JAI NARAYAN COLLEGE OF NURSING,

BHOPAL

SUBJECT: MEDICAL SURGICAL NURSING I

SEMINAR ON
“CANCER OF ORAL CAVITY”

SUBMITTED TO: SUBMITTED BY:

Dr. Monika David Mrs. Soumya S Nath

Principal (JNCN) Asst.Professor(JNCN)

INTRODUCTION:-
 Cancer is a disease of the cells in the body. The body is made up from millions of tiny
cells. There are several types of oral cancers, but around 90% are squamous cell
carcinomas originating in the tissues that line the mouth and lips.
 Oral or mouth cancer most commonly involves the tongue.
 It may also occur on the floor of the mouth, cheek lining, gingiva (gums), lips, or palate
(roof of the mouth). Most oral cancers look very similar under the microscope and are
called squamous cell carcinoma.

DEFINITION:-
“Cancer is defined as the uncontrollable growth of cells that invade and cause damage to
surrounding tissue. Oral cancer appears as a growth or sore in the mouth that does not go
away. Oral cancer, which includes cancers of the lips, tongue, cheeks, floor of the mouth,
hard and soft palate, sinuses, and pharynx (throat), can be life threatening if not diagnosed
and treated early.”

“Oral Cancer is a group of cancers in the mouth include tongue, oral mucosa, and gum. Oral
cancer can develop in any part of the oral cavity or oropharynx. Most oral cancers begin in
the tongue and in the floor of the mouth. Almost all oral cancers begin in the flat cells
(Squamous cells) that cover the surfaces of the mouth, tongue, and lips. These cancers are
Called squamous cell carcinomas.”

INCIDENCE:-
Oral cancer in short is cancer of mouth and buccal cavity. Oral cancer is the most common
form of cancer in India. 130,000 people succumb to oral cancer in India annually. The reason
for this high prevalence of oral cancer in India is primarily tobacco consumed in the form of
gutka, quid, snuff or misri. In the North East India, the use of areca nut is also a risk factor for
oral cancer.

ANATOMY AND PHYSIOLOGY

The oral cavity (mouth) includes the lips, cheeks, palate (roof of the mouth), floor of the
mouth and the part of the tongue in the mouth (oral tongue). A mucous membrane lines and
protects the inside of the mouth. The structures in the oral cavity play an important role in
speech, taste and the first steps of digestion.
Structure
The oral cavity begins at the border between the skin and the lips (vermillion border). The
roof of the mouth is formed by the hard palate. The oral cavity leads into the oropharynx,
which includes the soft palate, the back of the tongue and the tonsils. The inner surface of the
cheeks forms the sides of the oral cavity. The lowest part of the oral cavity is the floor of the
mouth, which is covered by the tongue.

The oral cavity can be divided into specific areas, including:

 Lips
 Labial mucosa (inner lining of the lips)
 Commissure of lips (where the upper and lower lips meet at the corner of the mouth)
 Vestibule (a space bounded by the teeth and gums on the inside and the mucosal
surface of the lips and cheeks on the outside)
 Oral tongue (the front two-thirds of the tongue)
 Floor of the mouth
 Buccal mucosa (the inner lining of cheeks)
 Gingiva (gums)
 Retromolar trigone (the area just behind the back molars in the lower jaw)
 Hard palate (the bony part at the front of the roof of the mouth)
 Teeth
 Lower jaw (mandible)
 Upper jaw (maxilla)

Function
The function of the oral cavity and its structures is to begin the process of digestion. The oral
cavity receives food, chews and mixes it with saliva and then begins the swallowing process.
The taste buds on the tongue provide the different sensations of taste. The oral cavity plays an
important role in speech. The mouth is also used for breathing, drinking, facial expressions
and social interactions.

