Comprehensive Report on Oral Cancer in Germany: A Detailed Analysis

This report provides a comprehensive overview of oral cancer in Germany, encompassing its definition, causes, and various types, with a particular focus on squamous cell carcinoma. It delves into the dental background, including the structure and function of the mouth, and explores both cancerous and precancerous conditions. The report identifies key risk factors, such as tobacco use, alcohol consumption, and HPV, and examines the signs, symptoms, and stages of oral cancer, along with screening methods. The epidemiology of oral cancer in Germany is analyzed, including the impact of drinking and smoking habits. The economic burden of the disease is also considered. Furthermore, the report outlines treatment options by stage, including radiation therapy, surgery, chemotherapy, and targeted drug therapy, alongside preventive measures. Overall, this report serves as a valuable resource for understanding and addressing oral cancer in the German context.

ORAL CANCER IN GERMANY
[Author Name(s), First M. Last, Omit Titles and Degrees]
[Institutional Affiliation(s)]

Contents
ABSTRACT....................................................................................................................................................5
DEFINITION AND CAUSES............................................................................................................................5
TYPES OF ORAL CANCER..............................................................................................................................7
DENTAL BACKGROUND................................................................................................................................8
The Mouth...............................................................................................................................................8
Structure of the Mouth........................................................................................................................9
The function of the Mouth................................................................................................................10
Cancerous tumors of the Mouth...........................................................................................................11
Rare Mouth tumors...............................................................................................................................11
Precancerous Mouth Conditions...........................................................................................................11
Leukoplakia........................................................................................................................................11
Erythroplakia.....................................................................................................................................13
Non-cancerous tumors and mouth conditions..................................................................................14
MAIN DRIVERS CAUSING ORAL CANCER....................................................................................................16
Known Risk Factors................................................................................................................................17
Tobacco.............................................................................................................................................18
Betel quid and areca nut....................................................................................................................18
Human papillomavirus.......................................................................................................................20
Inherited conditions..........................................................................................................................20
Graft versus host disease...................................................................................................................21
Lichen planus.....................................................................................................................................21
Weakened immune system...............................................................................................................21
Family history regarding squamous cell carcinoma...........................................................................21
Exposure to sun.................................................................................................................................21
Previous cancer.................................................................................................................................22
Poor oral health.................................................................................................................................22
Unbalanced diet (low in fruits and vegetables).................................................................................22
LINK OF ORAL CANCER WITH ALCOHOL AND SMOKING............................................................................22
SIGNS AND SYMPTOMS OF ORAL CANCER................................................................................................25

Stages of Oral Cancer.............................................................................................................................27
Grading of Oral Cancer..........................................................................................................................29
Low-grade oral cancer...........................................................................................................................29
High-grade oral cancers.........................................................................................................................29
SCREENING METHODS FOR ORAL CANCER................................................................................................30
Visual oral cancer examination..............................................................................................................31
Oral cytology.........................................................................................................................................31
Direct visualization................................................................................................................................32
Aspiration..............................................................................................................................................32
Excisional Biopsy....................................................................................................................................32
Incisional Biopsy....................................................................................................................................33
EPIDEMIOLOGY..........................................................................................................................................33
Epidemiology of Oral Cancer in Germany..............................................................................................36
EPIDEMIOLOGY OF DRINKING AND SMOKING IN GERMANY.....................................................................41
EPIDEMIOLOGY OF SMOKING IN GERMANY..............................................................................................44
ECONOMIC BURDEN OF ORAL CANCER.....................................................................................................47
Estimates of the Cost of Illness..............................................................................................................47
LIMITATIONS.............................................................................................................................................51
TREATMENT OPTIONS FOR ORAL CAVITY AND OROPHARYNGEAL CANCER BY STAGE..............................52
Stage 0...................................................................................................................................................52
Stages I and II.........................................................................................................................................53
Stages III, IV, IVA....................................................................................................................................54
Stages IV B and IV C...............................................................................................................................55
DIAGNOSIS AND TREATMENT OF ORAL CANCER.......................................................................................57
Diagnosis...............................................................................................................................................57
Stages of Mouth Cancer........................................................................................................................57
Treatment..............................................................................................................................................58
Radiation therapy..............................................................................................................................58
Surgery..................................................................................................................................................58
Surgery for reconstructing the mouth...............................................................................................59
Surgery to eliminate tumor...............................................................................................................59
Surgery for the removal of cancer that has spread to the neck.........................................................59

