Oral Cavity Odontomes Lip And Palate Oral Cancer Notes

Oral Cavity Odontomes Lip And Palate Introduction

• Oral cavity extends from vermilion junction of lips to junction of hard and soft palate above and the line of circumvalate papillae below or it is bounded by the lips anteriorly, the cheek on each side, tonsils posteriorly, superiorly by the palate and inferiorly by the floor of the mouth. It is lined by squamous epithelium.
• Oral cavity is a common site of malignancy because it is insulted by various agents such as alcohol, smoking, tobacco chewing. Oral cancer is the commonest malignant neoplasm in the head and neck. Risk factors are given.

Describe etiopathogenesis of oral cancer symptoms and signs of oropharyngeal cancer.

Read And Learn More: General Surgery Notes

•  Abuse of tobacco and alcohol are the most common preventable risk factors for development of head and neck cancers. Those who smoke 2 packs/day and drink 4 units of alcohol/day have an odds ratio of 35 for development of carcinoma.
• Tobacco quid is very dangerous and highly carcinogenic. An interaction occurs between redox-active metals in saliva and low reactive free radicals in cigarette smoke.

Risk Factors Associated with Cancer of Head and Neck:

• Tobacco quid1—‘Pan Masala’
• Oropharyngeal Ca—Plummer-Vinson syndrome
• Barr-Epstein virus
• Alcohol, areca nut
• Cigarette smoking and reverse smoking2
• Chronic irritation—dentures
• Oral hygiene poor and poor nutrition Remember as Tobacco

More than 70 to 100 carcinogens have been recognised in the tobacco smoke such as nitrosamines, polycyclic aromatic hydrocarbons, benzene, ammonia, arsenic, butanone, etc.

• Net result is that saliva loses its antioxidant capacity and instead becomes a potent pro-oxidant milieu.
• Field cancerisation is a concept based on prolonged exposure of oral and pharyngeal mucosa to carcinogens. 15 to 20% of the survivors of one cancer of head and neck develop another primary head and neck cancer.
• Oral cavity has many subsites which have been given. Importance of subsites (Fig. 35.1) is related to different methods of management which has been discussed later.

Oral Cavity Subsites:

• Lip – Buccal mucosa
• Lower alveolus – Retromolar trigone
• Oral tongue – Floor of mouth
• Upper alveolus – Hard palate

Oral Cancer

Incidence of Oral Cancer

• Tongue: 50%
• Cheek: 20–25%
• Floor: 10–15%
• Gums: 10%

Oral Cancer Definitions:

• Hyperkeratosis refers to increase in keratin layers. It occurs due to constant irritation. Once the cause is removed, it is reversible.
• It is a microscopic diagnosis. For example, smokers’ hyperkeratosis of the palate and lips. Once the aetiological agent is withdrawn, the lesion returns back to normal.
• Leukoplakia appears clinically as a white patch in the mouth and cannot be scraped off. It is irreversible and not attributable to any known disease. It is important to biopsy leukoplakic portion to rule out malignancy.

Premalignant Conditions For Oral Cancer

1. Leukoplakia:

The causes for leukoplakia are as follows:

• Smoking results in hyperkeratosis. Nicotine in the form of cigarettes, chewed tobacco, powdered snuff produces premalignant changes in the oral cavity.
• Spices
• Spirits have synergistic action with smoking
• Sharp tooth, sepsis, poor oral hygiene
• Sunlight actinic rays
• Syphilis causes endarteritis obliterans and results in chronic superficial glossitis of the tongue which is a precancerous condition (rare these days).
• Betel nut and slaked lime with betel leaf and tobacco (pan) is eaten and usually kept inside the cheek for many hours.
• Over the years, it brings about chronic irritation of mucosa of the cheek and causes leukoplakia.
• Tobacco contains multiple carcinogens including aromatic hydrocarbons.

Stages in the development of leukoplakia:

1. Keratosis appears as a milky blush on the surface.
2. Acanthosis refers to elongation of rete pegs. This appears as a smooth, white, dry patch—smooth paint.
3. Dyskeratosis means the formation of keratin cell layer in the deeper aspect of epidermis before they reach the surface—like wrinkled paint.
4. Carcinoma in situ—warty.
5. Invasive carcinoma.

Treatment of Leukoplakia:

• About 10% of leukoplakia patients develop oral cancer. Hence, superficial excision of the lesion followed by skin grafting should be done.
• Even though leukoplakia is irreversible, isotretinoin (13-cis-retinoic acid) can reverse some cases of leukoplakia and possibly reduce the development of squamous cell carcinoma.

2. Erythroplakia is a red, velvety lesion with an incidence of malignancy around 15% (17 times more malignant than leukoplakia). It is irregular in outline and may be nodular.

3. Chronic hyperplastic candidiasis

Chronic Hyperplastic Candidiasis:

• Commissures of the mouth commonly affected
• Albicans Candida invasion
• No response to drugs, then surgery/laser treatment
• Dense plaques of leukoplakia
• Immunodeficiency can precipitate this condition
• Dangerous because of malignant potential
• Antifungal treatment—Topical application may help Remember as CANDIDA

4. Submucous fibrosis

This is supposedly due to use of pan masala, arecanut with or without alcohol.

• Initially, it produces ulceration of mucosa of the cheek. These ulcers heal resulting in a dense submucous fibrosis, which appear clinically firm to hard.
• It can affect the tongue also. It is a progressive disease entirely confined to Asian population.
• Chances of malignancy are around 10–15%.
• Mouth opening may be restricted.
• It is treated by excision with reconstruction.

5. Sideropenic dysphagia (Plummer-Vinson and Paterson-Kelly syndrome). Iron deficiency occurs in the absence of anaemia in these patients. Common in Scandinavian women. Iron supplements reduce epithelial atrophy.

6. Papilloma of the tongue or cheek

7. Discoid lupus erythematosus

8. Dyskeratosis congenita

9. Syphilitic glossitis: Tertiary syphilis produces chronic superficial glossitis which can lead to carcinoma of the tongue. However, it is rare these days.

10. Human papillomavirus is an epitheliotropic virus. Its oncoproteins suppress tumour suppressor gene. It can give rise to tonsillar carcinoma and oropharyngeal carcinoma.

11. Miscellaneous: Saw dust—sinonasal adenocarcinoma.

UV rays—lip cancer:

• Reverse cigarette smoking—palatal cancer.
• Upper Aerodigestive Tract Cancers
• Most of them are squamous cell carcinomas.
• Tobacco and alcohol are the most common aetiological factors.
• Most common premalignant lesion is leukoplakia.
• Multiple anatomic sites can be involved simultaneously (synchronous).
• Second primary cancers develop in 10–15% of cases (metachronous).
• Clinical presentation can be peculiar/misleading depending on anatomic site.
• Generous biopsy and MRI (if necessary) are the investigations of choice.
• Surgery, radiotherapy and chemotherapy are used singly or in combination in appropriate cases.

Common Symptoms And Sites

Common symptoms and common sites of oral cancer:

Enumerate the appropriate investigations and discuss the principles of treatment.

General Principles In The Management

Investigations:

1. Wedge biopsy: from the edge of the ulcer is taken because of the following reasons:

• Tumour cells are concentrated more in the growing edge.
• Centre of the ulcer has slough.
• Histopathological report shows squamous cell carcinoma and in majority of the cases it is welldifferentiated with keratin pearls.

2. Orthopantomography: X-ray of mandible to rule out mandibular involvement.

3. Chest X-ray: to detect inhalation pneumonia.

4. Ultrasound-guided FNAC: Of the lymph node.

5. Magnetic resonance imaging (MRI):

• Large advanced lesion can be better assessed by MRI. Soft tissue infiltration can be assessed correctly, thus dictating the extent of resection, especially in patients with restricted mouth opening.
• It is the investigation of choice to look for involvement of the skull base, brachial nerve plexus, bone marrow, spinal nerve roots and lymph nodes.
• MRI has no radiation hazards.

6. CECT: This is done when growth is infiltrating mandible.

AJCC—American Joint Committee Cancer staging is followed uniformly while managing these patients.

