Pre – Malignant Lesion and Condition

It has been known for over a century that oral cancer may develop in areas of pre-existing mucosal pathology in the oral cavity.
Some oral mucosal lesions and conditions are specifically associated with quid-chewing habits. Two categories of quid-related lesions are recognized:
A precancerous lesion is a morphologically altered tissue in which oral cancer is more likely to occur than in its apparently normal counterpart. A precancerous condition is a generalized state associated with a significantly increased risk of cancer.

Of the 400 million individuals aged 15 years and above in India, 47% use tobacco in smoke form, while 16% use it in a smokeless form. About 250 million kilograms of tobacco is consumed each year, of which 86% is used for smoking, 13% in smokeless forms, and 1% as snuff.

Smokeless tobacco is used in diverse forms in different regions of India – for chewing, holding in the mouth, or applying over teeth and gums. Smokeless tobacco is chewed, more often as betel quid (paan), consisting of betel leaves (Piper betle), areca nut (Areca catechu), slaked lime and catechu (e.g., Manipuri tobacco, mawa, paan masala). A mixture of tobacco and slaked lime (khaini) is kept in the mouth and sucked. Other products like roasted and powdered tobacco (mishri), dry snuff (bajja), or tobacco paste with molasses (gudhaku) are applied over the teeth and gums.

Some of the common pre-malignant lesion/condition

• Leukoplakia and erythroplakia or erythroleukoplakia, when both
  coexist are two very common clinical lesions
• Oral submucous fibrosis (OSMF)
• Lichen planus (very low risk of turning malignant)
• Other lesions (smokeless tobacco keratosis, leukoedema, and leukoderma)

Leukoplakia

• Leukoplakia is a white patch or plaque occurring on the surface of mucous membrane of oral cavity.
• The beginning of lesions may be non-palpable , faintly transluscent, white discoloration may be seen.
• Later from opaque white and fine granular texture the lesion may progress to thickened white lesion and ulcer formation.
• Generally, most leukoplakias are asymptomatic and are found during a routine visual examination by a practitioner.

Erythroplakia

• An erythroplakia is a red lesion far less common than leukoplakia, erythroplakia has a much greater probability of showing signs of dysplasia or malignancy at the time of diagnosis.
• Such lesions have a flat, macular, velvety appearance and may be speckled with white spots.
• The most frequent sites where floor of mouth, retro-molar area, tongue, palate and then mandibular mucosa and sulcus.

Oral sub-mucous fibrosis

Very early cases : Here the common initial symptom is burning sensation of the mouth. There might be acute ulcerations and recurrent stomatitis. Mouth opening is normal.

Early cases : There is limited mouth opening. The buccal mucosa appeared mottled and marble like. Red erythroplakia patches may be seen. There is widespread fibrosis and inter incisal opening is of 26 to 35 mm.

Moderately advanced cases : Here trismus is evident, with an inter incisal mouth opening of 15 to 25 mm. The buccal mucosa is pale and firmly attached to the underlying tissues. Vertical fibrous bands could be palpated in the premolar area. Patients cannot blow or whistle with their cheeks.

Advanced cases : Here trismus is severe with an inter incisal mouth opening of 2 to 15 mm. movements are limited. There might be diffuse papillary atrophy. Lips on palpation showed the presence of circular bands around the mouth. Intra oral examination is difficult due to stiffness, in-elasticity of the oral mucosa and trismus. These cases might show leukoplakic changes.

Risk factors

• TOBACCO – The risk of developing oral cancer is 5-9 times greater for smokers than for nonsmokers, and this risk may increase to as much as 17 times greater for extremely heavy smokers who smoke 80 or more cigarettes per day.
• There is a common belief that waterpipe is less harmful than cigarette due to the water filter, which supposedly traps most of the smoke gases and nicotine. Subsequently, waterpipe smoking may affect different systems either directly by contact or the smoke itself (as in the respiratory system, lips, oral cavity, and hand skin) or indirectly by the metabolites of tobacco products. There is strong evidence that exposure to waterpipe smoking is as harmful as the exposure to cigarette smoking, if not more harmful.
• Snuff and chewing tobacco have also been associated with an increased risk for oral cancer.
• Alcohol use has been identified as a major risk factor for cancers of the upper aerodigestive tract.
• The chronic use of betel quid (paan) in the mouth often results in a progressive, scarring precancerous condition of the mouth known as oral submucous fibrosis.
• Chronic Irritation – Chronic irritation from sharp tooth, dentures, brushing, cheek biting may produce white lesions.
• Vitamin deficiency – Vit A deficiency will cause metaplasia of tissue specially glands and respiratory mucosa.
• Other factors include high-risk HPV, diet, oral hygiene, and socioeconomic status

