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Peoples lives can be saved through early detection of oral, head and neck cancers. Adriana Clark, DDS 1 Slide 2 Agenda Introduction Oral Cancer Facts Oral Cancer Screening. Mucosa lesion assessment. - Patient History - Visual Screening Examination Extraoral and Intraoral (Inspection-Palpation) 2 Slide 3 Agenda Red Flags Documentation Optional Screening Aids The Dawn of New Era Demo Extra- Intraoral Exam Glossary 3 Slide 4 4 Slide 5 Oral Cancer Facts Oral cancer is a common cancer of global concern. The five year survival rate is approximately 50 per cent. Early detection has the potential to significantly reduce oral cancer death and morbidity. Known risk factors include tobacco and alcohol consumption, which together are responsible for about 75 per cent of oral cancers. There is an alarming increase in oropharyngeal cancer cases seen in the 18-40 age group. (Types HPV). More than 25% of oral cancers do occur in people without risk factors of tobacco or excessive alcohol consumption. 5 Slide 6 Facts (Continued) Approximately 90% of oral cancers are classified as squamous cell carcinoma. In general, lesions that require monitoring include: nonhealing ulcerations white patches that do not rub off (leukoplakia) red patches that do no rub off (erythroplakia) High-risk sites: Lateral tongue, floor of mouth, and tonsillar pillars 6 Slide 7 Facts (Continued) Most oral premalignant lesions and cancers should be detectable at the time of a Comprehensive Oral Examination. These lesions often present as a white patch, or less frequently a red patch. Progression from premalignant lesions to cancer usually occurs over years. 7 Slide 8 8 Red patch White patch Slide 9 APPROACH Oral cancer screening and mucosal lesion assessment 9 Slide 10 Patient History The first step in screening for oral cancer is the completion of a patient history which should include review of: General health history with a list of current medications and medication allergies Oral habits and lifestyle, with particular reference to quantity, frequency and duration of tobacco use and alcohol consumption HPV + test Symptoms of oral pain or discomfort 10 Slide 11 Visual Screening Examination Explain to the patient the protocol for the exam. EXTRAORAL INSPECTION Head Neck Supraclavicular regions for lymph nodes 11 Slide 12 Palpation - Submandibular - Neck - Supraclavicular regions for lymph nodes (size, number, tenderness and mobility) - Lips and perioral tissues. 12 Slide 13 Extaoral Palpation 13 Slide 14 Intraoral 14 Slide 15 Tools Good source of light Basic tray 2x2 Tongue blade 15 Slide 16 Inspection - Palpation (Important to ask the patient to remove all dental appliances and piercing jewelry). All oral soft tissue Particular attention to the high risk sites such as: Lateral and ventral aspects of the tongue Floor of mouth Soft palate 16 Slide 17 Intraoral - Examination 17 Slide 18 Examination of Mucosa Recommendation to dry surface with 2x2 or air syringe Look for: Color changes Textures Red and white lesions 18 Slide 19 Lesions 19 Slide 20 Red Flags TOBACCO- ALCOHOL lesions tend to favor anterior tongue and mouth, and HPV (+) posterior oral cavity. Patients with habit of cheek biting - follow patient for any changes in color, size, or texture. Betel nut users. (Asia). Oral squamous cell carcinoma is common in long-term betel quid users. The carcinogenicity of the known risk factors for oral cancer is dose-dependent and magnified by multiple exposures. 20 Slide 21 Examination of the Tongue One of the most common sites of oral cancer is on the lateral aspect of the tongue. With a 2x2 pull the tongue out and roll it from side to side while retracting the cheek with a tongue blade. Palpation of the dorsum and lateral margins of the tongue is important. Ask the patient to touch the roof of their mouth with the tip of their tongue. 21 Slide 22 Lesion Inspection Evaluate the specific characteristics of lesion: Location Size Color Texture Attention to white, red and white, ulcerated and/or indurated lesions. 22 Slide 23 Lesion Inspection 23 Slide 24 Documentation If possible, take a photos of any suspicious lesions Record all findings and description of the lesion in medical and dental file Report to the Physician 24 Slide 25 Optional Screening Aids Techniques that are promoted to improve earlier detection and diagnosis of oral malignancy include: VITAL TISSUE STAINING: (TB). Tolonium Chloride. Has been used for more than 40 years. Staining of abnormal tissue in contrast to adjacent normal mucosa. (Mouth rinse or topical swab w/different concentrations) 25 Slide 26 Visualization Adjuncts Vizilite Plus with Tblue Microlux DL Orascoptic DK system The VELscope Tissue Fluorescence. (Differentiate between normal and abnormal tissues). 26 Slide 27 VELscope showing severe displasia. 27 Slide 28 VELscope showing normal tissue. 28 Slide 29 Cytopathology Use the OralCDxBrush for: Common, harmless appearing small white and red spots. Chronic ulcerations. Lesions with unusual surface such as a granular appearance Evaluation of mucocutaneous disorders (e.g., lichen planus) unresponsiveness to treatment. Follow-up of a persistent lesion despite a benign diagnosis from a previous brush or scalpel biopsy. All oral CDx atypical /(+) must be confirmed by incisional biopsy and histology. 29 Slide 30 30 Leukoplakia Dysplastic lesion TBlue 630 Test Slide 31 31 Vizilite Plus VELscope Slide 32 The Dawn of a New Era Salivary biomarker technology in oral cancer research and diagnosis is an exciting emerging field. 32 Slide 33 33 Slide 34 Biopsy It is the goldstandard diagnostic test for oral mucosal lesions that are suggestive of pre-malignancy or malignancy. Persistent lesion after removal of identified local irritants such as trauma, infection or inflammation. 34 Slide 35 Demo Extra-Intraoral Exam Video available for viewing. http://www.youtube.com/watch?v=yY9- 7pOTROM&feature=related 35 Slide 36 Glossary Erythema: Redness that suggest epithelial inflammation, thinness and irregularity. Erithroplakia: A well defined red, velvet or granular lesion of the oral mucosa. Homogenous: A descriptive term for a mucosal lesion that is uniform in appearance. Indurated: An abnormal firm or hard portion of tissue with respect to the surrounding similar tissue. 36 Slide 37 Glossary Leukoplakia: A white patch that cannot be rubbed off and cannot be characterized clinically or histologically as any other lesion. Nodular: Referring to a granular surface texture. Speckled: A mucosal lesion that has red and white components to it. Ulceration: The result of loss of epithelial integrity involving all layers of epithelium with resultant exposure of the underlying connective tissue. Verrucous: Referring to an irregular mucosal surface or wart-like white surface projection. 37