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EPIDEMIOLOGY OF ORAL CANCER
Oral Cancer is one of the ten leading cancer in the world.
In India it is a common cancer & is an important public health
problem (third commonest cancer).
Tongue is the most common site ( lateral borders).
90-95% of oral cancer are of the squamous cell ca type.
In the ICDS (WHO – 9th version) classification oral cancer is under
Squamous cell Carcinoma of lip(ICD140)
Tongue (ICD 141)
Floor of mouth (ICD144)
ICD refers to the WHO international classification of diseases
About 2.5 lakh new cases occur every year in India, Pakistan,
Study done in Mumbai, Pune, Chennai and Bangalore: Higher in
males except in Bangalore.
Indian Oral Cancer –
Buccal mucosa(65%), lower alveolus(30%) and
retro molar trigone(5%) : as these constitute more than 60% of all
WHAT DOES THE NUMBERS SAY??
Age, gender and site distribution
Predominant in older age group.
5th & 6th decade of life.
In developing countries as compared to industrialized countries it is 2.5 times more
in males & 4 times in females .
Cancer Registries in India
Hospital based registry.
Population based- definite population.
Special purpose registry for epidemiological study in a radiation exposed area.
Etiology of Oral Cancer
Exposure to sun
Diet and Nutrition
Trauma and dental irritation
It is estimated that 47 % of Indians aged 15 years or more use
tobacco in one form or other. High incidence rates in India is
associated with addition of betel quid chewing where addition
of tobacco to quid is a critical factor.
RECIPE FOR DISASTER
curing (fire curing, sun curing) for partial drying
fermentation/sweetening for months upto 2 years. During this time moisture loss reduces
weight of tobacco
Derived from Nicotiana tabacum and Nicotiana rusticum.
Hydrogen cyanide and other ciliatoxics
Constituents of Tobacco
CONSTITUENTS ADVERSE EFFECTS
Polycyclic aromatic hydrocarbon Carcinogenesis
Phenol Ganglionic stimulation and depression & tumour
Benzopyrene Tumour promotion & irritation
CO Impaired O2 transport
Formaldehyde and oxides of N2 Toxicity to cilia and irritation
0.2 to 0.3 gms of sun dried tobacco
flakes are hand rolled.
Nicotine 1.7 to 3.0 mgs
A 14 cms straight conical clay pipe
Coarsely cut tobacco pieces and a
glowing charcoal is kept on top.
It is held vertically and to prevent
tobacco from entering mouth a pebble
stone is introduced
Cured tobacco is wrapped in a dried
It is also called as cigar
1 gm of tobacco cured in the sun or
artificial heat is covered with a paper
Rolled leaf tobacco is used inside a leaf
of jack fruit tree
Tobacco smoke is drawn through the
water in the base of hookah which cools
and filters the smoke
It is also called water pipe or hobble-
Clay pipe of 7 to 10 cms long with a
mouth piece and a bowl
Powdered sundried tobacco, slaked
lime-paste mixture occasionally with
used with areca nut
Tobacco, slaked lime, finely cut areca nut,
Thin shavings of areca nut + tobacco +
slaked lime are wrapped in cellophane
paper and tied in a shape of a ball
It should be vigorously mixed before
The roasted tobacco is powdered +
catechu(a residual extract obtained by
soaking the heartwood of acacia
Betel leaf+ areca nut+ tobacco +lime+
cinnamon or coconut or cloves or sugar
are wrapped in betel leaf
Finely powdered air cured and fire
cured tobacco leaves+ areca nut + lime
carried in a metal container
It is locally called MUKKU PODUMU
Tobacco leaf is boiled in water along
with lime and spices until evaporation.
The residual tobacco is dried and
coloured with dyes.
Crushed betel nut, tobacco, sweet or
Paste of powdered tobacco, molasses,
and other ingredients primarily used to
clean the teeth.
It is an independent risk factor.
Synergistic effect of tobacco & alcohol .
Accounts for 75% of all oral & pharyngeal cancer .
Heavy drinkers who smoked over 20 cigarettes a day were observed to have 24 times
more risk of oral cancer.
Exposure to Sun
Effect of Solar Radiation – Sunlight- Chronic exposure to sunlight – cancer
of the lip.
Diet and Nutrition-
Vitamin A, C, E & Antioxidant
[β-carotene] , copper, zinc and manganese
shows protective effect against cancer.
Red chilli powder has emerged as a risk factor to cancer
Dysplastic lesions [leukoplakia] with candidial infection have greater risk of malignancy.
Human herpes virus1(HHV1),Herpes simplex virus1(HSV1),Human immunodeficiency virus have
been associated with squamous cell carcinoma(SCC).
