1. Prevention of Oral Cancer
Slide #1
This lecture discusses the screening for and prevention of oral cancer.

2. Outline
Discuss the assessment required to initiate a clinical program to prevent oral cancer development
Provide foundation knowledge on tobacco cessation and reduction in excessive use of alcoholic drinks
Slide #2
The objective of this lecture is to:
Discuss the assessment required to initiate a clinical program to prevent oral cancer development; and
Provide foundation knowledge on tobacco cessation and reduction in excessive use of alcoholic drinks

3. Blood pressure______ Pulse__________ Height_____ Weight____
VITAL SIGNS
Blood pressure______ Pulse__________
Height_____ Weight____
Tobacco use: Never Former Current
Glasses of alcohol drinks per day:
Slide #3
The first part of any assessment is collecting vital signs and information on use of tobacco products as well as alcohol use per day. This information may already be collected by your clinic.
Module 5

4. Prevention of Oral Cancer
Stop smoking or chewing tobacco.
Decrease use of alcohol (0-1 drinks/day).
Eat more fruits and vegetables.
See a dentist regularly.
Get screened- Early detection saves lives.
Slide #3
The basic concepts in any preventive program of oral cancer should focus on emphasizing the need to:
Stop smoking or chewing tobacco.
Decrease use of alcohol (0-1 drinks/day).
Eat more fruits and vegetables.
See a dentist regularly to get screened
Early detection saves lives.

5. Self-Determination Theory
Self-Determination Theory proposes that behavior changes motivated by intrinsic factors (e.g., inherently novel, enjoyable, stimulating, self-driven, and satisfying) are more sustainable than those produced by extrinsic factors (e.g., coercion, external reward, or fear) as well as those that are amotivational.
People have to decide when and how to change.
Your role is to assist people in the change process, only if they choose to change after receiving information that they choose to hear from you.
Slide #5
As was discussed before in the lecture on diet and oral hygiene behaviors it is important not to just give instruction.
A useful theory to adopt is the Self-determination theory (SDT) which is a macro-theory of human motivation concerned with the development and functioning of personality within social contexts. The theory focuses on the degree to which human behaviors are self-determined - that is, the degree to which people endorse their actions at the highest level of reflection and engage in the actions with a full sense of choice.
The theory begins with the assumption that people are active organisms, with innate tendencies toward psychological growth and development, who strive to master ongoing challenges and to integrate their experiences into a coherent sense of self. This natural human tendency does not operate automatically, however, but instead requires ongoing support from the social environment in order to function effectively. That is, the social context can either support or thwart the natural tendencies toward active engagement and psychological growth.
The theme of SDT is that people first have to decide to change and change can only occur if we assist individuals to overcome the barriers that they face. Hence, staging of the change message is very important.

6. Tobacco Use
The "5 A's" of a tobacco prevention program as recommended by the Surgeon General
Expanded to include alcohol use in this lesson.
Slide #6
For prevention of tobacco use we will use the "5 A's" of tobacco prevention as recommended by the Surgeon General and have been expanded in this lesson to include alcohol use.

7. Tobacco Use
Ask
Identify and document tobacco use status for every patient at every visit. Identify whether the individual is a heavy alcohol drinker.
Assess
Is the tobacco user willing to attempt to quit? Is the individual willing to reduce their consumption of alcohol?
Slide #7
Ask
Identify and document tobacco use status for every patient at every visit. Identify whether the individual is a heavy alcohol drinker.
Assess
Is the tobacco user willing to attempt to quit? Is the individual willing to reduce their consumption of alcohol?

8. Tobacco Use Advise Assist
It is important to engage the user in an open dialogue on what he thinks about tobacco use and the impact on his/her health. Work towards a position where the patient provides you with what he or she should do.
Assist
For the patient willing to attempt to quit, use counseling and pharmacotherapy to help him or her quit.
For the patient willing to reduce alcohol consumption, use counseling or refer to alcohol addiction counseling programs in his/her area.
Slide #8
Advise
It is important to engage the user in an open dialogue on what he thinks about tobacco use and the impact on his/her health. Work towards a position where the patient provides you with what he or she should do.
Assist
For the patient willing to attempt to quit, use counseling and pharmacotherapy to help him or her quit.
For the patient willing to reduce alcohol consumption, use counseling or refer to alcohol addiction counseling programs in his/her area.

