different treatment modalities: • Marginal resection:

It is the treatment of choice in small solid or multicystic lesions.

A safety margin of clinically uninvolved bone, 1.5 cm all around the boundaries of the lesion should be included in the resection.

AMELOBLASTOMA

• Segmental resection: It is indicated with large tumors

that have eroded the cortical bone and involved the periosteum and soft tissue.

It is also considered in cases of recurrent lesions.

At least 1 cm margin of normal appearing bone should be included in the resected specimen from each side.

AMELOBLASTOMA

• Curettage: Should not be used in the treatment of ameloblastoma

because of the high risk of recurrence. It is only appropriate in highly selected lesions

affecting elderly patients with other medical problems, when it is desired to spare them a more extensive surgical procedure. As ameloblastoma is a slow growing tumor, these patient could die of other causes before any recurrence is manifested.

AMELOBLASTOMA

Reconstruction of resected mandible • Immediate reconstruction with

bone graft (in case of intra operative frozen sections)• Delayed reconstruction ( we

do 1st reconstruction plate for 6 months and then we do bone graft provided that no recurrance occurs).

AMELOBLASTOMA

Peripheral AmeloblastomaIt the most rare variant of the ameloblastomaClinical picture:non ulcerated sessile or pedunculated gingival lesions. The tumor doesn’t infiltrate boneTreatment and prognosis:Treated with wide local excision

Ameloblastoma

Central

Solid or multicystic

Unicystic

peripheral malignant

ORAL CARCINOMA

ORAL CARCINOMA

Incidence: • Oral carcinoma accounts for about 5% of all malignant

neoplasms in man. • In India and west Asia it may increase to 40% due to

widespread use of tobacco and snuff chewing habit. • Squamous cell carcinoma represents about 90% of all oral

malignancies.

ORAL CARCINOMAEtiology:The etiology is unknown but the following pre-existing conditions may be considered as contributory predisposing factors:• Tobacco smoking: It was found that 8 out of 10 patients are

heavy smokers.• Chronic alcoholism: Increased consumption of alcohol has

been reported to be associated with increase in oral cancer.• Chronic dental irritation: long standing irritation from a

sharp broken tooth, ill fitting denture, or sharp clasp or edge of a prosthesis may be a source of chronic traumatization and irritation to oral mucosa.

ORAL CARCINOMA

• Oral sepsis: It has been traditionally regarded as contributing to oral cancer. Oral cancer is most common in patient with poor oral hygiene. • Sun light: Long exposure to sun rays as in case of

farmers and fishermen increases the incidence of lip cancer among these outdoor workers. They are exposed to ultraviolet ray of sun-light for long periods of time.• Syphilis: Syphilitic leukoplakia developing late in the

disease has a high malignant potentials.

ORAL CARCINOMA

• Malnutrition: Iron deficiency anemia (Plummer-Vinson syndrome) and hypo-vitaminosis of vitamin A and B complex, has lead to increased incidence of oral cancer.

• Betel leaf and/or tobacco chewing: The released materials from the chewing are considered carcinogenic and increase incidence of oral cancer.

• Oral premalignant lesions: e.g. leukoplakia, lichen planes and erythroplakia

ORAL CARCINOMA

Clinical features:• Age: It usually affects patients above middle age

between 50-70 years.• Gender: Males are more affected than females. In a ratio

of 3:1, Site: It may affect anywhere in the oral cavity; lips, buccal mucosa, gingiva, alveolar mucosa, tongue, floor of mouth, palate, retromolar area. Lower lip and tongue are more commonly affect by carcinoma than other sites in the oral cavity

ORAL CARCINOMA

Signs and Symptoms: Early: • The majority of oral cancer cause no symptoms in their early

stages. • The patient’s first complain may the appearance of a lump in the neck indicating that metastatic spread to cervical lymph nodes has already occurred. • The lesions are always painless in their early stage and

may be overlooked when they are located towards the back of the oral cavity.

ORAL CARCINOMALate:• Pain due to secondary infection or involvement of nerves in the

lesion.• Excessive salivation which may be blood stained.• Dysphagia.• Ankyloglossia in case of cancer tongue and floor of the mouth.

This indicates deep infiltration of extrinsic muscles of the tongue.• Inability to articulate clearly.• Foetid odour of the month.• Lymph nodes involvement due to metastatic spread.

ORAL CARCINOMAClinical forms: Ulcer:

It is the most common type.

Characters of malignant ulcer: • Deep and necrotic base with foul odour• It may be covered with a crust in exposed

areas (e.g. lip).• Long duration without signs of healing (more

than 2 weeks).• Raised or rolled borders.• Indurated periphery• Mostly painless at the beginning, until

superimposed by infection

ORAL CARCINOMA

Nodule:Usually hard below the oral mucosa without signs and symptoms of acute infection. Slowly growing and eventually ulcerates.

Chronic fissure:Usually on top of leukoplakia.Not responding to treatment.Ulceration may occur in the fissure.

ORAL CARCINOMA

Papillary form:• It is a soft warty growth

that may be extensive.

Atrophic mass:• It is rare and characterized

by fibers which produces a small hard mass

ORAL CARCINOMA

Spread of oral carcinoma:Local spread:• The lesion increases in size by direct local infiltration of the neighboring tissues.

Lymphatic spread: • Occurs at later stage.

• Submental, sublingual and upper cervical lymph nodes are chiefly affected.

• Supraclavicular lymph nodes may be involved.

Blood stream metastases:• It is rare and only occurs if the tumor invades a nearly vein.

• Spread to lung may occur.

ORAL CARCINOMA

Clinical staging and classification of oral carcinoma:• The system used for staging malignant neoplasms is

known as the TNM system. • Clinical staging is important in considering the plan of

treatment and prognosis.

ORAL CARCINOMAStage grouping:• Stage I: T1 N0 M0• Stage II: T2 N0 M0• Stage III:T3 N0 M0 T1 N1 M0

T2 N1 M0 T3 N1 M0

• stage IV: T1 N2 M0 T1 N3 M0

T2 N2 M0 T2 N3 M0

T3 N2 M0 T3 N3 M0 Any T or N with M1.

ORAL CARCINOMA

Treatment of oral carcinoma:Aim of treatment:• Cure the cancer.• Reconstruction of the surgical defect.• Patient rehabilitation to have an acceptable life with no

pain or deformity.

ORAL CARCINOMA Lines of treatment:Prophylactic measures:• Take care of oral hygiene.• Remove any cause for chronic irritation.

ORAL CARCINOMA

Curative treatment:• Surgery: Excision of the tumor with safety margin all

around and radical dissection of the lymph nodes• Radiotherapy: May be used as a primary line of treatment

for small lesions. It is used postoperative to kill residual tumor cell after surgical excision.• Chemotherapy: it never cure the disease if given alone. It

is used to kill residual malignant cells or to alleviate symptoms.• Combination of two or more of the above usually gives

better results.

oral tumors dr. omnia sultan. what is a tumor ? a tumor is simply a swelling or lump a neoplasm is a...

Documents

oral tumors oral tumors

diagnostic examination

specific lesion

aspiration biopsy

biopsytypes of biopsy

incisional biopsy

excisional biopsy

drill biopsy