Targeted drug therapy...........................................................................................................................60
Chemotherapy.......................................................................................................................................60
PREVENTION OF ORAL CANCER.................................................................................................................60
Quit tobacco smoking............................................................................................................................60
Quit consumption of alcohol.................................................................................................................61
Alternative medicine.............................................................................................................................61
CONCLUSION.............................................................................................................................................62
REFERENCES..............................................................................................................................................62

ABSTRACT
The main causes of oral cancer are among them use of tobacco, heavy consumption of
alcohol and chewing areca nut all of which can be avoided and thus preventing the disease.
Preceded by precancerous conditions and lesions, early-stage oral cancers present themselves as
tiny painless growths or ulcers which can be noticed through careful and elaborate examination
and further effective treatment administered. Prevention, early detection alongside treatment is
among the most effective interventions that can be used in the reduction of the burden of oral
cancer in Germany and the world at large.
DEFINITION AND CAUSES
Cancer can generally be defined as the presence of uncontrollable growth which attacks
and results in damage or wearing out of the neighboring cells and tissues. Oral cancer (mouth
cancer) comes out as a sore or growth inside the mouth but that does not disappear (Alkureishi et
al. 2010). There are various types of oral cancer among them cancer of lips, sinuses, throat or
pharynx, tongue, cheeks, and cancer of the floor of the mouth may turn out to be one of the
devastating occurrences in the human life in case treatment and diagnosis is not done early
enough. Oral cancer is a head and neck type of cancer having the growth of its cancerous tissue
being located in the oral cavity.
It may be as a primary lesion that is coming from any of the tissues found in the mouth
through metastasis, that is, from a different site of origin. Cancer may also be through an
extension from an anatomic structure that is from the neighboring cells, for example, the nasal
cavity (Audeh et al. 2010). Still, oral cancers may be from any of the numerous issues that are
found in the mouth and could be of different histologic types among them teratoma and

adenocarcinoma which originate from a major or minor salivary gland. It may also be from
melanoma which is from the cells which produce pigment the oral mucosa or even from the
lymphoma which is from the tonsillar or the other tissues of the lymphoid system.
Figure 1: Oral Cancer can appear as a tumor or lesion anywhere in the mouth extracted from
medicalnewstoday.com
Oral cancer starts in the cells of the mouth. A malignant or cancerous tumor refers to a
collection of cancer cells that have the capability to grow into the surrounding tissues and lead to
their destruction. A tumor may also spread or metastasize to the other various body parts. In most
cases, oral cancer spread to the lymph nodes that are found in the neck (Blomberg et al. 2011).
The mouth cells at times change and do not undergo normal growth or behavior. Such changes
result in non-cancerous tumors among them fibromas and warts. Such changes in the cells of the
mouth may also lead to precancerous conditions which basically refer to abnormal cells that are
not yet declared as cancer even though they have chances of becoming cancer should treatment
and diagnosis not be carried out (Brailo et al. 2012). Erythroplakia and leukoplakia are the most
common precancerous conditions of the mouth that may with time turn to be cancerous.

In other cases, the variations on the cells of the mouth may also result in oral cancer. A
lining called oral mucosa or the mucous membrane is a lining that covers the mouth. Oral
mucosa is composed of squamous cells known as squamous epithelium. In most cases, it is at
these flat and thin squamous cells that oral cancer begins. Such cancer types are called squamous
cell carcinomas of the mouth (Chaturvedi et al. 2011).
TYPES OF ORAL CANCER
There are numerous types of oral cancers of which 90% of them are squamous cell
carcinomas which come from the tissues that are lining the lips and the mouth. In most cases,
oral or mouth cancer involve the tongue even though it may also take place in the floor of the
mouth, the lining of the cheek, lips, gingiva or gums or in the palate (roof of the mouth). The
various oral cancer types are mostly similar in their appearance under the microscopes and are
known as squamous cell carcinomas however other types of cancer that are less common can
also occur among them Kaposi’s sarcoma (Cheema et al. 2012).
Oral cancer results when the cells on the human lips or inside one’s mouth undergo
changes or mutations into their DNA. Such mutations enable the cancer cells to continue
growing and undergo differentiation and division upon the death of mouth cells. The
accumulation of the unusual cells of mouth cancer may result in a tumor. As time goes, these
cells may spread across the mouth as well onto either different areas of the neck and head or the
other parts of the human body (Coelho 2012). Most of the mouth cancers often start in the flat
and thin cells also called the squamous cells which are lining the inside of the human mouth and
hence most of the oral cancers are squamous cell carcinomas.

