continuing education feature - Dentaltown€¦ · continuing education feature Abstract Both dentists and hygienists play a critical role in the detec-tion of oral cancer. ... al.,

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continuing educationfeature

AbstractBoth dentists and hygienists play a critical role in the detec-

tion of oral cancer. This course reviews the demographics andrisk factors relevant to oral cancer. Common diagnostic toolsare discussed with attention to scenarios when these toolsmight be appropriate. The course also provides an overview ofcancer staging.

Objectives1. Understand the various forms of oral malignancy2. Recognize the most common risk factors for oral and

oropharyngeal cancer3. Compare the various diagnostic adjuncts available4. Describe the TNM system for cancer staging

In the United States, oral cancer is diagnosed in morethan 23,000 patients every year. Approximately 5,300patients die of this disease yearly. Squamous cell carcinoma isthe predominant form of oral cancer, comprising more than90 percent of malignant pathology. Less common oral malig-nancies include salivary gland tumors, melanoma, lym-phoma and mesenchymal tumors. Oral cancer hashistorically been a disease of older age, with an average age of63 at the time of diagnosis. However, younger patients(under 40) have shown a disturbing increase in oral cancerincidence over recent years.1

Multiple risk factors for oral cancer have been identified.Tobacco smoking is the strongest independent risk factor witha relative risk up to eight times that of non-smokers.2 Smoking

This print or PDF course is a written self-instructional article with adjunct images and is designated for 1.5 hours of CE credit by Farran Media.Participants will receive verification shortly after Farran Media receives the completed post-test. See instructions on page 136.

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1/1/2013 to 12/31/2015

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Farran Media is an ADA CERP Recognized provider. ADA CERP is a service of the American DentalAssociation to assist dental professionals in identifying quality providers of continuing dentaleducation. ADA CERP does not approve or endorse individual courses or instructors, nor does itimply acceptance of credit hours by boards of dentistry.

1. Horner, M.J., et al., U.S. geographic distribution of prevaccine era cervical cancer screening, incidence, stage, and mortality. Cancer Epidemiol Biomarkers Prev, 2011. 20(4): p. 591-9.

by Fayette Williams, DDS, MD

continued on page 132

Oral Cancer in the Dental Office_Layout 1 6/25/14 1:51 PM Page 130



cessation effectively reduces risk, although a former smokerwill always be at higher risk than a patient who never smoked.A 50 percent reduction in risk has been noted for individualswho cease smoking for more than nine years.3 Alcohol is alsorecognized as a distinct risk factor for the development of oralcancer, especially for consumers of dark liquors. The majorityof patients in whom oral cancer develops are consumers ofalcohol. A Swedish study found that low to moderate alcoholuse does not increase the risk for oral cancer but high intake(>50 grams per day) was an independent risk factor. The studyalso noted that smoking had a synergistic effect with alcohol,with a relative risk of 22.1 versus a relative risk of 6.5 withsmoking alone.4 For consumers of very high levels of alcohol,risk for the development of oral cancer may be greater thanthat for smoking alone.

Smokeless tobaccos role in the development of oral cancerhas engendered a great deal of controversy. A recent meta-analysis of 89 studies (including 62 American and 18Scandinavian studies) revealed only slight associations withoropharyngeal cancer, but the association disappeared for esti-mates published since 1990 and for alcohol-adjusted esti-mates.5 Although the overall health risks associated withsmokeless tobacco are clearly significantly less than the riskswith tobacco smoke, patients should be advised that notobacco product is considered completely safe. The NationalCancer Institute continues to recommend that the publicavoid all tobacco products, including smokeless tobacco.

Human papillomavirus (HPV) has a clearly defined role inthe development of oropharyngeal carcinoma. However, datasupporting HPV as a causative agent in oral cavity cancer ismuch less impressive. An understanding of the anatomy of theupper aerodigestive tract is crucial to understanding HPVdemographics. The oral cavity includes the anterior two-thirdsof the tongue (everything anterior to the V-shaped circumval-late papillae). The base of tongue (posterior to the circumval-late papillae) is part of the oropharynx. The hard palate is inthe oral cavity but the soft palate is part of the oropharynx.The most common locations for oropharyngeal cancer are thetonsils and base of tongue, while the most common locationsfor oral cavity cancer are the lateral tongue and floor of mouth.Over half of oral squamous cell carcinomas have been reportedto harbor HPV.6 Direct causation has not been established,and the methodology of some studies has been questioned.The literature shows a broad range of oral HPV prevalence inoral cavity cancer because of the multiple techniques used for

detection of the virus, which vary in sensitivity. At present,HPV is considered a causative factor in oropharyngeal cancerbut seems to play a minimal role in oral cavity cancers.

