Post on 10-Apr-2015
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Oral Oral premalignancypremalignancy
Prepared by Saman W. Boskany
Oral Premalignancy are groups of Oral Premalignancy are groups of disorders or conditions that associated disorders or conditions that associated with increase risk for developing oral with increase risk for developing oral cancer and it can be divided to :cancer and it can be divided to :
OralOral premalignancypremalignancy
PremalignantPremalignant lesionlesion Premalignant conditionPremalignant condition
Premalignant lesionsPremalignant lesionsAre those lesions in which carcinoma Are those lesions in which carcinoma
may develop may develop
OR OR
Morphologically altered tissue in which Morphologically altered tissue in which cancer is more likely to occur than its cancer is more likely to occur than its apparent normal counterpart apparent normal counterpart
Is the abnormalities in Is the abnormalities in PROLIFERATION ,
PROLIFERATION , MATURATION or DIFFERENTIATION
MATURATION or DIFFERENTIATION of of the epithelium and these include:
the epithelium and these include: 1- nuclear hyperchromatism
1- nuclear hyperchromatism 2- nuclear pleomorphism
2- nuclear pleomorphism 3- incresed nuclear/cytoplasm ratio
3- incresed nuclear/cytoplasm ratio 4- abnormal mitosis 4- abnormal mitosis 5- Subsurface keratinazation
5- Subsurface keratinazation
In these lesions histopathological examination In these lesions histopathological examination demonstrate demonstrate epithelialepithelial dysplasiadysplasia or growth or growth abnormality abnormality
mild moderate severmild moderate sever
Grading of dysplasia Grading of dysplasia
Premalignant lesion Premalignant lesion
leukoplakialeukoplakia
ChronicChronic hyperplastichyperplastic candidiasiscandidiasis
ErythroplakiaErythroplakia
leukoplakia leukoplakia It’s a white patch or plaque that can not be It’s a white patch or plaque that can not be
diagnosed clinically or pathologically as any diagnosed clinically or pathologically as any other disease & other disease & will not rub offwill not rub off “WHO” “WHO”
Types Types
Thin leukoplakia Thin leukoplakia Thick or homogenous leukoplakia Thick or homogenous leukoplakia Granular or nodular leukoplakia Granular or nodular leukoplakia Verruciform leukoplakiaVerruciform leukoplakiaProliferative verruciform leukoplakia Proliferative verruciform leukoplakia Erythroleukoplakia or speckled leukoplakia Erythroleukoplakia or speckled leukoplakia
Clinical features :Clinical features :1- mostly above 40 years1- mostly above 40 years2- Strong male predilection 70%2- Strong male predilection 70%3- variable size (small to very wide lesion )3- variable size (small to very wide lesion )4- variable surface character (homogenous , 4- variable surface character (homogenous ,
nodular , erosive or speckled )nodular , erosive or speckled )5- may be soft or thick and fixed to the 5- may be soft or thick and fixed to the
underlying tissue underlying tissue 6- Its commonest Premalignant lesion it 6- Its commonest Premalignant lesion it
forms 85% of such lesions forms 85% of such lesions 7- low risk of malignant transformation 5%7- low risk of malignant transformation 5%
EtiologyEtiology
However its unknown but may be :However its unknown but may be :1- tobacco ;more than 80% are smokers 1- tobacco ;more than 80% are smokers 2- alcohol2- alcohol3- sanguinaria ‘toothpaste containing herbal3- sanguinaria ‘toothpaste containing herbal4- ultraviolet Lower lip vermilion 4- ultraviolet Lower lip vermilion 5- microorganism ,like treponema pallidum , 5- microorganism ,like treponema pallidum ,
candida albicans , human papilomavirus candida albicans , human papilomavirus 6- trauma 6- trauma
TreatmentTreatment Stop the causative habitStop the causative habitBiopsy is mandatory Biopsy is mandatory If dysplasia is mild 6 monthly follow up If dysplasia is mild 6 monthly follow up If moderate to sever dysplasia complete If moderate to sever dysplasia complete
removal is recommended either by surgical removal is recommended either by surgical excision , laser ablation , electrocautery and excision , laser ablation , electrocautery and cryosurgery cryosurgery
Chemo-preventive is experimental Chemo-preventive is experimental
Erythroplakia Erythroplakia
It’s a bright red plaque which can not be It’s a bright red plaque which can not be characterized clinically or pathologically as characterized clinically or pathologically as any other condition or disease any other condition or disease
Clinical feature Clinical feature 1- It’s the disease of old age 1- It’s the disease of old age
2- usually asymptomatic 2- usually asymptomatic
3- usually irregular in outline ,typically not plaque 3- usually irregular in outline ,typically not plaque instead its a flat or depressed , red color is due instead its a flat or depressed , red color is due to atrophied mucosal lining to atrophied mucosal lining
4- sometime there is coexisting area of leukoplakia 4- sometime there is coexisting area of leukoplakia
