Understanding of Oral Oncology and its Changes in Dynamics in Nepal

Abstract

With the increase in smoking habits, oral cancer is turning into a threat among smokers. It is also due to a lack of awareness among people, oral cancer is increasing rapidly. The increased rate of illiterate people in Nepal has been a reason for a change in dynamics. Due to a lack of awareness, people are diagnosed late with cancer which leads to an increased mortality rate. So, awareness is a must for the reduction of oral cancer. In most cases, surgery is the best chance. Since people in Nepal are mostly from middle-class families, it highly impacts their life. The article primarily addresses the incidence of oral cancer in Nepal. It also emphasizes the risk factors and causes of oral cancer along with its diagnosis and surgery.

Full text

1
www.europasianjournals.org Europasian J Med Sci.
Vol. 3 | No. 1 | Jan-Jun Issue | 2021
Europasian Journal
of Medical Sciences
https://doi.org/10.46405/ejms.v3i1.190
Understanding Oral Oncology and its Changes in Dynamics in Nepal
Aaniya Shrestha
ABSTRACT
With the increase in smoking habits, oral cancer is turning into a threat
among smokers. It is also due to a lack of awareness among people, oral
cancer is increasing rapidly. The increased rate of illiterate people in Nepal
has been a reason for a change in dynamics. Due to a lack of awareness,
people are diagnosed late with cancer which leads to an increased
mortality rate. So, awareness is a must for the reduction of oral cancer. In
most cases, surgery is the best chance. Since people in Nepal are mostly
from middle-class families, it highly impacts their life. The article primarily
addresses the incidence of oral cancer in Nepal. It also emphasizes the
risk factors and causes of oral cancer along with its diagnosis and surgery.
Keywords: awareness; dental oncology; oral squamous cell carcinoma;
tobacco; treatment
Original Article
Author Info:
Under Graduate Student,
Rajshahi University, Rangpur,
Bangladesh
Corresponding Author:
Email/Contact:
aaniyashrestha1999@gmail.
com
QR Code Article Info
Scan Me
Received: 28 November 2020; Accepted: 26 February 2021; Published Online: 27 February 2021
How to cite this article in Vancouver Style?
Shrestha A. Understanding of Oral Oncology and its Changes in Dynamics. Europasian J Med Sci. 2021; 3(1):
https://doi.org/10.46405/ejms.v3i1.190
Disclaimer
Conict of Interest: None Declared; Source of Support: Nil
Copyright © 2020 by author(s). This work is licensed under the terms and condition of Creative Commons Attribution International
License 4.0 (http://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited. This is an open access publication, and can be downloaded freely from the
website of the Journal:
www.europasianjournals.org. The Journal as well as publisher remain neutral with regards to any jurisdictional
claims in any published articles, its contents and the institutional afliations of the authors. The Europasian Journal of Medical Sciences
(EJMS) (www.europasianjournals.org) is an ofcial Journal of Nirvana Psychosocial Care Center & Ressearch Institute (www.nirvanapscc.
com).

www.europasianjournals.org Europasian J Med Sci.
Vol. 3 | No. 1 | Jan-Jun Issue | 2021
Europasian Journal
of Medical Sciences
2
https://doi.org/10.46405/ejms.v3i1.190
INTRODUCTION
Introduction: Cancer may be dened as a malignant
tumor either sarcoma or carcinoma. Whereas,
abnormal malignant swelling in any part of the
oral cavity (i.e. head and neck region) is called oral
cancer [Figure 1]. If a person has oral cancer, not
only will the person feel discomfort in the facial
region but also the digestive system will become
affected. One common sign of oral cancer is an
oral ulcer that may be painful. If the ulcer persists
for more than 2 weeks one has to visit a dentist
for early diagnosis and treatment. Oral cancer
is predominantly oral squamous cell carcinoma
(OSCC) and is mainly caused in the oropharynx by
human papilloma virus (HPV). It is believed that the
rate of HPV cancer will increase in the following
years based on the habits of the surrounding
population.1
EPIDEMIOLOGY
Oral cancer is a non-communicable disease that
holds the sixth position in the world.2 In 1990, there
were more than 84,000 deaths due to oral cancer.
