ORAL PATHOLOGY

ONLINE CONFERENCE Third year dental students

Supervised by Dr.Dalal ALQahtani

dalalq@ksu.edu.sa

College of Dentistry

King Saud University

SUMMARY

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

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

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

Iron deficiency anemia accompanied with dysphagia and esophageal webs known as plummer-vinsonsyndrome 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.

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.

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.

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

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

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.

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

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.

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.

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

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

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

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)

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 ToolsTo 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 lesionsDiagnostic aid for the detection of oral cancer and pre malignant early lesions .

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

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.

Disadvantagesheat 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

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

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

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http://www.beehealthy.org.nz/content/cdb77b34-7020-4a3b-86d4-a4085d84c349.cmr

http://www.abpsus.org/wp-content/uploads/Prepare-for-Oral-Board-Certification-Exam-300x200.jpg

http://dentistry.ouhsc.edu/portals/0/Images/microscope-cells.jpg

http://img.medicalexpo.com/images_me/photo-m/biopsy-punches-skin-veterinary-disposable-79716-

2937197.jpg

http://www.jomfp.in/articles/2012/16/3/images/JOralMaxillofacPathol_2012_16_3_325_102476_f3.jpg

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good-

oral-cancer-examination-0ushk2fy.jpg

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CNGcrOMEH6ec6EVjcb2fb8y3BVqxmw&ust=1418461880521171

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YQjB0&url=http%3A%2F%2Fwww.thetahealth.com%2Fmouth-cancer-from-

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h&source=og&sa=N&tab=wi&authuser=0&ei=p52KVKyJNYaAUa7egaAD

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