9. Tobacco Use
Arrange
Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date or scheduled counseling for reduction of alcohol use.
Slide #9
Arrange
Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date or scheduled counseling for reduction of alcohol use.

10. Stages of Change Treating Tobacco Use and Dependence
Assessing the patient's stage of change is very useful in determining the right type of advice to provide. For example,
A pre-contemplator may not be aware of the dangers of smoking, and would need to learn more about that, whereas a person in the preparation stage might need to learn about how to ease withdrawal symptoms using nicotine replacement
Slide #10
It is important to stage the message based on the status of each individual.
Assessing the patient's stage of change is very useful in determining the right type of advice to provide.
For example,
A pre-contemplator may not be aware of the dangers of smoking, and would need to learn more about that, whereas a person in the preparation stage might need to learn about how to ease withdrawal symptoms using nicotine replacement

11. Stages of Change
Health education may be considered successful if it helps to move the individual to consider quitting.
Complete behavioral change may not happen overnight, but persuading someone to reconsider his or her habits and view them in the light of the effect the habits have on their health can eventually promote behavior change.
Slide #11
Health education may be considered successful if it helps to move the individual to consider quitting.
Complete behavioral change may not happen overnight, but persuading someone to reconsider his or her habits and view them in the light of the effect the habits have on their health can eventually promote behavior change.

12. Stages of Change
To counsel a smoker with an oral lesion to quit, you need first to determine their willingness to quit. By asking the question: ‘Do you seriously plan to stop smoking in the future?’ you could determine their readiness to change or change status.
A patient may be in one of the following stages:
Slide #12
To counsel a smoker with an oral lesion to quit, you need first to determine their willingness to quit. By asking the question: Do you seriously plan to stop smoking in the future?, you could determine their readiness to change or change status.
A patient may be in one of the following stages:

13. Stages of Change
Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. People in this stage may be unaware of the problem.
Contemplation is the stage at which an individual is aware of the problem and is seriously thinking about making a change, but has not yet made a commitment to take action.
Slide #13
Precontemplation is the stage at which there is no intention to change behavior in the foreseeable future. People in this stage may be unaware of the problem.
Contemplation is the stage at which an individual is aware of the problem and is seriously thinking about making a change, but has not yet made a commitment to take action.

14. Stages of Change
Preparation is the stage at which an individual intends to take action within the next 30 days and has unsuccessfully made an attempt to change within the previous year.
Action is the stage at which an individual is changing his or her behavior, experiences, or environment in order to overcome the problem. This requires overt behavioral changes and a considerable commitment of time and energy.
Slide #14
Preparation is the stage at which an individual intends to take action within the next 30 days, and has unsuccessfully made an attempt to change within the previous year.
Action is the stage at which an individual is changing his or her behavior, experiences, or environment in order to overcome the problem. This requires overt behavioral changes and a considerable commitment of time and energy.

15. Stages of Change
Maintenance is the stage at which an individual is already practicing the behavior on regular basis.
Slide #15
Maintenance is the stage at which an individual is already practicing the behavior on regular basis.

16. Stage of Change
Precontemplators have no plans to quit tobacco in the foreseeable future and may be unaware of the problem. People in this stage should be encouraged to think about quitting.
Slide #16
Advice given to individuals should be tailored to the stage of change.
Precontemplators have no plans to quit tobacco in the foreseeable future and may be unaware of the problem. People in this stage should be encouraged to think about quitting.

17. Advice for Pre-Contemplators
I understand that you are not ready to quit smoking. It is your choice and no one can force you to do it. However, I would like you to start thinking about how smoking affects your life and your health. What are the positive and negative experiences you have had with smoking?
On a scale from 0 (not important) to 10 (very important), how important is your overall health to you? Ask the patient to explain his or her rating: for example, ask why “6”?
Slide #17
Advice for pre-contemplators:
I understand that you are not ready to quit smoking. It is your choice and no one can force you to do it. However, I would like you to start thinking about how smoking affects your life and your health. What are the positive and negative experiences you have had with smoking?
On a scale from 0 (not important) to 10 (very important), how important is your overall health to you? Ask the patient to explain his or her rating: for example, ask why “6”?