Similarly, 135,000 deaths in 2013 whereas in 2018,
355,000 people were victims and 177,000 were
dead worldwide. It occurs that almost one-fourth
of all new cases of cancer are oral.3
Compared to developed countries, developing
countries appear to be more victimized.4 Oral
cancer is also rising in Nepal. Oral cancer death
in Nepal had been 1,341 in 2017, according to
the World Health Organization (WHO). Hence
Nepal was named 25th in the world.5 It is the third
most common type of cancer in Nepal.6 The most
recurrent oral cancer site was found as tongue
(42.5%) followed by buccal mucosa (27.2%) based
on the survey done in 2010. But when analyzed
on the basis of the geographic location, buccal
mucosa in the Terai sector was the most common
site for OSCC (63.9%) and notably the Madhesi
ethic group (34.2%). 7
In recent times, there has been some change
in dynamics. The reason for the change in the
dynamics of oral cancer is mainly due to people’s
lifestyles and lack of knowledge among the people
about the harmful and adverse effects of tobacco
and other related items.8 Due to greater access
to these products with no supply restriction and
lack of awareness of oral cancer risk factors such
as tobacco, people with low socioeconomic status
are at higher risk. It mostly occurs to those who
drink and smoke often. It is important to note that
people who do not smoke and only drink alcohol
occasionally are victims of oral cancers. According
to data, over 25% of all population belongs to this
group.
Oral cancer is mostly seen in people over the age of
40; especially men possibly because of differences
in risk habits. But in the case of Nepal, it seems that
there is a change in dynamics. Females are more
likely to suffer from oral cancer mainly due to the
use of tobacco. The main concern arises among
pregnant women.9 The state of cancer affects not
only the mother but also the child. Babies from
such mothers are usually born with fetal disorders.10
RISK FACTORS AND CAUSES
Tens and thousands of microorganisms exist as
a part of oral ora in the mouth [Table 2]. They
usually benet the body by preventing infection.
Nevertheless, if a patient is immunocompromised,
the normal ora can overgrow and become
pathogenic and may contribute to the
development of a tumor. Based on the evidence,
chronic inammatory disease (periodontitis, poor
oral hygiene) can also cause oral oncogenesis. But
this might be a possibility as no evidence has been
proven yet.11
Oral potentially malignant disorders (OPMDs) like
leukoplakia (white or grayish patches) erythroplakia
(bright red velvety patch) [Figure 1], and oral
submucous brosis are also considered responsible
for OSSC. It is an aggressive tumor. The cases
are usually advanced and require multimodality
therapy. Therefore, in case of low and middle-
income countries like Nepal, the 5‐year survival of
OSCC patient’s is 23–57%.12
Another cause of mortality in OSCC is due to
metastasis to the lymph node. The neoplasm may
also be derived from connective tissues, lymphoid
tissues, minor salivary glands, melanocytes, and or
metastasis from distant tumors.12
Risk factors include the use of different forms of
tobacco, cigarette, cigar, gutkha, pan-masala, betel
nuts. Others include illiteracy, lack of awareness;
reverse end smoking, HPV virus, mouthwashes with
high alcohol content, trauma in the mouth, etc.
Alcohol promotes the activation of procarcinogens
and acts as a solvent for the introduction of harmful
carcinogens into the body cells.13 While tobacco
smoke comprises >4000 chemical compounds and
60 of them are considered to be toxic to humans.14
90% of the cases reported for oral cancer are due to
the intake of tobacco in various forms.15 However,
the survival rate also depends on factors including
Shrestha A. Understanding Oral Oncology ...........

3
www.europasianjournals.org Europasian J Med Sci.
