Oral cancer; recognizing it and referring it early
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Oral cancer; recognizing it and referring it early
- 1. ORAL PATHOLOGY ONLINE CONFERENCE Third year dental students Supervised by Dr.Dalal ALQahtani dalalq@ksu.edu.sa College of Dentistry King Saud University SUMMARY
- 2. ORAL CANCER; RECOGNIZING IT AND REFERRING IT EARLY Done by: Rawan AL-Ateeq Waad AL-Omran Dania AL- Madi Malak AL-Hdlaq Raghad AL-Amadi
- 3. The advertisement video: https://www.youtube.com/watch?v=QdgCLTaVoMU The introduction video: https://www.youtube.com/watch?v=i6JM8JIOqos Basic information video : https://www.youtube.com/watch?v=OOilCBtGWPU
- 4. Oral cancer can never be diagnosed by any doctor other than dentist, we are responsible to detect it,thus we must be ready for these lesions Early detection is very important because even if the patient have been treated with radiation, surgery and chemotherapy in advanced stage a 5 year survival rate were only for %55 of the patients How can history and social habits affect the oral mucosa, can you list some factors? Tobacco, alcohol ,previous cancer esp if its diagnosed before 2yrs , radiotherapy and etc.. Risk factors of oral cancers are tobacco , alcohol, chewing tobacco , age, betel quid ,marijuana , diet low of fruits and fibers , HBV 16,18 and chronic gum disease Chronic candida infection have been linked with oral cancer These days there is an increased risk of oral cancer in young adult especially in USA. Hmm what is the contributing factor in your opinion? Its Marijuana , and it will continue to increase because of the low awareness level . A risk factor that is found in India and southwest Asia is Betel quid, but can you mention a disease that transform to a cancer by it? Submucousal fibrosis that have 7.6% malignant transformation by it
- 5. Iron deficiency anemia accompanied with dysphagia and esophageal webs known as plummer-vinson syndrome have higher chance to cancer If there were leukoplakia in male and female, which one would have higher possibility of malignancy in your opinion, considering that all other factors are the same? The female patient. If there were leukoplakia in smoker and another in non-smoker, which one in your opinion have higher possibility of malignancy? Sadly, it is the non-smoker, due to other potent carcinogens. Immunosuppression increases the risk of oral cancer , do you know which cancer is usually associated with HIV? Kaposi sarcoma Carcinoma of the lip usually involves white middle aged men, can you guess why ? White:due to low melanin level thus less protection Men: because usually occupies outdoor job old: the older is the pt the more sun exposure Sadly, African American have higher mortality rate in oral cancer, do you know why? Simply because it get diagnosed at an advanced stage.
- 6. Do you know that there is a lack of skill in detection early oral cancer,which makes it more important to step up your clinical skill Bleeding, ulceration with pain ,elevation of lesion >3mm ,do you know which one of those are early clinical feature of oral malignancy ? None , those are actually considered late clinical features Very Early oral malignancy will have a smooth or granular surface or asymptomatic ulcer with no bleeding or induration Early signs of cancer are non-healing ulcer, thin patch of leukoplakia or erythroplakia especially when its in dangerous site as lateral surface of the tongue or floor of the mouth Other features involved are heterogeneity in color or thickness ,irregular border indurated and rolled borders One of the early signs of oral cancer is thin leukoplakia which is a white patch or plaque that cannot be characterized clinically or pathologically as any other disease. The most common site of leukoplakia are buccal mucosa, alveolar mucosa, and lower lip. But, lesions in the floor of mouth, lateral tongue, and lower lip are most likely to show malignancy.
- 7. Can you mention other Early Signs of Oral Cancer? 1-Persistent red and/or white patch,Prolonged hoarseness ,Nonhealing ulcer ,Progressive swelling ,Unusual surface changes 2-Sudden tooth mobility without apparent cause,Unusual oral bleeding or epistaxis Do you have any idea of why most of the malignancy occurs at the floor of the mouth or lateral surface of the tongue? Because carcinogens will tend to constantly pool in that area and those area covered by hinner nonkertinized membrane Most lip cancers manifest on the lower lip at the mucocutaneous junction as a chronic small lump, ulcer, or scabbed lesion. Carcinomas of the alveolus or gingiva are mostly seen in the mandibular premolar and molar regions, usually as a lump (epulis) or ulcer. Carcinomas of the buccal mucosa are mostly seen at the commissure or in the retromolar area. When should chronic oral lesion should be regarded with suspicion? Older patient, induration, with fixation to underlying tissues, with any recent changes in appearance, with associated lymphadenopathy, or with no obvious explanation for the lesion.
