Oral cancers form a significant portion of the cancer burden seen in our country. Typically, they tend to be preceded by a premalignant state for a long time. This article discusses the various types of premalignant disorders commonly seen in daily practice. Also, it is important to screen patients for these conditions so as to detect malignant changes early. Previously, the screening of patients for oral cancer and precancerous lesions has relied mainly on conventional oral examination. Nowadays, many newer techniques are available to potentially assist in the screening of healthy patients for evidence of oral cancer. This article attempts to review the current literature for screening methods and adjuncts such as toluidine blue, brush cytology, tissue chemiluminescence and autofluorescence.

It is increasingly being recognized that oral cavity cancer incidences are rising globally. Furthermore, these tumors represent a high risk group of tumors comparative to other head and neck tumor sub-sites and have a high preponderance of occult nodal metastases. Surgery alone leads to excellent outcomes in early stage disease. Advanced tumors require adjuvant radiotherapy with or without concomitant chemotherapy. Irradiation using 3D conformal radiotherapy results in high incidence of late radiation side-effects. Xersostomia and mandibular osteoradionecrosis result in most significant effects on patients' quality of life. Intensity modulated radiotherapy (IMRT) is an advanced approach to 3-D treatment planning and conformal therapy (3D-CRT). It optimizes the delivery of irradiation to irregularly-shaped volumes and has the ability to produce concavities in radiation treatment volumes and hence enables sparing of normal tissue while delivering adequate doses to the tumor volumes. In this manuscript, we discuss the advantages of IMRT based on review of published peer reviewed literature.

Radiotherapy-induced damage in the oral mucosa is the result of the deleterious effects of radiation, not only on the oral mucosa itself but also on the skin, adjacent salivary glands, bone, dentition, and masticatory apparatus. From basic skin care to dental and oral health maintenance, several ointments and lotions, oral and parenteral medications, biological response modifiers, cytoprotective drugs, newer radiation techniques and surgery have been introduced to combat and more importantly to prevent the development of these complications. Radiotherapy-induced oral complications involve complex and dynamic pathobiological processes. This in the immediate- and long-term course lowers the quality of life and predisposes patients to serious clinical disorders. Here, we focus on these oral complications of radiotherapy, highlight preventive and therapeutic developments, and review the current treatment options available for these disorders.

Surgical treatment of head and neck cancer frequently results in defects that challenge conventional prosthetic rehabilitation. Successful rehabilitation using tissue supported dentures in such cases has been reported to be less than 20%. With the loss of jaw bones and thus the support, there is loss of retention to a great deal. Also, teeth loss on the side of the defect adds to failure in retention. Scar tissue formation, deviation of jaw due to muscle pull, decreased mouth opening, loss of sulcus and non vertical force are some of the common adversaries of jaw resection especially mandibular resection which pose great limitation on the stability and success of prospective prosthetic rehabilitation. The advent and application of biologically acceptable implants in clinical dentistry has contributed to restoring the defects of the deficient maxillofacial systems. Surgical intervention in patients who had received head and neck irradiation is preferably avoided as it has been associated with decreased healing and increased potential for development of osteoradionecrosis. Hence an implant as an option when surgical field has received tumerocidal radiation is empirically excluded. The purpose of this article is to review the studies and reports published in various journals related to osseointegrated implant rehabilitation in irradiated bones.

Aim: This study aims to provide information on the accrual rate and to identify the reasons for non-enrollment of oral cancer patients into a clinical trial. Setting and Design: Prospective study conducted at the Tertiary Cancer Centre (India). Materials and Methods: Patients eligible and screened for the oral cancer adjuvant therapy (OCAT) were logged prospectively and reasons for non-enrollment were documented which were broadly divided into patient and trial related. Statistical Analysis Used: Demographic characteristics of the non-enrolees were compared with the enrolled. Factors predicting non-enrollment were analyzed using multivariate logistic regression test. Results: A total of 1335 patients with locally advanced cancer of the oral cavity were screened of whom 498 (37%) could be enrolled. Among non enrolled 837 patients, 182 (22%) had the trial-related reasons and 655 (78%) had patient-related reasons. Most important patient-related reasons were patients' preference of taking treatment closer to their native place (26.2%), lack of interest (16.8%) in trial participation. Anticipated poor compliance to treatment (5.9%) and follow-up (6.6%), inability to start treatment in time (6.2%) were important trial-related reasons for non-enrollment. Multivariate analysis identified the genders (female), education (illiterate), occupation (laborer) and non availability of support system in the city as significant predictors of non-enrollment. Conclusions: Both trial design and patient factors were important causes of non enrollment in eligible patients. Patients' need for being closer to home and refusal to participate were the most common reasons for non-enrollment.

