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Oral Pathology Exam 2 > 3 Screening Tools > Flashcards

3 Screening Tools Flashcards

1
Q

What is cancer screening? Goal?

A
  • looking for cancer before a person has any symptoms

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

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2
Q

Things considered to be screening tools (5):

A
  • 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
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3
Q

how to palpate floor of mouth

A

biannual palpation

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4
Q

where to palpate the neck

A
  • anterior and posterior to SCM

* entire border of mandible and submandibular tissues

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5
Q

prime locations for skin cancers

A

top/behind ears

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6
Q

What to do when you identify a suspicious oral lesion?

A
  • 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
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7
Q

Next step after examining a suspicious oral lesion:

A
  • 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
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8
Q

PMDs (potentially malignant disorders)

A

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

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9
Q

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

A

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

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10
Q

devices intended to assist in lesion DETECTION vs ASSESSMENT

A

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

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11
Q

Two types of devices intended to assist in lesion DETECTION:

A

Tissue reflectance types—ViziLite Plus

Tissue fluorescence tools—VELscope, ViziLite PRO

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12
Q

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?

A
  • 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)
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13
Q

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

A

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

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14
Q
  • 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
A

ViziLite Plus (tissue reflectance types)

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15
Q

Steps to ViziLite Plus:

A
  • 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
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16
Q

suggested pt fee of ViziLite plus

A

~ $40-$100

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17
Q

CDT-5 procedure code D0431

A

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

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18
Q

How do tissue fluorescence tools work?

A
  • 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
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19
Q

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

A

fluorophores

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20
Q

can scan the whole oral cavity relatively easily

A

tissue fluorescence tools

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21
Q

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

A
  • 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
22
Q

tissue fluorescence tools

A

Identafi, VELscope

23
Q

How does Identafi work (violet vs amber light)?

A

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

24
Q

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

A

VELscope

25
Q

manufacturer’s caution when it comes to autofluorescence tools

A

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

26
Q

how do devices intended to assist in lesion ASSESSMENT work

A

transepithelial cytology

27
Q

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”

A

brush test—OralCDx

28
Q

Brush test biopsy SHOULD vs SHOULD NOT be used for:

A

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)

29
Q

a different reason to use OralCDx brush test

A

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

30
Q

contraindications to the OralCDx brush test

A

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

31
Q

OralCDx brush test technique

A
  • 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
32
Q

possible results of a brush test

A
  • 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.

33
Q

disadvantages of the OralCDx brush test

A
  • 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
34
Q

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?

A

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

35
Q

Impact of these oral cancer screening tools:

A
  • 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?
36
Q

cost effectiveness of oral screening tools?

A
  • 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
37
Q

gold standard =

A

biopsy!!!

38
Q

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

A

biopsy (gold standard!!!!)

39
Q

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

A

10-14 days

  • inflammatory changes
  • ulcerations
  • swellings
  • hyperkeratotic lesions
  • any lesion that persists after removal of causal factors (ex: smoothing rough tooth or restoration)
40
Q

Contraindications for general dentist to perform the biopsy:

Absolute contraindications:

A

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
41
Q

Name the biopsy technique: removal of the entire lesion

A

excisional biopsy

42
Q

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

A

excisional biopsy

43
Q

Name the biopsy technique: clinically benign appearance, surgically accessible

A

excisional biopsy

44
Q

Name the biopsy technique: fibroma, papilloma, inflammatory cyst

A

excisional cyst

45
Q

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

A

incisional biopsy

46
Q

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

A

incisional biopsy

47
Q

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

A

punch biopsy

48
Q

Name the biopsy technique: simple, fast, relatively atraumatic

A

punch biopsy

49
Q

Conclusions:

A
  • 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
50
Q

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

A

use tobacco, alcohol, or both

51
Q

Recommendations from ADA panel:

A
  • 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
52
Q

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

A
  • 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

Oral Pathology Exam 2 (8 decks)

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