Advanced oral cancer has a low survival rate and poor quality of life in treated patients. This is an unfortunate fact. However, the relieving truth is that most of them are preventable. The key is early detection and prompt intervention of pre-cancerous and suspicious mucosal lesions.
I will be discussing a few important oral diseases and TMJ disorders.
Oral mucosal lesions are broadly classified as “red and white” and “mixed” lesions based on their clinical color appearance. These may be benign (non-cancerous), infectious, pre-malignant or potentially malignant disorders (PMDs), or malignant conditions. The morphological appearance or shape may be in the form of an ulcer, red/white patch, wrinkle of the oral mucosa, soft tissue growth/mass, a cyst or a tumor. Most of them remain asymptomatic unless secondary infection or inflammatory response sets in. This is one of the major causes for late diagnosis and poor prognosis.
The common oral mucosal lesions that we encounter in Northeast India are tobacco pouch keratosis (TPK), tobacco-induced melanosis, chemical burn, oral sub-mucous fibrosis (OSMF), oral leukoplakia (OLEP), oral candidiasis, aphthous ulcer, traumatic ulcer, oral herpes simplex stomatitis (HSV-1), and oral lichen planus (OLP).
TPK, tobacco melanosis, chemical burn, OSMF, and OLEP are all chewing habit-induced oral diseases. The main causative agents are tobacco (zarda/khaini), smoking, betel-quid (supari) chewing, pan masala, gutkha, slaked lime, etc., and alcohol consumption. It is not necessary that all tobacco/betel quid chewers and chronic alcoholics will develop such diseases. Rather, it depends on the individual’s biochemistry, body physiology, and immune response. However, the chances of acquiring such conditions significantly increase with oral deleterious habits. Among these, leukoplakia and OSMF have significant malignant potential (chances of transforming into oral cancer) if left untreated for a long duration. Other two factors of PMDs are lack of balanced nutrition and HPV infection (human papilloma virus).
The lesions are basically reactionary outcomes of various alkaloids and metabolites released during the chewing process that get absorbed into the buccal mucosa (cheek), tongue, palate, oropharynx, and floor of the mouth. The signs and symptoms that are usually noted are brown, greyish, yellowish, or white patch with wrinkling appearance present on the oral mucosa. It may or may not be associated with burning sensation. In some cases, fibrosis of the affected mucosa (taut texture) may occur followed by restricted mouth opening (feeling of tightness while wide mouth opening) – OSMF.
Considering the fact that the Northeast region has a very high incidence of oral squamous cell carcinoma (oral cancer), the main objective lies in disease prevention, especially during the stage of pre-malignancy and/or epithelial dysplasia. Abstinence from chewing habit and substance abuse, and periodic oral health check-up is of utmost priority in patient management. The treatment strategies for such diseases are basically as follows: tobacco cessation counselling, nicotine replacement therapy, cognitive behavioral therapy (CBT) for patients with stress and anxiety, micronutrients and antioxidant therapy, vitamin A administration, laser ablation, excisional biopsy, intra-mucosal enzymes, chemo-preventive agents, Imiquimod, Bleomycin, etc., only under a specialist care and strict follow-up maintenance for a prolonged period to ensure prevention and detection of relapse. It should be noted that if the patient resumes tobacco/betel quid consumption, this generally results in treatment failure and poor disease prognosis. Proper patient education and mass awareness are two effective tools for lowering the disease prevalence in our province.
Oral candidiasis is one of the most common fungal infections of the oral mucosa. It generally presents with white/greyish coating or reddish inflamed areas with burning pain. The lesions are observed commonly on the tongue dorsum, buccal mucosa. It is mostly encountered in immunocompromised patients, e.g. geriatric debilitated cases, infants, cancer patients, and HIV-infected patients. The disease may also occur in healthy individuals with poor oral hygiene and long-term antibiotic usage. Management involves stringent oral hygiene maintenance and antifungal therapeutics.
Traumatic ulcers generally result due to chronic irritation of the mucosa from sharp tooth. If left untreated, it may transform into oral cancer. Grinding or extraction of the offending teeth/tooth generally subsides the ulcerative region.
Aphthous ulcers are acute conditions, quite common in younger age group individuals occurring in labial mucosa (lips), buccal mucosa, and lateral border of tongue. Mental stress, micronutrient and trace element deficiency, accidental bite injury, immune disorder, are some of the common etiologic factors. This disease is extremely painful but self-limiting and naturally heals within 5-7 days. If not, medical supervision should be sought. Topical gels, corticosteroid therapies, antioxidants, and systemic immunotherapy are generally advised in recalcitrant and recurring cases (RAS).
HSV gingivostomatitis is a viral infectious disease of the oral mucosa accompanied by painful clusters of vesicles, ulcers, and red inflamed areas leading to the inability to eat food. It is generally associated with prodromal symptoms such as fever, malaise, and headache. This is also a self-limiting disease that subsides within 7-10 days. In severe cases, antiviral therapy (e.g., acyclovir, famciclovir, valacyclovir, foscarnet, etc.) is advised along with sufficient hydration and analgesia management.
OLP is a chronic, autoimmune, T-lymphocyte-induced cytotoxic cell-membrane reaction with oral manifestations such as burning pain, white striations, and redness of the buccal mucosa and other areas. This condition is also considered as a potentially malignant disorder, but the frequency is rare. It has a higher female predilection and is associated with mental stress and anxiety. Other causative factors may be drug-induced, allergy to dental restorations, hepatitis C virus infection, vitamin D deficiency, diabetes mellitus, etc. Treatment mainly depends on the evaluation and eradication of the causative factor, cognitive-behavioral therapy (CBT), corticosteroid therapy, and immunomodulators. The specific etiology for this disease is not yet established, and the treatment modality is of palliative intent.
There are also certain oral manifestations of systemic diseases (diabetes mellitus, renal disorders, blood dyscrasias, systemic infections, metabolic diseases, etc.) that require a team effort and multidisciplinary approach for effective management.
Two important points that I would like to mention for the benefit of the general public are: Any such chronic oral mucosal diseases associated with Candida superinfection and occurrence over the lateral border of the tongue or floor of the mouth should be considered a warning sign and immediate medical attention is required, instead of self-analysis.
TMD or Temporomandibular Disorders or TMJ disorders are a group of diseases affecting the TM-joint (just near to our ear region), its capsule, the fibrocartilage, and associated muscles and ligaments (MPS). It is the most complex articular joint of the human body with a dynamic range of motion requiring precise and complex neuro-muscular coordination. As such, the diagnosis and management of such diseases are quite challenging and tricky.
The symptoms are tightness/restriction of the jaw, joint pain during mouth opening or closure, occasional lock jaw during yawning, early morning stiffness of facial muscles, headache, muscle spasm, radiating pain to the shoulder, neck, and back region. Often, TMJ diseases are wrongly perceived or misdiagnosed as wisdom tooth pathology, earache, spondylosis, migraine, autonomic cephalgias, trigeminal neuralgia, etc., based on confusing clinical presentation and diverse patient complaints. Some of the known causes are stress, high masticatory force, teeth malalignment, occlusal discrepancy, faulty dental fillings of posterior teeth, sleep disorder, previous trauma, arthritis, etc. Diagnosis mainly relies on clinical examination and radiological investigation (MRI, TMJ-CBCT).
The treatment strategies cover eliminating the causative/precipitating factors, intra-oral appliances, TENS, physiotherapy, and pharmacotherapeutics.
For leading a quality of life, establishment of optimum oral health is of prime importance. I wish everyone a good health, and we are there to take care of you and guide you further.