Oral cancer—American Joint Committee Cancer (AJCC):

Primary Tumour (T):

• T0: No evidence of primary tumour
• Tis: Carcinoma in situ
• T1: ≤2 cm with DOI (depth of invasion) ≤5 mm
• T2: >2 cm and ≤4 cm with DOI ≤10 mm
• T3: >4 cm with DOI ≤10 mm
• T4: Any cancer invading adjacent structures such as cartilage, cortical bone, deep (extrinsic) muscles of the tongue, skin or soft tissue of the neck.
• T4a: Moderately advanced local disease.
• T4b: Very advanced local disease (skull base, pterygoid plate, internal carotid artery, masticator space)

Regional Lymph Nodes (N):

• Nx: Nodes cannot be assessed
• N0: No lymph node metastasis
• N1: Single positive ipsilateral node less than or equal to 3 cm in greatest dimension
• N2a: Single positive ipsilateral node more than 3 cm but less than or equal to 6 cm
• N2b: Multiple ipsilateral nodes but all less than 6 cm
• N2c: Bilateral or contralateral lymph nodes but all less than 6 cm
• N3: Lymph node more than 6 cm

Distant Metastasis (M):

• M0: No distant metastasis
• M1: Distant metastasis present

Stage  – Grouping

Stage 1  – T1, N0, M0

Stage 2  – T2, N0, M0

Stage 3  – T3, N0, M0, TI–3, N1, M0

Stage 4  – T4, N0, M0 , T, N2–3, M0

T0, N0, M1

Aim of the Treatment:

1. Cure of the patient: Cure of the cancer, if possible, with wide excision of the tumour which includes removal of the tumour with 1–2 cm of the normal tissues, with or without bone.
2. Palliation: If cure is not possible, palliation should be attempted by surgery or radiotherapy.
3. Preservation of function such as swallowing, speech and vision, should also be taken into consideration.
4. Cosmetic function: Following wide excision, the cosmetic function must be maintained by reconstruction with myocutaneous/osteomyocutaneous flap.
5. To achieve minimal mortality and morbidity.
6. Metastatic lymph nodes are treated by neck dissection or curative radiotherapy (RT). Even when nodes are not palpable, follow guidelines given.
7. When nodes are positive—refer.

Treatment of advanced tumours—T3 and T4 lesions: These are managed by combination of surgery with postoperative RT.

• Usually, surgery is the principal therapeutic modality of treatment followed by postoperative radiotherapy.
• The treatment depends upon general condition of the patient, risks of anaesthesia, adequate intensive care management, etc.
• Chemotherapy also has been tried before or after surgery. However, response rate has improved but it has not affected the survival.
• These are guidelines only, individualising the treatment. Flowchart showing treatment of primary tumour and metastasis is shown.

Clinically ‘Node Negative’ Neck from Oral Cancer:

• Carcinoma lateral tongue, floor of mouth and mandibular alveolus commonly cause occult metastasis.
• Occult metastasis is seen in up to 30% of patients.
• Hence, selective neck dissection of levels 1, 2 and 3 is indicated in continuity with tumour excision in these cases.

Clinically Node Positive Neck:

• N1: Selective supraomohyoid neck dissection
• {N2a and: Modified radical or radical neck dissection
• N2b} followed by postoperative radiotherapy
• N2c: Bilateral radical neck dissection—preserve at least one internal jugular vein (IJV) + postoperative radiotherapy
• N3: Preoperative radiotherapy, if feasible radical neck dissection later

Role of Chemotherapy in Head and Neck Cancers:

• The most important benefit of chemotherapy has been in the treatment of laryngeal and nasopharyngeal carcinomas.
• Cisplatin is clearly the most effective drug. Other drugs such as carboplatin, 5-fluorouracil (5-FU), bleomycin, gemcitabine, etc. are also used.
• Induction chemotherapy: In advanced cases, chemotherapy is given before surgery or RT. In more than 80% of cases, tumour regression can occur.
• Concurrent chemoradiotherapy (CCRT): It improves both local and regional controls, especially in those patients with high risk cancers, e.g. locally advanced cancers of the oral cavity, larynx, oropharynx.
• Drug used in CCRT can be high dose cisplatin—100 mg/m2 IV for 3 cycles every 21 days concomitantly with RT (for other dosage, kindly refer to oncology manual).
• Side effects include severe mucositis, xerostomia. Gastrostomy may be necessary for feeding.

Radiotherapy (RT):

Irradiation of the oral cancers achieves a cure in about 80–90% of patients. It preserves anatomical part and also preserves the function.

RT: Advantages:

• Easy, safe with minimal mortality
• Preservation of an organ
• Function of the part is preserved
• Cure rate is around 80–90%
• First line in early cases

RT: Disadvantages:

• Long stay in the hospital (can also be taken as an outpatient)
• Tumour cure cannot be assessed by pathology
• Soft tissue fibrosis resulting in ankylostomia
• Adverse effects on skin, loss of hair, mucositis of oral cavity, xerostomia, etc.

The dose of RT: 6500–7500 cGy units are required to eradicate squamous cell carcinoma of head and neck. It is usually given in the daily dose of 180–200 cGy units.

• Radiotherapy is given in T1 and T2 lesions as the first line of treatment and postoperatively in T3 and T4 lesions after surgery.

Role of Surgery:

• Surgery is done in all stages of oral cancers. It may be in the form of wide excision or wide excision with removal of the bone (composite resection).
• In advanced stages, it may be palliative surgery such as excision of a fungating, ulcerating, bleeding mass.
• Surgery is also done for the lymph nodes in the form of radical neck dissection (RND), or modified RND.
• The pectoralis major myocutaneous flap (PMMC flap): It is the most widely used flap for the reconstruction of oral cancers.

Indications for Surgery:

• Early disease, bulky disease
• Tumour involving mandibular alveolus
• Tumour invading bone
• Advanced disease
• Fungating and bleeding lesion
• Radiorecurrence
• Multiple tumours
• Extensive premalignant changes of oropharyngeal mucosa.

Surgery: Advantages:

• It removes a fungating, ulcerating, bleeding lesion
• It relieves the pain
• The specimen is available for histopathological examination for cancer clearance
• 80–90% cure is possible

Surgery: Disadvantages:

• Loss of an organ—total glossectomy
• Functional and cosmetic disability
• Significant morbidity
• Mortality: 8–10%

Carcinoma Of Buccal Mucosa

Carcinoma of the buccal mucosa is very common in India due to the habit of keeping tobacco quid in the cheek pouch (gingivoalveolar sulcus).

Pathological Types:

1. A nonhealing ulcer, with slough in the centre of the lesion.
2. An exophytic growth, or a proliferative growth— verrucous carcinoma.
3. An infiltrative lesion slowly involves the adjacent structures such as tongue, mandible, floor of the mouth and skin. Skin infiltration results in orocutaneous fistula.

Enumerate the appropriate investigations and discuss the principles of treatment.

Clinical Features:

• Clinical examination should be thorough—not just visible oral mucosa but also inside and outside of the lip, examine gums by pulling away the lips, retromolar trigone, etc.
• A nonhealing ulcer or cauliflower-like growth. Verrucous carcinoma is an exophytic growth.
• Edges are everted with induration at the base as well as at the edge. Induration clinically presents as a hard feeling. Pathologically, it is due to fibrosis, caused by malignancy (carcinomatous fibrosis).
• It is a diagnostic feature of squamous cell carcinoma. Possibly, it is a host reaction indicating good immunity.
• Due to fibrosis, some lymphatics get obliterated. This delays spread of the disease, thereby improving the prognosis.
• Proliferative lesions are often verrucous carcinoma.

Peculiarities of Verrucous Carcinoma:

• Very slow-growing
• Growth is exophytic (than infiltrative)
• Rarely spreads by lymphatics
• It is a well-differentiated carcinoma
• Surgery is the treatment of choice

Ulcer bleeds on touch. Due to secondary infection most of the oral cancers are tender to touch.