Objective: The aims of this study are to evaluate the impact of frozen section in achieving adequate surgical margin and to study the accuracy of frozen section in detection of occult metastases. Materials and Methods: This was a retrospective review of prospectively collected data of 877 patients with squamous cell carcinoma of the tongue who underwent surgery and intra-operative frozen section at our center from January 2007 to June 2010. Results: Frozen section was found to have very high accuracy in assessment of margin as well nodal status. On frozen section, 2% of our patients had positive margins and 21% had close margins. Most of these underwent intra-operative revision and at final pathology, 1.2% patients had positive margins and 11% were close. Of the 651 supraomohyoid neck dissections performed, one third were found to have occult metastases on frozen section. Of those reported positive on frozen section, 68% got additional removal of level 4 ± 5. Interestingly, 11% of these additionally removed nodes harbored metastases at final pathology. However, 7% of the patients were wrongly declared negative on frozen section. Tumor thickness was predictor of margin positivity as well as occult metastases. Tumor volume did not correlate with occult metastases or margin status. Conclusions: Frozen section nearly halves the rates of positive margin and close margins which certainly translates into clinical benefits. The incidence of 11% positive nodes in the frozen section guided removal of lower levels is an important finding in our study that questions the ability of supraomohyoid neck dissection to completely eradicate the nodal burden in such patients.

Context: To assess the feasibility of metronomic chemotherapy in the palliative care setting. Aims: To study the toxicity profile and efficacy of metronomic chemotherapy for palliation in oral cavity cancers. Settings and Design: Retrospective analysis of prospectively collected data. Materials and Methods: Subjects receiving metronomic chemotherapy from August 2010 to January 2011 for palliation in oral cancers subjected to certain criteria were included. Metronomic chemotherapy offered was a combination of twice daily celecoxib 200 mg and weekly methotrexate 15 mg/m ² .The chemotherapy was continued till disease progression, intolerable side effects or patients' desire to stop. The toxicity profile was reported in accordance with common terminology criteria for adverse events (CTCAE) version 4.02. The efficacy was noted in terms of symptom control, response rates, progression free survival (PFS) and overall survival (OS). Statistical analysis used: SPSS version 16 has been utilized. Descriptive analysis has been presented. The Kaplan-Meier survival analysis was performed for estimation of the PFS and OS. Results: Eighteen patients with a median age of 50.5 years, 13 males and 5 females, participated in the study. Five patients had received no previous treatment while the rest had some form of previous treatment. ECOG performance status was 1 in 14 patients and 2 in 4 patients. Grade 3-4 mucositis was seen in one patient. Clinical benefit rate was 66.67%. The estimated median PFS and median OS were 5.2 months and not reached respectively. Conclusions: Use of metronomic chemotherapy seems promising and well tolerated in this setting. Large trials are warranted to confirm these results.

Background: Minor salivary gland tumors (MSGTs) are unusual, accounting for only 15-20% of all salivary gland tumors. The commonest site of MSGTs of the head and neck is oral cavity. Aims: To describe our experience with MSGTs of oral cavity seen over a period of one decade and elucidate their prognostic factors. Materials and Methods: Over a period of 10 years, from 1991 to 2000, all MSGTs of oral cavity were analyzed. All demographic, treatment and survival data were recorded. Kaplan-Meier curves were used to find the survival. Multivariate analysis was performed using Cox regression. Results: We treated 104 patients with curative intent. The commonest site was hard palate, accounting for 54.8% of all sites. The commonest histology was adenoid cystic carcinoma (45.2%). There were 17 (16.34%) pleomorphic adenoma cases, while the remaining 87 (83.66%) were minor salivary gland malignancies. Treatment was surgical in 91.3% of patients. Adjuvant radiotherapy was administered in 38.5% of patients. The median follow-up was 50 months. Recurrences were seen in 22 (25.3%) of the 87 malignant cases. Using Kaplan-Meier analysis, the expected 10-year overall and disease-free survivals were 75.2 and 65.8%, respectively. Survivals were better in non-adenoid cystic tumors (non-ACC). On multivariate analysis, T status, tumor grade and adjuvant therapy were independent prognostic factors for disease-free survival. Conclusions: MSGTs of oral cavity have good overall survival despite recurrences. T stage, adjuvant radiotherapy and grade are independent prognostic factors for disease-free survival. Adenoid cystic tumors have worse outlook than non-ACC.

