PLENARY DISCUSSION

BLOK 14

1st Tutorial
Parama Aji Akasa 20160340001
Shylvia Muchsin Andewa 20160340006
Mesi Octavia Damayanti 20160340010
Sharon Sesita Frinces 20160340013
Sintya Andhika Wardhana 20160340014
Arsyadhea Khairunnisa 20160340021
Muhammad Nara Dewanto 20160340036
Hana Aulia Hapsari 20160340041
Bella Mutiara Hasymi 20160340079
Tata Pandu Ibadah Zen 20160340086

Department of Dentistry
Faculty of Medicine
Muhammadiyah University of Yogyakarta

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 Table of Content

Table of Content ..................................................................................................................................... ii

Preface ................................................................................................................................................... iii

Chapter I ................................................................................................................................................. 4

Scenario and Critical Questions .............................................................................................................. 4

Chapter II ................................................................................................................................................ 5

Analysis of Critical Questions ................................................................................................................ 5

CHAPTER III ....................................................................................................................................... 11

Conclusion ............................................................................................................................................ 11

Chapter IV............................................................................................................................................. 15

REFRENCES ........................................................................................................................................ 15

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 Preface
Assalaamu’alaikum warahmatullahi wabarakatuh,

Alhamdulillahirabbil ‘alamiin, ashalatu wassalamu ‘ala asyrafil anbiya iwal mursalin wa ‘ala
‘alihi wa shahbihi ajma’iin amma ba’du,

First of all we are grateful to Allah for the gift of pleasure and health, so our team can finish
this report on time. Not to forget, shalawat and salam to our Prophet Muhammad SAW who
has guided the Muslims from the darkness into the lightness.

Also, not to forget we want to thank our parents for their support, our tutor drg. Novitasari
RA, MPH for knowledge and guidance provided, to our friends for their support and
cooperation so that this report can be arranged in time.

We made this report for the needs of plenary discussion. Hopefully with the establishment of
this report will help in the continuity of the learning process dental students of UMY in the
future.

We realize that this report is far from perfect, but our team tried our best to prepare this report
and inshaAllah will provide many benefits to readers. We accept any criticism and
suggestions from readers for the perfection of this report.

We beseech Allah to bless us all with his abundant mercy, which overwhelms every living
thing, and to guide all truth seekers to Allah’s right path. May His peace, blessings, and grace
be upon Muhammad and his rightenous progeny. Aamiin.

Akhiru kalam,

Wassalaamu’alaikum warahmatullahi wabarakaatuh.

Yogyakarta, October 29th 2018

1st Tutorial

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 Chapter I
Scenario and Critical Questions

A. SCENARIO 1
A 50 year old man complained of a lump in the tongue since 3 months ago. Initially, it
appeared as a small lesion, but gradually became a bigger lesion. Since 2 weeks ago the
patient complained as a painful lesion. Recently, patient also experience weight loss.
These conditions have been examined by a dentist, and then the dentist has given
ciprofloxacin, analsik and benzydamine gargle but has not resolved. From the family
history, his mother died of ovarian cancer. The patient was a heavy smoker, but he has
stopped since 5 years ago. Physical examination revealed a palpable, fixed and non
tenderness in the left cervical lymph node. Intra oral examination revealed an exophytic
lesion with ulcerated surface on the right lateral of the tongue, with approximate size of
1.5x1.5 cm and induration. The dentists require microscopic examination to confirm
diagnose.

B. CRITICAL QUESTIONS
1. How to do the physical examination and what are the body parts that being examined?
2. Kinds of lesion?
3. How to diagnose the disease?
4. What is the difference of tumor and cancer? + definition
5. How does cancer spread to lymph nodes?
6. What are the stages of cancer? And how to classified?
7. What is the diagnose of the patient?
8. What are the causes of the disease in the scenario? (and in general)
9. What are the signs and symptoms?
10. What is the treatment?