18. Advice for Pre-Contemplators
Suggest that the patient remove tobacco products and paraphernalia from his or her environment.
On the quit date, the patient should throw away cigarettes or other tobacco products, lighters, ashtrays, rolling papers, pipes, spit containers, and any other objects that serve as prompts for his/her tobacco use.
Slide #18
Suggest that the patient remove tobacco products and paraphernalia from his or her environment.
On the quit date, the patient should throw away cigarettes or other tobacco products, lighters, ashtrays, rolling papers, pipes, spit containers, and any other objects that serve as prompts for his/her tobacco use.

19. Advice for PreContemplaters
Suggest to the patient that the physician at the clinic can provide or recommend nicotine replacement therapy, especially for highly addicted patients (those who smoke 25 or more cigarettes per day).
Slide #19
Suggest to the patient that the physician at the clinic can provide or recommend nicotine replacement therapy, especially for highly addicted patients (those who smoke 25 or more cigarettes per day).

20. Advice for Pre-Contemplators
At the end of this short dialogue, ask the patient if they need help or ask him/her to contact you if he/she decides to quit.
Slide #20
At the end of this short dialogue, ask the patient if they needs help or ask him/her to contact you if he/she decides to quit.

21. Advice for Contemplators
Use open-ended questions such as:
What actions have you taken to quit?
What do you expect will work for you?
When do you plan to start?
Who will help you in quitting?
How can I help you quit?
Slide #21
Advice for contemplators
Use open-ended questions such as:
What actions have you taken to quit?
What do you expect will work for you?
When do you plan to start?
Who will help you in quitting?
How can I help you quit?

22. Advice for Preparation Stage
Those in the preparation stage intend to quit within the next 30 days and have unsuccessfully made an attempt to quit within the previous year. People in this stage need support for their decision to take action and advice on how to devise and carry out a quit plan.
Slide #22
Those in the preparation stage intend to quit within the next 30 days and have unsuccessfully made an attempt to quit within the previous year. People in this stage need support for their decision to take action and advice on how to devise and carry out a quit plan.

23. Advice for Preparation Stage
You should set a date to quit, and do your best to stick to it.
Be sure to remove all tobacco products from your environment when you quit.
What do you think will be some challenges to quitting? Let's talk about some ways to overcome these barriers.
Slide #23
Advice for those in the preparation stage
You should set a date to quit, and do your best to stick to it.
Be sure to remove all tobacco products from your environment when you quit.
What do you think will be some challenges to quitting? Let's talk about some ways to overcome these barriers.

24. Advice for Individuals in the Action or Maintenance Stages
Individuals in Action or Maintenance:
Have stopped using tobacco. 
Have made significant changes in their lifestyles (diet and exercise)
Are highly susceptible to relapse, especially in the action stage.
The maintenance stage is a long, ongoing process and can last 6 months to a lifetime. 
Encourage, praise, and focus on the positive in the change process.
Slide #24
Individuals in Action or Maintenance:
Have stopped using tobacco. 
Have made significant changes in their lifestyles (diet and exercise)
Are highly susceptible to relapse, especially in the action stage.
The maintenance stage is a long, ongoing process and can last 6 months to a lifetime. 
Encourage, praise, and focus on the positive in the change process.

25. Stress and Tobacco Use
Smokers report more stress than non-smokers, and when smokers quit, they often report feeling less stressed over time.
Suggest that the patient try other ways of coping with stress, like exercising or meditation
If your patient is worried about facing addiction and withdrawal, acknowledge the fact that quitting is difficult
Refer the patient to a tobacco cessation clinic for further consultation
Slide #25
Stress and tobacco use
Smokers report more stress than non-smokers, and when smokers quit, they often report feeling less stressed over time. Suggest that the patient try other ways of coping with stress, like exercising or meditation.
If your patient is worried about facing addiction and withdrawal, acknowledge the fact that quitting is difficult.
Refer the patient to a tobacco cessations clinic for further consultation.

