CHAPTER I
INTRODUCTION
Diseases of the oral soft tissues has been a serious concern by experts, especially with the increase in cases of deaths caused by cancer in the oral cavity particularly in countries that are developing.
Oral cancer is approximately 5% of all malignancies occurring in men and 2% in women (Lynch, 1994). It has been reported that oral cancer is a major cancer in India, especially in Kerala where the incident was reported at an average height, about 20% of all cancers (Balaram and Meenattoor, 1996).
Although there is progress in the diagnosis and therapy, and death caused by an abnormality of oral cancer is still high and has long been a problem in the world. Some of the reasons put forward for this is mainly due to the lack of early detection and identification of high-risk groups, and the failure to control the primary lesion and cervical lymph node metastases (Lynch, 1994; Balaram and Meenattoor, 1996).
To overcome the problems caused by oral cancer, the WHO has made instructions for oral cancer control, especially for countries that are developing. Control is based on primary prevention where the main principle to reduce and prevent exposure to substances that are carcinogens. The second approach is through the implementation of secondary prevention, in the form of early detection of cancerous lesions and precancerous oral cavity (Subita, 1997). Folson et al, 1972, estimates that 80% of all cases of oral cancer deaths can be prevented with early detection of malignancy in the mouth (Folson et al, 1972).
In general, for the early detection of oral malignancy in the process can be done through anamnesis, clinical examination and confirmed by additional laboratory examinations. In this paper will put forward measures that can be performed by your dentist to detect early malignant processes in the mouth. It is expected to find a dentist lesions suspected of being malignant process early so the prognosis of oral cancer better.
CHAPTER II
Oral cancer
DEFINITION II.1
A. Restriction
Oral cancer is cancer originating from both epithelial mucosa or salivary glands in the walls of the oral cavity and the mouth organ.
The boundaries of the oral cavity is:
• Home: the edge of the upper lip vermilion and lower lip
• Above: the hard palate and palate
• Lateral: right and left buccal
• Bottom: floor of the mouth and tongue
• Rear: left right anterior arch faringeus and uvula, arch
glossopalatinus left and right, the lateral edge of the tongue,
circumvallate papilla tongue.
The scope of oral cancer include the following specific areas:
a. lip
b. tongue 2/3 anterior
c. buccal mucosa
d. floor of the mouth
e. ginggiva top and bottom
f. retromolar trigone
g. hard palate
h. soft palate
Excluding cancers of the oral cavity is:
a. Sarcomas and malignant tumors in the maxilla or mandible odontogen
b. Soft tissue sarcoma and peripheral nerves of the lips or cheeks.
c. Carcinoma of the skin of the lips or cheek skin.
II.2 EPIDEMIOLOGY
1. Incidence and relative frequency
How large is the incidence of oral cancer in Indonesia we do not know for sure. Relative frequency in Indonesia is estimated to 1.5% -5% of all cancers. The incidence of oral cancer in men who are high in France is 13.0 per 100,000, and is low in Japan is 0.5 per 100,000, was higher in women in India is 5.8 per 100,000 and are low in Yugoslavia is 0.2 per 100,000 (Renneker , 1988). The incidence of oral cancer in India by 20-25 per 100,000, or 40% of all cancers, whereas in the United States and Europe of 3-5 per 100,000, or 3-5% of all cancers. Oral cavity cancer most often on the tongue (40%), and floor of the mouth (15%), and lips (13%).
2. Gender Distribution
Oral cancer is more prevalent in males than females with a ratio of 3/2 - 2/1
3. Age distribution
Oral cavity cancer mostly occurs in the age above 40 years (70%).
4. The geographic distribution
Oral cancer is widespread throughout the world. Insidensnya high in France and India, being low in Japan.
5. Etiology and risk factors
The etiology of oral cancer is exposure to carcinogens, which are widely found in cigarettes or tobacco.
