Category: Oral Cancer

Healthcare articles on oral care management, prevention and screening for early detection of oral cancers.

Preventing Trismus Following or During Treatment – Surgery and Radiation

Introduction: Trismus is a painful condition in which there is restricted mouth opening. The purpose of this article is to help understand the lockjaw when going through treatment – surgery or radiation to the head and neck region.

Consequences of inadequate mouth opening (trismus)

  1. Feeding – the person will have difficulty in taking large bites of food.
  2. Difficulty in Chewing and Swallowing
  3. Poor oral hygiene – oral cleaning is inadequate causing foul smell and inflammation in the mouth. Poor dental hygiene with increase risk of caries. Difficulty in doing any dental procedure.
  4. Difficulty in speaking – some individuals find it difficult in communicating as they experience loss of words because of trismus
  5. Tingling sensation and hypersensitivity to certain foods and spices.
  6. Difficulty in the inspection of the oral cavity by self or by your doctor.
  7. Difficulty in surgery or for any procedure in the oral cavity
  8. Difficult anaesthesia – the endotracheal tube insertion may be difficult.

What is an adequate mouth opening?

The mouth opening of at least 3.5 cm measured between the front incisors (front teeth) of the upper and lower jaw. The range of mouth opening for a healthy individual would be 3.5 – 5.5 cms. The measurement can be done by TrisCaRe. Or for general purpose 4 vertical fingers or at least 3 vertically placed fingers can be put between the jaws.

Reasons for Trismus in patients for head and neck cancers –

  1. In India, most patients already have Submucosal Fibrosis at present due to the regular use of tobacco and beetle (Areca) nuts.
  2. Healing by Fibrosis – Following surgery of the oral cavity the healing is by fibrosis of the mucosa, flap, and muscles
  3. Radiation – to the masticatory muscles especially the masseter and temporalis causes inflammation and heals by fibrosis.

The trismus can develop during treatment or even a long time after treatment. Once trismus develops it is quite difficult to treat. Preventive steps to be taken from the beginning.

Diagnosis and Grading

The diagnosis is based on the mouth opening of the person. The measurement is made between the front teeth of the upper and lower jaws. The measurement can be done with TrisCaRe which is an instrument with a measurement scale.

Grading of Trismus: Trismus was graded as:

Mild

Grade I

35 – 26mm

Moderate

Grade II

25 – 16mm

Severe

Grade III

15 – 0mm

PREVENTION

  1. Preoperative assessment and intervention- Most patients with oral cancer would present with some degree of trismus. This is mostly due to the presence of associated submucosal fibrosis due to beetle nut and tobacco chewing. These patients would benefit from interventions at the beginning itself.
  2. Patients planned surgery for the oral cavity are advised about trismus and preventive steps to be taken.
  3. All patients for Radiation of the head and neck advised trismus care before the start of treatment.

What to do for treating Trismus?

  1. Massage and Exercises of the oral cavity
  2. Mechanical Stretching of the oral cavity
  3. Posture management
  4. Good Oral Hygiene

1.

Massage – The masseter muscles. Keep your fingers on the cheek palpate. Move your fingers in a circular fashion for 30-60 secs repeat 2-3 times a day.

 

Exercise – Mouth opening – open your mouth fully till you feel a stretch, keep for 10 seconds

 

Exercise – side movement -Right and left – Move your jaw to right hold for 3 seconds. Now move to the opposite side and hold for 3 secs.

 

Exercise – Circular motion – Move your lower jaw in a circular motion first clockwise and then anticlockwise. Repeat this 3-5 times

2.

Mechanical Stretch – With TrisCaRe – keep the blades between the two jaws. Open slowly with the screw, till you can comfortably open. Now turn few more rounds on the screw and open it till you feel the stretch. Keep it for 30 secs. Repeat this 5 times per day

3.

Posture exercises – to keep your body straight and aligned.