• Fixity to the underlying structures such as mandible may be present.
• Surrounding area may also show induration.
• Evidence of leukoplakia may be present in the oral cavity.
• Trismus is due to involvement of pterygoid muscles and masseter. This occurs when carcinoma buccal mucosa extends into the retromolar trigone. Trismus can also be due to soft tissue fibrosis caused by radiation. Once perineural lymphatics are involved, spread can occur in infratemporal fossa resulting in trismus.
• Retromolar trigone is triangular space behind the third molar tooth with base above. It is over the mucous membrane over the ascending ramus of the mandible.
• Halitosis is very characteristic.
• Assessment of fixity to mandible: Severe pain over the jaw indicates periostitis.

Trismus:

Difficulty in opening the mouth is called trismus. Normal mouth opening ranges from 35 to 45 mm.

Trismus Grades:

• Grade 1: Mouth opening is between 2.5 and 4 cm
• Grade 2: Between 1 and 2.5 cm
• Grade 3: Less than 1 cm
• Common causes of trismus
• Temporomandibular joint involvement—such as ankylosis, dislocation, synovitis, etc.
• Mandible fractures
• Pterygoid muscle infiltration by growth in the retromolar region
• Acute inflammatory lesions in the oral cavity
• Tetanus and tetany
• Radiation fibrosis of soft tissues/muscles of mastication

• Bidigital palpation of mandible is done by examining with index finger on the outer aspect of the mandible and the thumb on the under surface of the mandible. This test should be done on the opposite side first. Only then, the thickening of the mandible can be appreciated.
• Gingival cancers
  • Early cases present as mucosal change in leukoplakia
  • Loosening of tooth may be a presenting feature.
  • Can present as bleeding and pain
  • Bone involvement occurs early
  • Spread to adjacent structures occurs early.

Spread:

1. Local spread: Once it involves the entire thickness of the cheek it results in orocutaneous fistula. Involvement of mandible results in sinus.

2. Lymphatic spread: Submandibular nodes and upper deep cervical nodes get enlarged (levels 1 and 2).

• In 50% of cases, lymph node enlargement is due to infection and remaining 50%, it is due to metastasis.
• Metastatic deposits are hard in consistency, indurated and with or without fixity. Significant oedema of face can occur due to lymphatic spread.

3. Blood spread: It is very rare and it occurs late.

Carcinoma Buccal Mucosa and Mandible:

• Direct infiltration by the tumour
• Through mandibular canal
• Through periodontal membrane
• Orthopantomogram or spiral CT can be used for imaging
• Loss of central part of mandible results in pouting of lower lip and continuous drooling of saliva. It is called Andy Gump deformity
• Andy Gump was one of the characters in a popular comic strip, ‘The Gumps’ created by Sidney Smith in 1917. The character’s face seems to end at the upper lip due to ‘absence of mandible’ and is chinless. A statue of this comic character is on display at Lake Geneva Museum

4. Perineural spread: along inferior alveolar nerves may occur up to the skull base. In such cases frozen section may be required

Treatment of Carcinoma Buccal Mucosa:

It can be classified into early disease and advanced disease.

Early Disease:

Two modalities are given.

1. Surgery:

• A small superficial ulcer (T1, T2) is treated by wide excision followed by split skin graft (SSG).
• An infiltrative lesion is treated with wide excision followed by a flap reconstruction. Usually, PMMC, flap (pectoralis major myocutaneous flap) is used.
• PMMC flap: This is the most widely used flap now for head and neck reconstruction.
• The flap is raised along with muscle and an island of skin based on pectoral branch of thoracoacromial artery.
• It is tunnelled under the skin of chest wall and neck and brought to the area of the defect.
• It has been described as the ‘workhorse’ for head and neck reconstruction.  Radial artery based flap is the workhorse of microvascular reconstruction.

Early Carcinoma Buccal Mucosa:

• T1, T2 lesions—surgery/RT
• T1 lesion near commissure—RT
• T2—exophytic and superficial—RT
• T2—deep—surgery is better
• Early disease—no nodes—surgery is better—no other treatment is necessary
• Early disease—positive lymph nodes—same modality to be used for primary and secondary

2. Radiotherapy:

As mentioned earlier, early lesions can be managed with radiotherapy (RT). The advantage of RT is that it cannot only cure the disease but also preserve the organ and its function.

Indications for radiotherapy:

1. Patient not willing for surgery
2. Patient not fit for surgery
3. T1 and T2 lesions and
4. Lesion near the commissure.

Radiotherapy Types:

1. External radiotherapy: Large total dose of 6000–8000 cGy units are given at the rate of 200 cGy units/day.
2. Interstitial radiotherapy: This is indicated in infiltrative small lesions. Caesium 137 or iridium wires are placed within the tumour. Advantage of this method is minimal tissue reaction.

Advanced Carcinoma Buccal Mucosa:

Surgery: T3 and T4 lesions require surgery as the main modality of the treatment followed by postoperative radiotherapy.

• Most of the lesions require full thickness resection leaving behind large defects. Such defects can be repaired using myocutaneous flap.

Examples of Surgeries:

1. Carcinoma buccal mucosa fixed to the mandible:

Wide excision of the growth along with segmental resection of the man-dible or hemimandi-bulectomy is done depending upon the infiltration of the tumour. Very often, whole thickness of the cheek is lost which is reconstructed by using PMMC flap.

Types of Mandibulectomy:

1. Segmental mandibulectomy:

Indications:

• Clinical and radiological involvement of bone
• To obtain wide margins
• To facilitate reconstruction when one has to use ‘bulky’ PMMC flap
• Excision of full thickness of cheek.

2. Marginal mandibulectomy:

It can be done for carcinoma floor of the mouth or tongue. This involves removal of either inner or outer table of the mandible or excising the superior rim of the mandible. However, in large lesions, it is better not to do marginal mandibulectomy.

3. Hemimandibulectomy:

Very advanced lesion may necessitate removal of mandible.

Various methods of reconstruction of mandible following excision:

• Soft tissue: PMMC flap
• Soft tissue with bone: 2.4 mm reconstruction alloplastic material plate and PMMC flap
• Nonvascularised bone: Titanium tray and cancellous grafts chips from iliac crest
• Vascularised bone grafts: Fibula, iliac crest

2. Orocutaneous fistula: This is treated by wide excision which refers to removal of the entire thickness of the cheek along with the growth. Reconstruction is done by using PMMC flap. Radiotherapy should not be given as it results in persistence of fistula.

3. Carcinoma of the buccal mucosa with lymph nodes: Along with the primary, submandibular nodes and upper deep cervical nodes (levels 1, 2 and 3) are removed, along with submandibular salivary gland.

• This is called supraomohyoid block dissection. If surgery has been used to treat the primary, the lymph nodes also should be treated by surgery in the form of neck dissection.

4. Carcinoma of buccal mucosa with fixed lymph nodes: Both primary lesion and lymph nodes should be treated by radiotherapy and reassessment done after 3–4 weeks.

• If residual glands persist or if the glands become mobile, neck dissection can be done at a later date.
• Fixity to internal jugular vein and sternocleidomastoid muscle are not contraindications for radical block dissection.
• Those structures can be removed. However, when the lymph nodes are fixed to the carotid artery, radiotherapy is preferred.

Steps Of Pectoralis Major Myocutaneous Flap (Pmmc Flap):

Prophylactic Neck Dissection:

• It is advocated in T3 and T4 lesions irrespective of nodal status. This amounts to minimal supraomohyoid neck dissection with removal of levels 1, 2 and 3 lymph nodes. It has shown survival benefits.
• It is also indicated in carcinoma mandibular alveolus or buccal mucosa extending into the floor of the mouth.

Complications of Carcinoma Buccal Mucosa:

1. Orocutaneous fistula
2. Trismus: It can be due to direct infiltration of pterygoid muscles or masseter or soft tissue fibrosis following RT.
3. Recurrent respiratory tract infection
4. Cancer cachexia

Carcinoma Of Tongue

Carcinoma Of Tongue Pathological Types:

1. Nonhealing ulcer, commonly on lateral border of tongue in 60% of cases, with slough
2. A proliferative growth, with everted edge
3. Frozen tongue or indurated variety. In this variety, there is maximum induration and sometimes it is more than the size of tumour. The tongue is converted into a hard woody “mass”.
4. Fissure variety: The tongue is indurated with deep fissure.