High risk of oral cancer gets there in people who smoke, nginang / fringe, alcohol, dental caries, poor oral hygiene
II.3 CLASSIFICATION histopathology
A. Histology Study
NO TYPE histology ICD.M
1 Squamous cell carc. 5070/3
Adenocarcinoma 2 8140/3
Adenoid cyst.carc 3 8200/3
4 Ameloblastic carc 9270/2
5 Adenolymphoma 8561/3
6 Mal. mixed tumor 8940/3
7 pleomorphic carc 8941/3
Malignant Melanoma 8 8720/3
9 Malignant Lymphoma 9590/3-9711/3
Most ( 90%) cancers originate from the mucosa of the oral cavity in the form of epidermoid carcinoma or squamous cell differentiation skwamosa well, but can also berdiferensiasinya moderate, bad or anaplastic. When the pathological picture showed a rhabdomyosarcoma, fibrosarcoma, malignant or malignant tumors fibrohistiocytoma other soft tissue, should be carefully examined whether the tumor was actually a malignant tumor of the oral cavity (C00-C06) or a malignant tumor of the soft tissues of the cheek, skin or bone invasion held into the oral cavity.
B. Degree of Differentiation
GRADE Differentiation
GRADE
Differentiation either G1
G2 Differentiation was
Differentiation G3 ugly
Without differentiation G4 =
anaplastic
C. Pathology Reports Standard
To report on the results of the pathological examination of the specimen operations include:
1. histologic type of tumor
2. degree of differentiation (grade)
3. examination to determine the TNM stage
pathological (pTNM)
T = primary tumor
- Size of tumor
- The invasion into the blood vessels / lymph
- Operating radicalism
N = regional nodes
- Size of the KGB
- The number of nodes is found
- Level KGB positive
- The number of positive nodes
- Invasion of the tumor out kapsel KGB
- The existence of extra-nodal metastases
M = distant metastasis
II.4 CLINICAL CLASSIFICATION OF STADIUM
Determining the stage of cancer of the oral cavity is recommended using TNM system of UICC, 2002. Treatment depends on the stage of therapy. Instead of staging to delineate the severity of cancer can also be widely used extension of disease.
Stage carcinoma of the oral cavity:
ST T N M TNM FACTS
0 TIS N0 M0 T0 No tumor found
TIS tumors in situ
I T1 N0 M0 T1 2 cm
T2> 2 cm - 4 cm
II T2 N0 M0 T3> 4 cm
T4a
T4B Lips: bone infiltration, n.alveolaris inferior, base
mouth, skin
Oral cavity: the infiltration of bone, muscles of the tongue
(Extrinsic / deep), maxillary sinus, skin
Infiltration of Masticator space, pterygoid plates,
base of the skull, the internal a.karotis
Lips: bone infiltration, n.alveolaris inferior, base
mouth, skin
Oral cavity: the infiltration of bone, muscles of the tongue
(Extrinsic / deep), maxillary sinus, skin
Infiltration of Masticator space, pterygoid plates,
base of the skull, the internal a.karotis
III T3 N0 M0
T1 N1 M0 N0 There is no regional metastases
T2 N1 M0 N1 KGB ipsilateral singles, 3 cm
T3 N1 M0 N2A KGB ipsilateral singles,> 3-6 cm
N2B multiple ipsilateral nodes, <6 cm
IVA T4
each T N0, N1
N2 M0
N2C M0 KGB Bilateral / contralateral, <6 cm
N3 nodes> 6 cm
Each T N3 M0 IVB
IVC
each T
Each N M0 M1 Distant metastasis was not found
M1 distant metastases
Broad extension of cancer:
NO EXTENT OF EXTENSION
1 Cancer In Situ
2 local Cancer
3 local Extension
4 distant metastases
5 local extension with meta far
CLINICAL I1.5
Most patients had a history of oral cancer lesions / oral precancerous conditions before, such as leukoplakia, eritrplakia, submukus fibrosis and others. For that dentists should recognize the clinical picture these lesions (Balaram and Meenattoor, 1996).
