Oral Cancer Screening and ProductsDH 301 Clinic V

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Statistics•Oral cancer most commonly involves: check

lining, floor of the mouth, gums, palate.•Most oral cancers- squamous cell

carcinomas spread quickly.• Increased risks of oral cancer- smoking,

tobacco products, heavy alcohol use.•Other factors-chronic irritation: rough teeth,

dentures, fillings, immunosuppressant drugs, poor dental and oral hygiene care.

• US National Library of Medicine

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Statistics

•Approximately ½ of people with oral cancer will live more than 5 years after diagnosis and treatment.

•1 in 4 persons with oral cancer die because of delayed diagnosis and treatment.

•More than ½ of oral cancers have already spread to the throat or neck when it is detected.

•If detected early-cure rate is 90%• US National Library of Medicine

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Statistics• Squamous cell carcinoma of the oral cavity and

pharynx accounts for over 34,000 cases per yr in the US.

• Approximately 8,000 deaths per year.• 75% cancers related to alcohol and tobacco use.• 75% of all head and neck cancers begin in the

oral cavity.• 30% originate on tongue, 17% lips, 14% floor of

mouth.• HPV16 shows signs of oral cancer including

tonsils, tonsillar pillars and crypt, base of tongue and oropharynx

• Oral Cancer Foundation

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Statistics

•Some cancers start as white plaque-leukoplakia.

•Men twice as likely to get oral cancer than women, especially men over 40.

•Symptoms: usually painless at first, chewing problems, mouth sores, pain with swallowing, speech difficulties, swollen lymph nodes in neck, and weight loss.

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Statistics

•HPV positive patients-changing ratios and age groups. Younger, non smoking patients under 50-fastest growing segment of oral cancer population.

•HPV cancers show on posterior oral cavity.

•Tobacco and alcohol lesions show on anterior tongue and mouth.

• Oral Cancer Foundation

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Appearance of Oral Cancer

•White areas: vary from a filmy, barely visible change to heavy, thick, heaped-up areas of dry white keratinized tissue. ▫Leukoplakia: white patch that can not be

scraped off.▫Fissures, ulcers, or areas of induration in a

white area are most indicative of malignancy

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Appearance of Oral Cancer

•Red Areas▫Lesions of red, velvety consistency,

sometimes with small ulcers▫Erythroplakia: lesions of the oral mucosa

that appear as bright red patches or plaques that cannot be characterized as any specific disease

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Appearance of Oral Cancer•Ulcers:

▫May have flat or raised margins▫Palpation may reveal indurationsMasses:▫Papillary masses, sometimes with ulcerated

areas, occur above the surrounding tissuesPigmentation:▫Brown or black pigmented areas may be

located on mucosa where pigmentation does not normally occur

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Oral Cancer Screening Products:• Biopsy- removal and examination, usually by

microscope a section of tissue▫Excisional- entire lesion is removed▫ Incisional- part of the lesion is removedIndications for Biopsy▫Unusual oral lesion that cannot be indentified with

clinical certainty.▫Lesion that has not shown healing in 2 weeks▫Persistent, thick, white, hyperkeratonic

lesion/mass▫Any tissue surgically removed should be summited

for microscopic examination.

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Oral Cancer Screening Products• Cytologic Smear- when surface cells of a suspicious

lesion are removed for microscopic examination• Indications for Smear-

▫Biopsy not planned but examined by a smear▫Lesion that looks like potential cancer▫Positive report from a smear should be biopsied▫All lesions of high suspicion should be referred for a

biopsy• Limitations of Smear-

▫A clear cut lesion is present, should not delay treatment with a smear, go directly to biopsy

▫Smear only detects surface lesions▫Positive smear requires a biopsy▫Smear not diagnostically reliable- a negative report

cannot be considered conclusive

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Oral Cancer Screening Products•Exfoliative Cytology

▫Squamous epithelial cells constantly grow toward the surface of the mucous membrane where they are exfoliated

▫Exfoliated cells are scraped off and prepared on a slide where they are stained and studied through a microscope

▫Malignant cells stain differently from normal, healthy cells.

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VELscope: Cancer Screening Aid• Tissue fluorescence: emits a safe blue light,

causing tissue fluorescence from surface of epithelium through to the basal membrane where pre-malignant changes typically start.

• Hand held device, no rinse required• Unaffected tissue appears apple green• Areas of dysplasia or cancer do not fluoresce

and appear darker.• Useful in detecting lesions not visible with

white light.• Oral Cancer Foundation

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2-13VELscope

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Identafi: oral cancer screening aid

•Multi-spectral fluorescence and reflective technology▫3 distinct color waves: white, violet, green-

amber light▫Clinician wears filtered eyewear to enhance

visual effects▫Photosensitive glasses block the violet

excitation light and allows for observation

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Identafi

•Violet light enhances normal tissue’s natural fluorescence▫Suspicious tissue appears dark because of

its loss of fluorescence•Amber light used when clinician suspects

an abnormality.▫Enhances normal tissues reflectance

properties so the difference between normal and abnormal tissue can be seen.

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Grade II Dysplasia

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Invasive Cancer

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ViziLite•Pre-rinse solution: desiccates the cells to

make the nuclei more prominent and, therefore, more visible

•Low intensity light from the handheld light source is reflected off of these abnormal cells down to the basement membrane where the nuclei have been rendered more prominent and appear to “glow” – making abnormal cells easier to see

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Vizilite

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ViziLite

•TBlue is a toluidine blue-based metachromatic dye used to mark ViziLite identified lesions for further evaluation and monitoring of changes

•TBlue, packaged in an easy-to-use three-swab system, provides the blue staining that allows ViziLite identified lesions to be seen clearly under normal light

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Normal Light Vizilite

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Microlux/DL

•Refractive light technology•Patient rinses with a 1% acetic acid

solution for 60 seconds, then use a diagnostic light.▫The acetic acid dehydrates the cytoplasm

of lesions changing the refractive properties.

▫Fiber optic light guide makes leukoplakic lesions more visible

▫Irregular cells look whitest which contrasts with the healthy surrounding tissues.

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Oral Cancer ScreeningsFor Oral Cancer screening, have the patient rinse with 1% acetic acid and place the Microlux DL tip in mouth. Any acetowhite or leukoplakic lesions become more visible.

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Microlux

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Lab Reports

•Class I: Normal•Class II: Atypical, but not suggestive of

malignant cells•Class III: Uncertain, possible for cancer•Class IV: Probable for cancer•Class V: Positive for cancer

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Follow-Up

•Class IV and V: Refer for biopsy

•Class III: Reevaluate, indication for biopsy

•Class I and II: Watch lesion for healing, if lesion persist perform a biopsy

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•False-negatives are possible

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Documentation

•Document in the patient’s permanent dental record if a biopsy or smear is needed▫Detail oral exam, follow up procedures,

reports from consultants, labs, medical follow up and outcome

▫Recommendations for the frequency of oral exams and dental hygiene maintenance appointments

▫Review patients lifestyle habits and recommend preventive methods.