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 Chapter II
Analysis of Critical Questions
1. How to do the physical examination and what are the body parts that being
examined?
- Extra oral
Palpate lymph node bimanual or bidigital, usually dentist do it on 4 places :
submandibular, submental, cervical, sublingual
Palpation on TMJ : use bimanual, auskultasi, intraaurikular
Trismus examination
Palpate Salivary gland : parotis, submandibularis, and sublingualis
Lihat fasial, neuromuskular, kelenjar limfa (metode submandibular, submental,
cervical, sublingual), kelenjar ludah
Periksa deformitas, nyeri, gangguan fungsi
- Intraoral
With diagnostic set inspect any lesion : shape, color, consistency, surface, size,
location, thickness, temperature, mobility
*If the doctor found any sign of tumor or cancer the doctor can do biopsy of the
area of suspected cancer or tumor*
2. Kinds of lesion?
Primary lesion : it occur due to anatomic changes of the epidermis, dermis, or
subcutaneus tissue
- Makule (flat or no evidence; spot on the skin or mucosa; the color red, bluish red,
whitish brown, brownish blue
- Papule (is a white spot on the skin or mucosa and there is elevation, the size <1
cm, the example of papule are lichenplanous and fordyce spot)
- nodule,

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 - pustula(are small spot filled with pus. They can get itchy and are hard to get rid
of),
- tumor
Secondary lesion : lesion that arise due to changes in the orimary lesion, this lesion
will develop if the primary lesion is not treated immediately.
- Erosi
- Sinus
- Fisura
- crust
- Based on the color : white lesion, red lesion
Other lesion : red lesion, white lesion and pigmented mucous lesion

3. How to diagnose the disease?

- Physical examination is an exm to check the lips and oral cavity for abnormal
areas. Include Anamnesa (medical history, family history, dental history, social
history)
(look the signs of the disease, extraoral and intraoral)
Supporting examination
- Endoscopy: a procedure to look at organs and tissues inside the body (insisi,
eksisi)
- Biopsy : the removal of cells or tissues so it can be viewed under microscope.
- MRI : a procedure that uses a magnet, radiowave, computer to make a series of
detailed picturesinside the body
- CT scan : a procedure that makes a series of detailed pictures inside the body
taken from different angles
4. What is the difference of tumor and cancer? + definition
Tumor : a group of abnormal cell form from the result of excessive and uncoordinated
cell division process or neoplasma. The health of cells that growth abnormally is dead
or irreversible
Types of tumor : malign (cancerous) and benign

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 Malign : carcinomas are cancer that start in the cell that make up the tissue lining
organs, ex kidney. And sarcomas are cancer that form into connective tissue of the
body ex bone
Malign tumor (cancer) :
- has the potential to attack or damage the surrounding tissue
- the cellular shape is abnormal
- invasive growth : tumbuh dengan menyebar ke yang lain
- usually endophytic growth
- fast growth
- metastasis
- tissue atypia (selnya bentuknya abnormal) and polimorfism
- frequent high metotic activity
- usually with necrosis

Benign tumor :

- does not attack surrounding tissue and could grow bigger

- looked like a normal cell but has capsule that make it different from the normal
cell
- ekspansive growth : membesar tapi tetap di dalam kapsulnya
- usually exophytic growth
- slow growth
- without metastasis
- without cell atypia
- usually there is no high metotic activity
- usually without necrosis
5. How does cancer spread to lymph nodes?
Cancer has metastasis characteristic( the characteristic to spread to other organ or
tissue). It can spread through vascular system and lymph node

6. What are the stages of cancer? And how to classified?

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The stage indicates how far the cancer has spread. Each stages has three potential
classification (TNM)
a. T refers to the size of the tumor. A small to big tumor is classified as T1-T4
Tx : primary tumor cannot be assessed
T0 : no evidence of primary tumor
Tis carcinoma in situ
T1 : tumor 2cm or less in greatest dimension
T2 : tumor more than 2cm but not more than 4 cm in greatest dimension
T3 : tumor more than 4 cm in greatest dimension
T4 (lip) : tumor invades adjacents structures such as through cortical bone,
tongue, skin of neck
b. N refers to whether or not the cancer has spread to neck or servical lymph nodes.
N0 means the cancer has not spread while N3 means that it has spread to many
lymph nodes
NX : regional lymph node cannot be evaluated
N0 : no regional lymph node involvement or no cancer found in the lymph node
N1 : single ipsilateral lymph node metastasis 3cm or less
N2a : single ipsilateral lymph node metastasis greater than 3 cm ≤ 6cm
N2b : multiple ipsilateral lymph node metatasis ≤ 6cm
N2c : bilateral or contralateral lymph node metastasis ≤6cm
N3 : lymph node metastasis greater than 6 cm
c. M refers to whether or not there are metastasis (additional growth in other body
parts) to other organs such as the lungs
MX : precence of distant metastasis cannot be assessed
M0 : no distant metastasis
M1 : distant metastasis