Generally, early stage oral cancer does not cause symptoms, less than 2 cm in diameter, mostly red with or without white components, slick, smooth and showed a minimal elevation (Lynch, 1994). Often beginning of malignancy characterized by the presence of ulcers. If there are ulcers that do not heal within 2 weeks, then the situation can already be suspected as early in the process of malignancy. Other signs of malignancy include ulcers process painless ulcer, rolled edge, higher than the surrounding area and induration (harder), can essentially berbintil-nodule and peeling. Growth carcinoma ulcer forms are referred to as growth endofitik (Williams, 1990; Tambunan, 1993). Besides oral carcinoma is also seen as a growth eksofitik (superficial lesions) that can be shaped or papillary cauliflower, bleeds easily. Eksofitik lesions are more easily recognized its existence and has a better prognosis (Williams; 1990; Tambunan, 1993).
Clinical features of oral cancer at various sites of the oral cavity may have some differences (Daftary, 1992). To be more clear, the clinical picture will be discussed separately by location.
Cancer of the tongue.
Nearly 80% of tongue cancer is the 2/3 anterior tongue (usually on the lateral edge and under the tongue) and in small amounts in the posterior tongue (Daftary, 1992; Tambunan, 1993; Pinborg, 1986). Symptoms depend on the location in patients with cancer. When located at the 2/3 anterior tongue, the main complaint is the emergence of a mass that often feels no pain. When you arise in the 1/3 posterior, the cancer is not always known to the patient and the pain experienced is usually associated with throat pain.
Cancer that is 2/3 anterior tongue can be detected more early than war lies in the 1/3 posterior tongue. Sometimes regional node metastases limph may be the first indication of a small cancer of the tongue: Pinborg, 1986).
In the early stages, clinically tongue cancer can manifest in various forms, can be leukoplakia patches, thickening, development or endofitik eksofitik ulcer forms. But mostly in the form of ulcers: Daftary, 1992). Over time these ulcers will experience deeper infiltration edges not having induration (Pinborg, 1986). Generally painless unless there is secondary infection.
Cancer of the lip.
Lip cancer is always associated with people who have outside activities such as fishing and farming. Sunlight may be involved in cancer Datogenese lips. Generally more common in the lower lip jaripada upper lip (Daftary, 1992; Pinborg, 1986; Smith, 1989).
At the beginning of growth, the lesions may be small nodules or ulcers that do not heal. Detection of tumors in this situation provides an opportunity to discover early carcinoma (Daftary, 1992; Pinborg, 1986, Tambunan, 1993). Lesions that can further shape papillari, ulcerative or infiltrative. Type papilomatous can be initiated from a thickened epithelium and most of these remain on the epithelial superficial. Ulcerative lesions and infiltrative initiated from epithelial thickening but subsequently experienced a deeper infiltration (Daftary, 1992). The most important sign is the induration are obtained on the outskirts of the ulcer.
Cancer of the mouth.
Cancer of the floor of the mouth is usually associated with the use of alcohol and tobacco. At the initial stage may not cause symptoms. When lesions develop patient will complain of a lump in the mouth or feeling uncomfortable (Pinborg, 1986; Daftary, 1992).
Clinically the most common form of ulceration are lesions with a raised edge and hardened located near the lingual frenulum (Pinborg, 1986). The other form is a thickening of mucosal redness, nodules that do not hurt or be derived from the leukoplakia (Daftary, 1992). In the advanced stages of cancer can occur eksofitik or infiltrative growth.
Cancer of the cheek mucosa.
In developing countries, cancer of the cheek mucosa associated with the habit of chewing a mixture of areca nut, betel leaf, lime and tobacco. Susur is in contact with the left and right cheek mucosa for several hours (Daftary, 1992).
