1st Year BDS, Islamabad Medical and Dental College
Every patient with oral cancer presents the treating clinician with a
unique set of challenging, complex and multidisciplinary clinical problems, the
solutions to which impact both their survival and quality of life.1
The management of cancers of the oral cavity is very complex due to the functional and
aesthetic implications of treatment of tumors in this region. Several important
functions such as breathing, speech, deglutition, sight, smell, taste, mastication and
jaw function, can be impaired either temporarily or permanently by the tumor or its
treatment. The management of cancers of the oral cavity is very complex due to the
functional and aesthetic implications of treatment of tumors in this region. Our facial
and dental aesthetics are important in determining our self-esteem and self-conﬁdence. A
tumor in the oral cavity or its treatment can severely affect the self-esteem of a
person because of poor aesthetics. Dentists play a vital role in the management of oral
Figure 1; the seven subsites of the oral cavity. (onlinelibrary.wiley.com)
by detecting premalignant lesions, early detection of oral cancer, management of the oral cancer, surveillance of recurrent or new primary tumors, and rehabilitation of missing teeth or any other defect in that matter The oral cavity is deﬁned as the anatomical space extending from the junction of the soft and hard palate and the circumvallate papillae of the tongue to the vermillion of the lips. There are seven oral cavity subsites that are used to classify the oral cavity cancer (lip, tongue, ﬂoor of mouth, buccal, hard palate, alveolar, retromolar trigone and soft palate).1
Oral squamous cell carcinoma (OSCC) is the ﬁrst and second most common cancer in males and females of Pakistan respectively.2 The incidence rate of oral cancer in Pakistan is more than 10 per 100,000 population, and 8-10% of cancers diagnosed in the country were attributed to oral cancer.3 The ‘Oral Carcinoma Research Project’ JPMC, gave a prevalence rate of 50/100,000 4. The commonest age group involved by carcinoma was the 50-54 years age group
The main risk factors in the Pakistani population include the usage of chewable and non-chewable tobacco, areca nut, betel leaf, poor dental hygiene practices, oncogenic viral infections, and genetic predispositions. Low socioeconomic status and the inadequate health resources have a negative impact on the management of oral cancer. 4
Diagnosis and Staging
The diagnosis of oral cancer is dependent on obtaining a sample of tissue
from the lesion, a biopsy. Ideally, the biopsy should be done by an Oral & Maxillofacial
Surgeon. Broadly speaking, there are two types of biopsies that can be employed,
incisional and excisional. In almost all situations, an incisional biopsy is favored, at
the margin of the lesion with ‘normal’tissue, at an adequate depth for the pathologist
to assess invasion of the tumor (SCC) through the lamina propria. The diagnosis of other
malignancies in the oral cavity (e.g. lymphoma) may require not just histopathological
analysis (biopsy in formalin), but require fresh tissue to be sent for additional tests
(e.g. ﬂow cytometry). Tissue sample (biopsy) is sent to histopathology lab for the
histopathological analysis done by an oral pathologist. All maxillofacial surgeons
involved with oral cancer will have a close relationship with an oral pathologist.
Re-biopsy is done if the clinical behavior of the lesion is not in accordance with the
diagnosis from the initial biopsy.Once the tissue diagnosis has been established, the
treating surgeon will arrange appropriate radiologic scans to radiologically stage the
tumor: i.e. to assess the primary tumor dimensions and invasion of adjacent structures,
cervical node involvement, and whether there are distant metastases. The imaging
modalities commonly used in oral cancer evaluation are computed tomography (CT),
magnetic resonance imaging (MRI), ultrasound (US) and positron emission tomography (PET)
to stage the cancer. An orthopantomogram (OPG) is useful for assessment of the dentition
as well as evaluation of mandibular height in the event that part of the mandible will
need to be removed due to involvement or close proximity to the cancer.CT scans of the
head/neck/chest are excellent investigations for the assessment of cortical destruction,
potential cervical node metastases and pulmonary metastases.
Figure 2; Axial CT of the mandible with bone windows showing cortical destruction of the right body of the mandible. (onlinelibrary.wiley.com)
Staging:Staging is done according to the American Joint Commission of Cancer (AJCC) Cancer Staging Manual .Staging of the oral cavity cancer follows the TNM classiﬁcation: T= tumor, N = nodal status, M = metastases.
Table 1; TNM staging for tumors of oral cavity and oropharyngeal squamous cell cancer.
Principles of Management
- Surgery: Resective surgeries are done to remove the primary tumor and then reconstructive surgeries are done to minimize the morbidity of resection.
- Radiation therapy: It involves the use of ionizing radiation to destroy or damage cancer cells. Post-operative radiation therapy is often indicated but depends on the ﬁnal histopathological result and stage.
- Chemotherapy: It is done in addition to radiation therapy if extracapsular extension of the nodal disease is identiﬁed. Common drug protocols include cisplatin or Epidermal Growth Factor inhibitors such as cetuximab.
Oral cancer is a challenging disease with high mortality rates. Dentists play a crucial role in the management of patients. Prevention through education about smoking cessation and safe alcohol consumption is critical, detection and early referral of premalignant lesions and oral cancers and ongoing surveillance, follow up and preservation of oral health are just a few of the many roles of the dental practitioner in the management of oral cancer. Each and every patient with oral cancer should be managed within a multidisciplinary team specialized in the management of head and neck tumors.
- Wong TS, Wiesenfeld D. Oral cancer. Australian dental journal. 2018 Mar; 63:S91-9.
- Anwar N, Pervez S, Chundriger Q, Awan S, Moatter T, Ali TS. Oral cancer: Clinicopathological features and associated risk factors in a high risk population presenting to a major tertiary care center in Pakistan. PLoS One. 2020 Aug 6; 15(8):e0236359. doi: 10.1371/journal.pone.0236359. PMID: 32760151; PMCID: PMC7410283.
- Malkani N, Kazmi S & Rashid MU (2021) Epidemiological Assessment of Oral Cancer Burden in Pakistan, Cancer Investigation, 39:10, 842-853, DOI: 10.1080/07357907.2021.1982962
- Journal of Pakistan Medical Association (no date) JPMA. Available at: https://jpma.org.pk/article-details/3905.
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