Vol. 3 | No. 1 | Jan-Jun Issue | 2021
Europasian Journal
of Medical Sciences
https://doi.org/10.46405/ejms.v3i1.190
Shrestha A. Understanding Oral Oncology ...........
epidemiology and therapeutic development.16
DISTRIBUTION OF CANCER IN ORAL CAVITY
Signals from the connective tissue surrounding
a tumor are believed to play a vital role in the
spread of oral cancer.17 An invasive squamous
cell carcinoma means that cancer has entered to
deeper parts of the oral cavity.18 [Figure 2]
SIGNS AND SYMPTOMS
People usually know that they have cancer after
they experience some abnormal swelling, ulcer, or
difculty in the oral cavity. Unfortunately, patients
are diagnosed after the development of symptoms
in an advanced stage (such as discomfort,
dysphagia, reduced tongue movement, and ability
to open the mouth, weight loss, and loss of sensory
function).19
Nevertheless, cancer may be asymptomatic so
during a professional career, a dentist might not
experience an average of more than 5-10 patients
with oral cancer. This leads to a late diagnosis of
cancer.20
TNM CLASSIFICATION AND STAGING
TNM classication and staging of oral cancer are
presented in Table no. 3 and Table no. 4 respectively.
DIAGNOSIS
Some tests for diagnosis of oral cancer include
Physical examination, Endoscopy, Biopsy, Oral brush
biopsy, HPV testing, X-ray, Computed tomography
(CT or CAT) scan, MRI, Barium swallow, PET scan,
Panorex lm.21 These diagnosis and early detection
of oral cancer is encouraged by different aspects.
Salivary biomarkers namely L-phenylalanine,
Cluster of differentiation factor 34 (CD34), Genomic
biomarkers namely integrin α3 and β4, proteomic
biomarker aid evaluate and distinguish oral cancer
monitoring and differentiation.22
TREATMENT
Cancer treatment differs from person to person
based on the location, extension, stage, age, side
effects from the treatment, patient’s mental and
economic status as well as patient’s preference and
specialist’s advice.23
• Surgery: Surgery is the rst choice in most
cases. It may vary as per tumor size and location.
Surgery may either be to eliminate cancer or
to repair a function damaged by cancer. If the
cancer is in an advanced stage removing the
tumor might be straight forward but might
leave a void. To repair this, the surgeon will
perform a skin graft for reconstruction that
came from the thigh and upper arm.24 The
surgery can be complicated and can take more
than 6 hours in some cases
• Radiation therapy: radiation beams are aimed
every once, twice, and sometimes even ve to
eight times a week. It is given to suppress cancer
symptoms or prevent them from spreading.
• Chemotherapy: It is given by an oral or
parenteral route.
• Others include: Combined therapy, Targeted
therapy, Immune therapy, Gene therapy,
Hormone therapy
• Favorable chemo preventive agents for oral
cancer include β-carotene, retinoid, N-acetyl
cysteine, NSAIDs, vitamin-E.25
• Lastly, mouth should be kept healthy during
oral cancer.
• Patients in stage I or II do well after surgery and
therapy. If cancer is in the last stage, surgery
followed by chemotherapy and radiotherapy is
done. It is more expensive and aggressive than
in an early stage.26
COST-EFFECTIVE TREATMENT
1. Our body has a defense system for foreign
particles. Similarly, for cancer, our body secretes
melatonin which is known for its antioxidant
activity. This protects us from cancer.27 It is secreted
mostly during night time so a healthy and sound
sleep is necessary.
2. Tulsi (Ocimum sanctum) acts as a cytotoxic
substance mainly due to apoptosis. Its constituents
help to reduce early cancer.28
3. Besides therapy, one must also take care of
their diet. During the treatment, a person might
experience difculty in swallowing and a poor
appetite. So, a proper meal is essential which will
give the right nutrients like green leafy vegetables,
sweet potatoes, carrots, lemon, oranges, papaya,
tomatoes, grapes, avocado, green tea, etc. Evidence
also proves that drinking raspberry juice regularly
can cure oral oncogenesis.29
AWARENESS AND ALERTNESS
“Prevention is better than cure”. “Cancer” itself
sounds threatening and when it comes to a less
educated population like Nepal people usually have
misconceptions about it. It is most likely due to a
lack of health education in a particular population.
Although several dental health camps are placed
every year in different provinces of Nepal, this is

www.europasianjournals.org Europasian J Med Sci.
