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Evaluation & Treatment of the Dental patient for Cancerous & Precancerous Lesions

Evaluation & Treatment of the Dental patient for Cancerous & Precancerous Lesions Mac Whitesides DMD, MMSc. Atlanta, GA Doctormac@mindspring.com. Oral SCCA USA •3 % of all cancers •43,000 new cases •8,260 deaths •6th most common malignancy Georgia

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Evaluation & Treatment of the Dental patient for Cancerous & Precancerous Lesions

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  1. Evaluation & Treatment of the Dental patient for Cancerous & Precancerous Lesions Mac Whitesides DMD, MMSc. Atlanta, GA Doctormac@mindspring.com

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. Oral SCCA Risk Factors •TOB •ETOH •age •family Hx •previous Hx of oral SCCA •race •syphilis •poor oral hygiene •Betel Nut

  8. 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

  9. 40 yo w male: SCCA

  10. 40 yo w male: SCCA 1 wk post Bx

  11. 68 yo male: SCCA

  12. 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

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

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

  15. Staging T = Primary Tumor Size N = Node Involvement M = Metastasis Prognosis •State at Diagnosis •Location of Primary Tumor •Metastasis SCCA

  16. Radiation •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

  17. 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

  18. 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 ???

  19. 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

  20. Lichen Planus • most common dermatologic disease to affect oral cavity • W > M ; middle age adults ETI : unknown , ? Immune system CLINICAL : 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 Tx : flucinonide ointment & Orabase clobetasol & Orabase Steroids, Cyclosporine, Retinoids, Aloe PROGNOSIS; good, 1 to 5 %  SCCA

  21. 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

  22. 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

  23. Classification of Malignancies SCCA 85 Verrucous 4 Sarcomas 6 BCCA 4 SGT 5 Lymphoma 1 Met. Tumors 5 Myeloma 1

  24. Clinical 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 %

  25. Clinical Factors Vs Correct Diagnosis Clinical Hx Number Clinical Diagnosis GradeCasesMNM % Excellent 17 16 1 94 Good 44 41 3 93 Fair 14 11 3 79 Poor 10 8 2 80

  26. Dr. Mac Whitesides 1100 Lake Hearn Drive Ste 160 Atlanta GA 30342 Drmac@bellsouth.net

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