 
  • Neck stretch – Bend head backward and forward
  • Bend head sideways right and left bringing ear to the shoulder
  • Turn your head right and left side
  • Maintain position in each position for 10 secs

 

Head rotation – clockwise and anticlockwise – 5 times each

 

Chin Tuck – Tuck your chin, pulling your head so that the ears line up with shoulders. Hold this position for 3 secs

 
  • Shoulder exercises – up and down – pull your shoulder up and down keep in each position for 5 secs
  • Shoulder rotation – backward and forwards in a circular motion each 5 times
  • Shoulder push back – push both your shoulders backward to bring scapula (shoulder blades) together
  • Hand raise- Raise your hand straight upwards and pull up. Maintain the position for 5 secs.

4.

Oral Hygiene – Maintain oral hygiene regularly – brush your teeth on waking up after every meal and before bed, gargle with non-alcoholic gargles 2-3 times daily, floss regularly.

If you are using dentures remove and clean regularly, remove before going to bed

Self Oral Examination – at least once every month is a must. If you notice any changes and especially decreased mouth opening- do consult your doctor

Start early – if you notice decreased mouth opening during or after your treatment consult a doctor. A physiotherapist may help you with massages and exercise. Mechanical device TRISCaRe is an important adjunct device for all head and neck cancer patients undergoing treatment and would be needed to be used for a lifetime.

TrisCaRe - for Trismus Management and OSMF
TrisCaRe – Mouth Opening Device for Jaw Motion Rehab System

TrisCaRe by ICanCaRe – mechanical mouth opening device to stretch open the jaws. Mechanical Device (TRISCaRe) – TrisCaRe is the optimum device for jaw stretching. TrisCaRe is to be fitted between the upper and lower jaw and the blades are opened with the screw. Jaw stretching with a mechanical device is the only way one can ensure the mouth opening of a patient with trismus. Studies have shown that mechanical jaw stretching can increase mouth opening by 5-10 mm or more even in the severest form of trismus.

Cause – if it is due to tobacco and beetle nuts, the patient is referred to the Tobacco Cessation Intervention specialist to treat the patient for the tobacco disease. Call 011-43077695 or visit www. icancare.in/quit tobacco for assistance in quitting smoking and tobacco.

Conclusion –  Trismus may be acute(temporary) or chronic depending on the cause. Acute responds well to medications and exercises. The chronic long-standing needs long-term intervention with lifelong use of TrisCaRe. For all patients undergoing surgery or radiation for cancers early intervention with TrisCaRe is advised to avoid or reduce the permanent trismus. Early intervention helps for a better outcome.

(The Author – Dr. Pawan Gupta M.Ch. is Director of Surgical Oncology at Max Super Speciality Hospital, Vaishali. Patparganj and Noida. He is the author of the book – Win Over Tobacco Made Easy, Be Smart Do Not Start and is highly recognized for his work on Oral Cancer and Tobacco Cessation. He is the convenor for Certified Course in Tobacco Cessation under the Gujarat University)

Trismus – Restrictive Mouth opening

Introduction: Trismus is a painful condition in which there is restricted mouth opening.

Pathology: The masticator muscles (Chewing Muscles) of the jaw become contracted, inflamed preventing the mouth from opening fully. Or the elastic mucosa gets fibrosed loosing elasticity to allow mouth opening.

Degree of trismus: Mouth opening between 3.5 cm to 5.5 cm is considered normal. In order words around 3 fingers should go into the mouth in vertical position. For fully normal average Indian, mouth opening is found to be 4 fingers.

Consequences of inadequate mouth opening (trismus)

  1. Feeding – the person will have difficulty in taking large bites like rasagolla or panipuri.
  2. Difficulty in Swallowing
  3. Poor oral hygiene – oral cleaning is inadequate causing foul smell and inflammation in the mouth. Poor dental hygiene with increase risk of caries
  4. Difficulty in speaking – many individual experience loss of words and are not able to communicate well because of restrictive mouth opening
  5. Tingling sensation and hypersensitivity to certain foods and spices.

