Oral cancer screening

1. Oral Cancer screening
Submitted by,
Manisha Sahi

2. Definition of cancer:
“Abnormal mass of tissue the growth of which
exceeds and is uncoordinated with neighbouring
tissue and growth persist in same exceesive
manner even after the ceassation of the stimuli
which evoked the change.” –ROBBINS
Cancer occuring an any part of oral cavity is
termed as oral cancer.

3. Oral cancer is the sixth deadliest cancer in the
world.
While most cancer survival rates have increased
over the past 40 years., the five year survival rate of
oral cancer has remained below 50%.a

4. Pathogenesis:
The pathogenesis of oral cancer reflects an
accumulation of genetic changes that occur over a
period of years. (Genetic susceptibilty)
The major genes involved in oral cancer are proto
onco genes and tumor suppressor genes.
Other factors that play role in the progression of the
disease may include allelic loss at other
chromosome region,mutations to proto oncogenes
and TSGs, or epigenetic changes such as
deoxyribonucleic acid(DNA) methylation or histone
deacetylation.

5. Protooncogenes code for growth factors,growth
factor receptors,protein kinase, signal transducers,
nuclear phosphoproteins and transcription factors.
Overall effect is they increase cell growth and
differentiation.
TSGs negatively regulate cell growth and
differentiation. Both copies of TSG must be
inactivated or lost (LOH) for loss of function
( “two-hit” hypothesis).LOH commonly seen in
chromosome arms 3p,4q,8p,9p,11q,13q,and 17p.

7. Risk Factors:
• Chemical irritants(tobacco,alcohol,mouthwashes
with high alcohol content)
• Physical irritants(Denture use, prolonged
denture irritaion, irregular teeth or restoraion,
chronic cheek biting habits)
• Nutritional factors(defficiency of vitamin A and
caretenoid supplementation)

8. • Prolonged sun exposure
• Hormonal effects
• Increased cellular aging
• Decreeased immunologic surveillance with aging
• Viruses(HSV-1,HSV-2.HPV)

9. Increased risk:
 Patient age 40 and older(95% of cases)
18-39 years of age combined with the following:
• Tobacco use
• Chronic alcohol consumption
• Oral HPV infection
Highest risk:
Patient age 65 and older with lifestyle risk factors
Patients with history of other cancer

11. Signs and symptoms or oral cancer
• A sore in the mouth that doesn’t heal
• Persistent mouth pain.
• A lump or thickening in the cheek.
• A white or red patch on the gums, tongue, tonsil
or lining of the mouth.
• A sore throst or feeling that soomething is
caught in the throat that doesn’t go away.
• Difficulty in swallowing or chewing.
• Difficulty in moving the jaw or tongue.

12. • Numbness of the tongue or elsewhere in the
mouth.
• Jaw swelling that makes denture hurt or fit
pooryly.
• Loosening of the teeth.
• Pain in the teeth or jaw.
• Voice change.
• A lump in the neck.
• Significant weight loss.
• Persistent bad breath.

13. Oral cancer screening:
It is an examination performed by the dentist of
the doctor to look for the signs of cancer or
precancerous conditions in your mouth.
The goal of oral cancer screening is to identify mouth
cancer early, when there is a greater chance for a cure.
It can be done by examination of mouth during a routine
dental check up or by use of additional tests to aid in
identifying areas of abnormal cells in the mouth.

14. Screening preparation
Overview
• Head and neck exam should be routine.
• Review history of alcohol and tobacco use
• Follow up on suspicious signs.
Armamentarium
• Proper lighting,Probe mouth mirror tweezer
• Gauze sponges
• Disposable gloves
• 3 to 5 minutes of time

15. Points to remember when screening
for oral cancer
• Tell your patient whar are you doing with each
procedure and why??
• Special attention should be focused on the
lesions of lateral border of tongue and floor of
mouth .
• Always note any changes in colour texture of all
soft tissue or any swelling, if you detect an
abnormality determine the historu of the lesion
if the abnormality has been of more than 2
weeks duration,take appropriate action to obtain
a biopsy.

16. • Follow up to ensure a definitive diagnosis of an
abnormality.
• Teach your patient about signs and symptoms of
oral cancer.
• If patient uses tobacco products provide
appropriate counselling or refer patient for
counselling.
• Remove all removable prosthesis before starting
the examination.

17. Dianostic aids
Standard screening
aids
(conventional intra
and extra oral
examination)
Established
screening adjuncts
(oral cytology,oral
brush cytology)
Vital staining
(toluedine
blue,methylene
blue,lugol’s iodine)

18. Extra oral examination:
General appraisal
Skull
Facial form
Skin
Eyes
Neurological deficit
Lymph nodes of head and neck
TMJ
Masticatory musscles

19. Intra oral Examination

22. Drawbacks of conventional
examination:
It cannot discrimate between the lesion that are
progressive or malignant and those non
progressive counter parts.
It doesn’t identify all potentially premalignant
lesions.

23. Oral Cytology
It is the study of cells which exfoliate or abrade
from body surface.When epithelium becomes
seat of any pathology cells lose their
cohesiveness and cells in deeper layers may shed
along with superficial cells.
Drawback:
the sensitivity and specificity differs due to its
subjectivity or due to poor technique in
obtaining cells and smear preparation.