26. Advice about quitting
If your patient is worried about needing tobacco to help wake up, get moving, and stay focused on tasks, provide examples of other ways to feel more energetic.
Encourage the patient to get enough rest, exercise regularly (which will also reduce cravings), take a brisk walk when feeling sluggish, drink lots of cold water, and avoid situations that lead to boredom.
Slide #26
If your patient is worried about needing tobacco to help wake up, get moving, and stay focused on tasks, provide examples of other ways to feel more energetic.
Encourage the patient to get enough rest, exercise regularly (which will also reduce cravings), take a brisk walk when feeling sluggish, drink lots of cold water, and avoid situations that lead to boredom.

27. Light or Low-Tar Cigarettes
“Light” cigarettes may actually be more dangerous than regular cigarettes because smokers may inhale more heavily or more frequently or cover ventilation holes to get the chemicals their bodies crave.
Slide #27
Use of light cigarettes
“Light” cigarettes may actually be more dangerous than regular cigarettes because smokers may inhale more heavily or more frequently or cover ventilation holes to get the chemicals their bodies crave.

28. Barriers Discuss barriers to quitting, set goals, and devise a plan.
In addition, you may wish to assess whether the patient sees him/herself as addicted to nicotine, and recommend nicotine replacement or other pharmacotherapy as appropriate.
Slide #28
Discuss barriers to quitting, set goals, and devise a plan.
In addition, you may wish to assess whether the patient sees him/herself as addicted to nicotine, and recommend nicotine replacement or other pharmacotherapy as appropriate.

29. Alcohol Drinking Assist individual to seek care from a professional group
Slide #29
Patients or individuals who are heavy drinkers should be encouraged to seek care from a professional group in the area where they live.

30. Alcohol Counseling
Feedback to a patient by a primary care provider about the results of the oral cancer screening examination, clarification of the association between excessive alcohol consumption and negative consequences, and advice to reduce alcohol consumption, are modestly effective in helping patients with an alcohol problem.
Use the same principles followed in drafting messages based on the stage of change.
Tailor your messages based on the stage of change and the reasons for drinking.
Slide #30
Feedback provided to a patient by a primary care provider about the results of the oral cancer screening examination, clarification of the association between excessive alcohol consumption and negative consequences, and advice to reduce alcohol consumption, are modestly effective in helping patients with an alcohol problem.
Use the same principles followed in drafting messages based on the stage of change.
Tailor your messages based on the stage of change and the reasons for drinking.

31. Alcohol Counseling
The focus of the short counseling session for moderate drinkers should be on how to control drinking rather than abstinence as a treatment goal.
Abstinence, however, should continue to be the treatment goal in patients with severe alcohol dependency; these patients are generally not amenable to brief counseling interventions and should be referred for specialized treatment.
Refer individuals who want help with their alcohol drinking to professional or community alcohol management programs.
Slide #31
The focus of the short counseling session for moderate drinkers should be on how to control drinking rather than abstinence as a treatment goal.
Abstinence, however, should continue to be the treatment goal in patients with severe alcohol dependency; these patients are generally not amenable to brief counseling interventions and should be referred for specialized treatment.
Refer individuals who want help with their alcohol drinking to professional or community alcohol management programs.

32. Regular screening for oral cancer
Slide #32
Screening for oral cancer

33. Oral Cancer Risk Factors
75% of all oral cancer cases are related to tobacco use and/or moderate/heavy alcohol use.
Human Papilloma Virus may be a causative factor of oral cancer
Slide #33
The major risk factors for oral cancer are tobacco and alcohol use, which together account for about 75% of all oral cancers diagnosed in this country. The combined habits of smoking and drinking significantly increase the risk of developing oral cancer.
Listen to the medical history. Has the patient experienced oral cancer before; or has been diagnosed with a tobacco-related cancer? Does the patient have a history of suppressed immune system, for example, HIV infection? Did the patient use immunosuppressant medications, for example, for solid organ transplants? Has the patient had a previous or current oral papillomavirus infection, a history of syphilis, especially tertiary syphilis; or iron deficiency anemia?

34. Oral Cancer Risk Factors
Poor Oral hygiene and chronic irritation (poor fitting dentures, broken fillings).
HIV infection or compromised immune system.
25% of oral cancers occur in people that do not smoke or have other risk factors.
Slide #34
Oral cancer risk factors include:
Poor Oral hygiene and chronic irritation (poor fitting dentures, broken fillings).
HIV infection or compromised immune system.
25% of oral cancers occur in people that do not smoke or have other risk factors.