Common Causes – Trismus occurs due to damage or injury to mucosa or the masticator muscles due to:

  1. Submucosal fibrosis due to paan masala and tobacco chewing – the main ingredient is the beetle nut also known as areca nut.
  2. Trauma – due to jaw bone fracture
  3. Oral Surgery – injury of the muscles due to hyperextension or stretch on the muscle for mouth opening for the procedure
  4. Wisdom tooth extraction – mostly the lower last molars.
  5. Mandibular joint with skull bone (temporomandibular joint) dysfunction – This joint is very special as it allows many different movement of the jaw like sliding, rotation, side to side etc. The joint may get affected by trauma, arthritis, habitual clenching and grinding of teeth due to stress, and genetics.
  6. Radiation to head and neck – most who receive radiation to head and neck would have trismus. This is due to radiation can affect the temporomandibular joint, the masticator muscles – pterygoids and masseter causing inflammation and fibrosis. The risk of trismus increases with the dose of radiation.
  7. Painful ulcers of oral cavity – buccal mucosa may also cause trismus
  8. Cancer – ulcers or nodules of the buccal mucosa can lead to trismus by itself
  9. Mucosa surgery – for cancer or PML or otherwise heals with scar formation restricting the mouth opening.
  10. Partial skin grafting of the mucosa following surgery – especially when whole of the buccal mucosa from upper to lower BG sulcus is involved, or when buccinator muscle is removed.
  11. Inadequate flap – the dimensions where inadequate at the beginning or if the flaps get partial necrosis which heals with fibrosis.

Diagnosis and Grading: The diagnosis is based on the mouth opening of the person. The measurement is made between the front teeth of the upper and lower jaws. The measurement can be done with TrisCaRe which is an instrument with measurement scale.

Grading of Trismus: Trismus was graded as mild/grade I (35–26 mm), moderate/grade II (25–16 mm), and severe/grade III (15-0 mm)

For a complete diagnosis assessment is made by the doctor. The doctor would take the history of onset and cause assessment. Following which a clinical examination is done. Radiological examination may be advised as per the requirement.

Treatment:

  1. Cause – if it is due to tobacco and beetle nuts, the patient is referred to the Tobacco Cessation Intervention specialist to treat the patient for the tobacco disease. Visit www.icancare.in/quittobacco or call 011-430-77695 for seeking professional help for quitting tobacco and smoking.
  2. Mechanical Device (TRISCARE) – TrisCaRe is the optimum device for jaw stretching. TrisCaRe is to be fitted between the upper and lower jaw and the blades are opened with the screw. Jaw stretching with mechanical device is the one and the only way one can ensure mouth opening of a patient with trismus. Studies have shown that mechanical jaw stretching can increase mouth opening by 5-10 mm or more even in severest of form of trismus.
  3. Medicines – painkillers, anti-inflammatories and muscle relaxants may be given as per the need. If there is suspicion of infection appropriate antibiotics may be advised.
  4. Massages and exercises – two or three times a day. Advised to do massaging and exercise as follows:
    1. Massage – the painful area in circular motion with your fingers for 30 seconds.
    2. Right and left Jaw movement – move your jaw to right and left. Hold at each position for 30 seconds
    3. Circular movement of the jaw – make circular movements of the jaw in left direction and then in right direction repeat each circular motion for 5 times.
    4. Stretch open your mouth little more than what you are comfortable. Hold for 30-60 seconds
    5. Head movement – flex your neck with chin onto your chest, then bring your head back. Now move your head left and then to right. Hold in each position for 30 seconds. Finally, move the head in a circular motion clockwise and anticlockwise 5 times each.

Conclusion –  Trismus may be acute(temporary) or Chronic depending on the cause. Acute responds well to medications and exercises. The chronic long standing needs long term intervention with lifelong use of TrisCaRe. For all patients undergoing surgery or radiation for cancers early intervention with TrisCaRe is advised to avoid or reduce the permanent trismus. Early intervention helps for a better outcome.