RISK FACTORS:-
1. Tobacco smoking: there are more than 100 chemicals in tobacco out of which 6o and
more are carcinogenic. These carcinogens alter the mitosis and gives cancer.
2. Nonsmoking tobacco. Tobacco chewing causes cancer too.
3. Alcohol: absorption of alcohol starts from mouth itself and chemical cause’s cancer.
4. Prolonged sunlight exposure: UV lights causes mutation in cells and causes cancer.
5. Gender male> female
6. Age 45 years<
7. Fair skin>dark skin. Melanin is supposed to have preventive factor for cancer.
8. Poor oral hygiene.
9. Poor diet
10. Weakened immunity. Immunity compromised patient are more prone to cancer.
11. Marijuana use. As tobacco , marijuana too has carcinogenic affect
ETIOLOGY:-
1. Idiopathic
2. Tobacco smoking
3. Non smoking tobacco
4. Alcohol consumption
5. Radiation
6. Multiple injury in oral cavity
7. Mutation
8. Metastatic
9. Human papilloma virus
10. Candida
11. Lichen plannus

TYPES OF CANCER OF ORAL CAVITY:-

Squamous cell carcinoma More than 90 percent of cancers that occur in the oral cavity and
oropharynx are squamous cell carcinoma. Normally, the throat and mouth are lined with so-
called squamous cells, which are flat and arranged in a scale-like way. Squamous cell
carcinoma means that some squamous cells are abnormal. Verrucous carcinoma: About 5
percent of all oral cavity tumors are verrucous carcinoma, which is a type of very slow-
growing cancer made up of squamous cells. This type of oral cancer rarely spreads to other
parts of the body, but can invade the tissue surrounding the site of origin.

Minor salivary gland carcinomas: This category includes several kinds of oral cancer that
can develop on the minor salivary glands, which are found throughout the lining of the mouth
and throat. These types include adenoid cystic carcinoma, mucoepidermoid carcinoma, and
polymorphous low-grade adenocarcinoma.

Lymphomas: Oral cancers that develop in lymph tissue, which is part of the immune
system, are known as lymphomas. The tonsils and base of the tongue both contain lymphoid
tissue. See our pages on Hodgkin lymphoma and non-Hodgkin lymphoma for cancer
information related to lymphomas in the oral cavity. Benign oral cavity and oropharyngeal
tumors: Several types of non-cancerous tumors and tumor-like conditions can arise in the oral
cavity and oropharynx. Sometimes, these conditions may develop into cancer. For this
reason, benign tumors, which usually don’t recur, are often surgically removed. The types of
benign lesions include:

 Eosinophilic granuloma
 Fibroma
 Granular cell tumor
  Karatoacanthoma
 Leiomyoma
 Osteochondroma
 Lipoma
 Schwannoma
 Neurofibroma
 Papilloma
 Condyloma acuminatum
 Verruciform xanthoma
 Pyogenic granuloma
 Odontogenic tumors (lesions that begin in tooth-forming tissues)

PATHOPHYSIOLOGY:-

CLINICAL MANIFESTATION:-
Common symptoms of oral cancer include:

 Patches inside mouth or on lips that are white, a mixture of red and white, or red
  White patches (leukoplakia) are the most common. White patches sometimes become
malignant.
 Mixed red and white patches (erythroleukoplakia) are more likely than white patches
to become malignant.
 Red patches (erythroplakia) are brightly colored, smooth areas that often become
malignant.

Other sign and symptoms

1. A sore on lip or in mouth that won't heal

2. Bleeding in mouth
3. Loose teeth
4. Difficulty or pain in chewing, swallowing, speaking
5. Difficulty wearing dentures
6. A lump in neck and enlarged cervical lymph nodes
7. Numbness in the tongue or other areas of the mouth
8. Swelling of the jaw that causes dentures to fit poorly or become uncomfortable
9. Pain in one ear without hearing loss
10. Hoarseness, chronic sore throat, or change in voice

STAGES OF ORAL CANCER:-

Stage 1-

The cancer measures <2 cm (about 1 inch) and has not spread to area of lymph nodes

Stage 2-

The cancer measures >2 cm but <4 cm (<2 inches) and has not spread to area of lymph nodes

Stage 3-

Any of the following may be true ; The cancer measures >4cm; the cancer any size, but has
spread to only one lymph node on same side of neck as the cancer; the lymph node
containing cancer measures <=3 cm

Stage 4-

Any of the following may be true: The cancer has spread to tissue around the lip and oral
cavity; area lymph nodes may or may not contain cancer; the cancer is any size and has
spread to >1 lymph nodes on same side of neck as the cancer, to lymph nodes on one or both
side of neck, or to any lymph node measuring >6cm; cancer has spread to other parts of the
body.
HEALTH ASSESSMENT & DIAGNOSTIC EVALUATION:-
History collection:-

History for previous attacks of cancer, tumors , family history is taken. Occupational history
and habits like smoking and alcoholism are collected. Family history is collected.