At first the lesions do not cause symptoms, seen as an erythematous area, a small ulceration, induration and red areas are sometimes associated with the type of nodular leukoplakia (Daftary, 1992; Pinborg, 1986). With the increasing size of the tumor, trauma will be targeted at chew, so tend to become ulcerated and infiltrating.
Cancer of the gingiva.
Cancer of the gingiva usually come from areas where the quid of tobacco were placed on the people who have this habit. The area involved is usually more frequent in mandibular gingiva than maxillary gingiva (Daftary, 1992; Pinborg, 1986).
Early lesions appear as Ulger indolent, small granulomas or as nodules. Overview lesions appear similar to lesions produced by trauma or chronic inflammatory hyperplasia (Daftary, 1992). Lesions were more in the form of growth or growth eksofitik infiltrating deeper. Growth eksofitik like cauliflower, bleeds easily. Infiltrative growth usually grows invasive mandibular bone and cause desdruktif (Tambunan, 1993).
Cancer of the palate.
In areas where people have the habit of smoking cigarettes in reverse, on the palate cancer is cancer of the oral cavity are common of all oral cancers. Changes that occur in the oral mucosa associated with cigarette smoking in reverse is the ulceration, erosions, nodules and spotting areas. Reddy et al, 1974. describes a microinvasive carcinoma to describe an early lesion in the form of a small, oval or round reddish color, the smooth erosion areas surrounding hyperkeratotic lesions usually occur on the hard palate and glandular zone asymptomatic. If you are getting pressure to bleed (Daftary, 1992).
Most of palate cancer is eksofitik growth and extensive grounds with bernodul surface. If the lesion is growing will probably fill the entire palate. Cancer of the palate can lead to perforation of the palate and extends to the nasal cavity (Daftary, 1992).
Predilection.
In addition to recognizing the clinical features of malignancy and malignancy early in the process, the dentist must know the factors predilection for age, sex and place of oral cancer. As with cancer in other body parts, most cases of oral cancers occur in old age over 40 years. This situation is linked to the immune system decreases with increasing age. Men are more commonly affected, possibly associated with smoking and drinking alcohol.
Although oral cancer can occur in all areas of the oral mucosa, it is important to know the place of predilection. Early cancer that is localized essentially asymptomatic at three specific places in the oral cavity, including the floor of the mouth, soft palate complex and the ventral surface of the tongue and the middle third and posterior third of the lateral aspect of the tongue (Pinborg, 1986; Lynch, 1994).
II.6 DIAGNOSTIC PROCEDURE
1. Clinical Examination
a. Anamnesa
Anamnesa kwesioner by the patient or family.
1. Complaint
2. Course of the disease
3. Etiology and risk factors
4. What treatment has been given
5. How the results of treatment
6. How long delays
b. Physical examination
1) general status
General examination from head to toe
Determine: a. appearance
b. general condition
c. distant metastases
2) local status
By the way: 1. Inspection
2. Bimanual palpation
Abnormalities in the oral cavity checked by inspection and palpation with the help spatel tongue and illumination using a flashlight or head lamp. The entire oral cavity seen, from the lips to the posterior oropharynx. Palpability of lesions of the oral cavity is done by inserting one or two fingers into the mouth. To determine which lesions are performed by touching bimanuil. One or two fingers left or right hand is inserted into the cavity of the mouth and the fingers of his other hand fingered lesions outside the mouth.
For the inspection of the tongue and oropharynx can the tip of the tongue that has been wrapped with a 2x2 inch gauze is held with the examiner's left hand and pulled out the mouth and directed right and left to see the surface of the dorsal, ventral and lateral tongue, floor of the mouth and oropharynx. Inspections can be better when using the help of a mirror Examiner
Determine where the primary tumor site, how it would look, how much in cm, how much infiltration, how operabilitasnya
3) regional status
Palpation is there any enlargement of cervical lymph nodes ipsilateral and contralateral neck. If there is enlargement specify the location, number, size (the largest), and mobility.
