Category: Oral Cancer

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

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)

Oral cancers – Importance of Self Oral Examination: Identifying Chota Daana

April is recognized as Oral Cancer Awareness Month.

Head and Neck experts from multiple specialties’ unite together across the country to create sensitization about the importance of oral examination and hold oral screening camps for early detection and prevention of oral cancer. Experts always recommend to perform self examination once every month to detect the chota dana – the pre-malignant lesions that are curable, less dangerous and do not cause financial losses.

Importance of Self Oral examination Cannot be Underestimated

Any one with the habit of tobacco – chewing or smoking in any form is at a higher risk of cancers of oral cavity and it can happen anytime in life. But luckily oral cancer does not happen in just one day it takes few years of this habit to establish the changes required to get oral cancers. There is a long incubation period and you can take steps to rectify your life style.

Two things that is important for all tobacco users:

  1. Prevention
  2. Early detection

Prevention – Cancer can be prevented easily by quitting tobacco use and smoking. Most of the early mucosal changes can regress with quitting of smoking and tobacco. But if more advanced changes have taken place – like dysplasia and submucosal fibrosis they are likely to progress. The best thing any tobacco user can do is take help of the experts and quit tobacco and alcohol completely. This may halt or decrease the progression of the mucosal changes. Quitting tobacco is now easy with specialist care providing specific medicines, behavioral therapy, co-morbidity management and follow up by quit coaches. Download the ICanCaRe app (http://app.icancare.in). You can get your own book ‘WIN OVER TOBACCO – MADE EASY’. Or just call 011-43077695

Early Detection – Oral Cancers just do not happen in one day. If you had few smoking or chewing tobacco in your lifetime maybe you are at a low risk, but for those who had regular tobacco products and especially started as a teen, are at high risk throughout life even after quitting tobacco. Luckily the oral lesions can be self-examined and early changes detected easily by just self-examining the mouth and checking all the areas inside the mouth – inner walls of the cheeks, upper palate, below the tongue, on the gums, towards the epiglottis, etc. Just notice for occurrence of red patches, white patches or small white ulcer like lesions in the mouth. If such changes are noticed, medical assistance should be immediately taken to detect any malignant lesions early and treat them in the early stage itself. Checking the mouth once every month is advised by the experts. Following points should be notices again:

For all who are at high risk of oral cancers (all smokers and tobacco chewers) must examine their mouth at least once a month.

Steps of Oral Examination:

  • Rinse your mouth with plain water to remove all the removable stains from the paan masala
  • Wash your hands with soap, Stand in front of the mirror.
  • Look for any swelling or puckering on the face or neck.
  • Feel with your fingers for any hardness or lumpy areas on face or neck.
  • Check for any lesions on the lips both upper and lower.
  • Check your mouth opening
  • Measure mouth opening with TrisCaRe instrument or otherwise a rough estimate with the vertically placed number of fingers that can easily pass with the mouth open. Normally more than 3.5 cm on TrisCaRe or 4 fingers (atleast 3 fingers) will be considered as adequate.
Self-check for Trismus

TriCaRe for Mouth Opening Measurement and Jaw Motion Rehab System

Now open your mouth and in a clockwise direction visualize all the areas in the mirror for any lesion. Take help of your fingers to push the cheek and tongue. The cheek, both the sulcus, alveolus, Floor of mouth, hard palate and soft palate. Look for any restrictions of tongue movement. Protrude the tongue out and look at all the areas for any lesions. With the fingers feel for any lump, hardness in any area of the oral cavity.

If you find any abnormality please report to a specialist (trained for the purpose).

If you have decreased mouth opening it may be start of the submucosual fibrosis which would immediately require intervention to halt the progress. This would warrant regular use of TrisCaRe through out life.

Oral Cancer king of all cancers in 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. To control the disease you are important. Be the Tobacco Marshal  in the society, and crusade the change to save the youth from tobacco and cancer.

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.

Max Super Specialty Hospital understands the need of oral cancer screening in India and therefore have started Oral cancer screening program in association with ICanCaRe at Max Noida and Vaishali.

(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 convener for Certified Courses in Tobacco Cessation under the Gujarat University. Launched the campaign #SAVEtheyouth #winovertobacco)

Make quitting tobacco a pleasure journey. Talk to the experts. Call ICanCaRe Quitline 011-43077695  or visit www.icancare.in/quittobacco to join the tobacco/smoking quit program today.

Make your appointment today for ORALSCREENING at MAX HOSPITAL  – Noida and Vaishali.