(The Author – Dr. Pawan Gupta M.Ch. is Director of Surgical Oncology at Max Super Speciality Hospital, Vaishali. Patparganj and Noida. He is author the book – Win Over Tobacco Made Easy, Be Smart Do Not Start and is highly recognized for his work on Oral Cancer and Tobacco Cessation. He is the convenor for Certified Course in Tobacco Cessation under the Gujarat University)

Oral cancers – King of all Cancers in India

Introduction

India the land of Chewing tobacco is also the land of Oral Cancer. India ranks the highest in the World in terms of both incidence and prevalence of Oral Cancers. And more than that we have the highest number of people harboring premalignant lesion in the mouth potential to turn malignant. Fortunately, oral cancers are the easily detectable, easily curable and more importantly easily preventable. But tragically most of the patients reach the health care facility in late stage with dismal anatomical, functional and life expectancy outcome.

April is designated as the oral cancer awareness month with a purpose to make all out efforts to reach out to public, physicians, surgeons and dental specialists so that they incorporate the knowledge in their practice which will make a huge difference in the incidence as well as outcome for these patients. Further the common problem of tobacco, Submucosal fibrosis and premalignant lesions needs to be handled by the primary doctors themselves to prevent and control at the primary level itself. For this it is important that the healthcare workers be updated with the knowledge. There is a huge gap and more of the primary health care specialists need to be trained.

For a common public and especially those into tobacco use both smoking or chewing have to practice self-examination of oral cavity as a routine.

In India, oral cavity cancer is among the three most common types of cancer. In India, the age standardized incidence rate of oral cancer is 12.6 per 100 000 population accounting for 30-40%of all malignancies in India.

Oral malignancies occur mostly as squamous cell carcinomas (SCCs) presenting as ulcers. They have a long period of premalignancy stage and mostly associated with a preventable cause. The treatment and outcome of these cancers depends on the stage at diagnosis. Early cancers 5 year survival can be 80% however most cancers present at late stage with a dismal 5 year survival of 20-30%. The only way to change the scenario in India is by early detection of these king of all cancers in India, and more importantly work for prevention of these cancers by stopping the cause- Tobacco

ICanCaRe understands the need of oral cancer screening in India and therefore have started Oral cancer screening and Tobacco Cessation Program in multiple hospitals including RSD Hospital Moradabad, Omaxe Green Valley Plaza Faridabad, Max Super Speciality Hospital Vaishali and more. 

Oral Cancer Prevention

The oral cavity starts from the lip upto the oral anterior pillar of the oropharynx. This consists of the following parts – the lips, the lining of the lips and cheeks, the teeth, the floor of the mouth under the tongue, the front two-thirds of the tongue, the glands that secrete saliva, the bony top of the mouth (hard palate), the gums, and the small area behind the wisdom teeth (retromolar trigone). Oral cancers can occur at any of these areas – the commonest areas being – sulcus between cheek and teeth, and the tongue, mostly related to the tobacco chewing habits the are where the quid is kept.

Oral cancer risk factors

Who have the higher chances of having these oral cancers? Risk factors determine the increase chance of having the cancers. Fortunately most of these risk factors are preventable or modifiable, unfortunately people are not ready to change!