Cancer staging serves to group patients into statistical clas-sifications that provide useful information on treatment andprognosis. Additionally, a standardized format facilitatesresearch, assessment of outcomes, and communication amongclinicians by establishing uniform reporting parameters. As ageneral rule, more advanced stage implies a worse prognosis.The TNM (Tumor, Node, Metastasis) system is used to stageoral cancer. The T stage classifies the size of the primary oraltumor and describes any invasion into surrounding structuressuch as bone. Invasion into bone is automatically a T4 cancer,regardless of size. The N stage describes the presence orabsence of cancer in the lymph nodes of the neck. Spread ofcancer to lymph nodes of the neck decreases the five-year sur-vival rate by 50 percent. As such, the status of these cervicallymph nodes is the strongest prognostic factor for oral cancer.The M stage denotes metastatic spread to distant regions ofthe body. At present, metastatic oral cancer is incurable andonly palliative therapy is available.

Early diagnosis of oral cancer allows higher survivability,lower treatment morbidity and improved quality of life.Multiple diagnostic tools intended to detect oral cancer at ear-lier stages have become commercially available in recent years.Considerable disagreement exists among experts regarding theefficacy of these products. The three most used tools are theBrushTest (CDx Laboratories, Suffern, New York), ViziLite(Zila, Fort Collins, Colorado), and VELscope (LED Dental,Atlanta, Georgia).

The OralCDx BrushTest was introduced in 1999 as anon-invasive method for sampling surface cells for analysis.A small circular brush is rotated in a lesion, which collects

HPV is considered a causative factor in

oropharyngeal cancer but seems to play

a minimal role in oral cavity cancers.

2. Moreno-Lopez, L.A., et al., Risk of oral cancer associated with tobacco smoking, alcohol consumption and oral hygiene: a case-control study in Madrid, Spain. Oral Oncol, 2000. 36(2): p. 170-4.

3. Macfarlane, G.J., et al., Alcohol, tobacco, diet and the risk of oral cancer: a pooled analysis of three case-control studies. Eur J Cancer B Oral Oncol, 1995. 31B(3): p. 181-7.

4. Lewin, F., et al., Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck: a population-based case-referent study in Sweden. Cancer, 1998. 82(7): p. 1367-75.

5. Lee, P.N. and J. Hamling, Systematic review of the relation between smokeless tobacco and cancer in Europe and North America. BMC Med, 2009. 7: p. 36.

6. Miller, C.S. and D.K. White, Human papillomavirus expression in oral mucosa, premalignant conditions, and squamous cell carcinoma: a retrospective review of the literature. Oral Surg Oral Med Oral Pathol

Oral Radiol Endod, 1996. 82(1): p. 57-68.


continued from page 130


thousands of epithelial cells. This sample is transferred to aglass slide and submitted to OralCDx Labs. A report is gen-erated with four possible results: positive, atypical, negativeor inadequate. The product is marketed to diagnosebenign-appearing lesions which otherwise do not appearsuspicious enough to warrant a scalpel biopsy. Case selec-tion is therefore critical since this tool has no role in themanagement of lesions clinically suspicious for malignancy.Only benign-appearing lesions are appropriate for theBrushTest since malignant-appearing lesions should pro-ceed straight to a scalpel biopsy.

In addition, all positive and atypical results shouldbe followed by a scalpel biopsy to obtain a histologic diag-nosis. The scalpel biopsy remains the gold standard fordiagnosis, as the BrushTest does not provide a true histo-logic diagnosis. The greatest concern for the Oral CDxBrushTest is the possible false negatives which were foundto be 3.5 percent in a 2003 study.7 In other words, not allpotentially malignant lesions are detected with this modal-ity. Therefore, persistent negative lesions still require fol-low up and may require excision if they are in a high-riskarea. Researchers disagree on the accuracy of this test andhave documented sensitivity ranging from 52 to 100 per-cent and specificity ranging from 29-100 percent.8,9 Possibleindications for the brush biopsy are diffuse or multifocallesions which would otherwise require multiple biopsysites, or for a fearful or non-compliant patient who is reluc-tant to proceed with referral to a surgical specialist.However, both of these situations still require long-termfollow up.