Aim: The aim of the study has been to quantitatively estimate and compare the circulating immune complexes (CIC) in pre-malignant and malignant lesions of oral cavity and to serially monitor the CIC levels in oral squamous cell carcinoma (SCC) during / following radiotherapy as to assess the status of the disease and to understand the prognostic significance. Materials and Methods: The present study was carried out on 90 individuals divided into three groups and CIC was estimated by spectrophotometric method using polyethylene glycol (PEG) precipitation method. The mean CIC level was determined in each group and was correlated with the degree of differentiation and degree of dysplasia in malignant and pre-malignant group respectively. The effect of radiotherapy on the level of CIC was studied after 2400 rad and after one week of 4500 - 5000 rad. Results: It was observed that the mean CIC level in the control group was significantly lower (59.56 ± 8.11) when compared with the pre-malignant group (75.93 ± 12.89) and malignant group (92.66 ± 13.96). Among the pre-malignant group, leukoplakia had the highest mean CIC level followed by lichen planus and oral submucous fibrosis (OSMF), suggesting its greater malignant potential. No correlation could be established between degree of differentiation and degree of dysplasia with the CIC levels in malignant and premalignant groups respectively. There was a definite decrease in the mean CIC levels in patients undergoing radiotherapy. Conclusion: The pretreatment value of CIC can be used as a prognostic indicator. A high CIC level would probably indicate a poor prognosis.

Background: Oral cancer is the third most common form of malignancies in India. In many cases it develops at the site of premalignant lesion. Transformation of normal tissue to premalignant lesion and further to oral cancer results in alteration in glycolytic pathway and hence the lactate dehydrogenase levels. Therefore, a study was carried out to determine the changes in the salivary alterations in lactate dehydrogenase (LD) levels oral leukoplakia (OL) and oral cancer (OC). Methods: Seventy-five patients reporting to department of oral medicine and radiology, were enrolled into the study which includes 25 patients each of oral leukoplakia, 25 of oral cancer and 25 healthy controls (HC). Unstimulated whole saliva measuring 1 mL will be collected from each of these patients by spit method in centrifuged and evaluated for LDH levels using the standard kit method. The data obtained were subjected to statistical analysis using the SPSS software version 17. Results: The mean salivary lactate dehydrogenase levels were higher in males in comparison to females in all three study groups OL, OC and HC. The salivary lactate dehydrogenase levels in the controls group, oral leukoplakia group and oral cancer were 79.50 ± 4.67 IU/L, 136.46 ± 3.36 IU/L and 148.77 ± 4.83 IU/L, respectively. There was a significant difference in the mean salivary levels of the above groups. Conclusion: Salivary lactate dehydrogenase levels are consistently higher in oral precancer and cancer hence it could be future marker

Aims: To test the spectral reproducibility of earlier findings under ex vivo conditions and to record good quality in vivo spectra in clinically implementable time in finger print region. Materials and Methods: Spectra from 20 ex vivo tissues (10 normal and 10 tumor) were recorded using fiber optic probe coupled Raman spectrometer. In vivo spectra from 10 healthy volunteers were also recorded. Spectral differences were analyzed by PC-LDA method followed by validation by leave-one-out and test samples. Results: Spectral features of ex vivo normal tissue suggest predominant lipid features while protein is high in tumor conditions. Major spectral features of in vivo healthy volunteers share several commonalities with ex vivo normal tissues except minor differences in amide III region. Classification efficiency of 90, 85 and 96% for ex vivo tumor, normal and in vivo normal standard models, respectively after leave-one-out cross validation, was observed. Test prediction efficiency of standard models of ex vivo normal, ex vivo tumor and in vivo healthy volunteers were 82.5, 92.5 and 100%, respectively. Conclusions: Our findings corroborate with the reported ex vivo and in vivo normal spectral features. Features of in vivo Raman spectra show strong similarities with ex vivo normal spectra minor but significant differences were also observed. Findings of this study indicate that with our instrument in vivo Raman spectra in finger print region can be recorded in short and clinically implementable time.