Questionnaire to Ask from the Patient

• Do you have any habit on a daily basis or not?
• Have you had a habit of somking or betel nut or any other related component consumption history in the past?
• On an average how many of the following products do you currently consume each day/week (cigarettes, bidi, mawa, tobacco)?
• Do you currently use smokeless tobacco instead of tobacco smoking?
  Since how many years have you had the habit(s), and what was the frequency of it, in a day?
• Have you ever noticed any kind of discoloration associated with your buccal mucosa?
• Have you ever noticed any symptoms of burning sensation or reduced mouth opening?
• Have you ever visited a healthcare facility for any complaint regarding your habit? Have you ever undergone any kind of treatment in the past for any kind of lesions?
• Have you ever tried to stop smoking after you got notified about the presence of any lesions?
  In the past 12 months, during your visit to the doctor, were you advised to stop smoking?
• Have you ever read warnings on the dangers of smoking cigarettes on packets, magazines or TV? Do they in any way encourage you to quit the habit?
• Will you be quitting tobacco after this questionnaire session?

Techniques for investigation of pre-malignant lesion

The “gold standard” for identifying and diagnosing oral malignancies is the proper clinical examination and histopathology examination of potentially malignant lesions and conditions

• BIOPSY AND CYTOLOGY
• ORAL EXFOLIATIVE CYTOLOGY
• BRUSH BIOPSY
• CLINICAL TISSUE STAINING TECHNIQUES
• CHEMILUMINESCENCE TECHNIQUE
• LIGHT EMISSION TECHNIQUE

Management of Potentially Malignant Disorders

• Treatment of PMD can be in three categories namely close observation, surgical excision/ablation, and medical treatment.
  Observation: patients with early small lesions that are clinically benign looking and appear at favorable sites can be observed. However, the need for frequent follow-ups and possibility of malignant transformation has to be explained to the patient.
• Conservative surgical excision with negative margins remains the treatment of choice for leukoplakia. Surgical resection is performed to remove areas at high risk to progress to early carcinoma or to undergo early malignant transformation.
• Laser ablation has also been advocated for eradication. This approach offers the potential advantage of reduced scarring, but a major disadvantage is the lack of a resected specimen for histopathologic and genetic studies. CO2 laser, Nd : YAG laser, and KTP are used.
• Cryosurgery does not seem to be of particular benefit.
  Photodynamic therapy – The tissue to be targeted is exposed to a specific wavelength of light, which activates the photosensitizer, causing it to transfer energy to molecular oxygen, generating reactive oxygen species locally, and subsequent tissue damage.

FAQ

Q: My dentist said I have a pre-malignant lesion, what does it mean?
A: It means that there are slight changes that may progress to malignancy but there is no cancer. Not all such lesions undergo malignant transformation (i.e. turn into a cancer) but since we cannot predict which lesions will, they should all be treated and/or observed closely. You should talk to your dentist and discuss any lifestyle changes you can make to reduce the risk of transformation.

Q: I have a premalignant lesion on the cheek will this spread to other parts of my mouth or body?
A: Oral premalignant lesions do not typically spread as would a cancer or an infection. However, there are chances that these lesions can transform into a cancer over time.

Q: If I quit my smoking habit , will the lesions disappear?
A: Many lesions do improve and in some cases may even disappear. It is certainly desirable to stop smoking for many health reasons. Even after you stop smoking, you are still at risk for oral premalignant lesions, although your risk will decrease over time.

Q: If the lesion was removed, do I still need to see my dentist?
A: Yes. Sometimes lesions may recur. Sometimes new lesions develop at other sites in the oral cavity. Repeated check up are essential.

Q: Are biopsies complicated or painful?
A: No. Biopsies are usually minor procedures taking only a few minutes. Local anesthesia is administered first, a small piece of tissue is taken, some pressure is applied to stop any minor bleeding, and the area may feel a little sore and usually heals without complications.

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