35. Human Papilloma Virus and Oral Cancer
The human papilloma virus (HPV) is a common virus group that causes skin and mucosal infections.
There are over 80 types of HPV in humans.
Some types of HPV infect the mouth, throat, tongue and tonsils.
The skin covering sexual organs can also be infected with HPV.
The infection is manifested with skin ulceration and pain.
Infected skin can transfer the virus to other parts of the body or other humans.
Slide #35
The human papilloma virus (HPV) is a common virus group that causes skin and mucosal infections.
There are over 80 types of HPV in humans.
Some types of HPV infect the mouth, throat, tongue and tonsils.
The skin covering sexual organs can also be infected with HPV.
The infection is manifested with skin ulceration and pain.
Infected skin can transfer the virus to other parts of the body or other humans.

36. Human Papilloma Virus and Oral Cancer
Warts are a form of HPV infection
Warts are small, cauliflower-type growths on the skin.
Warts are usually painless, but can cause some irritation, itching, or burning.
Slide #36
Warts are a form of HPV infection
Warts are small, cauliflower-type growth on the skin.
Warts are usually painless, but can cause some irritation, itching, or burning.

37. Human Papilloma Virus and Oral Cancer
Some HPV types can cause cervical or oral cancer
The types associated with these cancers are: HPV-16, HPV-18, HPV-31, and HPV-45.
HPV causes abnormal alteration and growth of the infected mucosa covering the inner of the mouth (dysplasia).
Dysplasia is not cancer, but it is a tissue change seen prior to the formation of cancer.
The most dangerous types of HPV-- 16 and 18-- are transmitted through sexual contact and are known to cause up to 95% of cervical cancers.
These two types have also been linked to oral cancer.
Slide #37
Some HPV types can cause cervical or oral cancer
The types associated with these cancers are: HPV-16, HPV-18, HPV-31, and HPV-45.
HPV causes abnormal alteration and growth of the infected mucosa covering the inner of the mouth (dysplasia).
Dysplasia is not cancer, but it is a tissue change seen prior to the formation of cancer.
The most dangerous HPVs, 16 and 18, are transmitted through sexual contact and are known to cause up to 95% of cervical cancers.
These two HPVs have been linked to oral cancer.

38. Human Papilloma Virus and Oral Cancer
Human papilloma virus associated tumor on the lip.
Slide #38
In this slide we see a human papilloma virus associated with a tumor on the lip.
Courtesy of: MDchoice.com, Accessed September 2,2007

39. Who Can Get Oral Cancer? Oral cancer is most common in: Men
African Americans
Adults over 40 years old
Smokers and heavy drinkers
Slide #39
Oral cancer is most common in:
Men
African Americans
Adults over 40 years old
Smokers and heavy drinkers

40. 5 Year Cancer Survival Rates
Early Detection is Key
5 Year Cancer Survival Rates
Localized
80%
Regional
50%
Distant
32%
Slide #40
In localized oral cancer, the cancer cells have not spread to the lymph glands and other tissues.
Regional: the cancer has spread to lymph glands in the area of the head or neck
Distant: the cancer has spread to distant lymph glands or tissues in other parts of the body
Cancer survival rates depend on the stage of oral cancer.

41. Where to Start? Early Detection starts with: Listen Look Feel
Slide #41
The recommended steps in screening are listen, look and feel:
Listen to the patient – symptoms, medical history, risk factors.
Ask about risk factors for oral cancer. The major risk factors for oral cancer are tobacco and alcohol use, which together account for about 75% of all oral cancers diagnosed in this country. The combined habits of smoking and drinking significantly increase the risk of developing oral cancer.
Listen to the medical history. Has the patient experienced oral cancer before; or been diagnosed with a tobacco-related cancer? Does the patient have a history of suppressed immune system, for example, HIV infection? Did the patient use immunosuppressant medications, for example, for solid organ transplants? Has the patient had a previous or current oral papillomavirus infection, a history of syphilis, especially tertiary syphilis; or iron deficiency anemia?
Look for signs of oral cancer
Conduct a thorough intra-oral soft tissue screening examination.
Feel for signs of oral cancer
Palpate the patient’s intra-oral tissues for swelling or pain.
Palpate the patient’s neck to check for enlarged lymph nodes.

