MANAGEMENT OF ORAL CANCER; A GROWING RESPONSIBILITY FOR THE DENTAL PROFESSION British Dental Journal The profession has

entered an era of even greater responsibility in the areas of referral, pretreatment, evaluation and rehabilitation of these cancer patients. The contribution of the dentist and the dental hygienist can make in oral cancer detection have long been acknowledged. However, in the interest of optimum patient care and in an attempt to improve the quality of life offered to oral cancer patients, the dentist and hygienist have, in addition, become valuable members of the oncology team. As a result the dental profession has moved into an era of yet even greater responsibility in the areas of referral, pre-treatment evaluation, rehabilitation and management of patients with oral cancer. This discussion is an attempt to provide the dental student with some of the current concepts and general information necessary in order to accept their roles as viable, contributing members of the oral cancer treatment team. THE DENTISTS ROLE IN DETECTION AND REFERRAL The oral cavity is one of the most accessible areas of the body for examination. Despite this fact, the incidents of early cancer detection in this area have been very low. As a result, by the time most malignant neoplasms are recognized and diagnosed, the lesions are extensive and the probability of cure is decreased. Early detection of oral cancer is often impeded by the following factors: The clinicians ( be he or she dentist or hygienist) failure to recognize the early malignant tumour, with a resulting delay between the time at which the lesion is first examined and the time at which a diagnosis is made and treatment begun The existence of inadequate referral procedures once a malignancy is suspected or confirmed by biopsy The patients unawareness of the lesion or his hesitancy in seeking a professional examination because there is no discomfort. EXAMINATION AND RECOGNITION OF THE EARLY MALIGNANT LESION The dentist and hygienist, through the vehicle of routine dental examinations, are in a position to play a vital role in the initial detection of early malignant lesions of the oral cavity. The American Cancer Society has distributed a pamphlet entitled Oral Cancer Examination Procedure which is very thorough, concise and informative. It is a suggest that such a procedure be incorporated in each and every dental examination. The delay in diagnosing malignant tumours in their early stages may, at times, arise from the clinicians failure to recognize these lesions. The most common histological type of oral malignancy is squamous cell carcinoma. Clinically it appears as an ulcerated lesion with a surrounding white and\or red elevated margin. The most common sites for such lesions are the lateral borders of the tongue, the floor of the mouth and the tonsillar lesions are immediately suspect, however red lesions( erythroplakia) represent a large percentage of positive results and should therefore, not be overlooked. A delay in treatment may also be brought about when a malignancy is not suspected. The lesion may by treated as a benign with a variety of agents, or a period of waiting-and-watching may ensue. Under no circumstances should an undiagnosed lesion be allowed to exist for more than two weeks without definitive action being taken .If the dentist is not equipped to perform biopsy procedures in his office, or if the lesion clinically appears malignant, the patient should be referred immediately to someone who can handle the case for diagnosis through treatment and rehabilitation. If the dentist is adequately prepared and and if no clinical impression of the malignancy exists, a biopsy may be performed.

REFERRAL Referral patterns have indicated that the patient is often not seen immediately by a member of the head or neck therapeutic team once a malignancy is suspected or proved by biopsy. It is not uncommon, for example for such a patient to be referred to a general physician for examination or\ and confirmation of the diagnosis. The physician, whose expertise is the diagnosis of oral lesions is considerably less than that of the dentist, is required to refer the patient for further treatment. In the interim valuable time is wasted. It is essential, therefore, that the dentist be aware or referral patterns in his area in order to ensure that his patient be seen immediately by a head or neck specialist. When referral is indicated it is advisable that the dentist personally make an appointment for his patient with the head and neck specialist. If left to make his own appointment the patient may delay, especially if he fails to understand the immediacy of his problem. It should also be remembered that a patient seeking further consultation on his own( such as calling for an appointment without specific referral) may have to wait weeks or months possible and the patient must be made aware both of the importance of following strict oral hygiene program and the sequelae which may occur if he doesnt. Although recent dental literature suggests that teeth can be retained during radiotherapy to the oral cavity due in part to the use of cobalt 60 which has reduced the incidence of osteoradionecrosis it remains important to assess the patients desire and ability to maintain good personal oral hygiene on a daily basis. If the patient shows a lack of concern for his oral hygiene, it is recommended that all teeth be extracted in order to eliminate later complications. If on the other hand, it is determined that the patient shows an interest in maintaining his remaining phylaxis and fluoride treatments should be performed. In either case, the dentists role in pre-radiation evaluation is critical. If surgery is the chosen method of treatment of the oral cancer patient, the role of the prosthodontis in presurgical evaluation becomes important. It is necessary that dental radiographs and study models be obtained prior to surgery in order to construct a suitable oral prosthesis During any surgical procedure that will result in the need for an oral prosthetic replacement, it is recommended that the prosthodontist be a part of the surgical team and be physically present in the operating room. MANAGEMENT OF THE ORAL CANCER PATIENT AFTER TREATMENT Many unique dental problems are associated with the cancer patient who has received surgical treatment or radiation therapy or both. Today it is not enough to tell the patient that he has been cured of cancer. Equally important the patient must be returned to society at a quality of life which approximates, as nearly as possible, his pre-treatment statues. Patients who has received radiation therapy in the past and who seek constructions of Dentures, not only for nutritional purpose but also for cosmetic considerations, should and can be accommodate by the dentist who is informed. Dentures should be made with soft liners and the patient should be informed that frequent dental examinations (every three months) are necessary for the rest of their lives. Xerostomia and concomitant rampant caries is an enormous problem for those patients receiving radiation therapy for treatment of tumours of the oral cavity and adjacent areas. The first apparent effect of such irradiationis the decrease in the salivary flow rateviscosity of the saliva increases significantly due, in part, to the fact that the acini cells of serous glands are more affected by irradiation than those of mucous glands In addition the saliva of irradiated patients becomes more acidic .Therefore the cleansing, lubricating and buffering actions of saliva become drastically altered. As a result of the decreased salivary flow and an inherent change in the composition of saliva, irradiated patients may be plagued by radiation caries .

In order to prevent or minimize the development of radiation caries, it becomes necessary to increase the frequency of dental examination, professional oral prophylactics and fluoride treatment. The patients should be seen at intervals necessary to accommodate his needs. The patients personal oral hygiene habits and home care practices become very important in the attempt to control radiation curiosity has been reported that applying a stannous fluoride gel twice a day significantly retards the progression of these caries .therefore it would appear advantageous to instruct the patient in such a technique. Particular attention should be devoted to designing a personalized home care regime for the patient and instructing him in the mechanics of such a program. We are well aware of the need for saving oral structures when at all possible. However, pral and maxillofacial surgeons who have treated osteoradionecrosis, post-treatment complication, highly recommend that the teeth must be removed from a patient who will receive radiation therapy to the head and neck. This removal should be accomplished in order to eliminate complications caused by severe fibrosis and endarteritis, both of which are long-term effects of radiation to the tissues. It becomes extremely hazardous to perform future surgical procedures on these patients (i.e. periodontal surgery or simple extractions) without seeding the area with bacteria and traumatizing the tissues, conditions which are known to lead to osteoradionecrosis. CONCLUSIONS The dental profession has moved into a position of expanded opportunities for involvement in the field of oral cancer detection, referral, pre-treatment evaluation and post-treatment management and rehabilitation. Along with these expanding opportunities, however, come concomitant obligations which require basic knowledge of the pathophysiology of malignant diseases and the rationale for treatment. These obligations no longer allow you, as dentist, to assume the historical role of passive involvement; instead they demand your active participation as member of the head and neck cancer treatment team.