Poor Oral Hygiene and Dental Trauma As the Precipitating Factors of Squamous Cell Carcinoma

View metadata, citation and similar papers at core.ac.uk brought to you by CORE

provided by Elsevier - Publisher Connector Oral Oncology EXTRA (2005) 41, 109–113

http://intl.elsevierhealth.com/journal/ooex

CASE REPORT Poor oral hygiene and dental trauma as the precipitating factors of squamous cell carcinoma

Recep Orbak a, Cigdem Bayraktar a, Fahri Kavrut a,*, Cemal Gu¨ndogdu b

a Department of Periodontology, Faculty of Dentistry, Atatu¨rk Universitesi Disß Hekimlig˘i Faku¨ltesi, Periodontoloji Anabilim Dalı 25240, Erzurum, Turkey b Department of Pathology, Faculty of Medicine, Atatu¨rk University, Erzurum, Turkey

Received 4 February 2005; accepted 5 February 2005

KEYWORDS Summary Oral cancer is one of the six most frequently occurring cancers. The Squamous cell most common type of oral cancer is squamous cell carcinoma (SCC). Squamous cell carcinoma; carcinoma is a malignant neoplasm of mucosal origin. The most common site of Poor oral hygiene and intraoral squamous cell carcinoma is the lateral border and ventral surface of the dental trauma; tongue. The cause of oral SSC is multifactorial. In this paper, a case of SCC in the Tongue tongue due to poor oral hygiene and dental trauma is presented. The lesion was initially described by the patient as a dental trauma but biopsy-proven SCC on histopathologic evaluation. The emphasis is on early diagnosis and correct treatment planning which can affect the prognosis. c 2005 Elsevier Ltd. All rights reserved.

Introduction mors. Other geographic areas with high incidences are eastern, western and southern Europe, Austra- Cancer is a major cause of disease and death lia and New Zealand, and Melanesia.4 Latin throughout the world.1 Oral cancer is one of the America and the Caribbean have intermediate inci- six most frequently occurring cancers.2 Incidence dence rates for oral cancer; however, the rate rates of oral cancer are higher in developed coun- among countries of the region varies widely.5 tries than in developing countries 3; however, in There is no analytic studies in Turkey about Inci- countries of southern Asia, oral cancer is the most dence rates of oral cancer. common cancer affecting males and the third one Oral cancer may occur at any age, but is primar- affecting females, after breast and cervix uteri tu- ily a disease of the elderly; more than 95% of oral cancers occur in persons older than age 40 years.6 * Corresponding author. Tel.: +9004422314378. The most common type of oral cancer is 7 E-mail address: [email protected] (F. Kavrut). squamous cell carcinoma (SCC). Squamous cell

1741-9409/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ooe.2005.02.006 110 R. Orbak et al. carcinoma is a malignant neoplasm of mucosal ori- Intraoral examination, the lesion was gin.6 Squamous cell carcinoma (SCC) often causes 1.9 · 2.4 cm in size, yellowish in colour an ulcer- abnormality of the covering mucosa of the oral cav- ated exophytic mass was seen on the posterior lat- ity and oro-pharynx.8 Although the mucosa af- eral border of the tongue (Fig. 1). The patient had fected by SSC usually shows ulceration, tumour lost her mandibular right second and third molar formation, or leukoplakia.9 There are some cases and left three molar teeth (Fig. 2). The patient in which mucosal thickening is the only abnormal had poor oral hygiene, difficulty in speaking or clinical sign.8 The most common site of intraoral swallowing, and a burning sensation, swelling of squamous cell carcinoma is the lateral border and the tongue (Fig. 3). During the palpation of the ser- ventral surface of the tongue, followed by the vical lymph nodes, firm, painless enlargements oropharynx, floor of the mouth, gingiva, buccal were noticed, In our case, biopsy for diagnosis mucosa, lip, and palate.6,7 was made. The cause of oral SSC is multifactorial.1 It is ac- The lesion was initially described by the patient cepted in the light of current literature that both as a dental irritation but biopsy-proven SCC on hist- extrinsic and intrinsic factors may be responsible opathologic examination. In the histopathologic for the malignancies.7 Extrinsic factors include evaluation, SCC was characterized histopathologi- the agents such as tobacco smoke, alcohol, syphi- cally by invasive island and cords of malignant epi- lis, poor oral hygiene and sunlight (vermilion can- thelial cell, which demonstrate differentiation cers only). Intrinsic factors include systemic or toward a squamous morphology. Lesional cells gen- generalized disorders such as malnutrition, general erally was showed abundant eosinophilic cytoplasm resistance and iron-deficiency anemia.7 with large nuclei and an increased nuclear-cyto- In this paper, we described a 55-year-old woman plasmic ratio (Fig. 4–6). with SCC in tongue, who had not any extrinsic and The oral cavity was divided into the following six intrinsic factors apart from poor oral hygiene.The subsites with reference to the Union International lesion was initially described by the patient as a Controle Cancer classification10: buccal mucosa, dental trauma but biopsy-proven SCC on histopa- upper alveolus and gingiva, lower alveolus and gin- thologic evaluation. giva, hard plate, tongue and floor of the mouth. Individualized-size (T), regional Iymph nodes (N), and distant metastases (M)-(TNM) systems are used 6,7,10 Case report for most human cancers. In the present case, staging of the tumor according to the TNM system was evaluated. She was found stage III (T N M ). A woman patient, 55 years old, was referred with a 3 1 0 Panoramic radiograph of the patient was given. complaint of pain and lesion at the posterior lateral We could not come across any pathological finding border of the tongue, and poor oral hygiene to the by performing panoramic radiography analysis Periodontology Department, Dental Faculty of Ata- (Fig. 7). tu¨rk Universty. She had low life standards. She had In our case, oral hygiene reinforcement, scall- no systemic disease. The patient was a non-smoker ing, root planning were carried out with respect and did not consume alcohol. to systematic periodontal treatment. She was given SCC due to poor oral hygiene 111