Vol. 3 | No. 1 | Jan-Jun Issue | 2021
Europasian Journal
of Medical Sciences
4
https://doi.org/10.46405/ejms.v3i1.190
still not enough for the vast population living
around. Cancer begins with dysplasia in the body
and risk factors and preventive measures play
a greater role in this.22 For oral cancer to decline
at a larger scale people must be made aware of
the importance of oral hygiene and the Minister
of Health and Population (MoHP) should make
rules of regular dental checkups and programs like
National Strategic Plan for Oral Health for Nepal
(2001-2002) [WHO].30 Dental checkups must of
course include screening tests. It is a test used by
the dentist or dental assistant to check possible
signs of cancer or precancerous condition in the
oral cavity. The main objective is to identify oral
cancer at an early stage for a better cure. Oral-
based questionnaires can help us to be sure
about the oral health condition. Evidence shows
that visual evaluation is useful in reducing oral
cancer mortality in patients at risk. Mass media
campaigns like broadcasting in television, radio,
and public campaigns are also helpful. But till the
Shrestha A. Understanding Oral Oncology ...........
Figure 3: A screening test for oral cancer38
Figure 2: Chances of oral cancer in different parts
of oral cavity
Figure 1: Parts of the oral cavity with precancerous
conditions

5
www.europasianjournals.org Europasian J Med Sci.
Vol. 3 | No. 1 | Jan-Jun Issue | 2021
Europasian Journal
of Medical Sciences
https://doi.org/10.46405/ejms.v3i1.190
Shrestha A. Understanding Oral Oncology ...........
Table 1: Risk factors of oral cancer39
Environmental factor Emergency risk factors Genetic factor Not modiable Infective viruses
Lifestyle(drinking
alcohol, smoking,
poor oral hygiene)
Immunosuppression
(like candidiasis)
Plummer-vinson
syndrome Age HPV (Human Papilloma Virus)
Low socio- economic
status
HPV (Human
Papilloma Virus)
Fanconi’s
anemia
Family history
of cancer Ebv(Epstein Barr Virus)
Exposure to radiation Diabetes Ethnicity HSV (Herpes Simplex Virus)
Improper diet Dyskeratosis
dysgenesis Gender HCV (Hepatitis C Virus)
Table 2: Virus associated with Oral Cancer40
Virus Event
HSV 1 It is a strongly associative factor. Causes oral infections. The virus acts as a mutagen and results in malignancy.
HCV Causes risk of genetic instability in the cells. From saliva and serum, squamous cells of the oral cavity are exposed
to HCV in the affected patient resulting in the development of OSSC.
EBV The virus might not have a direct effect but is associated with immunodeciency.
HPV It is also a strongly associative factor. It is a sexually transmitted disease. The oral lesion is the major cause of
cancer. They are :vulgar wart (HPV-4), papilloma’s (HPV-11), leukoplakia (HPV-6)
Table 3: TNM classication41
TX Primary tumor cannot be assessed.
TO No evidence of a primary tumor.
Tis Carcinoma in situ. It is the early stage of cancer that has not been spread to deeper tissues or metastasized. It
gives you the idea about cancer without any invasion.
T1 Tumor ≤ 2 cm
T2 Tumor 2 - 4 cm.
T3 Tumor ≥4 cm.
T4 Tumor invades adjacent structures such cortical bone, base of the skull, inferior alveolar nerve, oor of mouth,
skin of face , chin or nose, maxillary sinus etc.
NX Nearby lymph nodes cannot be assessed.
N0 No involvement of lymph node
N1 One lymph node involved on the same side as the primary tumor. This lymph node is smaller than 3 cm across.
N2a Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N3 The cancer has spread to a lymph node that measures more than 6 cm across.
M0 No spread of cancer to other parts of the body
M1 Metastasis occurred.

www.europasianjournals.org Europasian J Med Sci.
Vol. 3 | No. 1 | Jan-Jun Issue | 2021
Europasian Journal
of Medical Sciences
6
https://doi.org/10.46405/ejms.v3i1.190
government does not emphasize these rules, we as
our caretaker can visit the dentist and do a regular
dental checkup. The willingness of individual health
practitioners and medical centers to engage in pre-
cancer screening and oral health promotion needs
to be strengthened. Since the screening test is
simple one can self-examine at home from time to
time via the internet [Figure 3].