Physical examination:-

Oral examination is done and the presence of ulcers, change in taste as well as the dental
health is seen. Coating of tongue and changes in buccal mucosa are seen.

 x-ray
 Xrays shows the changes in gums as well as the salivary glands.
 MRI
 CT scan
 PET: A PET scan creates pictures of organs and tissues in the body. First, a technician
gives you an injection of a small amount of a radioactive substance. Your organs and
tissues pick up this substance. Areas that use more energy pick up more. Cancer cells pick
up a lot, because they tend to use more energy than healthy cells. Then a scan shows
where the radioactive substance is in your body.
 DNA studies
 Endoscopy
 Biopsy
 Oral screening
MANAGEMENT:-

MEDICAL MANAGEMENT:-
RADIATION THERAPY:

Radiation therapy (also called radiotherapy) affects cells only the treated area. It may be used
before surgery to kill cancer cells and shrink the tumor. It is used for small cell carcinoma. It
also may be used after surgery to destroy cancer calls that may remain in the area. Radiation
therapy uses high-energy rays to kill cancer cells. Doctors use two types of radiation therapy
to treat oral cancer:
EXTERNAL RADIATION:

The radiation comes from a machine. Patients go to the hospital or clinic once or twice a day,
generally 5 days a week for several weeks.

INTERNAL RADIATION (IMPLANT RADIATION):

Radioactive implant is inserted directly in tissue with the use of needles and thin plastic tubes
for several days. Patient has to stay in the hospital.

CHEMOTHERAPY:

Medical oncologist administers chemotherapy if cancer has spread to lymph nodes or other
organs. The medicine circulates in the blood and disrupts the growth of the cancer cells.
Chemotherapy medications are taken by mouth or given through a vein for several months.
Chemotherapy is not curative for this type of tumor, but when combined with surgery it is
helpful in controlling the tumor. Most commonly used chemo therapy drugs are

 Cisplatin
 Carboplatin
 5-fluorouracil (5-FU)
 Paclitaxel (Taxol)
 Docetaxel (Taxotere)

Chemotherapy is the prescribed for:

After surgery to decrease the risk of the cancer returning To slow the growth of a tumor and
control symptoms when the cancer cannot be cured

IMMUNOTHERAPY

Cancer immunotherapy refers to a diverse set of therapeutic strategies designed to induce the
patient's own immune system to fight the tumor.

Genetic engineering

Monoclonal antibodies

Hormones
SURGICAL MANAGEMENT:
Surgery to remove the tumor in the mouth or throat is a common treatment for oral cancer.
Sometimes the surgeon also removes lymph nodes in the neck. Other tissues in the mouth and
neck may be remove as well. Patients may have surgery alone or in combination with
radiation therapy.

Maxillectomy (can be done with or without orbital exenteration)

Maxillectomy is the removal of all or part of the maxilla bone. It is indicated for tumors of
the hard palate, nose, maxillary sinus or other tumors that have grown to involve the maxilla.

Mandibulectomy (removal of the mandible or lower jaw or part of it)

Mandibulectomy is a procedure that is used to eradicate disease that involves the lower jaw
or mandible. This procedure can be used in various settings, including infectious etiologies
(eg, osteomyelitis) or a benign or malignant neoplastic process (eg, invasive squamous cell
carcinoma) that involves the jaw. In cases of severe oral and maxillofacial trauma, if a section
of the mandible is not salvageable, mandibulectomy may be an appropriate treatment.

Glossectomy (tongue removal, can be total, hemi or partial)

A glossectomy is the removal of all or part of the tongue.