25. Brush Biopsy(Oral CDx)
It utilizes a stiff brush to colled the sample cells
from the basal layer cells non invasively and
assess the dysplasia by computer asssisted
neural network.Its accurancy can be increased
by using DNA cytometry, silver nucleolar
organisation regions
analysis,immunocytochemistry and fluorescent
insitu hybridization(FISH).

27. Vital Stains:
1. Toluedene blue:
It is a topical dye,which gets concentrate in
cells with abundant nucleic acid.It has high
sensitivity for detecting carcinoma.
Interpretation
Dark blue colour :positive for lesions
suspicious malignancy
Light blue: positive for premalignant lesions
proved otherwise by biopsy.

28. Advantages:
Specify area for biopsy.
Cheap and non invasive,disposable
Has high sensitivity for carcinoma
Disadvantages:
It is distasteful.
Its sensitivity for identifying dysplasia is poor.
The colour of the dye remains in the mouth for 4
to 6 hours.
It may give false positive results(inflammatory
and ulcerative conditions).

29. 2. Methylene Blue
• It is a heterotropic aromatic chemical
compound.At room temperature it is
solid,odourless dark green powder which yields
a blue colour when dissolve in water.
Advantages:
It is cheaper and less cyto toxic.

30. Disadvantage:
the result is not confirmatory.
Application:
Early detection of suspected oral cancer
Treat Alzhiemer disease
Examine(RNA) or (DNA) under microscope.

32. 3.Lugol’s iodine
It consist of 10 parts of potassium iodide to 5 parts
of iodine.Application of iodine results in brown or
black colour staining in areas containing glycogen.
In areas lacking glycogen iodine isn’t absorped and
such areas remain colourless or turn yellow.
Advantages:
 Used for non keratinized stratified squamous
epithelium.
 It is simple,low costs.
High sensitivity with low false negative
Result are fast

33. Disadvantage:
It is an irritant cause abdominal pain,heart burn
and nausea.
Allergic reaction to iodine.
Less accurate when used in post menopausal
women.
Application:
Used routinely for the patient with head and
neck cancer.
Heavy smokers and drinkers.

34. Velscope
The velscope handpiece emits a safe blue light
into the oral cavity causing tissue fluorescence
from the surface of epithelium through to the
basal membrane-where pre malignant changes
typically start.

35. By utilizing special optical filters in the velscope
hand piece the clinician is able to immediately
view the different fluorescence signatures in the
oral tissues to help differentiate between normal
and abnormal cellular activity.
Abnormal tissue typically appears as an
irregular, dark area that stands out against the
green fluorescence pattern of surrounding
healthy tissue.

37. Advantages:
It takes only 1-2 mins and is painless and non
invasive,with no stains and rinses required.
Improves the distinction between normal and
abnormal tissues.
Thorough visual and digital soft tissue
examination.
Useful benefit in the determination of surgical
border and post surgical evaluation.
It covers large surface area so small lesions can
also be identified.

38. Disadvantage
Heat from prolonged and close tissue
examination may cause patient discomfort.
Lack of methodologically sound clinical trails.
Insufficient use of histologic and molecular
mapping.

40. Orascoptic DK:
This instrument work in conjunction with a mild
acedic acid rinse to improve the visualization of
oral lesions.
This examination enhances the ability to identify
potentially cancerous at its earliest stages.
Early detection of precancerous tissue can
minimize or eliminate the disfiguring effects of
oral cancer and possibly save a life

41. It includes a transilllumination instrument and
lightened mirror.
It uses a battery powered handled LED light
source and three interchangeable diagnostic
instruments.

42. Microlux diagnostic Light
With refractive light technology,this aid help save
lives in the detection of pre cancerous
abnoramalities and makes this advance in
patient care simple and inexpensive.

43. After noting any acetowhite soft tissue lesions
during a routine exam,simply have the patient
rinse with Microlux DL 1% acetic acid solution
for 1 minute. Then repeat the oral exam using
Microlux DL.
When used in conjunction with conventional oral
mucosal exams,it improves identification
evaluation and monitoring of soft tissue
abnormalities and changes in all patients

44. The irregular cells take on a whitish hue which
contrasts with surrounding tissue, helping to
identify abnormalities which require further
testing.
Since the acetic acid dehydrates the cytoplasm of
aceto white lesions the lesions refractive properties
are changed.Under diffused light from the special
Microlux DL fiber optic light guide, acetowhite or
leukoplakic lesions become more visible.

45. ViziLite Plus with TBlue630
• ViziLite Plus with TBlue630 is an oral lesion
identification and marking system that is used as
an adjunct to the conventional head and neck
examination.
• It is comprised of a chemiluminescent light
source (ViziLite) to improve the identification of
lesions and a blue phenothiazine dye to mark
those lesions identified by ViziLite.

46. • Similarly in the oral cavity, after rinsing with a
dilute acetic acid solution, abnormal squamous
epithelium tissue will appear acetowhite when
viewed under ViziLite's diffuse low-energy
wavelength light.
• Normal epithelium will absorb the light and
appear dark. ViziLite can assist a dentist or
hygienist in identifying an abnormality in the
oral cavity.

47. How ViziLite Plus Works