Oral Cancer Screening and Products DH 301 Clinic V

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 2-13

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 2-13

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 2-13

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. 2-13

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 2-13

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 2-13

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 2-13

Appearance of Oral Cancer Ulcers: ▫May have flat or raised margins ▫Palpation may reveal indurations Masses: ▫Papillary masses, sometimes with ulcerated areas, occur above the surrounding tissues Pigmentation: ▫Brown or black pigmented areas may be located on mucosa where pigmentation does not normally occur 2-13

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 removed Indications 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. 2-13

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 2-13

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. 2-13

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 2-13

VELscope

2-13 VELscope

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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 2-13

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. 2-13

Grade II Dysplasia 2-13

Invasive Cancer 2-13

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 2-13

Vizilite 2-13

How It Works 2-13

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 2-13

Normal Light Vizilite 2-13

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. 2-13

Microlux/DL. Oral Cancer Screenings For 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. 2-13

Microlux 2-13

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 2-13

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 2-13

False-negatives are possible 2-13

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. 2-13