Grading :

Stage 1 : 2cm in size and has not spread to lymph node in the area
Stage 2 : 2 – 4cm and has not spread to lymph node

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 Stage 3 : more than 4 cm, has spread only to the lymph node that contain cancer
measures no more than 3 cm
Stage 4 : cancer has spread to lips and oral cavity but the lymph node may or may
not contain cancer. Size more than 6 cm and has spread to other parts of the body

Stage grouping :

Stage 0 -> Tis -> N0 ->M0

Stage 1 -> T1 ->N0 -> M0

Stage 2 -> T2 -> N0 ->M0

Stage 3 -> T1, T2-> N1 ->M0

T2 N1 M0

T2 N2a M0 stadium 4A

7. What is the diagnose of the patient?

Oral carcinoma cancer stage 1
8. What are the causes of the disease in the scenario? (and in general)
There is a mutation in cell that causing the cell to divide abnormally
Risk factors :
- Alcohol
- Tobacco use of any kinds
- Virus infection (HPV)
- Family history of cancer
- Age
- Radiation exposure
- Low nutrition
- Personal history of certain cancer
- Weakened immune system
9. What are the signs and symptoms?
Symptoms :

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 - Sore that doesnt heal
- Sore that bleeds
- A growth lump or thickening of the skin or lining of the mouth
- Difficult in chewing or swallowing
- Mouth numbness
- Dramatic weight loss

Signs :

- Tongue ulcers
- Red or white patch on tongue
10. What is the treatment?
Multidisciplinary approach
- Surgery
Chemotherapy

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 CHAPTER III
Conclusion
1. Exophytic lesion : tending to grow outward beyond the surface epithelium from
which it originates. The term of exophytic lesion is described as pathological growth
above the normal contours of the oral mucosa. Endophytic lesion :crawl under the
mucous carpeting the interior of the larynx. The submucosal tumor is hidden from
the view and maybe quiet extensive. This type of cancer is more difficult to diagnose
and consequently therapy of endophytic tumor is usually delayed as compared to
exophytic tumor.
The endophytic growth pattern has depressed, irregularly shape, ulcerated, central
area with a surrounding border of normal, red or white mucous.
2. Extra oral
Palpate lymph node bimanual or bidigital, usually dentist do it on 4 places :
submandibular, submental, cervical, sublingual
Palpation on TMJ : use bimanual, auskultasi, intraaurikular
Trismus examination
Palpate Salivary gland : parotis, submandibularis, and sublingualis
Lihat fasial, neuromuskular, kelenjar limfa (metode submandibular, submental,
cervical, sublingual), kelenjar ludah
Periksa deformitas, nyeri, gangguan fungsi
Intraoral
With diagnostic set inspect any lesion : shape, color, consistency, surface, size,
location, thickness, temperature, mobility
3.
A. Primary lesion : it occur due to anatomic changes of the epidermis, dermis, or
subcutaneus tissue
o Makule (flat or no evidence; spot on the skin or mucosa; the color red, bluish
red, whitish brown, brownish blue
o Papule (is a white spot on the skin or mucosa and there is elevation, the size <1
cm, the example of papule are lichenplanous and fordyce spot)
o nodule,
o pustula(are small spot filled with pus. They can get itchy and are hard to get rid
of),
o tumor

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 B. Secondary lesion : lesion that arise due to changes in the orimary lesion, this
lesion will develop if the primary lesion is not treated immediately.
o Erosi
o Sinus
o Fisura
o crust
o Based on the color : white lesion, red lesion
C. Other lesion : red lesion, white lesion and pigmented mucous lesion
4. A. Tumor : a group of abnormal cell form from the result of excessive and
uncoordinated cell division process or neoplasma. The health of cells that growth
abnormally is dead or irreversible
Types of tumor : malign (cancerous) and benign