2. Radiography Examination
a. X-plain
o X-mandibular photo AP, lateral, Eisler, panoramic, occlusal, mandibular gingiva done on the tumor or tumors attached to the mandible
o lateral head X-photo, Waters, occlusal, gingival done on the tumor, maxillary or maxillary tumor attached to
o X-Hap photo done on the hard palate tumor
o X-thorax photo, for the presence of pulmonary metastases
b. Imaging (made only on indication)
o liver ultrasound to look at the liver metastases
o CT-scan or MRI to assess tumor extension vast lokoregional
o Bone scan, if suspected metastasis to bone
3. Laboratory
Routine laboratory examinations, such as blood, urine, SGOT / SGPT, alkaline phosphatase, BUN / creatinine, albumin, globulin, serum electrolytes, physiological hemostasis, to assess the general condition and preparation of the operation
4. Pathology examination
All patients with oral cancer or suspected cancer of the oral cavity should be carefully examined pathologically.
Specimens were taken from tumor biopsies
Fine-needle biopsy (FNA) for cytological examination can be performed on the primary tumor or metastatic lymph nodes in the neck.
Excision biopsy: when the tumor is small, 1 cm or less excision done
is wide excision as definitive surgery (1 cm
from the edge of the tumor)
Cakot incisional biopsy or biopsy (punch biopsy) using alligator forceps:
when the tumor is large or inoperable
Which should be examined in histopathological preparations are types, and extensive differentiation of tumor invasion.
Large tumors are expected to remain operabel:
A biopsy should be performed under general anesthesia and can be done at the same time bimanuil exploration to determine the extent of tumor infiltration (staging)
Expected large inoperable tumor:
A biopsy is done with local anesthetic block in normal tissue around the tumor. (Anesthetic infiltration of the tumor should not be done to prevent the spread of cancer cells).
KIND OF DIAGNOSIS upheld
1. Primary diagnosis
Is the macroscopic picture of the cancer disease itself, which is a clinical diagnosis
2. Diagnosis of complications
Another disease that is caused by cancer
3. Secondary Diagnosis
Is another disease that has nothing to do with cancer suffered, but it may affect treatment or prognosenya.
4. Diagnosis pathology
Is a microscopic picture of the cancer
II.7 THERAPY PROCEDURES
Oral cavity cancer treatment should be multidisciplinary involving several specialist areas, namely:
- Oncologic Surgeon
- Plastic & Reconstructive Surgeon
- Radiation oncologist
- Medical oncologist
- Dentists
- Rehabilitation specialists
Some things to consider in the treatment of oral cancer is the eradication of the tumor, restoring the function of the oral cavity, as well as aspects of cosmetic / appearance of the patient.
Some factors to consider in determining the kind of therapy is
a) Age of patients
b) The general state of the patient
c) Facilities available
d) The ability of physicians
e) selection of patients.
For small lesions (T1 and T2), surgery or radiotherapy alone can provide a high cure rate, with a note that radiotherapy alone on T2 gives a higher recurrence rate than surgery.
For T3 and T4, the combination of surgery and radiotherapy treatment gives the best results. Giving neo-adjuvant radiotherapy and or chemotherapy prior to surgery may be given to the cavity cancer locally advanced (T3, T4).
Radiotherapy can be given as interstitial or external tumors eksofitik with small size will be more successful than endofitik tumors with large size.
The role of chemotherapy in the treatment of oral cancer is still not much in the research phase of chemotherapy is only used as neo-adjuvant pre-operative or post-operative adjuvant for sterilization possibility of micro-metastasis.