Figure 3 Gingival tissue with characterized by inﬂam- Figure 6 Hyperkromatic large nuclei prominent pleo- mation and calculus. morphism, keratious stoplsma and mitosis (H&E · 400).

Figure 7 The panoramic radiograph of patient with Figure 4 Low-power photomyograph showing a papil- SCC. lamatous growth accompanying by hyperkeratosis and invasion into the dermis (H&E · 100). 0.2% chlorhexidine digluconate (CHX) mouth-rinse. Our patient was referred to the Atatu¨rk University Otolaryngology-Head and Neck Surgery Clinic for surgery procedures.

Discussion

More than 90% of all oral malignancies are squamous cell carcinomas.7 SCC of the tongue was the cancer seen most frequently (27.6%), followed by cancer of the oropharynx (22.8%), lip (16.5%), ﬂoor of the mouth (14%), gingiva (9.1%) hard palate (4.1%), and buccal mucosa (3.5%) in a report covering the years between 1983 and 1993 in America.11 The most common site of intraoral carcinoma involvement is the tongue, usually the posterior lateral ant ventral surfaces.7 In our patient, SSC was posterior lateral border of the tongue. 112 R. Orbak et al.

As with so many carcinomas, the risk of intraoral the poor prognosis of the SSC, early diagnosis and cancer increases with increasing age, especially for using effective diagnostic methods is of great males. In the past, the prevalance was much higher importance in increasing the patients survival per- in males, but the male to female ratio has dramat- iod.7 Surgery and radiation therapy have been the ically decreased in recent years to approximately principal forms of treatment for oral cancer. 2:1 because of the increased number of female Through an increased interest for epidemiologi- who smoke.10 Our patient was 55 years old and fe- cal studies certain factors are suspected as carcin- male. She doesn’t smoke. ogenic. Even though it is often hard to prove the Early lesions are often asymptomatic and slow- real relation of cause to effect, one can no longer growing. As the lesion develops, the borders deny the detrimental role of tobacco, of many become diffuse and ragged, and induration and fix- alcoholic drinks, of poor oral hygiene, of nutri- ation ensue. If the mucosal surface becomes ulcer- tional deficiencies, of short wave irradiation, and ated, the most frequent oral symptom is that of a possibly of certain viruses. These factors must fur- persistent sore or irritation. Not uncommonly, ther be investigated because the overall prognosis patients may report numbness or a burning sensa- of oral cancer is not very good.15 Also, our patient tion, swelling, or difficulty in speaking or swallow- had poor oral hygiene. ing. Lesions can extend to several centimeters in Required periodontal treatment procedures diameter if treatment is delayed; this delay per- were applied and the complaints of the patient mits large lesions to invade and destroy vital osse- were diminished at an important level. Late com- ous structures. Persons with oral squamous cell plications should be reduced by improvements in carcinoma are most often older men who have dental and oral hygiene. Professsional dental fol- aware of an alteration in oral cancer site for 4–8 low-up should be integrated into the medical fol- months before seeking professional help.7 There low-up. The lesion was initially described by the is minimal pain during the early growth phase, patient as a dental irritation but biopsy-proven and this may explain the delay in seeking profes- SCC on histopathologic evaluated. Consequently, sional care.7 Likewise, the patient had applied to early recognition of this entity as well as a multidis- the clinic, after having six mouth lesions. It is