42. What Do You Need?
Oral cancer screenings will require the following tools:
Listen
Oral Screening form
Look and Feel
Gloves
Gauze
Disposable mirror
Slide #42
Oral cancer screenings will require the following tools:
Listen
Oral Screening form
Look and Feel
Gloves
Gauze
Disposable mirror

43. Oral Screening Form Make sure these items are included:
Current or past tobacco use
Age 40 or older
Sore on lips, mouth, or cheeks that doesn’t heal in two weeks
Sore in throat or a feeling that something is caught in the throat
Numbness of the tongue or other area of the mouth
Swelling of the jaw that causes denture to fit poorly or become uncomfortable
Slide #43
Make sure these items are included in the clinic’s screening form:
Current or past tobacco use
Age 40 or older
Sore on lips, mouth, or cheeks that doesn’t heal in two weeks
Sore in throat or a feeling that something is caught in the throat
Numbness of the tongue or other area of the mouth
Swelling of the jaw that causes denture to fit poorly or become uncomfortable

44. Oral Screening Form Persistent ear pain Hoarseness or voice changes
A lump or mass in the neck, behind the ear or under the jawbone
Had or scheduled to have chemotherapy or radiation treatment
Sexually transmitted disease such as HIV or Syphilis
Slide #44
Ask and check for the following
Persistent ear pain
Hoarseness or voice changes
A lump or mass in the neck, behind the ear or under the jawbone
Had or scheduled to have chemotherapy or radiation treatment
Sexually transmitted disease such as HIV or Syphilis

45. Location of lymph nodes in head and neck
Oral Cancer Screening
Location of lymph nodes in head and neck
Slide #45
This slide identifies the location of the lymph glands. The clinician should feel for lumps in the areas where the glands are located. Using your index, middle and thumb fingers, feel the areas. Walking and palpating the fingers in the areas will help detect presence of lump(s).
Lymph gland (from answers.com): Any of the small bodies located along the lymphatic vessels, particularly at the neck, armpit, and groin, that filter bacteria and foreign particles from lymph fluid. During infection, lymph nodes may become swollen with activated lymphocytes.
Lymph gland (from medicinenet.com): Lymph node or glands are small rounded or bean-shaped masses of lymphatic tissue surrounded by a capsule of connective tissue. Lymph nodes are located in many places in the lymphatic system throughout the body. Lymph nodes filter the lymphatic fluid and store special cells that can trap cancer cells or bacteria that are traveling through the body in the lymph fluid. The lymph nodes are critical for the body's immune response and are principal sites where many immune reactions are initiated. During a physical examination, doctors often look for swollen lymph nodes in areas where lymph nodes are abundant, including the neck, around the collarbone, the armpit (axilla), and the groin.

46. Oral Cancer Screening
Ask the individual or patients whether they have felt new lumps in the mouth, head, neck, or behind their ears. Are these lumps present on both sides of the face or head? (Symmetrical presence may be sign that the lump is a normal structure.)
Slide #46
To conduct the exam you need a good light, your eyes, and fingers.
Silverman, in the American Cancer Society book titled “Oral Cancer”, describes the following signs that may be associated with an oral cancerous lesion:
Ulceration or erosion
Erythema
Induration or hardness
Fixation due to invasion of deeper tissues
Chronicity or failure to heal
Lymphadenopathy: hardening or enlargement of regional nodes
Leukoplakia: a white patch on the mucosal surface, reflecting excessive epithelial keratin production.
These 7 most common signs are guides for deciding whether a patient may have oral cancer. There are a number of cancers and other diseases that can cause one or more of these signs. For example, a patient wearing dentures may develop ulceration due to poorly fitting denture or dentures. Dentures may also cause papillary hyperplasia. Tuberculosis, syphilis and other bacterial, fungal or viral infections, non-malignant oral mucosal diseases such sarcoidosis, diabetes, nutritional diseases, and many benign neoplasms may have one or more of the signs described earlier.

