18

MALIGNANT DISEASE
Mark McGurk

The risk of developing cancer is increased in patients who have

already had a cancer. Do not ignore unusual symptoms in this
population of patients.

Epidemiology
Approximately 270 000 new cases of cancer are reported
each year in the UK where this disease is now the commonest cause of death (26% of all deaths in the UK) (see Fig. 18.1).
Cancer can be viewed as a degenerative disorder as the
incidence of neoplasia increases markedly with age.
Against this background different types of cancer have
their own prole, some occurring only in childhood (retinoblastoma), others having a bimodal presentation such as
Hodgkins lymphoma. Cancers that occur in children tend
to arise from discrete genetic defects whereas those in the
elderly occur through gradual accumulation of nonspecic genetic damage over time.

Aetiology
Aetiological factors that predispose to neoplasia vary
between the different types of tumour and some relationships are complex, although they can have a common
theme. Breast cancer is related to the reproductive cycle.
The risk of disease increases with the duration of time a
woman is fertile whereas pregnancy has a protective effect
so long as it commences before 35 years of age.
Tobacco and alcohol are recognised carcinogens and are
incriminated in the development of mouth, throat, lung,
oesophagus, pancreas and bladder cancer. Radiation is
associated with haematological disorders and thyroid
cancer. Infective agents such as papilloma virus and hepatitis B are linked to cervical and liver cancer respectively
whereas solar radiation is responsible for cancer of the
skin (squamous cell carcinoma, basal cell carcinoma,
melanoma) which together are numerically by far the most

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Malignant disease

17 492

30000

9934

3773
7697

885
780

2049
2950

20000

24 227
24 780

40000

10000

49 715
49 927

42 929

Male cases
Female cases

31 961

50000

760
566

Number of new cases (thousands)

60000

Under 1524 2534 3544 4554 5564 6574 Over

15
75
Age at diagnosis

Fig. 18.1 New cases of cancer by age and sex. The number of
new malignancies can be seen to rise rapidly with age.

common cancers in the body (109 000 cases per year in the
UK).
It is apparent that most of the common cancers are
related to lifestyle and environmental factors. It has been
estimated that up to 90% of human cancer is potentially
avoidable by changes in lifestyle.

Treatment

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Treatment regimes for different cancers cannot be discussed in detail but therapy can be divided into local and
systemic. Also, cancers can be separated into solid or
haematogenous. Local therapy depends mainly on surgical excision and radiotherapy and is usually the mainstay
of treatment for solid tumours. Systemic therapy is the
more complex and depends on a range of cytotoxic drugs
that are usually administered in combination. Haematological malignancies (leukaemia, lymphomas, myelomas)
are more responsive to chemotherapeutic agents than are
solid tumours. In general tumour is dose-dependent and
the challenge has been to devise ways of delivering increasingly higher doses of toxic drugs but at the same time rescuing normal tissues. Escalating doses of chemotherapy
can be used to advantage, particularly in haematological

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Childhood malignancy

18

Table 18.1
New therapeutic modalities in the treatment of malignancy.
Agent

Tumour treated

Interferon
EGF receptor blocker
Papilloma virus vaccine
Angiogenesis inhibition
Haematogenous growth factors
Hormone blocking drugs

Melanoma
Squamous cell carcinoma
Cervical cancer
Solid tumours
Leukaemias
Breast cancer

malignancies and childhood cancers. Techniques include

autologous stem cell rescue and marrow transplantation.
However, success is achieved at a price that includes subtle
persistent diminution in function of remaining normal
body tissues. The systems particularly at risk are the
nervous system, heart, lungs and bone marrow. There is
a diminution of reserve which can manifest itself as an
inability to respond adequately when the body systems are
severely stressed such as following major trauma or extensive surgery.
In addition to these mainstays of therapy new modalities
are continually being developed. Gene therapy is still
in its infancy but molecular engineering has produced
designer drugs in the form of monoclonal antibodies to
facilitate bone marrow clearance in leukaemia, receptor
blockers for growth promotion epidermal growth factor)
and tissue cytokins (see also Table 18.1).
The new therapeutic agents have side-effects which take
the form of fevers, malaise and hypertension but their longterm effects on body function seem minimal. Rather it is
cytotoxic drugs that carry their legacy into adulthood.

Childhood malignancy
Approximately 1500 new cases of childhood cancers (at
<14 years) are recorded each year in the UK.
The most common cancer of childhood is leukaemia, of
which 80% of cases are acute lymphoblastic type. Over 90%
of these children achieve remission for over 20 years based
on multiple-agent chemotherapy. Relapses can be treated
by marrow transplantation if histo-compatible sibling donors
are available. Common cancers of childhood are shown in
Figure 18.2.

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Malignant disease

All cancers
Children (0.5%)

Adults

Childhood cancers
Leukaemias

Other (6%)

Acute lymphoblastic
leukaemia (26%)

Lymphomas
Hodgkins (4%)
Non-Hodgkins
lymphomas (6%)

Brain and
spinal (24%)
Other (19%)
Embryonal
(15%)
Fig. 18.2 Contribution of childhood malignancy to total
malignancy and the relative frequency of the different types of
malignancy in children.