-Malign : carcinomas are cancer that start in the cell that make up the tissue lining
organs, ex kidney. And sarcomas are cancer that form into connective tissue of the
body ex bone
Malign tumor (cancer) :
-has the potential to attack or damage the surrounding tissue
-the cellular shape is abnormal
-invasive growth : tumbuh dengan menyebar ke yang lain
-usually endophytic growth
-fast growth
-metastasis
-tissue atypia (selnya bentuknya abnormal) and polimorfism
-frequent high metotic activity
-usually with necrosis

-Benign tumor :

-does not attack surrounding tissue and could grow bigger

-looked like a normal cell but has capsule that make it different from the normal cell

-ekspansive growth : membesar tapi tetap di dalam kapsulnya

-usually exophytic growth

-slow growth

-without metastasis

-without cell atypia

-usually there is no high metotic activity

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 -usually without necrosis

The stage indicates how far the cancer has spread. Each stages has three potential
classification (TNM)

T refers to the size of the tumor. A small to big tumor is classified as T1-T4

Tx : primary tumor cannot be assessed

T0 : no evidence of primary tumor
Tis carcinoma in situ
T1 : tumor 2cm or less in greatest dimension
T2 : tumor more than 2cm but not more than 4 cm in greatest dimension
T3 : tumor more than 4 cm in greatest dimension
T4 (lip) : tumor invades adjacents structures such as through cortical bone, tongue,
skin of neck

N refers to whether or not the cancer has spread to neck or servical lymph nodes.
N0 means the cancer has not spread while N3 means that it has spread to many
lymph nodes
NX : regional lymph node cannot be evaluated
N0 : no regional lymph node involvement or no cancer found in the lymph node
N1 : single ipsilateral lymph node metastasis 3cm or less
N2a : single ipsilateral lymph node metastasis greater than 3 cm ≤ 6cm
N2b : multiple ipsilateral lymph node metatasis ≤ 6cm
N2c : bilateral or contralateral lymph node metastasis ≤6cm
N3 : lymph node metastasis greater than 6 cm

M refers to whether or not there are metastasis (additional growth in other body
parts) to other organs such as the lungs
MX : precence of distant metastasis cannot be assessed
M0 : no distant metastasis
M1 : distant metastasis

5. Grading :
Stage 1 : 2cm in size and has not spread to lymph node in the area
Stage 2 : 2 – 4cm and has not spread to lymph node
Stage 3 : more than 4 cm, has spread only to the lymph node that contain cancer
measures no more than 3 cm
Stage 4 : cancer has spread to lips and oral cavity but the lymph node may or may
not contain cancer. Size more than 6 cm and has spread to other parts of the body

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 Stage grouping :

Stage 0 -> Tis -> N0 ->M0

Stage 1 -> T1 ->N0 -> M0

Stage 2 -> T2 -> N0 ->M0

Stage 3 -> T1, T2-> N1 ->M0

T2 N1 M0

T2 N2a M0 stadium 4A

6. There is a mutation in cell that causing the cell to divide abnormally

Risk factors :
- Alcohol
- Tobacco use of any kinds
- Virus infection (HPV)
- Family history of cancer
- Age
- Radiation exposure
- Low nutrition
- Personal history of certain cancer
- Weakened immune system

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 Chapter IV
REFRENCES
http://staff.ui.ac.id/system/files/users/yuniardini/material/lesiputihppdgs2007.pdf

http://repository.umy.ac.id/bitstream/handle/123456789/7263/Neoplasma%20suplemen.pdf?sequence=1

https://www.cancer.net/navigating-cancer-care/diagnosing-cancer/stages-cancer

https://thetruthaboutcancer.com/benign-malignant-tumors-difference/

http://screening.iarc.fr/atlasoralclassiftnm.php

https://oralcancerfoundation.org/cdc/early-detection-diagnosis-staging/

https://www.cancerresearchuk.org/about-cancer/mouth-cancer/getting-diagnosed/tests-stage/blood-tests

http://oralcancerfoundation.org/discovery-diagnosis/cancer-screening-protocols/

https://www.cancer.net/navigating-cancer-care/diagnosing-cancer/stages-cancer

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3818094/pdf/nihms398693.pdf

https://www.healthline.com/symptom/skin-lesion

https://emedicine.medscape.com/article/2048034-overview

https://www.google.co.id/amp/s/amp.cancer.org/cancer/oral-cavity-and-oropharyngeal-cancer/treating/by-
stage.html

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