Radical neck dissection

The neck dissection is a surgical procedure for control of neck lymph node metastasis. This
can be done for clinically or radiologically evident lymph nodes or as part of curative surgery
where risk of occult nodal metastasis is deemed sufficiently high. The aim of the procedure is
to remove lymph nodes from the neck into which cancer cells may have migrated. Metastasis
of tumours into the lymph nodes of the neck is one of the strongest prognostic indicators for
head and neck cancer.

Mohs surgery or CCPDMA

Mohs surgery is a precise surgical technique used to treat skin cancer. During Mohs surgery,
thin layers of cancer-containing skin are progressively removed and examined until only
cancerfree tissue remains. CCPDMA is the acronym for "complete circumferential peripheral
and deep margin assessment"

Combinational, e.g. glossectomy and laryngectomy done together

Feeding tube to sustain nutrition Sustained formula are given by tube feeding

Reconstructive surgery

Reconstructive surgery is, in its broadest sense, the use of surgery to restore the form and
function of the body; maxillo-facial surgeons, plastic surgeons and otolaryngologists do
reconstructive surgery on faces after trauma and to reconstruct the head and neck after cancer
NURSING MANAGEMENT:-
Early diagnosis of disease

Check for signs and symptoms

Preoperative care

 patient identification band

 informed consent documentation
 surgical site identification
 medical history and physical exam
 all preoperative testing (e.g. laboratory testing, ECG)
 radiological exams
 preoperative vital signs
 medications
 allergies and sensitivities
 NPO status
 surgical site marked
 voiding
 eye glasses/contact lens
 dentures/dental work
 hearing aids
 jewelry
 make-up removal

Intraoperative care

Postoperative care

 Airway obstruction Hypoxia

 Haemorrhage: internal or external Hypotension and/or hypertension
 Postoperative pain Shivering, hypothermia
 Vomiting, aspiration Falling on the floor Residual narcosis

Rehabilitation

Psychological care

Nursing Diagnosis:-

1. Ineffective airway clearance related to tumor in nasogastric tract.

2. Impaired oral mucous membrane related to drying effect of prolonged use of steroids
3. Imbalanced Nutrition less than body requirements related to hypermetabolic state
associated with cancer
4. Impaired verbal communication, related to excision of a portion of the tongue
5. Chronic Pain related to growth / metastatic tumor
6. Anxiety related to change in health status
7. Imbalanced nutritional status less than body requirement related to anorexia as
manifested by decreased food intake.
8. Anxiety related to lack of knowledge
9. Pain related to the pressure of the tumor
10. Disturbed body image, related to surgical excision of the tongue
 EXPECTED
S.NO ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONALE
OUTCOME
Objective Data- Impaired oral Assess oral cavity at least Oral examination can show
Patient Patient verbalizes
1. mucous once daily and note any signs of oral disease,
membrane describes or discoloration, lesions, symptoms of systemic absence of discomfort or
Restlessness,
related to edema, bleeding, exudate, or disease, drug side effects, or
dyspnea drying effect of demonstrates dryness. Refer to a physician trauma of the oral cavity. inflammation of oral
prolonged use measures to or specialist as appropriate. mucous membrane.
of steroids
regain or
maintain intact
Plan and implement a Mouth care prevents
oral mucous meticulous mouthcare regimen formation of oral plaques
after each meal regularly and and bacteria. Patients with
membranes.
every 4 hours while awake. oral catheters and oxygen
may require additional care.

Provide systemic or topical This will provide comfort

analgesics as prescribed. and relieve pain.

Discontinue flossing if it Increased sensitivity to pain is a

causes pain. result of thinning of oral mucosal
lining.