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Adult malignancy

18

Head and neck tumours in children

These cancers are rare and usually consist of sarcomas or
retinoblastoma.
Local therapy in the form of surgery or radiotherapy can
have a signicant impact on dento-facial development.
Focal growth retardation is the norm which leads to facial
deformity as the child grows. The teeth may not develop
or may form with short roots, wide pulp cavities and
altered crown morphology. This places the teeth at risk of
dental decay. There is also the long-term effects of radiation on bone healing which make these patients at potential risk of osteoradionecrosis. Childhood tumours tend
not to occur in the mouth and so the full force of radiation
is not normally delivered to the jaws. Consequently the
risk of radionecrosis is low following treatment of childhood cancer unless the cancer was sited in the oral
cavity.

DENTAL RELEVANCE OF CHILDHOOD CANCER

The majority of children with cancer receive chemotherapy as a

part of their treatment.
Local treatment in the head and neck (surgery and
radiotherapy) can lead to facial deformity, altered tooth
morphology, malocclusion.
Systemic chemotherapy may have long-term effects in the
form of growth retardation, cardiac toxicity, lung brosis and
diminished bone marrow function.
Also, there is a risk of the patient developing second primary
cancers in childhood.
Unless the individual received a course of radiotherapy directed
at the jaws (which is uncommon) the risk of bone infection is
low.
Dental treatment does not pose a particular risk to the patient
(see childhood cancer).

Adult malignancy
Cancers of the breast, lung, large bowel and prostate
account for over half of all the new cancers diagnosed each
year in the UK (see Fig. 18.3).
The majority of neoplasms occur after the 6th decade of
life and so management of late side-effects of therapy is
less of an issue than in children. Also in adults, solid

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Malignant disease

Breast
Prostate
Lung
Colorectal
Bladder
Male cases
Female cases

Ovary
Stomach
Uterus
Non-Hodgkins
lymphoma
Oesophagus
0

10

15
20
Thousands

25

30

35

Fig. 18.3 Incidence of the most common cancers affecting adults

by sex.

tumours predominate and usually with these cancers

chemotherapy is not usually used with such intensity as
for haematologically tumours.
However, adult haematological malignancies are still
treated aggressively apart from the sub-population of
patients with chronic leukaemias. This is an indolent disease
that can persist for years without symptoms. Nevertheless,
these patients may have subtle alteration in immune competence which is revealed only in the face of an infective
challenge. Dental sepsis may be such a challenge and the
risk of infection should be kept to a minimum.

Cancers in the head and neck

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Cancers of the skin surface are particularly common especially in light-skinned subjects in tropical climates. These

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Cancers in the head and neck

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tumours (squamous cell carcinoma and basal cell carcinoma)

are relatively indolent. However, a small proportion (13%) of
the squamous cell carcinomas of skin have the propensity to
metastasise. So, in Australia, with its hot climate and Caucasian population, the commonest cause of a parotid lump is
metastasis from a primary skin cancer in the scalp.
Mouth and throat cancer have an incidence of 80120
cases per million per annum in the UK. It is a disease of
the elderly and the median age of presentation is about 60
years. Salivary and thyroid tumours are much less common
(715 cases annually/1 000 000 population). The peak incidence of disease is a decade earlier (50 years of age).
The treatment of head and neck tumours is usually by
surgery and/or radiotherapy. But there is now an increasing contribution made to treatment from chemotherapy. In
mouth and throat cancer it is used in conjunction with
radiotherapy and improves outcome by about 710%.
Occasionally tumours from distant primary sites can
metastasise to the jaws. These tumours migrate in the
blood stream and tend to alight at areas of high vascularity
such as the temporomandibular joint or where the inferior
dental artery enters and exits the mandible. Paraesthesia
is an important sign that should never be ignored. Tumours
that tend to metastasise to the jaw are those from the
breast, kidney, prostate, lung and thyroid.

DENTAL RELEVANCE OF HEAD AND

NECK CANCERS

The dental implications of treatment of solid tumours outside

the head and neck is minimal.
Dental implications of cancer therapy pertain mainly to cancer
of the mouth and to a lesser extent to salivary gland. This is
because the full force of treatment is focused on the jaws.
Those patients who continue to smoke and drink have a
2% accumulative risk of a new cancer each year. Growth
retardation is not a problem in the adult population. Surgery
can lead to trismus and poor access to the oral cavity. A liquid
diet increases the risk of dental caries. Similarly, radiation
therapy reduces salivary secretions, alters the oral ora and
even with excellent oral hygiene patients are still at signicant
risk of root caries. Dental extractions, particularly in the
mandible, place the patient at risk of osteoradionecrosis.
It is recommended that all extractions in the mandible
post-radiotherapy should be undertaken at specialist centres.

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