- 8. Screening aids of oral cancer 1- standered screening test: COE (conventional oral examination) 2. Established screening adjuncts: Oral cytology- -Oral brush biopsy 3. Vital staining: -Toluidine blue (TB) (tolonium chloride) - Lugol's Iodine - Methylene Blue
- 9. Conventional oral examination is performed by doctors, can you mentions any requirement of it? Adequate light and retraction of soft tissue COE cannot discriminate between lesions that are progressive or become malignant and those non-progressive counterparts. COE is a useful tool in detecting some oral cancer lesions, it does not identify all potentially premalignant lesions. There is an adjunct way to detect oral cancer which is by using oral cytology Oral cytology is carried out to detect cancer pre-invasive stage by use of exfoliative cytology
- 10. But the sensitivity and specificity differs due to its subjectivity or due to the poor technique in obtaining cells and smear preparation. In order to decrease its subjectivity they developed oral CDx cytobrush which claims to collect the basal layer cells non-invasively and assess the dysplasia by computer-assisted neural network its accuracy can be increased by using (DNA) cytometry, silver nucleolar organisation regions (AgNOR) analysis immunocytochemistry and fluorescent insitu hybridization (FISH). We can also use staining likeToluidine blue that is believed to stain nucleic acids, it is used to detect carcinomas but not dysplasia It is not used as diagnostic tool in clinic due its false positive reading , do you know what that mean? False positive means that the test was positive for cancer, even if the lesion was not.
- 11. recent study by Moyer, showed that TB stained evident lesions with high risk molecular patterns and predicted risk and outcome in cases where little to no microscopic evidence of dysplasia was present Do you know what the dark and the light blue means in TB stain? Dark blue=positive for lesions suspicious malignancy Light blue=positive for premalignant lesions unless proved otherwise by biopsy Can you mention the advantages and disadvantages of TB? Adv: Specify area for biopsy, cheap, not invasive, disposable and 100% sensitivity Disadv: taste , it can remain in the mouth for 4-6hrs and its false positive
- 12. There is another satin which is Lugol's iodine consisting of 10 parts of potassium iodide to 5 parts of iodine Lugol's iodine was used as an antiseptic. Application of iodine results in brown or black color staining in areas containing glycogen .In areas lacking glycogen, iodine is not absorbed and such areas remain colorless or turn yellow. Can you name Advantages? It can be used for non-keratinized stratified squamous epithelium, Simple, Low costs High sensitivity with low false negatives, result are fast, no follow up to know the result But It is an irritant, cause abdominal pain, heart burn and nausea, Allergic reaction to iodine, Induces shock Less accurate when used in post-menopausal women. Used routinely in patients at risk - those with head and neck cancer and Heavy smokers and drinkers.
- 13. Lugol's Iodine consisting of 10 parts of potassium iodide to 5 parts of iodine Application of iodine results in brown or black color staining in areas containing glycogen .In areas lacking glycogen, iodine is not absorbed and such areas remain colorless or turn yellow. Advantages: 1- Used for non-keratinized stratified squamous epithelium 2-Simple and many doctors do it 3- cheap 4-High sensitivity results in a low proportion of false negatives 5-Test results are immediate 6-Decreased loss to follow-up. Disadvantages : It is an irritant ,cause abdominal pain, heart burn and nausea Allergy to iodine induces shock Less accurate when used in post- menopausal women. Applications 1-Used routinely in patients at risk - those with head and neck cancer 2-Heavy smokers and drinkers.
- 14. The 3rd stain is Methylene blue It is a heterocyclic aromatic chemical compound. At room temperature appears as a solid, odorless, dark-green powder, which yields a blue solution when dissolved in water. It is Cheap and less cytotoxic Used as an Early detection of oral cancer,treat Alzheimer's disease and Examine (RNA) or DNA under the microscope
- 15. Methylene Blue It is a heterocyclic aromatic chemical compound. At room temperature appears as a solid, odorless, dark-green powder, which yields a blue solution when dissolved in water. Advantages: Cheap and less cytotoxic Applications 1-Early detection of suspected oral cancer 2-Detect gastric, prostate, and bladder cancers 3-To treat Alzheimer's disease 4-Examine (RNA) or DNA under the microscope
- 16. Another adjunct way to COE is Chemiluminiscence . it is the emission of light from a chemical reaction which is of varying degrees of intensity with colors that span the visual spectrum. It involves the use of an oral rinse with a 1% acetic acid solution for 1min followed by another examination under blue/white light
- 17. 1-The theory behind this technique is that the acetic acid removes the glycoprotein barrier and slightly desiccates the oral mucosa; 2-the abnormal cells of the mucosa then absorb and reflect the blue/white light in a different way with respect to normal cells. Hence normal mucosa appears blue, whereas abnormal mucosal areas reflect the light (due to higher nuclear/cytoplasmic ratio of epithelial cells)
- 18. Advantages delineating the sharp borders between normal and abnormal oral mucosa and often extended beyond the clinically identified outline Malignant lesions could be recognized without the aid of adjunctive diagnostic Tools To screen for the possibility of field cancer change in other parts of the apparently normal mucosa. It is used to diagnose leukoplakias and radiation mucositis Identification of asymptomatic and clinically non-evident lesions Diagnostic aid for the detection of oral cancer and pre malignant early lesions .