Instruct patient to hold

solution for several minutes This measure enhances therapeutic
before expectoration. effect.
S.NO ASSESSMENT GOAL PLANNING RATIONALE EXPECTED
DIAGNOSIS OUTCOME

Objective Data- Ineffective Patent  Noisy respirations,

2. Increased airway airway, with  Auscultate chest for rhonchi, and Report decreased
fluid character of breath wheezes are
amount/viscosity clearance secfretions indicative of episodes of dyspnea.
of secretions related to tumor easily sounds and presence of retained secretions
in nasogastric expectorated, secretions. and airway
tract. clear breath obstruction.
sounds, and
noiseless
respirations.  Suction if cough is  “Routine”
weak or breath sounds suctioning increases
not cleared by cough risk of hypoxemia
and mucosal
effort. Avoid deep damage. Deep
endotracheal/nasotrach tracheal suctioning
eal suctioning in is generally
pneumonectomy contraindicated
following
patient if possible. pneumonectomy to
reduce the risk of
rupture of the
bronchial stump
suture line
 Encourage oral fluid  Adequate hydration
intake(atleast aids in keeping
2500ml/day) within secretions
loose/enhances
cardiac tolerance. expectoration.

 Assist patient  Upright position favors

with/instruct in maximal lung expansion,
effective deep and splinting improves
force of cough effort to
breathing and mobilize and remove
coughing with upright secretions.
position (sitting)
DIETARY MANAGEMENT

Tell patient to avoid cold drinks, banana, cold milk, curd preparations, ice cream, refrigerated
food items and also tell about take salt restricted diet because hypertension

Protein is essential for a healthy immune system, without which the body takes longer to
recover from illness and lowers resistance to infection

Carbohydrates and fats assist the body by supplying the calories required for a healthy living.

ACTIVITY:-

Do's and don'ts include:

 Rest when you are tired. Don’t worry if you are fatigued. Fatigue and weakness are
normal for a few weeks after having a lung removed.
 Limit your activity to short walks. Gradually increase your pace and distance as you feel
able.
 Avoid strenuous activities, such as mowing the lawn, using a vacuum cleaner, or playing
sports.
 If an activity causes pain, stop. Breathing may cause some pain at the incision (cut) site.
This is normal.
 Don’t drive until you are free of pain and no longer taking opioid pain medicine. This
may take 2 to 4 weeks.

INCISION CARE:-
Suggestions for caring for your incision include:

 Always keep your incision clean and dry.

 Shower as needed. Wash your incision gently with mild soap and warm water and pat
dry. Avoid scrubbing your incision.

HEALTH EDUCATION:-
1. Stop smoking.
2. Smoking is the major cause of mouth cancer and switching to lowtar cigarettes makes
no difference.
 3. Do not drink large amounts of alcohol as this poses almost as big a risk as smoking.
4. People who both smoke and drink heavily are up to 38 times more likely to develop
the condition.
5. Avoid excessive exposure to sunlight to help prevent lip cancer.
6. Avoid Electromagnetic field.
7. Avoid radiation in occupational area.
8. Personal hygine
9. Light exercise
10. Avoid obesity
11. Eat plenty of fruit and vegetables like carrot, pumpkin, leafy vegetable, ascorbic foods
12. Avoid cosmetics containing formaldehyde and other carcinogens.
13. Go and see a dentist if a mouth ulcer or a white or red patch in your mouth does not
clear after three weeks.
14. Visit your dentist at least once a year.
15. Cancer can be cured if detected at early stage

CARE AFTER RADIATION

SKIN CARE

Do's and don'ts include:

 Don’t scrub or use soap on the treated area.

 Ask your therapy team which lotion to use.
 Avoid sun on the treated area. Ask your therapy team about using a sunscreen.
 Don’t remove ink marks unless your radiation therapist says it’s OK. Don’t scrub or use
soap on the marks when you wash. Let water run over them and pat them dry.
 Protect your skin from heat or cold. Avoid hot tubs, saunas, heating pads, and ice packs.
 Wear soft, loose clothing to avoid rubbing your skin.

Follow-up care

Make a follow-up appointment as directed.