If a patient is found with OPMDs, they can then
be referred for verication, conrmation, and case
management with necessary counseling. The main
drawback is that the people remain unaware of
the condition as it might not show any symptoms.
Some of them are of low evidence so research
must include therapeutic strategies and prognostic
markers.
RECOVERY, RECONSTRUCTION, AND
REHABILITATION FROM ORAL CANCER
TREATMENT
Cancer has a huge effect on the economy as well as
on the mental health of an individual. In a country
like Nepal where people are mostly middle class
and about 66% being farmers, it is hardly possible
for them to pay their medical bills.
Surgery in the head and neck region may have a
psychological effect. It can affect the appearance of
people. With intense reconstructive surgery, there
is a high chance of injury.32-35 Surgery may include
graft transplant, dental implants, and articial
palates to replace any missing tissue or teeth.31
Maxillofacial trauma is another reason for death in
people even after the successful removal of cancer.
The lengthy recovery time causes depression,
frustration, and or Post Traumatic Stress Disorder
(PTSD).32-35 Radiation can lead to pancytopenia so
after cancer treatment patients are advised for CBC.
Recovery from oral cancer may rely on both tumor
and surgery. If the huge tumor has been removed
from the tongue, palate, or gum and replaced
it by a skin graft, the graft might not be able to
perform the normal function. Usually, people need
rehabilitation with eating and speaking during
recovery. Speech therapy is necessary post-surgery
for optimal improvement.36-37
CONCLUSION
Oral cancer is a widespread disease and Nepal has
been a victim of it for the past few years. There has
been a change in the dynamics of oral oncology
where females have been more victimized than the
male. It can be easily prevented by avoiding cancer-
responsible factors such as maintaining a better
lifestyle and oral hygiene. Treatment of cancer can
cost a fortune. So, the best solution would be to
take preventive measures and reduce the chance
of oral cancer for better. “Why cure cancer when we
can prevent it from happening”.
REFERENCES
1. Westra WH. The changing face of head and
neck cancer in the 21st century: the impact of
HPV on the epidemiology and pathology of
oral cancer. Head and neck pathology. 2009;
3(1): 78. [https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC2807531/][Google scholar] [Full
Text]
2. Zakrzewska JM. Oral cancer. BMJ. 1999 Apr
17; 318(7190): 1051-4. [https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC1115452/][Google
Scholar] [Full Text]
3. Gajurel R, Gautam D, Pun C, Dhakal H, Petrovski
B, Costea D et al. Trends and clinicopathological
characteristics of oral squamous cell carcinomas
reported at a tertiary cancer hospital in Nepal
during 1999 to 2009. Clinical and Experimental
Dental Research. 2020; 6(3): 356-362.
[https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC7301398/][Google Scholar] [Full Text]
4. Gupta N, Gupta R, Acharya AK, Patthi B, Goud
V, Reddy S, Garg A, Singla A. Changing Trends
in oral cancer-a global scenario. Nepal journal
of epidemiology. 2016 Dec; 6(4): 613. [https://
pubmed.ncbi.nlm.nih.gov/28804673/] [Google
Scholar][Full Text]
5. Warnakulasuriya S. Global epidemiology of oral
and oropharyngeal cancer. Oral oncology. 2009
Apr 1; 45(4-5): 309-16. [https://pubmed.ncbi.
nlm.nih.gov/18804401/][Google Scholar] [Full
Text]
6. Moore SR, Johnson NW, Pierce AM, Wilson
DF. The epidemiology of mouth cancer: a
Shrestha A. Understanding Oral Oncology ...........
Table 4: Oral Cancer Staging41
Stages T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III
T1
T2
T3
N1
N1
N0, N1
M0
M0
M0
IV
T4
Any T
Any T
N0 ,N1
N2, N3
Any N
M0
M0
M1

7
www.europasianjournals.org Europasian J Med Sci.