Trauma and dental irritation
Continuous irritation from jagged teeth and dentures poor oral hygiene are risk factors for oral cancer .
Alterations in in many genes have been implicated in development and progression oral cancer. Eg:3p (FHIT), 9P
Is defined as morphologically altered tissue in which cancer is
more likely to develop than its apparently normal counter part.
Its is a generalized state associated with a significantly
increased risk of cancer.
Squamouscell carcinoma (Epidermoid carcinoma)
Most malignant neoplasm in the oral cavity
Can occur as:
• Carcinoma of lip
• Carcinoma of tongue
• Carcinoma of floor of mouth
• Carcinoma of buccal mucosa
• Carcinoma of gingiva
• Carcinoma of palate
• Carcinoma of maxillary sinus
GLOBAL INITIATIVES IN PREVENTION AND CONTROL OF
THE CRETE DECLARATION ON ORAL CANCER PREVENTION 2005.
WHO FRAMEWORK CONVENTION ON TOBACCO CONTROL.
BLOOMBERG INITIATIVE TO REDUCE TOBACCO CONTROL.
Provision of systemic epidemiological information on prevalence of oral cancer and
cancer risk specially in developing countries. Promotion of research (biological, behavioral
and psychosocial factors of oral cancer).
Integrating oral cancer information into national health surveillance system.
Dissemination of information.
Active involvement of oral health professionals.
Training of primary health care worker in screening.
Access to health facilities and provision of system for early detection and intervention.
WHO Frameworkconvention on tobacco control
WHO FCTC treaty opened – 16th to 22 June 2003.
Most widely embraced treaties in UN history.
Member states – strive in good faith to ratify, accept or approve it and
show political commitment not to undermine the objective set out in it.
Into force – 27 Feb 2005
Cross border effect, trade liberalization and direct foreign investment.
Global marketing, promotion and sponsorship and international
movement of contraband and counterfeit cigarettes.
Assert importance of –
Demand reduction strategies.
Supply reduction provisions.
BLOOMBERG INTIATIVETO REDUCE TOBACCO USE
This initiative funded by Bloomberg philanthropies, is 2 year contribution of US$125 million by Michael R
Bloomberg for global tobacco control.
In 15 developing countries (Bangladesh, Brazil, China, Egypt, India, Indonesia, Pakistan, Poland, Thailand).
5 key partner organizations-
Campaign for tobacco free kids.
Centre for disease control and prevention foundation.
John Hopkins Bloomberg School of Public Health Education/training.
World Lung Foundation.
Prevention and control of oral cancer
Mainly focuses on modifying habits associated with the use of tobacco.
India- 4th largest consumer and 3rd largest producer of tobacco.
3 well-known approaches:
In India, Cigarette act 1975 – print warnings on cigarette packets.
National Cancer Control Programme, 1985 – health warning displays & banning of advertisements on tobacco products.
In countries like Italy, Norway, Portugal etc – ban on advertising tobacco products.
Ban tobacco and alcohol use.
Ensure adequate legislation .
Ensure warnings on products sold .
Avoid glorification of products through advertisements.
Services provided by the professionals.-
In order to be suitable for screening certain criteria have to be met
Disease is serious yet treatable in early stages.
Facilities for diagnosis and treatment exists.
Natural history of disease is known.
Screening tool is inexpensive and safe.
For early detection –
Toludine Blue Vital Staining
Other techniques used are –
See harmful effects
Counsel child and youth patients
Spend more time with patients
Treat women of childbearing age
Build patient’s interest in quitting
Speak with authority in community
Any persistent scaly white patch
Any lesion which increase in size
Non healing ulcer
Non healing extraction socket
Oral numbness or pain during jaw movements.
Guide to Counseling for tobacco cessation (5A’s)
Ask – use of tobacco
Advise – non users to never use and users to quit
Assess- the patient readiness to quit
Assist- with quitting
Arrange- for follow ups
Use of Pharmacotherapy
Nicotine replacement therapy
Antidepressants (Selegeline, Clonidine)
No Tobacco Day” is being observed on the 31st May.
The suffering, disfigurement and death due to oral cancer is easily avoidable since
the factors associated with the disease have been identified.
Another important aspect is its easy accessibility for diagnosis. This feature along
with the finding that oral cancer is generally preceded by precancerous lesions
provide an excellent opportunity for early detection and control.
For further reading, Refer..
1. Hiremath S. S. Textbook of Preventive and Community Dentistry. (2nd
edition). New Delhi: Elsevier; 2011
2. Soben Peter. Essentials of Preventive and Community Dentistry. 4th ed.