While the BrushTest is used to sample and diagnose alesion that is already clinically apparent, the ViziLite isintended to improve visualization while searching formucosal lesions. This light-based tool allows chemilumines-cent visualization of the oral mucosa after performing arinse with 1% acetic acid to remove debris. A blue stain(Toluidine Blue) is available to mark suspicious lesions sothey may be located when the chemiluminescent light isremoved. The light source is a disposable stick that is acti-

vated by breaking an inner vial. Under the light, abnormalepithelium appears a deeper white hue.

Several studies have reported on the efficacy ofViziLite. Multiple studies have shown that ViziLite doesnot allow the clinician to differentiate between malignant,pre-malignant, traumatic/keratotic and inflammatorylesions.10,11 The tool is marketed as an adjunct to visualexam which allows dentists to identify abnormal lesionsthat may be difficult to see during a regular visual exam.However, no study has been able to demonstrate thatViziLite allows a clinician to see any lesions that are notalready apparent with the naked eye.

In their study of 100 patients who presented for rou-tine screening, Oh and Laskin12 noted that all lesions visi-ble with the chemiluminescent light were already visibleunder normal operatory lights. The authors concluded thatthe chemiluminescent light produced reflections thatmade visualization more difficult and thus was not benefi-cial. Another author reported that ViziLite examinationdid not alter the provisional diagnosis nor change the loca-tion of biopsy.11 In summary, ViziLite may allow forimproved visualization of oral mucosa lesions, but it doesnot detect lesions that were not already available with thenaked eye.

The VELscope Vx is another light-based tool that oper-ates under the principles of tissue fluorescence. This hand-held scope allows the clinician to visualize oral mucosa andidentify abnormal tissue. Normal mucosa viewed under thelight produces a pale green fluorescence, whereas abnormaltissue loses fluorescence and appears dark. The majority ofdata on this product comes from a British Columbia groupwhich has shown very promising abilities of this technologyto recognize otherwise undetected precancerous marginssurrounding malignant tumors during excision.13 Otherresearchers have suggested the VELscope may help differen-tiate necrotic from viable bone during surgical treatment ofBisphosphonate Related Osteonecrosis of the Jaws(BRONJ).14 While these studies suggest a use for this tech-nology in referral clinics specializing in oral pathology, the


continuing educationfeature continued from page 132

7. Potter, T.J., D.J. Summerlin, and J.H. Campbell, Oral malignancies associated with negative transepithelial brush biopsy. J Oral Maxillofac Surg, 2003. 61(6): p. 674-7.

8. Hohlweg-Majert, B., et al., Sensitivity and specificity of oral brush biopsy. Cancer Invest, 2009. 27(3): p. 293-7.

9. Sciubba, J.J., Improving detection of precancerous and cancerous oral lesions. Computer-assisted analysis of the oral brush biopsy. U.S. Collaborative OralCDx Study Group. J Am Dent Assoc, 1999. 130(10):

p. 1445-57.

10. Huber, M.A., S.A. Bsoul, and G.T. Terezhalmy, Acetic acid wash and chemiluminescent illumination as an adjunct to conventional oral soft tissue examination for the detection of dysplasia: a pilot study.

Quintessence Int, 2004. 35(5): p. 378-84.

11. Farah, C.S. and M.J. McCullough, A pilot case control study on the efficacy of acetic acid wash and chemiluminescent illumination (ViziLite) in the visualisation of oral mucosal white lesions. Oral Oncol,

2007. 43(8): p. 820-4.

12. Oh, E.S. and D.M. Laskin, Efficacy of the ViziLite system in the identification of oral lesions. J Oral Maxillofac Surg, 2007. 65(3): p. 424-6.

13. Poh, C.F., et al., Fluorescence visualization detection of field alterations in tumor margins of oral cancer patients. Clin Cancer Res, 2006. 12(22): p. 6716-22.

14. Assaf, A.T., et al., Intraoperative efficiency of fluorescence imaging by Visually Enhanced Lesion Scope (VELscope) in patients with bisphosphonate related osteonecrosis of the jaw (BRONJ). J Craniomaxillofac

Surg, 2013.


dentaltown.com JULY 2014135



majority of marketing efforts are aimed at general dentistsfor routine screening of the general population.