Vol. 3 | No. 1 | Jan-Jun Issue | 2021
Europasian Journal
of Medical Sciences
https://doi.org/10.46405/ejms.v3i1.190
Shrestha A. Understanding Oral Oncology ...........
review of global incidence. Oral diseases. 2000;
6(2): 65-74. [https://pubmed.ncbi.nlm.nih.
gov/10702782/][Google Scholar] [PubMed]
[Full Text]
7. MoHP (2010) Brief Prole on Tobacco Control
in Nepal. Government of Nepal, Ministry of
Health and Population, Kathmandu. [https://
www.who.int/fctc/reporting/party_reports/
nepal_2012_annex2_tobacco_prole.pdf] [Full
Text]
8. Nagy KN, Sonkodi I, Szöke I, Nagy E, Newman
HN. The microora associated with human
oral carcinomas. Oral oncology. 1998 Jul 1;
34(4): 304-8. [https://pubmed.ncbi.nlm.nih.
gov/9813727/] [Google Scholar] [PubMed]
[Full Text]
9. Bloch M, Althabe F, Onyamboko M, Kaseba-
Sata C, Castilla EE, Freire S, Garces AL, Parida
S, Goudar SS, Kadir MM, Goco N. Tobacco
use and secondhand smoke exposure during
pregnancy: an investigative survey of women
in 9 developing nations. American journal of
public health. 2008; 98(10): 1833-40. [https://
pubmed.ncbi.nlm.nih.gov/18309125/] [Google
Scholar] [PubMed] [Full Text]
10. New Age Dentistry - Aordable Cosmetic
& Family Dentist in Albuquerque [Internet].
New Age Dentistry. 2020 [cited 9 August
2020]. Available from: [https://www.
newagedentistryabq.com/] [Full Text]
11. Mager DL, Haffajee AD, Devlin PM, Norris
CM, Posner MR, Goodson JM. The salivary
microbiota as a diagnostic indicator of oral
cancer: a descriptive, non-randomized study of
cancer-free and oral squamous cell carcinoma
subjects. Journal of translational medicine.
2005; 3(1): 1-8. [https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC1226180/] [Google Scholar]
[Full Text]
12. Bagan J, Sarrion G, Jimenez Y. Oral cancer:
clinical features. Oral oncology. 2010 Jun 1;
46(6): 414-7. [https://pubmed.ncbi.nlm.nih.
gov/20400366/] [Google Scholar] [PubMed]
[Full Text]
13. Levitz JS, Bradley TP, Golden AL. Overview of
smoking and all cancers. Medical Clinics. 2004;
88(6): 1655-75. [http://www.sciepub.com/
reference/56040] [Google Scholar] [Full Text]
14. Johnson NW, Amarasinghe HK. Epidemiology
and aetiology of head and neck cancers.
In Head and neck cancer 2016 (pp.
1-57). Springer, Cham. [http://link-
springer-com-443.webvpn.fjmu.edu.cn/
chapter/10.1007%2F978-3-319-27601-4_1]
[Google Scholar] [Full Text]
15. Mourad M, Jetmore T, Jategaonkar AA,
Moubayed S, Moshier E, Urken ML.
Epidemiological trends of head and neck cancer
in the United States: a SEER population study.
Journal of Oral and Maxillofacial Surgery. 2017;
75(12): 2562-72. [https://pubmed.ncbi.nlm.nih.
gov/28618252/] [Google Scholar] [PubMed]
[Full Text]
16. Mahal BA, Catalano PJ, Haddad RI, Hanna GJ,
Kass JI, Schoenfeld JD, Tishler RB, Margalit
DN. Incidence and demographic burden of
HPV-associated oropharyngeal head and
neck cancers in the United States. Cancer
Epidemiology and Prevention Biomarkers.
2019; 28(10): 1660-7. [https://pubmed.ncbi.
nlm.nih.gov/31358520/] [Google Scholar]
[PubMed] [Full Text]
17. Cheng YS, Rees T, Wright J. A review of research
on salivary biomarkers for oral cancer detection.
Clinical and translational medicine. 2014; 3(1):
3. [https://clintransmed.springeropen.com/
articles/10.1186/2001-1326-3-3] [Google
Scholar] [Full Text]
18. Mackay J, Crofton J. Tobacco and the
developing world. British Medical Bulletin.
1996; 52(1): 206-21. [http://europepmc.org/
article/MED/24494133] [Google scholar] [Full
Text]
19. Ford PJ, Farah CS. Early detection and diagnosis
of oral cancer: Strategies for improvement.
