3 Screening Tools Flashcards
What is cancer screening? Goal?
- looking for cancer before a person has any symptoms
* goal is to identify a malignancy at an early stage before symptoms appear
Things considered to be screening tools (5):
- 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
how to palpate floor of mouth
biannual palpation
where to palpate the neck
- anterior and posterior to SCM
* entire border of mandible and submandibular tissues
prime locations for skin cancers
top/behind ears
What to do when you identify a suspicious oral lesion?
- 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
Next step after examining a suspicious oral lesion:
- 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
PMDs (potentially malignant disorders)
mucosal lesions that have an increased risk of developing into SCC (may include leukoplakia, erythroplakia, erythroleukoplakia)
Conclusion of expert panel that convened to evaluate potentially malignant disorders in the oral cavity? Summary of recommendations?
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
devices intended to assist in lesion DETECTION vs ASSESSMENT
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
Two types of devices intended to assist in lesion DETECTION:
Tissue reflectance types—ViziLite Plus
Tissue fluorescence tools—VELscope, ViziLite PRO
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?
- 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)
the purpose of the 1% acetic acid wash for 30-60 seconds
remove the glycoprotein (surface debris) covering the mucosa, thus reducing the layer and to slightly desiccate the cellular tissues
- 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
ViziLite Plus (tissue reflectance types)
Steps to ViziLite Plus:
- 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
suggested pt fee of ViziLite plus
~ $40-$100
CDT-5 procedure code D0431
prediagnostic test that aids in detection of mucosal abnormalities including pre-malignant and malignant lesions, not to include cytology or biopsy
How do tissue fluorescence tools work?
- 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
chemical molecules that can absorb energy at a certain wavelength and then re-emit light
fluorophores
can scan the whole oral cavity relatively easily
tissue fluorescence tools
Light range that tissue fluorescence tools use? Viewed through? Normal vs abnormal mucosa?
- 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
tissue fluorescence tools
Identafi, VELscope
How does Identafi work (violet vs amber light)?
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
theory is that you use this device to detect changes that are not visible to the naked eye with routine, WHITE light examination
VELscope
manufacturer’s caution when it comes to autofluorescence tools
loss of autofluorescence is not limited to epithelial abnormalities (premalignant or malignant)
• prominent surface vascularity
• areas of inflammation
• melanin pigment
how do devices intended to assist in lesion ASSESSMENT work
transepithelial cytology
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”
brush test—OralCDx
Brush test biopsy SHOULD vs SHOULD NOT be used for:
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)
a different reason to use OralCDx brush test
provide evidence to “nudge” a patient who has a lesion that should be biopsied, but they are reluctant to do so
contraindications to the OralCDx brush test
if the lesion is clinically suspicious for oral cancer or precancer, it should receive a scalpel biopsy
OralCDx brush test technique
- 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
possible results of a brush test
- 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.
disadvantages of the OralCDx brush test
- 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
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?
not all potentially malignant disease is detected with the brush biopsy procedure
Impact of these oral cancer screening tools:
- 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?
cost effectiveness of oral screening tools?
- 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
gold standard =
biopsy!!!
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
biopsy (gold standard!!!!)
Indications:
• May wait ______ days if history surrounding lesion is unclear
• After that, must biopsy:
10-14 days
- inflammatory changes
- ulcerations
- swellings
- hyperkeratotic lesions
- any lesion that persists after removal of causal factors (ex: smoothing rough tooth or restoration)
Contraindications for general dentist to perform the biopsy:
Absolute contraindications:
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
Name the biopsy technique: removal of the entire lesion
excisional biopsy
Name the biopsy technique: lesions should be 1 cm or less in diameter
excisional biopsy
Name the biopsy technique: clinically benign appearance, surgically accessible
excisional biopsy
Name the biopsy technique: fibroma, papilloma, inflammatory cyst
excisional cyst
Name the biopsy technique: removal of a representative portion of the lesion
incisional biopsy
Name the biopsy technique: large, diffuse, ill-defined, concern of malignancy
incisional biopsy
Name the biopsy technique: alternative technique to perform excisional or incisional biopsy
punch biopsy
Name the biopsy technique: simple, fast, relatively atraumatic
punch biopsy
Conclusions:
- 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
Community-based screening by means of visual and tactile examination may decrease oral cancer-specific mortality among people who…?
use tobacco, alcohol, or both
Recommendations from ADA panel:
- 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
Patient education: educate your patients about worrisome features of oral lesions
- 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