While the VELscope is able to distinguish between nor-mal and abnormal tissue, it may not have the same accuracyto distinguish between abnormal cancerous and abnormalnon-cancerous tissue such as aphthous ulcers, frictional ker-atosis, lichen planus and cheek biting.15 Therefore, this toolwith high sensitivity and low specificity is more likely todetect these more common non-cancerous lesions producinga high number of false positives, further increasing patientanxiety and cost as further referrals and tests are performed.

While multiple diagnostic adjuncts are available, no studyhas demonstrated conclusively that any of these tools improveearly detection or outcomes in the management of oral can-cer. Inspection, palpation and visualization under operatorylights remain the standard of care in the dental office. Asresearch continues, hopefully a technology will emerge totruly decrease the morbidity and mortality of oral cancer.

15. Lane, P.M., et al., Simple device for the direct visualization of oral-cavity tissue fluorescence. JBiomed Opt, 2006. 11(2): p. 024006.

16. Balevi, B., Evidence-based decision making: should the general dentist adopt the use of the

VELscope for routine screening for oral cancer? J Can Dent Assoc, 2007. 73(7): p. 603-6.

Dr. Fayette Williams is an oral and maxillofacial surgeonpracticing in Fort Worth, Texas. He completed his DDS atthe University of Tennessee and his MD and surgical res-idency at the University of Texas Southwestern MedicalCenter in Dallas. Dr. Williams then completed a two-yearfellowship in Maxillofacial Oncology and Reconstructive

Surgery at the University of Michigan. He is a Diplomate of the AmericanBoard of Oral & Maxillofacial Surgery, and is one of less than 30 oral sur-geons in the USA who is fellowship-trained in both head and neck oncol-ogy and microvascular reconstruction. Dr. Williams maintains both anacademic and private practice and is actively involved in training oralsurgery residents from the University of Texas Southwestern/ParklandMemorial Hospital residency in Dallas. Dr. Williams has authored multi-ple textbook chapters and journal articles on oral cancer, and continuesto pursue clinical research activities with his residents. He has lecturednationally on the surgical reconstruction of cancer-related defects. Heis Vice-Chairman of the Cancer Committee at John Peter Smith Hospitalin Fort Worth, Texas, and a member of the Head & Neck Tumor Board atBaylor All Saints Hospital. Dr. Williams passion lies in the treatment andreconstruction of oral cancer and their related defects.

Disclaimer: The speaker declares that neither he nor any member of hisfamily have a financial arrangement or affiliation with any corporateorganization offering finacial support or grant monies for this continuingdental education program.

Authors Bio

FREE FACTS, circle 21 on card


1. The most common form of oral cancer is:a. Melanomab. Squamous cell carcinomac. Adenocarcinomad. Mucoepidermoid carcinoma

2. The strongest prognostic factor for oral cancer is:a. Size of the tumorb. Location of the tumorc. Status of the lymph nodes in the neckd. Presence of human papillomavirus

3. The strongest risk factor for oral cancer is:a. Human papillomavirusb. Cigarettesc. Alcohold. Smokeless tobacco

4. An oral cancer invading into bone is staged as:a. T1b. T2c. T3d. T4

5. Which of the following is not a light-based diagnostic adjunct?a. BrushTestb. Vizilitec. VELscope

6. The BrushTest is a substitute for a scalpel biopsy for lesionsclinically suspicious for malignancy.a. Trueb. False

7. The gold standard in diagnosis of oral mucosal lesions is:a. BrushTestb. Vizilitec. VELscoped. Scalpel biopsy

8. Which of the following may allow clinicians to identify pre-cancerous margins surrounding malignant tumors duringexcision?a. BrushTestb. Vizilitec. VELscoped. All of the above

9. Possible indications for a BrushTest include all of the fol-lowing except:a. A fearful or non-compliant patient reluctant to go see a

specialistb. A lesion clinically suspicious for squamous cell carcinomac. Diffuse or multi-focal lesions that may otherwise require

multiple scalpel biopsiesd. Common, harmless-appearing white mucosal lesions

10. A 67-year-old male presents with a painful 2cm induratedulcer on the left lateral tongue. The most appropriatecourse of action is:a. BrushTestb. Vizilitec. VELscoped. Scalpel biopsy

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continuing education feature - Dentaltown€¦ · continuing education feature Abstract Both dentists and hygienists play a critical role in the detec-tion of oral cancer. ... al.,