Journal of Cancer Policy. 2013; 1(1-2): e2-
7. [https://www.sciencedirect.com/science/
article/pii/S2213538313000039] [Google
Scholar] [Full Text]
20. Robbins KT, Clayman G, Levine PA, Medina
J, Sessions R, Shaha A, Som P, Wolf GT. Neck
dissection classication update: revisions
proposed by the American Head and Neck
Society and the American Academy of
Otolaryngology–Head and Neck Surgery.
Archives of otolaryngology–head & neck
surgery. 2002; 128(7): 751-8. [https://pubmed.
ncbi.nlm.nih.gov/12117328/] [Google Scholar]
[PubMed] [Full Text]
21. D’souza S, Addepalli V. Preventive measures
in oral cancer: An overview. Biomedicine &
Pharmacotherapy. 2018; 107: 72-80. [https://
pubmed.ncbi.nlm.nih.gov/30081204/] [Google
Scholar] [PubMed] [Full Text]
22. Shah S, Kaur M. Biomarkers and chemo-
preventives in oral carcinogenesis and its
prevention. Journal of oral and maxillofacial
pathology: JOMFP. 2014 ; 18(1): 69. [https://www.

www.europasianjournals.org Europasian J Med Sci.
Vol. 3 | No. 1 | Jan-Jun Issue | 2021
Europasian Journal
of Medical Sciences
8
https://doi.org/10.46405/ejms.v3i1.190
Shrestha A. Understanding Oral Oncology ...........
researchgate.net/publication/263355142_
Biomarkers_and_chemopreventives_in_oral_
carcinogenesis_and_its_prevention] [Google
Scholar] [Full Text]
23. Liu HE. Changes of satisfaction with appearance
and working status for head and neck tumor
patients. Journal of clinical nursing. 2008;
17(14): 1930-8. [https://www.researchgate.net/
publication/5276985_Changes_of_satisfaction_
with_appearance_and_working_status_for_
head_and_neck_tumour_patients] [Google
Scholar][Full Text]
24. Diagnosis [Internet]. Stanfordhealthcare.org.
2020 [cited 10 August 2020]. Available from:
[https://stanfordhealthcare.org/medical-
conditions/cancer/oral-cancer/oral-cancer-
diagnosis.html] [Full Text]
25. Girod SC, Pfahl M. Retinoid actions and
implications for prevention and therapy of
oral cancer. International journal of oral and
maxillofacial surgery. 1996; 25(1): 69-73.
[https://pubmed.ncbi.nlm.nih.gov/8833305/]
[Google Scholar] [PubMed] [Full Text]
26. Treatment Options for Oral Cavity and
Oropharyngeal Cancer by Stage [Internet].
Cancer.org. 2020 [cited 11 August 2020].
Available from: [https://www.cancer.org/
cancer/oral-cavity-and-oropharyngeal-cancer/
treating/by-stage.html] [Full Text]
27. Shivpuje P, Ammanangi R, Bhat K, Katti S. Effect
of Ocimum sanctum on Oral Cancer Cell Line:
An in vitro Study. The journal of contemporary
dental practice. 2015; 16(9): 709. [https://
pubmed.ncbi.nlm.nih.gov/26522595/] [Google
Scholar] [PubMed] [Full Text]
28. Key TJ, Schatzkin A, Willett WC, Allen NE,
Spencer EA, Travis RC. Diet, nutrition and the
prevention of cancer. Public health nutrition.
2004; 7(1a): 187-200. [https://pubmed.ncbi.
nlm.nih.gov/14972060/] [Google Scholar]
[PubMed] [Full Text]
29. Warner BM, Casto BC, Knobloch TJ, Accurso BT,
Weghorst CM. Chemoprevention of oral cancer
by topical application of black raspberries
on high at-risk mucosa. Oral surgery, oral
medicine, oral pathology and oral radiology.