Carcinoma Of Tongue Clinical Presentation:

• A bleeding ulcer non-healing and progressive
• Pain in the tongue is due to involvement of lingual nerve. In such cases, pain from the tongue can be referred to the ear and lower temporal region.
• Ankyloglossia is restricted mobility of the tongue. It is due to infiltration of the floor of the mouth or mandible, or due to an advanced lesion.
• Disarticulation—difficulty in talking is due to inability of the tongue to move freely.
• Dysphagia is a common presentation from carcinoma of posterior 1/3rd (in 20% of cases).
• An elderly gentleman sitting in the outpatient department spitting blood-stained saliva is suggestive of carcinoma posterior 1/3rd of the tongue.
• Foetor oris is due to infected necrotic growth.
• Bilateral massive enlargement of lower deep cervical nodes in an elderly patient is suggestive of carcinoma of posterior 1/3rd.
• The patient may not be aware of growth at all.

Carcinoma Of Tongue Clinical Examination:

• Inspection and palpation of the growth or the ulcer should be described in the same manner as that of carcinoma cheek.
• Typically, the ulcer bleeds on touch with central slough. The edge, base and surrounding area are indurated.
• Carcinoma of the tongue and carcinoma of the penis are two places in the body wherein induration can be much more extensive than the primary growth or an ulcer. In some cases, induration may be the only finding. Everted edge is commonly seen.
• Digital palpation of posterior 1/3rd of tongue should be done with a glove.
• Test for mobility of the tongue.
  • Forward protrusion—genioglossus. This is the muscle commonly involved.
  • Backward movement—styloglossus
  • Elevation—palatoglossus
  • Depression—hyoglossus

All these muscles are supplied by hypoglossal nerve except palatoglossus which is supplied by glossopharyngeal nerve.

• Bidigital palpation of the mandible should be done which may show thickening.

Carcinoma Of Tongue Lymphatic Spread:

1. Apical vessels drain the tip of the tongue into submental lymph nodes, bilaterally.
2. Lateral vessels drain into submandibular lymph nodes, from here to the lower deep cervical lymph nodes and jugulo-omohyoid nodes—level 3.
3. Central vessels drain into submandibular nodes.
4. Basal vessels drain the posterior 1/3rd of the tongue. There is a crisscrossing of the lymphatics on both sides. Hence, they drain into bilateral lower deep cervical lymph nodes.

• In 50% of cases, the lymph node enlargement is due to secondary infection. Such nodes are tender and firm and respond to antibiotics. In remaining cases, they are hard and fixed and hence, significant. However, in all such cases of lymph node enlargement, ultrasound-guided FNAC is done.

Carcinoma Posterior 1/3rd:

• It presents with dysphagia or with a change in voice.
• Easily missed in a clinical examination
• Biopsy should be done under general anaesthesia to avoid aspiration and to assess the spread posteriorly.
• Palpation will give the diagnosis—induration
• It is one of the occult primaries for lymph node secondaries in the neck.
• Criss-crossing of the lymphatics explain bilateral lymph nodes in the neck.
• Blood spread is more common.
• Prognosis is bad because well-differentiated carcinoma in this location is rare.

Carcinoma Of Tongue Investigations:

1. Wedge biopsy from edge of the ulcer can be taken under local anaesthesia. In cases of proliferative growth, punch biopsy is recommended.
2. In cases of growth arising from posterior 1/3rd of the tongue,biopsy can be taken under general anaesthesia. It also provides an opportunity to examine in detail the posterior spread of the disease into tonsils, pharynx, etc.
3. Biopsy is done to confirm the diagnosis, to know the grade of the tumor (Broder’s classification page 256) and depth of invasion. More the keratin pearls means it is well-differentiated squamous cell carcinoma.
4. Orthopantomogram: X-ray of the mandible can demonstrate an irregular defect due to invasion, erosion or pathological fracture.
5. Chest X-ray is taken to rule out aspiration or inhalation pneumonia.
6. Routine investigations such as complete blood picture, fasting and postprandial sugar estimation to rule out diabetes and electrocardiography to assess cardiovascular function should be done. These patients will undergo often combined modalities specially in advanced stages. ECOG criteria should be calculated.
7. Tongue lesions respond well to surgery and to decide partial or hemiglossectomy MRI is the ideal investigation.

Carcinoma Of Tongue Treatment:

Carcinoma of the tongue is managed similarly to cancer in the oral cavity. However, to preserve the function of the tongue, widespread disease in the posterior one-third tumours, general health of patient (elderly with bad bronchopneumonia) may decide the treatment in favour of radiotherapy. However, results of surgery or radiotherapy for early carcinoma of tongue are equivalent.

Carcinoma Of Tongue Various Types of Surgery:

1. Carcinoma in situ: This type is uncommon in our country. Wide excision with a 1cm margin and a depth of 1 cm is sufficient. Reconstruction of the tongue is not necessary.

2. Partial glossectomy is indicated when the lesion is less than 2 cm (T1) and confined to the lateral border of the tongue. The principle is to do wide excision. The wide excision should include at least 2 cm of tissue away from the palpable indurated edge of the tumour.

• Alternatively, radiotherapy can be given.

3. Hemiglossectomy refers to removal of around 50% of the tongue. This is indicated in a radio-residual tumour, radio-recurrent tumour or where radiotherapy facilities are not available. Reconstruction of the tongue can be done by nasolabial flap and division of pedicle at a later date. Radial forearm free flap can also be used.

4. Total glossectomy: Indications are similar to those mentioned above. However, very extensive growth involving the entire tongue is given radiotherapy initially, to reduce the size of the tumour. Surgery can then be undertaken. Total glossectomy carries significant mortality and morbidity.

5. Commando’s operation: This is indicated when carcinoma of tongue is fixed to the mandible with infiltration of the floor of the mouth. Hemiglossectomy with hemimandibulectomy, removal of the floor of the mouth and radical neck dissection is described as Commando’s operation.

• However, in a few selected cases, removal of the hemimandible is not necessary. Growth which

Structures Removed in Radical Block Dissection of the Neck:

• The fat, fascia, lymphatics from midline to the anterior border of trapezius, from mandible to clavicle below.
• The lymph nodes—submental, submandibular, upper and lower deep cervical nodes, posterior group of nodes (levels 1–5).
• Submandibular salivary gland, sternocleidomastoid and one side internal jugular vein (IJV) are sacrificed.
• Spinal accessory nerve is removed.
• Lower pole of parotid is removed to facilitate lymph node clearance.

is close to the margin of the mandible without infiltration (confirmed by X-ray) needs to be treated by marginal mandibulectomy.

• Carcinoma of the tongue with involvement of only a small portion of mandible can be managed by segmental excision.
• Advantage of this method is that it is not only cosmetic but also preserves the function of the tongue by preserving genioglossus. Hence, the tongue may not fall backwards after surgery.

Treatment of Lymph Nodes:

• Lymph node metastasis in the neck from squamous cell carcinoma can be managed both by surgery as well as radiotherapy.
• Radiotherapy can be given in all stages of secondaries in the neck. However, its main indication is a large primary tumour with neck nodes.
• In such situations both the primary and secondary can be managed with radiotherapy alone which carries minimal morbidity and mortality.
• If the general condition of the patient is good and the lymph nodes are hard and mobile, hemiglossectomy with excision of the floor of the mouth with radical dissection of the neck is done (Commando’s operation).
• If radical neck dissection has to be done on both sides, the IJV should be preserved at least on one side to prevent cerebral oedema. In such cases, radiotherapy is a very good alternative.

Causes of Death in Carcinoma Tongue:

1. Recurrent aspirational pneumonia
2. Gross local recurrence, fungation, ulceration, cachexia.
3. Uncontrolled haemorrhage from growth: In such cases, ligation of external carotid artery above superior thyroid branch should be done. If ligature is applied below the origin of superior thyroid artery, it results in eddy currents and thrombus at bifurcation of common carotid artery.