- 19. The adjunct way is VELscope . When cells interact with light they become excited and re-emit light of varying colors (fluorescence) and this can be detected by sensitive detectors All tissues fluoresce due to the presence of fluorescent fluorophores with in them (autofluorescence) Florescence spectroscopy and imaging can detect these substances and provide characteristic spectra that reflect biochemical changes
- 20. Advantages It takes only 1-2 min and is painless and non-invasive, with no stains or rinses required Improves the distinction between normal and abnormal tissues Useful adjunct to a thorough visual and digital soft tissue clinical examination Possesses useful benefit in the determination of surgical borders and post-surgical evaluations. It covers large surface area, Non invasion method and Small lesions can be identified. Disadvantages heat from prolonged and close tissue examination may cause patient discomfort. Limitations: Analysis of small sample sizes, Lack of methodologically sound clinical trials Insufficient use of histologic and molecular mapping
- 21. REFERENCES : •Text: •http://www.treatmentfororalcancer.com/ •http://drperrone.com/blog/velscope-key-to-diagnosing-oral-cancer-early/ •Malignant Tumors of the Jaws Lecture Slides - Dr. Asma’a Al-Ekrish - Assistant Prof., OMF Radiology •http://ccnmtl.columbia.edu/broadcast/hs/dental/oralradiology2/2008/malignant.pdf •http://www.jmedicalcasereports.com/content/5/1/291 •http://www.exodontia.info/files/Dent_Update_2013._Early_Detection_of_Oral_Cancer__How_Do_I_Ensur •e_I_Don_t_Miss_a_Tumour.pdf •http://www.nidcr.nih.gov/oralhealth/topics/oralcancer/detectingoralcancer.htm •http://oralcancerfoundation.org/cdc/cdc_chapter5.php •http://www.brainyquote.com/quotes/topics/topic_knowledge.html •http://www.oralcancerfoundation.org/cdc/cdc_chapter5.php •http://www.nidcr.nih.gov/oralhealth/topics/oralcancer/detectingoralcancer.htm#EarlyDetection •http://www.oralcancerfoundation.org/dental/pdf/Dental_professional_overview.pdf •http://www.eaoms.eg.net/PDF/vol-1-1/EJOMS0105.pdf
- 22. Videos: http://www.youtube.com/watch?v=xtG8LcGv3Zw Dx O. Cancer http://www.youtube.com/watch?v=0VzSG3uCulw O. Cytology http://www.youtube.com/watch?v=egnOjnvGmgc http://www.youtube.com/watch?v=zth7C7i2AxU Hopeful Music Turning Tides Wanderer http://www.youtube.com/watch?v=SZBlXJ0kEU8 Pictures: http://www.orangectdentist.com/dental-services/oral-cancer-screening/ http://ar.iiarjournals.org/content/32/8/3327/F3.large.jpg https://www.google.com/search?q=smoking+animated+gif&source=lnms&tbm=isch&sa=X&ei=28iTVKzfIMK3O P66geAM&ved=0CAgQ_AUoAQ&biw=1366&bih=657#tbm=isch&q=oral+cancer&facrc=_&imgdii=_&imgrc=u3L gQVc7cQ18BM%253A%3Broqs7pC1WarKeM%3Bhttp%253A%252F%252Fwww.killthecan.org%252Fwp- content%252Fuploads%252F2013%252F07%252FCancer-Of-The- Tongue.jpg%253F95a937%3Bhttp%253A%252F%252Fwww.killthecan.org%252Ffacts-figures%252Fcancer- pictures%252F%3B1200%3B900 http://houstonimplantperiodontist.com/images/oral-cancer-screening-2.jpg http://mouth-tongue-gum-throat-cancer.com/wp-content/uploads/2011/12/Mouth-Cancer-on-Hard-Palate.j http://meded.ucsd.edu/clinicalmed/head_lymphnodes2.jpg http://www.riversideonline.com/source/images/image_popup/mcdc7_salivary.jpg