gen- ciplinary management may help in the prognosis of erally recognized that the diagnosis of SSC of the these cases. The dentists should have adequate oral cavity is not difficult when the patient com- knowledge about the disease with regard to the pa- plains of intraoral pain and dysfunction.12 Dentists tients who visit the dentist first. have the best oppurtunity to discover early lesions of the oral cavity. It is their responsibility to exam- ine the oral cavity carefully and to refer the pa- References tient with suspicious lesions for proper evaluation 13 and possible biopsy. Also, the lesion was initially 1. Dambi C, Voros-Bolog T, Czegledy A, Hermann P, Vincze N, described by the patient as a dental trauma but as Banoczy J. Risk group assessment of oral precancer biopsy-proven SCC on histopathologic evaluation. attached to X-ray lung-screening examinations. Community Squamous cell carcinoma spreads by local exten- Dent Oral Epidemol 2001;29:9–13. 2. Melrose RJ. Premalignant oral mucosal diseases. CDA J sion or by way of the lymphatic vessels. During the 2001;29:593–600. palpation of the cervical lymph nodes, firm, pain- 3. Parkin DM, Pisani P, Ferlay J. Estimates of the worldwide less enlargement was noticed. When tongue cancer incidence of 25 major cancers in 1990. Int J Cancer is first diagnosed, metastasis in the neck is found in 1999;80:827–41. 20–30% of the cases.14 Franceshi et al.14 reported 4. Parkin DM, Whelan SL, Ferlay J, Raymond L, Young J. Cancer incidence in five continents, vol VII. (IARC Scientific that 37% were at stage I, 34% at stage II, 21% at Publications No.143). Lyon: IARC; 1997. stage III and 8% at stage IV at the time when they 5. Wu¨nsch-Filho V, Camargo EA. The burden of mouth cancer were first diagnosed with tongue cancer. In the pain Latin America and the Caribbean: Epidemiologic issues. tient, staging of the tumor according to the TNM Seminars in Oncology 2001:158–68. 6. Langlass R, Miller C. Colour atlas of common oral diseases. system was stage III (T3N1M0). The overall five-year 2nd ed. Williams & Wilkins: A Waverly Co; 1998. p. 93–128. survival seems to range between 41% for T3N1M0 13,15 7. Neville B. Oral and maxillofacial pathology. 1st ed. Phil- and % 85 for T1N0M0 cases. adelphia: WB Saunders Co; 1995. p. 295–304. The prognosis for oral cancer depends in large 8. Suei Y, Tanımato K, Taguchi A, Wada T. Mucosal condition measure, on the site involved, the clinical stage of the oral cavity and sites of origin of squamous cell at the time of diagnosis, the width of the tumor carcinoma. J Oral Maxillofac Surg 1995;53:144–7. 9. Shafer WG, Hine MK, Levy BM. A textbook of oral pathol- at its greatest diameter, the patients access to ogy. 4th ed. Philadelphia: PA Saunders; 1983. p. 112–30. adequate health care, and patients ability to cope 10. Spiessl B, Hermanek P, Scheibe O. TNM. Atlas Illustrated and mount an immunologic response. Because of guide to the TNM/p TNM-classification of malignant SCC due to poor oral hygiene 113

tumors. 2nd ed. New York, NY: Springer-Verlag; 1985. 13. Rosai J. Ackermans surgical pathology. 8th ed. Philadel- p. 18–24. phia: Mosby Co; 1989. p. 223–57. 11. National Cancer Institute. Surveillance epidemiology and 14. Franceschi D, Gupta, Spiro RH, Shah LP. Improved survival end results program (SEER), 1983–1993. in the treatment of squamous carcinoma of the oral tongue. 12. Mashberg A, Morrissey J, Garﬁnkel L. A study of the Am J Surg 1993;166:360–5. appearance of early asymptomatic oral squamous cell 15. Fossion E, De Coster D, Ehlinger P. Oral cancer: Epidemi- carcinoma. Cancer 1973;32(1–6):1436–45. ology and prognosis. Rev Belge Med Dent 1994;49(1):9–22.