5- risk of malignant transformation is very high 5- risk of malignant transformation is very high (may reach 100%) , and often already malignant (may reach 100%) , and often already malignant on first biopsyon first biopsy
TreatmentTreatment
Biopsy is mandatory Biopsy is mandatory Removal regarding to degree of dysplasia Removal regarding to degree of dysplasia
as recommended for leukoplakia as recommended for leukoplakia
Chronic hyperplastic candidiasis Chronic hyperplastic candidiasis
Chronic candidial infection cause white Chronic candidial infection cause white plaque or lesion that can not be removed plaque or lesion that can not be removed by scraping , specially it affects oral by scraping , specially it affects oral commissures also the immunological commissures also the immunological condition of the patient may be affected to condition of the patient may be affected to cause candidial infection cause candidial infection
Its least common form of candidasis Its least common form of candidasis Such lesions have increased frequency of Such lesions have increased frequency of
epithelial dysplasia epithelial dysplasia
Treatment Treatment
Polyene agent (nystatin , amphotericin B)Polyene agent (nystatin , amphotericin B) Imidazole agent (clotrimazole and ketoconazoleImidazole agent (clotrimazole and ketoconazoleTriazole (fluconazole , itraconazole )Triazole (fluconazole , itraconazole )
Premalignant conditions Premalignant conditions Are generalized state or condition Are generalized state or condition
associated with significantly increase risk associated with significantly increase risk for cancer development for cancer development
OROR Are groups of conditions which affect Are groups of conditions which affect
epithelium of oral mucosa makes it epithelium of oral mucosa makes it atrophied and more susceptible to atrophied and more susceptible to environmental carcinogens environmental carcinogens
PremalignantPremalignant conditionsconditions
OralOral submucoussubmucous fibrosisfibrosis
ErosiveErosive lichenlichen planusplanus
SyphiliticSyphilitic glossitisglossitis
SideropenicSideropenic dysphagiadysphagia
Actinic chelitisActinic chelitis
PreviousPrevious oraloral malignancymalignancy
ImmuneImmune suppressionsuppression
OralOral submucoussubmucous fibrosisfibrosis * * Is a chronic ,progressive scaring Is a chronic ,progressive scaring In which there is In which there is
a fibrous band formation beneath the epithelium a fibrous band formation beneath the epithelium and it will cause limitation of mouth opening and and it will cause limitation of mouth opening and tongue movement tongue movement
**Its mostly confined to Indians and south east Asia it Its mostly confined to Indians and south east Asia it may be due to hypersensitivity to chili , release of may be due to hypersensitivity to chili , release of enzymes from betel nut or vitamin deficiency enzymes from betel nut or vitamin deficiency
**it has 5% risk for oral carcinoma development it has 5% risk for oral carcinoma development
** Female are more susceptible than male Female are more susceptible than male
** 19 times more liable to get carcinoma than normal 19 times more liable to get carcinoma than normal person person
TreatmentTreatment
Not regress by habit cessationNot regress by habit cessation In mild type may be treated by intra-lesional In mild type may be treated by intra-lesional
corticosteroid injection corticosteroid injection In late stages by splitting or excision of In late stages by splitting or excision of
fibrous bands to improve opening fibrous bands to improve opening Recent study show intralesional injection of Recent study show intralesional injection of
interferon gamma for full improvement interferon gamma for full improvement Frequent evaluation Frequent evaluation
Actinic cheilitis Actinic cheilitis It’s a common Premalignant alteration of It’s a common Premalignant alteration of
lower lip vermilion that results from lower lip vermilion that results from continuous or over extended exposure to continuous or over extended exposure to ultraviolet light of sun ultraviolet light of sun
Most common in outdoor occupation Most common in outdoor occupation farmer’s lip or sailor’s lipfarmer’s lip or sailor’s lip
Clinical features Clinical features
Mostly above age of 45Mostly above age of 45Male to female ratio is 10:1Male to female ratio is 10:1Very slow progressionVery slow progressionAtrophy ,Smooth and blotchy area then Atrophy ,Smooth and blotchy area then
rough , dry and scaly area then chronic rough , dry and scaly area then chronic focal ulceration then sq. cell carcinomafocal ulceration then sq. cell carcinoma
Treatment Treatment Most of the changes are irreversible Most of the changes are irreversible Use of sunscreen Use of sunscreen Biopsy should be submitted to rule out Biopsy should be submitted to rule out
carcinoma carcinoma If not carcinoma do shaving of lip If not carcinoma do shaving of lip
vermilionectomyvermilionectomy Alternatively CO2 laser ablation or Alternatively CO2 laser ablation or