47. Oral Cancer Screening
Begin with the hairline and look for any changes in skin color, including moles, lumps, bumps and sores.
Both sides of the face and neck should be the same size, shape and form. Feel the entire face for lumps and numbness.
Slide #47
Begin with the hairline and look for any changes in skin color, including moles, lumps, bumps and sores. Both sides of the face and neck should have the same size, shape and form. Feel the entire face with your fingertips for lumps and numbness.

48. Oral Cancer Screening Next, the neck exam:
Feel the front and back of the large muscles running from the ears to the collar bone.
Feel under the jaw from the ears to the chin.
Slide #48
Next examine the side of neck: Using your hand, feel the front and back of the large muscles running from the ears to the collar bone, the sternocleidomastoid muscle. Feel under the jaw from the ears to the chin. Examine the two borders of the sternocleidomastoid muscle by placing one hand on each side of the muscle borders.

49. Oral Cancer Screening
Find the “Adam’s Apple” and ask the patient to swallow.
Feel for lumps and soreness on both sides to the collarbone.
Slide #49
Next examine the center of the neck: Find the "Adam's apple," place your fingers against it and ask the patient to swallow; it should move. Feel for lumps and soreness on both sides to the collarbone.

50. Oral Cancer Screening Lymph nodes: Lymph nodes:
Normally lymph nodes feel like peas under our fingers as we press the tissue against the neck muscles or jaw bone.
A cancerous lymph node will feel rubbery or hard to touch, it can present as a lump in the neck that does not move when pressure is applied
Slide #50
Lymph nodes:
Normally lymph nodes feel like peas under our fingers as we press the tissue against the neck muscles or jaw bone.
A cancerous lymph node will feel rubbery or hard to touch, it can present as a lump in the neck that does not move when pressure is applied

51. Oral Cancer Screening Next the patients’ lips should be examined:
Squeeze the lip and check for swelling, tenderness and color change
Pull the upper and lower lips back and look for sores or color changes.
Slide #51
Next the patients lips should be examined:
Squeeze the lip and check for swelling, tenderness and color change
Pull the upper and lower lips back and look for sores or color changes.

52. Oral Cancer Screening Now the cheeks will be examined:
Place the index finger on the outside of the cheek and the thumb on the inside and gently squeeze the cheek to check for any swelling, lumps or soreness.
Pull the patients’ cheek back and look for color changes such as red, white or dark areas.
Slide #52
Next examine the cheeks: Place your thumb on one side of the cheek and the index finger on the other side; gently squeeze the cheek. Note any swelling, lumps or soreness. Then pull back the cheek so you can see the tissue and look for color changes such as red, white or dark areas. Repeat the examination for the other cheek.

53. Oral Cancer Screening Next the gums will be examined:
Look on the inside and outside of the gums for lumps, bleeding, or red and white areas
Ask, “Are there any sores that have not healed for longer than 2 weeks?”
Slide #53
Next examine the gums: Look on the inside and outside of the gums for lumps, bleeding, or red and white areas. If the patient wears dentures, look for white or red areas on the gums. Are there any sores that have not healed for longer than 14 days?

54. Oral Cancer Screening Next the tongue will be examined:
Ask the patient to place the tip of their tongue on the roof of their mouth to look for sores under the tongue.
Using gauze pull the tongue to the side and examine the top and sides for color changes, lumps or sores.
Slide #54
Using gauze, pull the tongue all the way to the side and examine and feel the top and the sides for color changes, lumps or sores.

55. Oral Cancer Screening
Next the floor and roof of the mouth will be examined:
Feel the floor of the mouth for lumps and growths.
Use an index finger to gently press against the roof of the mouth to feel for lumps, swelling or soreness.
Slide #55
With an index finger gently press against the roof of the mouth to feel for lumps, swelling or soreness.

56. Oral Cancer Screening
The dentist should also examine other tissues such as the lingual tonsil and may perform other tests (such as brush biopsy)
Slide #56
The dentist should also examine other tissues such as the lingual tonsil and may perform other tests (such as brush biopsy).
Oral cancer screening is painless.

57. Leukoplakia White patch
Potentially pre-cancerous
Slide #57
The next series of slides will present different manifestations of oral mucosal lesions

58. Leukoplakia
Is a clinical term for a white plaque that cannot be removed by scraping, and cannot be classified clinically or histologically as another disease entity.
Some leukoplakias are cancerous.
Slide #58
Leukoplakia is potentially pre-cancerous. It is important to biopsy and follow these lesions and advise patients to stop smoking and heavy drinking.
A white line on the cheek that is parallel to teeth may result because the patient may bite.

