3 Screening Tools

Question 1

What is cancer screening? Goal?

Answer 1

• looking for cancer before a person has any symptoms

* goal is to identify a malignancy at an early stage before symptoms appear

Question 2

Things considered to be screening tools (5):

Answer 2

• review of medical history—health habits, past illnesses and previous tx that put someone at increased risk for developing cancer (smoking habits)
• routine physical—examine for general signs of health, checking for signs of disease or anything else that seems unusual (breast/prostate exam)
• laboratory tests—samples of tissue, blood, urine, or other substances (pap smear)
• imaging procedures (mammogram)
• genetic testing

Question 3

how to palpate floor of mouth

Answer 3

biannual palpation

Question 4

where to palpate the neck

Answer 4

• anterior and posterior to SCM

* entire border of mandible and submandibular tissues

Question 5

prime locations for skin cancers

Answer 5

top/behind ears

Question 6

What to do when you identify a suspicious oral lesion?

Answer 6

• palpate it
• try and wipe it off (use gauze)
• compare it to contralateral side
• look for possible sources of irritation (adjacent teeth, oral appliances, oral habits)
• ask the patient if they know how long it has been there and if it hurts

Question 7

Next step after examining a suspicious oral lesion:

Answer 7

• ALWAYS DOCUMENT THE LESION
• do nothing
• determine the lesion can be safely monitored periodically (next visit/6 month recall)
• provide tx
• recommend reevaluation of lesion in 2 weeks
• preform an additional clinical examination test
• biopsy the lesion
• refer the pt for a second opinion or biopsy

Question 8

PMDs (potentially malignant disorders)

Answer 8

mucosal lesions that have an increased risk of developing into SCC (may include leukoplakia, erythroplakia, erythroleukoplakia)

Question 9

Conclusion of expert panel that convened to evaluate potentially malignant disorders in the oral cavity? Summary of recommendations?

Answer 9

They concluded that no available adjuncts demonstrated sufficient diagnostic test accuracy to support their routine use as triage tools during evaluation of lesions in the oral cavity.

Summary of recommendations:
• no clinically evident lesions —> no action
• innocuous lesion —> follow-up
• suspicious lesion —> biopsy

Question 10

devices intended to assist in lesion DETECTION vs ASSESSMENT

Answer 10

Devices intended to assist in lesion detection:
• special light source
• claim to enhance practitioner’s ability to specifically identify potentially malignant lesions that may not be visible with conventional lighting

Devices intended to assist in lesion assessment:
• transepithelial cytology

Question 11

Two types of devices intended to assist in lesion DETECTION:

Answer 11

Tissue reflectance types—ViziLite Plus

Tissue fluorescence tools—VELscope, ViziLite PRO

Question 12

How do tissue reflectance types of devices assist in lesion detection (color range)? What do you use before the light source? What color does abnormal epithelium appear?

Answer 12

• uses blue-white light (440 nm range)
• use 1% acetic acid wash before use of light source
• with blue-white illumination, abnormal epithelium is reported to be distinctly white (acetowhite)

Question 13

the purpose of the 1% acetic acid wash for 30-60 seconds

Answer 13

remove the glycoprotein (surface debris) covering the mucosa, thus reducing the layer and to slightly desiccate the cellular tissues

Question 14

• disposable chemiluminescent light packet
• Zila pharmaceuticals
• patients rinse with with 1% acetic acid solution for 30-60 seconds
• patient is then examined using chemiluminescent light stick (crack to activate)
• recommended to be used for white lesions
• red lesions are reportedly negative
• normal tissue appears bluish-white while abnormal tissue is distinctly white

Answer 14

ViziLite Plus (tissue reflectance types)

Question 15

Steps to ViziLite Plus:

Answer 15

• after white lesion is identified
• apply toluidine blue to the area in question
• have pt swish with 1% acetic acid for 1 min to remove excess then rinse with water
• access area of staining if any
• expertise necessary to interpret, true stain vs diffuse film or mechanical retention
• may be used as a guide for where to take a biopsy from in a large lesion

Question 16

suggested pt fee of ViziLite plus

Answer 16

~ $40-$100

Question 17

CDT-5 procedure code D0431

Answer 17

prediagnostic test that aids in detection of mucosal abnormalities including pre-malignant and malignant lesions, not to include cytology or biopsy

Question 18

How do tissue fluorescence tools work?