Carcinoma Of Lip

• Incidence of carcinoma of the lip is about 10 to 12%. It is common in the western, elderly, white people, specially those exposed to sunlight.
• The actinic rays produces actinic cheilitis—inflammation of the lip, especially lower lip, which over a period of years can turn into malignancy.
• Sinc e this is common in agriculturists, who are constantly exposed to sunlight, it is called Countryman’s lip.
• Carcinoma lip includes growth arising from vermilion surfaces and mucosa.
• Leukoplakia is also responsible for squamous cell carcinoma. Smoking, spirits and spices are the common precipitating factors.

Countryman’s Lip:

• Genetic factors also may play a role. Blacks are less susceptible. On the other hand, increased incidence of carcinoma lip has been found in Caucasians.
• Khaini chewers are more susceptible for carcinoma of the lip (Khaini is a mixture of tobacco and lime).
• It can also present as verrucous carcinoma of lip.

Carcinoma Of Lip Clinical Features:

• Elderly males are affected in 90% of cases.
• Nonhealing ulcer or growth is a common presentation.
• Edge is everted and indurated. Induration of the edge and the base is characteristic.
• Floor is covered with slough. Bleeding spots may be visible.
• Mobility: Ulcer or the growth moves with the lip, it is fixed to the subcutaneous structures of the lip.
• The entire upper lip and lateral portions of the lower lip drain into upper deep cervical nodes.
• Central portion of the lower lip drains to submental nodes and submandibular nodes.
• Like elsewhere in the oral cavity, in 50% of the cases, nodes are enlarged due to secondary infections.
• In remaining 50% of the cases, they are enlarged due to metastasis. Such nodes are hard, with or without fixity. Blood spread is uncommon.

Carcinoma Of Lip Differential Diagnosis:

In a classical case of carcinoma of the lip with everted edges and induration, there is no differential diagnosis. However, following are a few conditions to be remembered:

Differential Diagnosis of Carcinoma Lip:

1. Keratoacanthoma
2. Ectopic salivary gland tumour
3. Pyogenic granuloma
4. Leukoplakia

1. Keratoacanthoma:

• It is a cutaneous tumour arising from hair follicles on the lips. It is common in White, Western males between 50 and 70 years of age.
• Sunlight (actinic rays), chemical carcinogen, viral factors may be responsible for this lesion.
• The central portion of the nodule may ulcerate. The lesion may progress for 6 weeks and may resolve spontaneously within 4–6 months.

2. Ectopic salivary gland tumour:

• The lip is one of the common sites of malignant salivary gland tumours. This presents with submucous nodules that grow slowly and ulcerate and may mimic squamous cell carcinoma.
• They are also indurated lesions.
• However, the characteristic everted edge may not be seen.
• These are adenocarcinomas which are treated by surgery.

3. Pyogenic granuloma:

• Recurrent infections or trauma produce a polypoidal mass with significant bleeding.
• It is rich in granulation tissue and resembles a polyp.
• It is devoid of epithelium.
• Histologically, it is a capillary haemangioma.
• Absence of induration gives the diagnosis.

4. Leukoplakia:

A slow developing leukoplakia presents as whitish nodule or an ulcer. However, biopsy confirms the diagnosis.

Carcinoma Of Lip Treatment:

Surgery and radiotherapy are the two modalities available for the treatment of carcinoma of the lip.

1. Carcinoma Of Lip Surgery:

• T1 and T2 lesions can be excised followed by direct suturing without much functional problems. This is described as “V” excision which includes removal of growth with a 1 cm healthy margin. Care should be taken to excise full thickness of the lip.
• When removal of more than 1/3rd of the lip is required, flap reconstruction may be necessary. The primary goal in lip reconstruction surgery is oral competence.

Examples:

• Abbe flap: Based on upper labial artery—a pedicled flap is rotated down and sutured to the defect at the lower lip.
• Estlander’s flap: A wedge-shaped flap is used to reconstruct carcinoma of lower lip, when it involves the angle.
• Larger tumours: T3 and T4 lesions are irradiated first. If the tumour persists after radiotherapy, excision of the entire lip may be necessary followed by PMMC flap reconstruction.
• Significant lymph nodes can be removed along with the primary tumour supraomohyoid block dissection.

2. Carcinoma Of Lip Radiotherapy:

• It is indicated in all stages of carcinoma of the lip. Radiotherapy produces tumour necrosis resulting in a slow-healing rate. Treatment lasts for several weeks and it delays the wound healing. Elderly patients who are not fit for surgery and carcinoma lip with fixed nodes are treated by irradiation.
• Commissure involvement is treated with RT than surgery.
• Dose: 4000–6000 centigray (cGy) units.

Reconstruction of the Lips:

• There are various methods available to reconstruct the lip
• Up to 1/3rd of the lip can be sacrificed with direct closure
• Details are given on page 364 and summary.

Please note: Students are advised to refer plastic surgery books for more details. Knowledge of some of these flaps will help you in getting more marks in the examinations.

Reconstruction following resection of oral malignancy:

Lip Reconstruction Pictures

Carcinoma Maxillary Antrum

It is rare in Western countries but common in Asia. The workers in furniture industries, chromic and nickel industries are more prone for the development of carcinoma maxillary antrum.

Ohngren’s Line:

• Antral carcinoma can be divided by a line joining medial canthus of eye to the angle of mandible. This line is called Ohngren’s line.
• The region above the plane is suprastructure and one below is termed infrastructure.
• Poor prognosis in suprastructure because of proximity to skull base and pterygoid region.
• These suprastructure lesions as usually inaccessible and unresectable.

Carcinoma Maxillary Antrum:

• Majority are squamous cell carcinoma
• Most important method of spread is contiguous spread
• Early presentation is rare because maxillary antrum serves no important function
• Tissue diagnosis is by biopsy of the mass protruding through nasal cavity/oral cavity or transnasal needle through medial wall of the maxilla
• CT scan for bone involvement and MRI for soft tissue involvement are investigations of choice

Carcinoma Maxillary Antrum Clinical Presentation:

• Growth originating on the floor of antrum may result in bulge of the hard palate. This results in pain in the teeth and they may become loose.
• When medial wall is involved, nasal obstruction and epiphora occurs due to obstruction of the lacrimal duct. Bleeding from the nose can also occur if there is ulceration.
• If anterolateral wall is involved, asymmetry of the face results in pain in the cheek. Anaesthesia over the skin of the cheek including upper lip occurs due to involvement of infraorbital nerve, a branch of maxillary division of the trigeminal nerve.
• If the roof is invaded, proptosis and diplopia occurs.
• Posterior extension of the growth is difficult to assess clinically. When it involves the pterygoid muscles, it results in trismus.
• Paraesthesia over the cheek, gums, lower lip, postnasal discharge are the other features of these tumours. They carry poor prognosis because of late presentation.

Carcinoma Maxillary Antrum Lymphatic Spread:

Nodal metastasis is uncommon in sinonasal malignancies. Investigations

1. Computed tomography (CT scan) can define a lesion, its extent, bony destruction, posterior extension, etc. Hence, it is the first investigation of choice.
2. Sinoscopy: Fenestration will provide tissue for biopsy followed by curettage to reduce the tumour bulk and to drain necrotic contents outside.

Carcinoma Maxillary Antrum Treatment:

• Radiotherapy is the main modality of treatment in carcinoma maxillary antrum. Curative rate is around 70% in early cases.
• In advanced cases, radiotherapy is given first. This reduces the tumour bulk so that an unresectable lesion becomes resectable and maxillectomy can be done.
• Surgery can be done in the form of total maxillectomy when the growth involves entire maxilla or it is of high grade followed by postoperative radio-therapy.
• Tumours of the lower half of the antrum are treated by partial maxillectomy. It includes removal of the entire hard palate, alveolus and medial wall of the antrum up to and including middle turbinate.

Clinical examination of a case of carcinoma maxillary antrum:

• Indications and contraindications for surgery and radiotherapy are in similar lines as discussed earlier in this chapter.