electrodesiccation electrodesiccation Long term follow upLong term follow up If sq cell carcinoma identified treat accordinglyIf sq cell carcinoma identified treat accordingly
ErosiveErosive lichenlichen planusplanus its not as common as reticular type but is more its not as common as reticular type but is more
significant for patient as its symptomaticsignificant for patient as its symptomatic Lesion is atrophic , erthymatos with central necrosis Lesion is atrophic , erthymatos with central necrosis
and at the periphery there is border of fine white and at the periphery there is border of fine white radiating striae or some time may be at the gingival radiating striae or some time may be at the gingival margin produce a reaction called desquamative margin produce a reaction called desquamative gingivitis gingivitis
Some data shown that there is an association between Some data shown that there is an association between erosive or atrophic lichen planus and oral erosive or atrophic lichen planus and oral squamous cell carcinoma cell carcinoma
Treatment Treatment Biopsy is recommended Biopsy is recommended Corticosteroid is recommended sp. TopicalCorticosteroid is recommended sp. TopicalBe aware of candidacies development Be aware of candidacies development Topical retinoid and cyclosporine Topical retinoid and cyclosporine
occasionally is advocated occasionally is advocated Re evaluation at 3 months intervals Re evaluation at 3 months intervals
SideropenicSideropenic dysphagiadysphagia
Also its called plummer-vinson syndrome Also its called plummer-vinson syndrome those patient suffer from iron deficiency those patient suffer from iron deficiency anemia which cause atrophy of oral anemia which cause atrophy of oral mucosa and difficulty in swallowing mucosa and difficulty in swallowing because iron is an essential requirement because iron is an essential requirement for growth of oral epithelium , mostly it for growth of oral epithelium , mostly it leads to esophageal carcinoma also may leads to esophageal carcinoma also may leads to oral carcinoma leads to oral carcinoma
Angular cheilitis
Papillary atrophy
Clinical featuresClinical features Most of the pt. are north European backgroundMost of the pt. are north European background Mostly women 30-50 years Mostly women 30-50 years They are typically complain from burning mouth They are typically complain from burning mouth
syndrome syndrome Angular cheilitis is often present Angular cheilitis is often present Red , smooth tongue Red , smooth tongue Difficult swallowing (esophageal web )Difficult swallowing (esophageal web ) Spoon-shaped nail (koilonychia )Spoon-shaped nail (koilonychia ) Sign and symptom of anemia Sign and symptom of anemia
TreatmentTreatment
Treat anemia by dietary iron supplement Treat anemia by dietary iron supplement Occasionally esophageal dilatation Occasionally esophageal dilatation Regular follow up (5% to 50% risk of Regular follow up (5% to 50% risk of
carcinoma)carcinoma)
SyphiliticSyphilitic glossitisglossitis
In Tertiary syphilis the tongue In Tertiary syphilis the tongue may involve diffusely with may involve diffusely with GummaGumma and appear large , and appear large , lobulated and irrigular shape lobulated and irrigular shape this lobulated form is termed this lobulated form is termed interstitial glossitis ,and diffuse interstitial glossitis ,and diffuse atrophy and loss of dorsal atrophy and loss of dorsal tongue papillae produce a tongue papillae produce a condition called Luetic condition called Luetic Glossitis which makes it more Glossitis which makes it more susceptible to environmental susceptible to environmental carcinogens carcinogens
TreatmentTreatment
Penicillin Penicillin Erythromycin or tetracycline for penicillin Erythromycin or tetracycline for penicillin
sensitive pt.sensitive pt.For neurosyphilis pt. may not get total cure For neurosyphilis pt. may not get total cure
from such medication from such medication
Factors for malignant transformationFactors for malignant transformation
1- habit like tobacco , betel nud 1- habit like tobacco , betel nud
2- Clinical conditions of the patient ex. 2- Clinical conditions of the patient ex. Immunity and nutrition Immunity and nutrition
3- Female has high risk 3- Female has high risk
4- Age of the patient 4- Age of the patient
5- Size of the lesion 5- Size of the lesion
6- Period or duration of the disease6- Period or duration of the disease
7- Degree of dysplasia (sever dysplasia has 7- Degree of dysplasia (sever dysplasia has high risk )high risk )
8-Area affect there is some area have higher 8-Area affect there is some area have higher risk risk
A- floor of mouth A- floor of mouth
B- posteriolateral side of tongue B- posteriolateral side of tongue
C- retromolar area C- retromolar area
D- D- anterior pillar of fauces
9- If the lesion ulcerated fissured or nodulate9- If the lesion ulcerated fissured or nodulate
In which In which very highvery high means more than 25% means more than 25% after 5 become malignant and after 5 become malignant and lowlow means if means if
2-3% during 5 years become malignant2-3% during 5 years become malignant