COMPLICATIONS:-
 Dry mouth
 Cavities
 Oral communication with the sinuses
 Difficulties speaking, drinking and eating
  Malocclusion(misalignment or incorrect relation between the teeth of the two dental
arches)
 Facial deformities Isolation from society

PROGNOSIS:-
 Postoperative disfigurement of the face, head and neck
 Complications of radiation therapy, including dry mouth and difficulty swallowing
 Other metastasis (spread) of the cancer
 Significant weight loss
 Death
JOURNAL ABSTRACT:-
Oral Health Practices and Oral Cancer Knowledge Attitudes and Behaviors among
College Students

Objective: This study examines the knowledge about the risk factors and symptoms of oral
cancer, attitudes toward oral cancer and associated behaviors of college students using
constructs of the Health Belief Model and the predictors of oral screening of college students.
Participants: College of Health Science students (N = 300) at a State university located in the
North eastern US were surveyed. Methods: A 25-item questionnaire was administered during
the Fall 2009 semester, which measured knowledge and behaviors related to oral cancer risk
factors. Results: Participants perceived their oral health to be good (63.6%), were unaware of
dental diseases (95.5%), visited a dentist (60.5%), had a dental visit (62.2%) within the last 6
months, and scheduled one (66.3%) in the next 6 months. There was a significant correlation
between the behavior of use of tobacco and the perceived susceptibility to oral cancer (t =
8.10, p < 0.05) and perceived severity (t = 2.22, p < 0.05) if a person got oral cancer. There
were no significant variables which predicted oral cancer screening. Having a dental visit best
predicted the scheduling of a future dental visit. Conclusions: Findings from this study may
further assist in future health education and dental screening programs for this population
group across the US. Keywords: Oral cancer, Oral health, Oral cancer screening, College
students, Health belief model.
THEORY APPLICATION:-
I would like to apply Kristen Swanson Theory in this diseases condition where my patient
Mrs. X is suffering from Cancer of oral cavity.
Kristen Swanson, RN, PhD, FAAN

• Dean of School of Nursing University of North Carolina

• Robert Wood Johnson Foundation

• American Academy of Nursing

• Department of Family and Child Nursing

Education

Bachelor Degree from University of Rhode Island

Master Degree from University of Pennsylvania

PHD from University of Colorado

Caring is a nurturing way of relating to a valued other person, towards whom one feels a
personal sense of committent and responsibility
 •Accepting the patient’s pain as described by the patient
•Generating ideas or thinking through alternatives to
manage pain
• Teaching how to take care of their pain. (take medication
before pain escalates, coping strategies)
Anticipate their pain needs to help them help themselves
Recognizing the patients pain level and identifying what
they need
help with
Convey availability, Taking the time to listen
to how their, pain is being managed
Make sure they know you are there
for them to address their pain needs

• Thoroughly assess the type and level of pain

• Don’t make assumptions about the patient’s pain
• What does this pain mean to the patient
• Seek physiological cues to pain

•Being optimistic about being able to make them

comfortable, Maintaining a hopeful attitude that they will
get through this painful event, Helping patients through
this painful transition in their life.

CONCLUSION:-
Oral cancer be prevented through public health promotion in education them about oral
cancer and screening plays an important role in oral cancer. If oral cancer can be detected in
an early stage than the chances of healing and improvement is high.
REFERENCES:-

BOOKS REFERENCES:-

1. Nettina,M.Sandra.(2009).Lippincott Manual of Nurisng Practice.IX edition.New

Delhi: Wolters kluwer Pvt.Ltd

2. Brunner and Suddharth. (2004). Textbook of Medical Surgical Nursing.

Philadelphia: Williams & Wilkins.

3. Heitkemper, Lewis & O’Brien Dirksen Bucher.(2010)Lewis Medical Surgical

Nursing. I edition Elsevier

4. Joyce M Black Jane Hokanson Hawks “ Medical surgical Nursing ” 7th edition
volume no 7 Elsevier publications

5. Ansari Dr. Javied B.T. Basavanthappa’s, Medical Surgical Nursing, Edition-1st.

JOURNALS REFERENCES:-_
1. Aarthi Shanmugavel,etal “Oral Health Practices and Oral Cancer Knowledge
Attitudes and Behaviors among College Students” World Journal of Dentistry,:2010
Vol: 1 issue 3 Oct-Dec141-148

INTERNET REFERENCES:-
1. https://www.mayoclinic.org/
2. emedicine.medscape.com/article/155919-overview
3. https://www.cancer.org/cancer/oral-cavity-and...cancer/.../what-is-oral-cavity-
cancer.h...
4. https://www.cancer.org/cancer/oral-cavity-and...cancer/.../signs-symptoms.html