59. Early or thin leukoplakia on the palate
Slide #59
In this slide, there is early or thin leukoplakia on the palate. Notice the several isolated white patches. These patches have clearly demarcated borders separating them from the normal mucosa.

60. Leukoplakia on the lateral surface of the tongue
Slide #60
Here, there is leukoplakia on the lateral surface of the tongue.

61. Leukoplakia on the buccal mucosa, gingiva and floor of mouth
Slide #61
Leukoplakia on the buccal mucosa, gingiva and floor of the mouth

62. Homogenous or thick leukoplakia
Slide #62
The lesion here is homogenous and thicker than the previous lesions; however, a clear border is still noticeable.

63. Proliferative verrucous leukoplakia - precancerous
Slide #63
This lesion is called verrucous leukoplakia, which is most likely precancerous. This lesion is more widespread than the smaller patches in the previous slides.

64. Proliferative verrucous leukoplakia on the buccal mucosa
Side #64
This verrucous leukoplakia proliferated and appears as a growth above the mucosal surface.

65. Other White Patches
Slide #65
Other oral mucosal white patches

66. Slide #66
Lichen planus is present bilaterally on the buccal mucosa.
Lichen planus: a benign inflammatory lesion. Typically this type of lacy white plaque is seen bilaterally on the buccal mucosa in a patient with lichen planus.

67. Tongue Biting
Slide #67
A common lesion found on the side of the tongue is a white line caused by tongue biting.

68. Candidiasis: yeast infection on the tongue
Slide #68
Candidiasis is a yeast infection which appears as a white plaque that can be wiped off, leaving small bleeding points underneath. The area may be painful and sensitive.
Candidiasis: yeast infection on the tongue
Candidiasis can present as a white plaque that wipes off, leaving small bleeding points underneath. The are may be painful or sensitive.

69. Differential Diagnosis
Most red or white lesions, such as lichen planus, should be assessed by biopsy.
There is no way to be absolutely certain that these lesions are not cancer, so biopsy is necessary.
Slide #69
Most red or white lesions, such as lichen planus, should be assessed by biopsy.
There is no way to be absolutely certain that these lesions are not cancer, so biopsy is necessary.

70. Erythroplakia = Red Batch
Red lesions can be caused by processes such as infection, trauma and inflammatory diseases.
An erythroplakia with no known cause/diagnosis is more likely to undergo malignant transformation than a white lesion
Speckled erythroplakia is a combination of leukoplakia and erythroplakia
5I% of cases will show invasive carcinoma on biopsy .
Slide #70
Red lesions can be caused by processes such as infection, trauma and inflammatory diseases.
An erythroplakia with no known cause/diagnosis is more likely to undergo malignant transformation than a white lesion
Speckled erythroplakia is a combination of leukoplakia and erythroplakia
5I% of cases will show invasive carcinoma on biopsy

71. Erythroplakia: a red lesion that may be caused by cancer
Slide #71
An example of erythroplakia or a red lesion that may be caused by cancer

72. Erythroplakia: a red lesion with swelling that is most likely cancerous
Slide #72
Erythroplakia: a red lesion with swelling that is most likely cancerous.

73. Erythroleukoplakia: Red and white lesion
Slide #73
Erythroleukoplakia: Red and white lesion

74. Erythroleukoplakia (Red-White Patch)
Slide #74
Erythroleukoplakia (Red-White Patch)

75. Ulcerative erythroplakia on the buccal mucosa
Slide #75
Ulcerative erythroplakia on the buccal mucosa

76. Kaposi Sarcoma: HIV Slide #76
Many of these lesions may be confused with lesions associated with HIV infection.

77. Kaposi Sarcoma: AIDS Slide #77
Kaposi sarcoma may appear as a red, blue, or brown macules or plaque in the mouth.
Kaposi Sarcoma: AIDS

78. Slide #78
Two other examples of Kaposi sarcoma.
Kaposi Sarcoma: AIDS

79. Slide #79
This is an example of Kaposi sarcoma
Kaposi Sarcoma: AIDS