Nasopharynx—Cancer

• Carcinoma arises in a small anatomic site bordered by nasal fossae, posterior wall continuous with posterior wall of oropharynx, body of the sphenoid and basilar part of occipital bone and soft palate.
• >90% are squamous cell carcinoma out of which 40–50% are undifferentiated (lymphoepithelioma) and 5% are lymphomas.
• Incidence is higher in Asia—Southern China, Malaysia, etc.
• May be associated with Epstein-Barr virus (EBV)
• Present as high posterior cervical lymphadenopathy
• Cranial nerve syndromes are common due to tumour invasion of base of skull.
  • Retrosphenoidal syndrome from involvement of cranial nerves 2 through 6 manifests as unilateral ophthalmoplegia, trigeminal neuralgia, ptosis, etc.
  • Retroparotid syndrome: Occurs due to compression of cranial nerves 9 through 12 and causes various symptoms depending on nerve involvement including Horner’s syndrome.
• Diagnosis by endoscopy, biopsy, CT and MRI.
• Mainly managed by radiotherapy and chemotherapy.

Benign Lesions In The Oral Cavity

Differential Diagnosis Of Ulcer In The Tongue

1. Aphthous ulcer:

• Small, multiple, very painful ulcers, can occur at any age group. More common in females at the time of menstruation. These are called minor aphthous ulcers.

Painful Ulcers in the Tongue:

• Aphthous ulcers
• Dental ulcers
• Tubercular ulcers

Painless Ulcers in the Tongue:

• Carcinomatous ulcers
• Gummatous ulcers
• Systemic diseases

When they are larger, deeper and painful, they are called major aphthous ulcers.

• They are due to viral infection. These ulcers are superficial ulcers with erythematous margin.
• They subside within a few days. Temporary relief can be obtained by applying salicylate gel.
• Vitamin B complex is usually given for the satisfaction of the patients.

2. Dental ulcer:

• These ulcers occur due to broken tooth, sharp tooth, ill-fitting dentures, prosthesis, etc. They are very painful ulcers.
• Such ulcers are common on the lateral margin and they heal when the tooth is removed. This is an example for traumatic ulcer.
• It should not be confused with carcinomatous ulcer which commonly occurs on the lateral margin.

3. Tubercular ulcer of tongue:

• Tuberculosis affects tip of the tongue. These ulcers are very painful with enlargement of regional nodes.
• It occurs in patients with fulminating pulmonary tuberculosis.
• Ulcers have undermined edges. These ulcers are sometimes multiple with serous discharge.

4. Gummatous ulcer:

• Gumma is a complication of tertiary syphilis resulting in a firm swelling in the midline in the anterior 2/3 rds of the tongue. Induration is absent.
• Ulcer is nontender. Severe endarteritis obliterans results in the necrosis of gumma giving rise to gummatous ulcer.
• It has punched out edges and wash leather slough on the floor. Other sites of gumma include testis, palate, clavicle and liver. These ulcers are rare these days.

5. Systemic diseases:

• Pemphigus
• Systemic lupus erythematosus (SLE)
• Lichen planus

6. Post-pertussis ulcer:

It occurs in children due to repeated coughing. Typical location of the ulcer on the under surface of the tongue and on the frenulum clinches the diagnosis.

7. Carcinomatous ulcer:

• Lateral margin
• Nonhealing ulcer
• Everted edge
• Edge and base are indurated
• Bleeds on touch
• Fixity
• Significant lymph nodes in the neck.

Macroglossia

Diffuse painless enlargement of the tongue is described as macroglossia. It is a rare condition and can occur due to various causes.

1. Lymphangioma: In this condition, the tongue diffusely enlarges. Sometimes, it is a localised swelling.

• It may be associated with lymphangiomas elsewhere in the body such as cheek mucosa, lips, etc.
• The tongue becomes larger, indurated and gives rise to severe discomfort to the patients. Due to repeated trauma, the surface becomes ulcerated.
• It is treated by injecting sclerosants such as ethanolamine oleate, hypertonic saline. Partial excision may be necessary in cases of large lymphangioma.

2. Haemangioma: Cavernous haemangiomas occur in the tongue, lips, etc. It is present since birth but manifests during childhood.

• It presents with soft, cystic, fluctuant swelling and at times, pulsatile. Trauma due to teeth or food results in bleeding.
• Haemangioma of the tongue is treated on the same lines as lymphangioma. It is much more difficult to excise it, especially a large haemangioma.
• Preoperative angiography and ligation of lingual artery on both sides is necessary.

3. Neurofibroma: It may be associated with von Recklinghausen’s disease. It is treated by hemiglossectomy.

4. Muscular macroglossia: This condition, though rare, is seen in cretins. The tongue is thickened and cannot be held in place. Hence, it protrudes outside. It is treated by partial excision.

Syphilitic Lesions Of The Tongue

1. Primary syphilis: Primary chancre that occurs in the tongue is highly contagious. It affects the tip of the tongue. It produces a painful ulcer with large significant enlargement of regional lymph nodes.
2. Secondary syphilis: Produces a white patch in the tongue, lips and on the anterior pillars of fauces. In the tongue, these are multiple which coalesce to form snail track ulcers. The ulcers heal with fine tissue paper scar. In some cases syphilitic organisms produce a flat, hypertrophied epithelium which is described as condyloma. This is called Hutchinson’s wart.
3. Tertiary syphilis: It produces gumma. Syphilis also produces chronic superficial glossitis, which is characterised by bald tongue with loss of papilla and fissured tongue. It is a precancerous condition.

Odontomes

Odontomes Definition: Odontomes are the cysts, malformations arising from epithelial or mesothelial elements of tooth resulting in swelling of the jaw. As a developmental anomaly, a few epithelial cells proliferate, persisting as epithelial debris of Mallasez. Three important odontomes have been given.

Dental Cyst: Radicular Cyst/Periapical Cyst

Odontomes Pathogenesis:

• This arises from a normally erupted, chronically infected, pulpless caries tooth. The caries tooth produces a low grade, chronic inflammation which stimulates epithelial debris to proliferate.
• Later this brings about degeneration of epithelial and mesothelial cells resulting in a cyst within the maxilla.

Odontomes Clinical Features:

• Common in women around 3rd–4th decades.
• Commonly affects the upper jaw (maxilla).
• It presents as a slow-growing swelling in the maxillary region resulting in deformity of the face.

Odontomes Diagnosis:

• Presence of caries tooth with expansion of maxilla.
• X-ray—large, unilocular cyst in maxilla or orthopantomogram showing cyst in the mandible.
• Aspiration of the cyst demonstrates cholesterol crystals.

Comparison of three common odontomas:

Odontomes Treatment:

Excision of cyst with its epithelial lining through intraoral approach. After excision of the epithelium, the cyst wall should be curetted, followed by soft tissue ‘pushin’ to obliterate dead space.

Dentigerous Cyst: Follicular Odontome

• Common in lower jaw (mandible) in women 30–40 years.
• It occurs in relation to unerupted, permanent, molar tooth, most commonly the upper or lower third molar tooth.
• This unerupted tooth constantly irritates the cells, produces degeneration of the cells resulting in a dentigerous cyst.
• The cyst is lined by squamous epithelium surrounded by connective tissue. Within the cyst, the tooth lies obliquely or sometimes is embedded in the wall of the cyst.
• As it grows further, the cyst displaces the tooth to which it is attached. Thus, the tooth is displaced deeper and deeper and prevented from eruption.

Follicular Odontome Clinical Features:

• Absence of molar tooth
• Expansion of mandible—since the inner table of the mandible is strong, the expansion mainly occurs in the outer aspect of mandible.
• The bone gets thinned out resulting in egg-shell crackling.

Follicular Odontome Diagnosis:

X-ray mandible orthopantomogram (OPG)

1. Tooth in the cyst
2. Soap-bubble appearance due to multiple trabeculations of the bone
3. Radiolucent well-defined swelling.

Follicular Odontome Treatment:

• Small cyst—excision of the cyst by intraoral approach.
• Large cysts—managed by marsupialisation.

Adamantinoma

• It is also called multilocular cystic disease, ameloblastoma, Eve’s disease.
• This tumour arises from ameloblasts (enamel-forming cells).
• It is a benign tumour, very slow-growing and behaves like a basal cell carcinoma. Inadequate treatment results in local recurrence and later metastasis.
• Hence, even though the tumour is benign, it has to be treated like malignant tumour.