2014; 118(6): 674-83. [https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC4254525/] [Google
Scholar] [Full Text]
30. Srii R, Kleinegger C, Marla V, Upadhyaya C.
Tobacco related oral cancer in Nepal: Smoked vs
Smokeless Tobacco. Oral Surgery, Oral Medicine,
Oral Pathology and Oral Radiology. 2017;
124(3): e206-e207. [https://www.oooojournal.
net/article/S2212-4403(17)30868-4/fulltext]
[Google Scholar][Full Text]
31. Soares Ade J. Farias Rocha Lima T, Nagata JY,
Gomes BP, Zaia AA, de Souxa-Filho FJ. Intra
canal dressing paste composed by calcium
hydroxide, chlorhexidine and zinc oxide
for the treatment of immature and mature
traumatized teeth. Braz J Oral Sci. 2014; 13: 1-6.
[https://www.scielo.br/scielo.php?pid=S1677-
32252014000100006&script=sci_arttext]
[Google Scholar] [Full Text]
32. Friedland PL, Bozic B, Dewar J, Kuan R, Meyer
C, Phillips M. Impact of multidisciplinary team
management in head and neck cancer patients.
British journal of cancer. 2011; 104(8): 1246-8
[https://pubmed.ncbi.nlm.nih.gov/21448166/]
[Google Scholar] [PubMed] [Full Text]
33. Frodel Jr JL. Dealing with the difcult trauma
and reconstructive surgery patient. Facial
Plastic Surgery Clinics of North America. 2008;
16(2): 225-31. [https://pubmed.ncbi.nlm.nih.
gov/18355709/] [Google Scholar] [PubMed]
[Full Text]
34. VanSwearingen J. Facial rehabilitation: a
neuromuscular reeducation, patient-centered
approach. Facial plastic surgery. 2008;
24(02): 250-9. [https://pubmed.ncbi.nlm.nih.
gov/18470837/] [Google Scholar] [PubMed]
[Full Text]
35. Shepherd JP, Qureshi R, Preston MS, Levers
BG. Psychological distress after assaults and
accidents. BMJ: British Medical Journal. 1990
Oct 13; 301(6756): 849. [https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC1663975/] [Google
Scholar] [Full Text]
36. Sen P, Ross N, Rogers S. Recovering maxillofacial
trauma patients: the hidden problems. Journal
of wound care. 2001 Mar; 10(3): 53-7. [https://
www.researchgate.net/publication/11441626_
Recovering_maxillofacial_trauma_patients_
The_hidden_problems] [Google Scholar] [Full
Text]
37. Valdez JA, MAS MT. Impact of oral cancer on
quality of life. Oral Cancer, An Issue of Dental
Clinics of North America, E-Book. 2017;
62(1): 143. [https://pubmed.ncbi.nlm.nih.
gov/29126491/] [Google Scholar] [PubMed]
[Full Text]
38. Oral Cancer Screening | Carrollton Advanced
Family Dentistry [Internet]. Dentistatdallas.
com. 2020 [cited 12 August 2020]. [https://
dentistatdallas.com/index.php/therapies/oral-
cancer-screening/] [Full Text]
39. Malay Kumar, Ronak Nanavati, Tapan G. Modi,
Chintan Dobariya. Oral Cancer: Etiology
and Risk factor: A review. Journal of Cancer

9
www.europasianjournals.org Europasian J Med Sci.
Vol. 3 | No. 1 | Jan-Jun Issue | 2021
Europasian Journal
of Medical Sciences
https://doi.org/10.46405/ejms.v3i1.190
Shrestha A. Understanding Oral Oncology ...........
Research and Therapeutics. 2016 Jul 25; 12(2):
458-463 [https://www.cancerjournal.net/
article.asp?issn=0973-1482;year=2016;volume
=12;issue=2;spage=458;epage=463;aulast=Ku
mar] [Google Scholar] [Full Text]
40. Patil SP, Sodhi SJ, Tambe SD, Gada V, Vikhe
D. Viruses in Oral Squamous Cell Carcinoma:
A Review, Pravara Med. Rev. 8 2016; 8(1):4–7
[https://www.pravara.com/pmr/pmr-8-1-2.pdf]
[Google Scholar] [Full Text]
41. Hermanek P, Sobin LH. TNM
classication of Malignant Tumours
[https://books.google.com.np/