As a guideline for the treatment of oral cancer is recommended as table 9 below:
Prompts therapy for cancer of the oral cavity
ST T.N.M. OPERATION Radiotherapy chemotherapy
I T1.N0.M0 radical excision or Curative, 50-70 Gy not recommended
II T2.N0.M0 radical excision or Curative, 50-70 Gy not recommended
III T3.N0.M0
T1, 2,3. N1.M0 radical excision and Post op. 30-40 Gy
(And) CT
IVA T4N0, 1.M0
Each T.N2.M0 radical excision and Post.op 30-40 Gy
IVB Each T.N3.M0
-Operabel
-Inoperable
radical excision
-
and Post.op 30-40 Gy
Palliative, 50-70 Gy
(And) CT
IVC TiapT.tiapN.M1 Palliative Palliative Palliative
Residif local operations to
residif post RT residif Not recommended for post op RT and CT
Metastases not recommended not recommended CT
Carcinoma of the lip
T1: wide excision or radiotherapy
T2: wide excision
When the commissure, radiotherapy will provide relief to the function and better cosmetic
T3, 4: wide excision + + deseksi suprahioid postoperative radiotherapy
Carcinoma of the mouth
T1: wide excision or radiotherapy
T2: not attached periosteum wide excision
Sticking periosteum wide excision with marginal mandibulektomi
T3, 4: wide excision with marginal mandibulektomi + dissection
supraomohioid + postoperative radiotherapy
Carcinoma of tongue
T1, 2: wide excision or radiotherapy
T3, 4: wide excision + + deseksi supraomohioid postoperative radiotherapy
Carcinoma of the buccal
T1, 2: wide excision
When the commissure oris, radiotherapy provide relief to the function and better cosmetic
T3, 4: wide excision + + radioterapipasca different supraomohioid deseksi
Carcinoma ginggiva
T1, 2: wide excision with marginal mandibulektomi
T3: wide excision with marginal mandibulektomi + dissection
supraomohioid + postoperative radiotherapy
T4 (infiltration of bone / tooth extraction after tumor):
wide excision with segmental mandibulektomi dissection supraomohioid + + postoperative radiotherapy
Carcinoma of the palate
T1: wide excision to periost
T2: wide excision to the underlying bone
T3: wide excision to the underlying bone dissection +
supraomohioid + postoperative radiotherapy
T4 (bone infiltration):
Maksilektomi infrastructural partial / total lesion + depending on the area
supraomohiod dissection + radiotherapy after surgery
Retromolar trigone carcinoma
T1, 2: wide excision with marginal mandibulektomi
T3: wide excision with marginal mandibulektomi
+ + Supraomohioid dissection postoperative radiotherapy
T4 (bone infiltration): Wide excision with segmental mandibulektomi dissection supraomohioid + + postoperative radiotherapy
For carcinoma of the oral cavity T3 and T4, N0 handling do deseksi selective neck or postoperative regional radiotherapy. While N1 obtained at each T to do deseksi radical neck. Where possible, wide excision of the primary tumor and neck deseksi should be done en-block.
Giving regional radiotherapy after surgery depends on the results of pathological lymph node metastases (the number of positive lymph node metastasis, lymph node capsule penetration / extra lymph nodes
A. Curative Therapy
Curative treatment for cancer of the oral cavity is given in oral cavity cancer stage I, II, and III.
1. Major therapeutic
Primary therapy for stage I and II is that surgery or radiotherapy, each of which has advantages and disadvantages of each. Whereas for stage III and IV are still operabel is a combination of surgery and postoperative radiotherapy
In curative therapy should be considered:
a) According to the correct procedure, because if one of the results are not being
curative.
b) Functions mouth to speak, eat, drink, swallow, breathe, stay well.
c) cosmetic quite acceptable.
a. Operation
Indication of operation:
1) Case operabel
2) Age is relatively young
3) The general state of good
4) There were no severe co-morbidities
The basic principle of operation of oral cancer are:
1) The opening should be large enough to be able to see the entire tumor
with extension
2) Exploration of tumor: to determine the extent of tumor extension
3) Wide excision of tumor
o The tumor did not invade the bone, 1-2 cm wide excision of tumor beyond
o invaded bones, wide excision with resection of the invaded bone
4) regional nodes dissection (RND = Radical Neck Disection or
modification), if there are regional nodes metastasis.