Answer 18

• exposure of tissue to one specific wavelength of light
• leads to autofluorescence of cellular fluorophores after excitation (fluorophores-chemical molecules that can absorb energy at a certain wavelength and then re-emit light)
• cellular alterations change the concentration of fluorophores
• color change can be observed with imaging

Question 19

chemical molecules that can absorb energy at a certain wavelength and then re-emit light

Answer 19

fluorophores

Question 20

can scan the whole oral cavity relatively easily

Answer 20

tissue fluorescence tools

Question 21

Light range that tissue fluorescence tools use? Viewed through? Normal vs abnormal mucosa?

Answer 21

• intense blue excitation light (400-460 nm)
• viewed through a selective filter on the handpiece
• normal oral mucosa = pale green autofluorescence
• abnormal oral mucosa = appears dark, sometimes maroon

Question 22

tissue fluorescence tools

Answer 22

Identafi, VELscope

Question 23

How does Identafi work (violet vs amber light)?

Answer 23

Violet light
• enhances normal tissue’s natural fluorescence
• “suspicious tissue” appears dark because of its loss of fluorescence
• clinician wears reusable filtered eyewear

Amber light
• enhances normal tissue’s reflectance properties
• observe the difference between normal and abnormal tissue’s vasculature

Question 24

theory is that you use this device to detect changes that are not visible to the naked eye with routine, WHITE light examination

Answer 24

VELscope

Question 25

manufacturer’s caution when it comes to autofluorescence tools

Answer 25

loss of autofluorescence is not limited to epithelial abnormalities (premalignant or malignant) • prominent surface vascularity • areas of inflammation • melanin pigment

Question 26

how do devices intended to assist in lesion ASSESSMENT work

Answer 26

transepithelial cytology

Question 27

technique applied to uterine cervical tissues that is now used for oral lesions, “developed precisely to evaluate benign-appearing oral spots (which are not routinely observed in the dental office) several times each week, and not those infrequent, highly suspicious lesions that dentists may see only several times a year”

Answer 27

brush test—OralCDx

Question 28

Brush test biopsy SHOULD vs SHOULD NOT be used for:

Answer 28

Should: • red, white, or mixed lesions • chronic ulcerations • evaluating mucocutaneous disorders (lichen planus) unresponsive to tx • follow-up of a persistent lesion despite a benign dx from a previous brush or scalpel biopsy • pts with a history of oral or other head and neck cancer, who have evidence of mucosal changes Should NOT: • lesions with intact normal epithelium (fibroma, mucocele, hemangioma) • submucosal masses • melanocytic lesions (pigmented brown) • vermillion border of the lip (dry surface) • any location outside the oral cavity • verrucous carcinoma (rare variant of oral SCC)

Question 29

a different reason to use OralCDx brush test

Answer 29

provide evidence to “nudge” a patient who has a lesion that should be biopsied, but they are reluctant to do so

Question 30

contraindications to the OralCDx brush test

Answer 30

if the lesion is clinically suspicious for oral cancer or precancer, it should receive a scalpel biopsy

Question 31

OralCDx brush test technique

Answer 31

* oral lesion is identified * small brush with plastic bristles is rotated on the lesion until pinpoint bleeding is observed (“painless”) * the harvested cells are smeared on a glass slide, fixed with alcohol, and mailed to OralCDx lab * computer technology identifies the worst cells and photographs them * pathologist examines the images of the most atypical cells and determines whether the changes observed are significant or not

Question 32

possible results of a brush test

Answer 32

* incomplete specimen—too few cells from all layers * negative—no evidence of abnormal cells * atypical—abnormal epithelial cells of uncertain significance * positive—definitive evidence of dysplastic or cancer cells If atypical or positive result, company recommends a surgical biopsy of the lesion.

Question 33

disadvantages of the OralCDx brush test

Answer 33

* limited to reporting presence or absence of cellular abnormalities * no definitive dx * atypical epithelial cells are often found in benign reactive inflammatory conditions * unnecessary scalpel biopsies may be ordered as a result * delay of necessary scalpel biopsies and dx of dysplasia/cancer

Question 34

Brush test studies: • 4 cases of brush test-negative SCCs out of 115 total cases = 3.5% false negative rate (average delay in dx between negative brush test and follow-up biopsy was 117.25 days) • reported 1 SCC and 5 epithelial dysplasias among 75 pts with “negative” brush test—8% false negative rate Conclusion?

