Evaluation & Treatment of the Dental patient for Cancerous & Precancerous Lesions Mac Whitesides DMD, MMSc. Atlanta, GA

Oral SCCA USA 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 weeks biopsy 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 benign Age: 5th to 9th decade Grades: CA in situ, mild, moderate, severe dysplasia Location: 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 should venture upon snuff who is not sure that he 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> F BM> Gingiva> other sites TX: Surgical removal PROGNOSIS: 75% five year survival rate

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

Treatment 1. Radiation 2. Chemotherapy 3. Surgery 4. Combination

Staging T = Primary Tumor Size N = Node Involvement M = 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 Gy Hyperfractionation: deliver < 2.0 Gy BID advantage: net 10 to 15 % increase in dose, with less effect on normal tissue Acceleration: 2.0 Gy BID advantage: counteracts tumor cell re-population Side Effects: Xerostomia, Tissue Fibrosis, Caries, Osteomyelitis Radiation

Chemotherapy Treats macroscopic, microscopic, and metastatic disease Used with XRT, Surgery Therapy: Combination, Neoadjuvant, Adjuvant, Palliative Agents: Cisplatin, Carboplatin, Fluoroucil, Methotrexate Side Effects: Xerostomia, Caries, Infections, Alopecia, Bone marrow toxicity, Nausea, Vomiting, Mucosal toxicity

Surgery Primary 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 system CLINICAL : Tx : flucinonide ointment & Orabase clobetasol & Orabase Steroids, 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 p.63-65

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

Classification of Malignancies SCCA85Verrucous4 Sarcomas6BCCA4 SGT5Lymphoma1 Met. Tumors5Myeloma1

Clinical Factors on Bx Form Race82/85 = 96 % Age80/85 = 94 % Site of Lesion80/85 = 94 % Duration of Lesion55/85 = 65 % Size of Lesion49/85 = 58 % Tob use27/85 = 32 % ETOH use19/85 = 22 % Presence of Pain 6/85 = 7 %

Clinical Factors Vs Correct Diagnosis Clinical Hx Number Clinical Diagnosis GradeCasesMNM% Excellent Good Fair Poor108280

Dr. Mac Whitesides 1100 Lake Hearn Drive Ste 160 Atlanta GA 30342