There has not been established a clarity on the cause of the mutation in the squamous
cells which then results in the cancer of the mouth even though doctors and other medical
practitioners have been able to establish the factors that are at stake of causing oral cancer. As of
2013, there were reported deaths to the tune of 135,000 resulting from cancer which is a
tremendous increase from 84,000 deaths that were reported in 1990.
DENTAL BACKGROUND
The Mouth
The mouth or the oral cavity is one of the most important parts of the digestive system
and is inclusive of the lips, cheeks, the floor of the mouth, the palate which is the roof of the
mouth, as well as part of the tongue, is found in the mouth also known as the oral tongue. The
structures found in the mouth are used in speaking, tasting and chewing.
Figure 2 (a): Head and Neck (Cheema et al. 2012)

Figure 2(b): Mouth (Oral Cavity) (Cheema et al. 2012)
Structure of the Mouth
The mouth starts at the boundary of the lips and the skin. The roof of the mouth is made
of the hard palate and the soft palate. The mouth is a passage into the oropharynx which is the
middle part of the pharynx (De Souza Setubal Destro et al. 2010). The soft palates help in
creating a difference between the mouth and the nasopharynx which is the upper part of the
pharynx. The sides of the mouth are formed by the inner surfaces of the cheeks with the tongue
occupying most of the floor of the mouth which is the lowest parts of the mouth.
The mouth is divisible into specific regions including the:
 Lips
 Uvula
 Tonsils
 Tongue
 Soft palate
 Teeth

 Lower jaw bone also called the mandibles
 The inner lining of the cheeks
 Alveolar ridge and gum
 Upper jaw bone called the maxilla
 Hard palate
 The floor of the mouth
The function of the Mouth
There are numerous tasks in which the mouth is directly involved. One of such important
roles in the analysis of food substances and any other materials that get into the body through it
to enable the making of choice of either swallowing or not (Friedrich 2010). The teeth in the
mouth are used in chewing food. There are chemicals called enzymes in the saliva that initiate
the process of breaking down of starch. In the mouth are also taste buds that are found on the
tongue and are useful in telling the taste of food. The tongue with the aid of the soft palate plays
a role in the movement of food around inside the mouth to help in the achievement of chewing
and swallowing.
Other roles of the mouth include:
 Drinking
 Speaking
 Breathing
 Kissing; and
 Changing the facial expressions

Cancerous tumors of the Mouth
A cancerous tumor of the mouth has the capability to grow and lead to the destruction of
the surrounding tissues. It also has the capability to spread to the other body part. The cancerous
tumors are also known as malignant tumors (Garavello et al. 2010).
Squamous cell carcinoma
This is the most common oral cancer type and it has been established to begin from the
flat and thin cells that are also called squamous cells which are an integral aspect of the oral
mucosa
Rare Mouth tumors
Some of the cancerous tumors of the mouth that seldom include:
 Lymphoma
 Melanoma
 Cancer of the salivary glands
 Bone and soft tissue sarcoma
Precancerous Mouth Conditions
Precancerous conditions of the mouth define the alterations that occur to the cells of the
mouth which make the cells more susceptible to the development of cancer. Such conditions are
not yet cancer, however, if they are left untreated, there is a potential that such abnormal
alterations may culminate into oral cancer (Gomes et al. 2012). Leukoplakia and erythroplakia
are the main and most common precancerous mouth conditions.
Leukoplakia
This refers to an unusual white or grey region which forms on the tongue, the floor of the
mouth, the gums or even inside of the cheek. Leukoplakia presence in the body is not a direct

indication of cancer. The risk of the development of oral cancer is influenced by the various
shapes, appearances, and sizes of the unusual cells in comparison to the normal cells of the
mouth. Such an abnormality is defined as dysplasia. A close look at people that have leukoplakia
or related symptoms is done by a team of healthcare professionals to establish the presence of
any signs of cancer (Guntinas-Lichius et al. 2010).
Risk factors for Leukoplakia
Among the factors that increase the chances of development of leukoplakia include:
 Chewing tobacco
 Heavy smoking
 Excessive consumption of alcohol
Signs and Symptoms of leukoplakia
The signs and symptoms of leukoplakia are inclusive of a whitish region or spots that are
found inside the mouth which cannot easily be scrapped off (Hensel et al. 2011).
Diagnosis
The diagnosis of leukoplakia would involve the doctor interrogating the patient of any
symptoms experienced and perform a dental or oral examination. Still, a sample of the cells may
be taken from the abnormal region for a testing to be conducted in the laboratory.
Treatment
Research has not established any standard treatments for leukoplakia. The condition is
managed through active surveillance. In active surveillance, the team of healthcare professionals
closely monitors the condition of the patient (Hertrampf et al. 2012). Regular tests and
examinations are done on the patient to establish any changes that are indicative of cancer in the
early stages. Since leukoplakia has the potential of developing into cancer, it is of importance