Dissection is done with the primary tumor when enblok
possible.
5) Determine radicalism durante operation of edge incision surgery
by examination of frozen cut. If you do not make an outline radical
new wider incision to free the tumor.
6) Reconstruction of defects that occur.
b. Radiotherapy
Indications of radiotherapy
1) Case inoperable 2) T1, 2 specific place (see above)
3) Cancer of the tongue 4) Age is relatively old
5) Refusing surgery 6) There is a serious co-morbidity
Radiotherapy can be given by:
1) Teletherapy wear: ortovoltase, Cobalt 60, Linec dose
5000 - 7000 rads.
2) Brachytherapy: a booster with intratumoral implantation needles
Irridium Radium 192 or 226 at a dose of 2000-3000 rads.
2. Adjunct therapy
a. Radiotherapy
Additional radiotherapy is given in the case of the main therapy surgery.
(1) post-surgical radiotherapy
Given on T3 and T4a after surgery, the case can not be done radical excision, radikalitasnya doubtful, or the operating field contamination by cancer cells.
(2) pre-surgical radiotherapy
Pre-surgical radiotherapy is given in cases operabilitasnya doubt or inoperable.
b. Operation
Operations carried out in cases of therapy after primary radiotherapy or radiotherapy to operabel residif arising after radiotherapy.
c. Chemotherapy
Chemotherapy given in the case of the operating field contamination by cancer cells, cancer stage III or IV or raised residif after surgery and or radiotherapy.
3. Therapy Complications
a. Therapeutic complications of disease
In general, stage I to II disease has been no complications, but complications can occur due to therapy.
Treatment depends on the complications that exist, for example:
1) Pain: analgesics 2) infection: antibiotic
3) Anemia: haematinics 4) Etc.
b. Therapeutic complications of therapy
1) Complications of surgery: by type of complication
2) Complications of radiotherapy: by type of complication
3) Complications of chemotherapy: by type of complication
4. Assisted therapy
Can be given proper nutrition, vitamins, etc..
5. Secondary Therapy
If there is a secondary disease according to the type of therapy given
illness
B. Palliative Therapy
Palliative therapy is to improve the quality of life of patients and reduce the grievances especially to people who are no longer curable.
Palliative therapy given to patients with oral cavity cancer:
1. Stage IV has demonstrated distant metastases
2. There are severe co-morbidities with a short life expectancy
3. Curative treatment fails
4. Very advanced age
Complaints need dipaliasi include:
1. Loko regional
a) ulcers in the mouth / throat b) Pain c) It is difficult to eat, drink,
swallow
d) Oral smelled e) Anorexia f) oro-cutaneous fistula
2. Systemic:
a) pain b) Shortness of breath c) It is difficult to talk
d) Cough-cough e) The agency took care f) A weak
(1) The main therapy
1. Without meta far: Radiotherapy dose 5000-7000 rads.
If you need to combine the operations
2. There are distant metastases: Chemotherapy
Chemotherapy can be used include:
1) epidermoid carcinoma:
Drugs that can be used: Cisplatin, Methotrexate,
Bleomycin, Cyclophosphamide, Adryamycin, with numbers
20 -40% remission. For example:
a) a single drug: Methotrexate 30 mg/m2 2x a week
b) Drug combinations:
V = vincristine: 1.5 mg/m2 hl
B = Bleomycin: 12 hl + 12 mg/m2 repeated every hour
M = Methotrexate: 20 mg/m2 h3, 8 2-3 weeks
2) adeno carcinoma:
Drugs that can be used include: Flourouracil,
Mithomycin-C, Ciplatin, Adyamycin, the remission rate 20 -
Of 30%. For example:
a) a single drug: Flourouracil:
Dose starters: 500 mg/m2
Maintenance dose: 20 mg/m2 every 1-2 weeks
b) Drug combinations:
F = Flourouracil: 500 mg/m2, hl, 8,14,28
A = Adryamycin: 50 mg/m2, hl, 21 repeated every
M = Mithomycin-C: 10 mg/m2, h1 6 weeks
(2) Additional Therapy
If necessary: Surgery, chemotherapy, or radiotherapy
(3) Treatment of complications
1. Pain: analgesics according to the "step ladder WHO"
2. Shortness of breath: tracheostomy
3. Difficult to dine: gastrostomy
4. Infection: antibiotic
5. Halitosis: mouthwash
6. Etc..
(4) Therapeutic aid
1. Good Nutrition
2. Vitamin
(5) Secondary Therapy
If there is a secondary disease, treatment according to disease
concerned.
Leukoplakia / erythroplakia
Eliminate the causes,
exfoliative cytology (Papanicolaou),
Class I Class II Class IV Class V ClassIII
3 bl
Deuteronomy cytology
Biopsy
If 2x repeat cytology
results REMAIN Class I-III
Suspect Mouth Carcinoma, N0, M0
<1 cm> 1 cm
Exicitional biopsy (wide exicion) Incicional Biopsy
benign malign malign benign
non radical radical exicion
re-exicion / non Operable Operable / doubt
local radiotherapy
T1 T2 T3, 4a cemo and / radiotherapy
preoperative local
radiotherapy non Operable Operable
excone wide wide exicion +
desection selective neck limf * /
radiotherapy lokoregional
radiotherapy
non radical Radica lokoregional
+ (Citostatica)
re-excision / limf meta (+) limf meta (+)
local radiotherapy
T T high grade low grade
radiotherapy
lokoregional
+
(Citostatica) local radiotherapy
radiotherapy lokoregional
* Suprahioid dissection for carcinoma of the lip
Supraomohioid dissection for carcinoma of the oral cavity
Bilateral dissection for lesions in the midline
N POSITIVE
N 1.2 N 3
T operated T radiotherapy radiotherapy preoperatifve
1.
2.
3.
4.
+
CHAPTER III
CONCLUSION
Oral cancer at an early stage it is difficult to detect clinically, because it often does not cause symptoms in the patient or accompanying changes may not be so obvious, it only produces a slight change in terms of functionality, color, texture, continuity or consistency of the network that are . As a result, patients often come to the dentist with a cancerous lesion that has been in a state of advanced stage. It required an act by dentists to detect precancerous lesions and oral cancer in its early stages. Cancerous lesions at an early stage can not be adequately identified only by visual inspection alone. Knowledge of the clinical picture is good even from a dentist is not yet able to establish a proper diagnosis of cancerous lesions at an early stage, because there is no definitive clinical indicators to determine a lesion is benign or ferociously. But even so, the dentist should know the symptoms and clinical features of oral cancer lesions at an early stage, so that will be able to plan the next stages of the examination. The following are signs to look out for the dentist to the possibility of a new oral cancer begin to occur or the
advanced stages (Bolden, 1982):
1. White patches, scaly, persistent.
2. Pigment spots that suddenly increased its size.
3. Ulcer that does not heal.
4. Swollen and bleeding gums are not associated with these drugs.
5. Progressive facial asymmetry.
6. Missing teeth suddenly, without any history of trauma to the jaw.
7. Parastesi, anesthesia and numbness in the oral cavity.
8. Trismus and pain when moving the jaw.
9. There is a lump in the neck, face or mouth tissue.
10. Revocation wound that does not heal.
11. Change
If there are one or more of these signs, the dentist must immediately conduct a further examination for early detection of cancerous lesions at an early stage, the results of which can support the clinical picture that is inside the oral cavity. Histopathological examination is conducted. The results of histopathologic examination and accurate diagnosis depends on the collaboration between clinicians and pathologists, especially in terms of accuracy collect and process materials inspection and identify gels.
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