Answer 34

not all potentially malignant disease is detected with the brush biopsy procedure

Question 35

Impact of these oral cancer screening tools:

Answer 35

* if this technique is to have an impact on oral cancer survival, one must hypothesize that a significant number of lesions will be detected earlier than usual * no data to say that the poor prognosis of oral cancer is due to the dental community not recognizing disease in its earliest stages * even a stage II lesion is 2-4 cm in diameter—are the majority of dental professionals overlooking or ignoring such lesions? * estimates are that about 60% of the population sees the dentist on a biannual basis—what about getting physicians to do oral exams also?

Question 36

cost effectiveness of oral screening tools?

Answer 36

* atypical results leads to necessity of biopsy (should the lesion have been biopsied in the first place?) * cost—pts and insurers pay an additional several hundred dollars for evaluation of some oral lesions * mental anxiety over an “atypical” brush biopsy result

Question 37

gold standard =

Answer 37

biopsy!!!

Question 38

removal of tissue from a living organism for the purpose of microscopic examination, typically it can be accomplished with local anesthetic in an outpatient setting

Answer 38

biopsy (gold standard!!!!)

Question 39

Indications: • May wait ______ days if history surrounding lesion is unclear • After that, must biopsy:

Answer 39

10-14 days * inflammatory changes * ulcerations * swellings * hyperkeratotic lesions * any lesion that persists after removal of causal factors (ex: smoothing rough tooth or restoration)

Question 40

Contraindications for general dentist to perform the biopsy: Absolute contraindications:

Answer 40

1) Health of the patient—coagulopathy 2) Location of the lesion—proximity to vital structures, vascular/nerve/ductal structures, access! (what if lesions is on uvula and pt has extremely sensitive gag reflex) ``` Absolute contraindications (send to a surgeon): • pulsatile, vascular lesions • intrabony RL lesions • pigmented lesions (melanoma) • lesions suspicious for malignancy ```

Question 41

Name the biopsy technique: removal of the entire lesion

Answer 41

excisional biopsy

Question 42

Name the biopsy technique: lesions should be 1 cm or less in diameter

Answer 42

excisional biopsy

Question 43

Name the biopsy technique: clinically benign appearance, surgically accessible

Answer 43

excisional biopsy

Question 44

Name the biopsy technique: fibroma, papilloma, inflammatory cyst

Answer 44

excisional cyst

Question 45

Name the biopsy technique: removal of a representative portion of the lesion

Answer 45

incisional biopsy

Question 46

Name the biopsy technique: large, diffuse, ill-defined, concern of malignancy

Answer 46

incisional biopsy

Question 47

Name the biopsy technique: alternative technique to perform excisional or incisional biopsy

Answer 47

punch biopsy

Question 48

Name the biopsy technique: simple, fast, relatively atraumatic

Answer 48

punch biopsy

Question 49

Conclusions:

Answer 49

* stage of cancer at dx has an impact on tx decisions and resultant health outcomes * community-based screening by means of visual and tactile examination in the general adult population * intended to detect early and advanced oral cancers * may not alter disease-specific mortality

Question 50

Community-based screening by means of visual and tactile examination may decrease oral cancer-specific mortality among people who…?

Answer 50

use tobacco, alcohol, or both

Question 51

Recommendations from ADA panel:

Answer 51

* screening is only one component of a thorough exam and evaluation * pt history * cancer risk assessment * if mucosal lesion is noted, re-eval in 7-14 days to confirm lesion persistence can reduce the potential for errors in clinical dx * clinician can reduce the risk of performing unnecessary biopsies by obtaining an opinion by a dental or medical provider who has advanced training and experience in dx of oral cancer and its precursor lesions

Question 52

Patient education: educate your patients about worrisome features of oral lesions

Answer 52

* a sore that bleeds easily or does not heal * a color change of the oral tissue * a lump, thinkening, rough spot, crust, or small eroded area * pain, tenderness, or numbness in the mouth * difficulty chewing, swallowing, speaking, or moving the jaw or tongue * a change in the way the teeth fit together