  • Tobacco and Alcohol Use: Tobacco consumption both smoking (cigarettes, bidi, hookah, etc) form or non smoking form (gutka, zarda, mawa, kharra, khaini, etc) is the commonest factor causing oral cancer. Oral cancers are in the rise in the young as well as the adult Indian population. This is mostly related to tobacco habit being started at early age. Alcohol, any form increases the risk of developing oral cancer. Alcohol accentuates the permissiveness of tobacco substantially increasing the chance of cancers of oral cavity. Alcohol alone also increases the risk. Stopping the use of tobacco and/or alcohol will decrease the risk of oral cancer.
  • HPV:  The sexually transmitted human papillomavirus (specifically the HPV 16 type) has been linked to a subset of oral cancers, Although not common it is increasing in India.
  • Diet: A diet high in fruits, vegetables, and fiber may decrease the risk of oral cancer.
  • Age: The risk of developing oral cancer increases after 45 years of age. The age is rapidly decreasing in India due to starting of tobacco use at early age.
  • Dentures and sharp teeth: Ill-fitting dentures or sharp teeth causing chronic trauma and friction is a risk factor for developing oral cancers.
  • Sun Exposure: Sun avoidance or the use of sunscreen may decrease the risk of cancer of the lower lip. These cancers we commonly see in farmers exposed to sun for long duration.

Who are at risk of Oral Cancer?

  •  Tobacco smokers/chewers.
  • Drink excessive amounts of alcohol.
  • Feel difficulty in swallowing or chewing food.
  • Oral habits such as cheek or lip biting.
  • Wear dentures that are old or ill fitting.
  • Any swelling or lumps anywhere in the mouth.
  • White, red or dark patches anywhere in the mouth.
  • Repeated bleeding anywhere in the mouth.

Symptoms of oral cancer

  •  Ulcer in the mouth that is not healing for more than 2 weeks (most common symptom).
  • Any Non healing painless ulcer or growth anywhere in the mouth, which bleeds on touch.
  • White or red patches (leukoplakia or erythroplakia) in the oral cavity.
  • A lump or thickening in the cheek. 
  • Notice any tingling or numb feeling anywhere in the mouth, neck or facial regions.
  • Pain during swallowing.

Oral cancer early detection Quitting Tobacco

The oral cavity can be easily examined physically by self and by clinician. Many malignancies can be diagnosed at early stage and many lives saved

With awareness, self and clinical oral examination the number of new cases of oral cancer, as well as the number of deaths from oral cancer, has been decreasing.

Oral cavity examination – Once only once a month

The examination of the oral cavity is the best single modality that can detect oral abnormal lesions.  Self oral examination is easy to perform and is free. Mostly done self by standing in front of a mirror or by spouse or colleagues. Examine each and every area of oral cavity including by pushing the tongue to the opposite side. Look for any lesion – white, red patches, nodules, ulcers, swelling, bleeding points needs to be consulted by specialists. Self oral examination as an effective screening technique that includes extraoral and intraoral examination. A simple test of extent of mouth opening (by TrisCaRe) can detect the development of Submucosal fibrosis and the chance of harboring some Premalignant or frank malignancy in the oral cavity.

Each individual must self -examine the oral cavity atleast once a month and if they notice any of the symptoms mentioned above should immediately visit the doctor.

A clinical examination by a specialist is advised on a regular basis. For a tobacco user please get yourself examined every 6 monthly and continue this even after you quit tobacco. The health professional will examine your oral cavity and when needed with advise more tests.  

Clinical oral examination by a trained or certified specialist is a must every 6 months for those who consume tobacco and/or smoke.

Oral cancer prevention – Quitting Tobacco!

This is the single most important factor can change the outcome. Quitting Tobacco can help you prevent many other associated diseases as well. Quitting tobacco is possible through proper medical evidence intervention technique by medication,7D behavioral therapy, and co-morbidity management.

Please visit ORAL SCREENING AND TOBACCO CESSATION CENTRE at the nearest centre to you for early detection and treatment of oral cancer.

Visit www.icancare.in/quittobacco or call 011-430-77695 for seeking assistance in quitting tobacco and preventing oral cancers.

(The Author – Dr. Pawan Gupta M.Ch. is Director of Surgical Oncology at Max Super Speciality Hospital, Vaishali. Patparganj and Noida. He is author the book – Win Over Tobacco Made Easy, Be Smart Do Not Start and is highly recognized for his work on Oral Cancer and Tobacco Cessation. He is the convenor for Certified Course in Tobacco Cessation under the Gujarat University)