Odontomes Sites:

• Mandible is the most common site.
• Tibia is the 2nd common site. It can be explained by inclusion of abnormal embryonic epithelium.
• Pituitary is another common site where adamantinoma can occur. Both pituitary stalk and enamel arise from oral epithelium.

Odontomes Clinical Features:

• Patients in the 4th or 5th decade are commonly affected.
• This is a slow-growing jaw tumour in the region of angle of mandible and horizontal ramus of the mandible.
• As the tumour grows, it undergoes cystic degeneration resulting in multiple cystic spaces. Hence, it is called multilocular cystic disease.
• As it grows it causes expansion of the outer table of the mandible and causes fracture mandible.
• Patient may present with complaints of falling teeth.

Odontomes Diagnosis:

X-ray: A large cyst and small multiple cysts due to the trabeculations giving it a ‘honeycomb’ appearance.

Odontomes Treatment:

Even though it is benign, simple curettage or enucleation may result in recurrence and chances of recurrent adamantinoma turning into malignancy are high. Hence,

Adamantinoma:

• Locally invasive solid tumour
• Nonfunctional, intermittent in growth, unicentric, multilocular
• Spreads within the medullary bone
• Invades soft tissues
• Should not fragment the tumour cells
• Subperiosteal excision should not be done as it may result in recurrence
• Incomplete excision results in recurrence and metastasis to the lung
• Hence, even though it is a benign tumour it is treated by wide excision or hemimandibulectomy.

wide excision with 1 cm of healthy normal tissue should be removed. It may amount to segmental excision of the mandible or hemimandibulectomy.

Odontomes Differential Diagnosis:

Giant Celled Reparative Granuloma (Jaffe Tumour):

It is a benign tumour which occurs due to haemorrhage within the bone marrow.

Odontomes Pathology:

• It affects antral part of maxilla or mandible causing enlargement of the jaw.
• Stroma is vascular consisting of thin-walled blood vessels, scanty collagen, connective tissue cells.
• Microscopic features mimic giant cell epulis or brown tumour of hyperparathyroidism.

Odontomes Clinical features:

• Unlike an adamantinoma, this tumour affects females in the age group of 10–25 years.
• Painless enlargement of the jaw is the presenting feature. X-ray demonstrates radiolucent artery.

Odontomes Treatment:

• Calcitonin 0.5 mg (100 units) daily subcutaneous injection over a period of one year has been recommended as a first line of treatment. It has shown resolution of the tumour.
• Curettage is the surgical line of treatment.

Odontomes Osteoclastoma:

• This is a rare tumour seen in the lower jaw.
• Males between the age of 25 and 40 years are commonly affected.
• Unlike adamantinoma, it is a rapidly growing tumour.
• As the tumour enlarges, both tables of the lower jaw are thinned out.
• X-ray may show a large, radiolucent cyst with pseudotrabeculation.
• Even though benign, it is radiosensitive.
• However, recurrence can occur and can turn into malignancy like that of adamantinoma.

Epulis

• Epulis means “upon the gum”. It refers to solid swelling situated on the gum.
• It arises from alveolar margin of the jaw.
• Very often patients present with swelling on the gum which is painless.

Epulis:

• Soft epulis – Granulomatous
• Firm epulis – Fibrous
• Giant cell
• Hard epulis – Carcinomatous
• Malignant epulis – Carcinomatous
• Dangerous epulis – Fibrosarcomatous

Odontomes Types:

Granulomatous Epulis:

• Precipitating factors are caries tooth, dentures, poor oral hygiene.
• It manifests as a mass of granulation tissue around the teeth on the gums. It is a soft to firm, fleshy mass and bleeds on touch.
• Pregnancy epulis refers to this variety (gingivitis gravidarum).

Clinical Notes:

• 65-year-old man was getting recurrent attacks of pain and swelling beneath the chin. Sometimes there was purulent discharge.
• He was treated with antibiotics and incision drainage had been done twice. Sinus persisted.
• Chief cause of his problems was his incisor teeth. Nobody had examined the oral cavity. He had caries teeth.
• Once these were removed, sinus healed. This case highlights the importance of clinical examination.

Odontomes Fibrous Epulis:

It is the commonest form. A simple fibroma arising from periodontal membrane, presents on the gum. It may undergo sarcomatous change. It is a firm polypoidal mass, slowly growing and nontender.

Odontomes Giant Cell Epulis:

• It is also called myeloid epulis.
• It is an osteoclastoma arising in the jaw. It presents as hyperaemic vascular, oedematous, soft to firm gums with indurated underlying mass due to expansion of the bone. It may ulcerate and result in haemorrhage.
• X-ray shows bone destruction with ridging of walls (pseudo-trabeculation).
• Small tumours are treated by curettage.
• Large tumours are treated by radical excision.

Odontomes Carcinomatous Epulis:

• This is an epithelioma arising from mucous membrane of the alveolar margin.
• Typically, it presents as a nonhealing, painless ulcer. It slowly infiltrates the bone.
• Hard regional lymph nodes are due to metastasis.
• Treated by wide excision which includes removal of segment of the bone.

Median Mental Sinus

This is a sinus in the midline just beneath the mentum.

Median Mental Sinus Aetiopathogenesis:

• It is produced by an apical abscess of lower incisors which penetrate buccal cortical plate below the origin of mentalis muscle.
• This muscle takes origin from labial surface of alveolar process just above the labial sulcus. Hence, pus discharges through a sinus in the centre of chin.

Median Mental Sinus Clinical Presentation:

• Patients present with recurrent swelling in the submental region which bursts open spontaneously discharging at times mucus and seropurulent fluid.
• Repeated history of swelling, discharge and healing are common presentations.
• Diagnosis is established by examination of the oral cavity, which reveals evidence of caries tooth.

Median Mental Sinus Treatment:

Once the caries tooth is extracted, sinus will heal spontaneously.

Vincents Angina

• It is an acute ulceromembranous stomatitis or acute ulcerative gingivitis and stomatitis. The disease is caused by Vincent’s organisms—Borrelia vincentii, an anaerobic spirochaete and fusiformis.
• These are gram-negative rods which are the normal pathogens of oral cavity. However, streptococci and staphylococci are the common organisms involved here resulting in severe symptoms and toxicity.

Precipitating Factors

• Malnutrition, diabetes mellitus, caries tooth, warm seasons, winter, etc.
• The disease starts in the intergingival defects as a deep penetrating ulcer which results in a spontaneous gingival haemorrhage. There is a thick membrane covering the ulcer.
• Once infection spreads to tonsillar region, it is called Vincent’s angina—very severe painful condition.

Vincents Angina Clinical Features:

• Common in children and young adults between 20 and 40 years of age.
• It presents with very painful gums with fever, malaise and toxaemia.
• Gums are swollen, red, inflamed with or without slough.
• Difficulty in swallowing, painful swallowing (odynophagia), foetor oris, features of toxaemia and high-grade fever are characteristic of this condition.

Vincents Angina Treatment:

• Improve nutrition. Mouthwashes with hydrogen peroxide help in washing away the membrane.
• Broad spectrum antibiotics such as Piperacillin-tazobactum combination are given, metronidazole 400 mg thrice/ day for 7–10 days should be given.

Cleft Lip And Cleft Palate

Cleft Lip

Describe the etiology and classification of cleft lip and palate.

• Cleft lip results from abnormal development of the median nasal and maxillary process.
• Cleft palate results from a failure of fusion of the two palatine processes.

Epidemiology and Etiology:

Cleft lip-palate has a varied incidence of 1 in 500–2,500 live births depending on geographic location, maternal risk factors, prenatal exposure, ancestry, and socioeconomic status.

• The latest CDC reported incidence is 1 in 940 live births, with the highest rates in Asians and Native Americans (1 in 500 births) and the lowest rate in Africans (1 in 2,500 births) Cleft lip is seen in a Male: Female ratio of 2:1 and in contrast to cleft palate has a 1:2 ratio.
• It is postulated that maternal hormones may be involved in both sex determination and orofacial clefts.

The sporadic causes are multifactorial and involve genetics, environmental factors, and teratogens

1. Syndromes: Most commonly van der Woude syndrome, Stickler syndrome, Hardikar syndrome, Treacher-Collins syndrome.
2. Genetics-IRF 6 which is commonly implicated in the syndromic forms, ch8q24, VAX1, FGFR2, BMP.
3. Maternal risk factors: Smoking, alcohol consumption, pre-gestational and gestational diabetes, advanced maternal age, folate deficiency, zinc deficiency.
4. Teratogens: Medications like anti-epileptics (valproate/phenytoin), retinoic acid, occupational exposure to pesticides/solvents etc.

Cleft Lip And Cleft Palate Types of Cleft Lip:

1. Central: It is very rare and occurs due to failure of fusion of two median nasal processes.

2. Lateral: It is the commonest variety wherein there is a cleft between the frenulum and the lateral part of the upper lip. This is due to imperfect fusion of maxillary process with median nasal process. The lateral variety can be unilateral or bilateral.

3. Complete or incomplete: In cases of complete variety, cleft lip extends to the floor of the nose. In cases of incomplete variety, the cleft does not extend up to the nostril.

4. Simple or compound: Compound refers to cleft lip associated with a cleft in the alveolus.

Cleft Lip And Cleft Palate Clinical Features:

1. In 80% of the cases, cleft lip is unilateral and in about 60% of the cases, it is associated with cleft palate.
2. In many cases, nostril is widened.
3. Maldevelopment or malalignment of the teeth in relation to the cleft is common.

Cleft Lip And Cleft Palate Functional Effect:

1. Presence of cleft lip does not interfere much with sucking. However, there may be some difficulty in bottle feeding.
2. Some degree of difficulty in speech (dysarticulation) is present.

Cleft Palate

Development of Palate:

• Palate is developed around 6–8 weeks of intrauterine life from 3 components. The premaxilla is developed from the median nasal process and maxillary process contributes one palatine process on each side.
• The line of fusion of these processes is in the form of a letter Y.
• Imperfect fusion or developmental anomalies results in cleft palate.

Cleft Lip And Cleft Palate Types:

1. Complete: Failure of fusion of palatine processes and premaxilla results in complete cleft palate.

• In such situations, the nasal cavity and mouth are interconnected. When premaxilla is not fused with both palatine processes, it hangs down from the septum of nose.
• Thus, complete cleft can be of two types as shown below in the diagram.

2. Incomplete: When the fusion of three components of palate takes place, it starts from uvula and then backwards. Thus, various types of incomplete fusion result.

• Bifid uvula.
• The whole length of soft palate is bifid.
• The whole length of soft palate and the posterior part of hard palate are involved. On the other hand, anterior part of palate is normally developed.
• In about 25% of cases, cleft palate alone and in 50% of cases, both cleft palate and cleft lip are encountered.

Effects of Cleft Palate:

1. Presence of cleft palate interferes with swallowing to some extent.
2. They are unable to pronounce consonant sounds such as B, D, K, P, and T.
3. Teeth: Upper lateral incisors may be small or even absent. The maxilla tends to be smaller. Teeth are crowded.
4. Nose: Oral organisms contaminate the upper respiratory mucous membrane through cleft palate.
5. Hearing: Even with repair, acute and chronic otitis media and hearing problems can occur.

Describe the principles of reconstruction of cleft lip and palate.

Management of Cleft Lip and Palate:

• A multidisciplinary approach involving plastic surgery, orthodontics, speech pathology, ENT department, prosthodontics and paediatrics department is needed to rehabilitate the cleft palate cases.
• This approach to the problem results in aesthetically acceptable end result without much functional deficiencies.
• Feeding advice: Cleft palate babies are unable to suck mothers’ milk because intraoral negative pressure cannot be created due to communication between oral and nasal cavity.
• Thus, expressed mother’s milk is given by spoon with head end of baby elevated by 45 degrees. Swallowed air during feeding is released frequently by burping.

Cleft Lip Repair:

Timing: Majority of surgeons follow “RULE OF 10” as a guide for timing of lip and anterior palate repair.

• At the time of repair, haemoglobin should be more than 10 g%, age approximately 10 weeks, weight more than 10 lb (4.54 kg) and total leucocyte count less than 10,000/ cu mm (i.e. no infection).

Rule of 10:

• Hb >10 g%
• Age approx: 10 weeks
• Weight >10 lb (4.54 kg)
• TC <10,000/mm3

Cleft Lip And Cleft Palate Types of Cleft Lip Repair:

• For unilateral cleft lip repair most commonly used methods are Millard rotation advancement flap and Tennison-Randall triangular flap method.
• Bilateral cleft lip can be repaired in single stage or in two stages at the interval of 3–6 months.
• For two-stage repair, any one of the methods described for unilateral cleft lip can be used. For bilateral repair in one stage, Veau 3 method is simple and gives satisfactory results.
• Other single stage methods which give good results are Millard’s single stage procedure and Black procedure.

Basic Steps of Lip Repair:

• Markings are made according to the method selected.
• Adrenaline-saline solution (1:200,000) is injected in the lip and labial sulcus for haemostasis.
• Full thickness of lip is incised along the marking.
• Lip repair is done in three layers—mucosa, muscle and skin. For better aesthetic result, Cupid’s bow

should become horizontal, white line continuity should be repaired and there should be no vermilion notching.

Cleft Palate Repair:

Timing: Early repair results in retarded maxillary growth due to surgical trauma to growth centre and periosteum. Delay in repair results in speech defect. Best balanced result is achieved by repairing between one and a half years.

Cleft Lip And Cleft Palate Types:

• Palate repair: Palate is repaired by palatal shelves. Mucoperiosteal flaps raised from various methods are available for palate repair.
• Most commonly used method is V-Y, pushback palatoplasty.

Steps of ‘V-Y’ pushback palatoplasty:

• Palate is infiltrated with 1:2 lakh adrenaline-saline solution.
• Two mucoperiosteal flaps are elevated, one from either side of palatal shelves. Then, nasal layers are mobilised.
• Palate is closed in three layers— nasal layer, muscle layer, oral layer.
• In V-Y pushback palatoplasty, palatal lengthening is achieved by V-Y plasty. Hook of hamulus can be fractured to relieve tension on suture line by relaxing the tensor palati muscle.

Miscellaneous

Ectopic Salivary Gland Tumour:

• Palate is the most frequent site.
• These tumours can also occur anywhere in the mouth or pharynx.
• It is a slow-growing and painless tumour. At this stage, it may feel firm or hard without ulceration of mucous membrane.
• Slowly it ulcerates. Thus, it can have the shape of a ‘verrucous’ carcinoma. Such lesions are ulcerated, hard, and painful with irregular margins.
• They are of low-grade malignancy.
• Neglected cases can invade base of skull and spread to lymph nodes.
• Wide excision with or without reconstruction is the treatment of choice.

Mucous Cysts

• They are examples of retention cysts.
• They occur due to obstruction of the duct of many mucous-secreting glands which cover the inner surface of the lips and whole inside of mouth.
• They are also a type of extravasation cyst.

Clinical Symptoms and Signs:

• Painless, slow-growing swelling on the inner side of lip or cheek.
• Most common on the lower lip.
• Typically round, soft, fluctuant, pale pink swelling or blue-domed.
• Transillumination is positive but difficult to demonstrate as the cysts are small.
• Mucous membrane is free over swelling.

Mucous Cysts Differential Diagnosis:

Pyogenic granuloma: It is red in colour, soft and bleeds. It may be associated with trauma or persistent infection.

Ectopic salivary gland tumours: They are firm and non-tender swellings.

Mucous Cysts Treatment:

• Excision can be done under local anaesthesia.
• Once mucous membrane is incised, swelling can be dissected all around separating it from orbicularis oris/buccinator muscle and it is removed.
• The mucous membrane is closed with absorbable sutures.

Miscellaneous

A case of malignant melanoma of the oral cavity (see the clinical notes)

Clinical Notes:

• This 48-year-old manpresented with an innocent looking, painless submandibular lymph node enlargement. It was firm and nontender.
• Initially, it was thought to be due to dental caries. Examination of the floor of the mouth revealed an interesting melanomatous lesion.
• Diagnosis was malignant melanoma with metastasis in nodes. This is just to remind that melanoma can also occur in the oral cavity (mucosa and firm skin).