Oral cancer – Clinical Update & Screening Part 1

Oct 8th, 2013 | By | Category: Dental Fears, Dental News, Oral Cancer, Oral Health, oral surgery, Patient Education

Oral Cancer- Screening, Diagnosis, and Treatment

In the United States over 35,000 new cases of cancer of the oral cavity are diagnosed annually, with over 25,000 occurring in men and over 11,000 in women. Nearly 7,880 people die of cancer of the oral cavity and pharynx each year. There are 30 times this amount when it comes to cases of skin cancer.  Because many patients see their dentists more frequently than their medical doctor, dentistry is in an advantageous position to reduce the mortality/ morbidity of this common malignancy. The median age at diagnosis for this cancer is 60 years, age adjusted incidence rate of 10.6 per 100,000 men and women.

Oral Cancer

7% of skin cancers are life-threatening melanomas, and approximately 75% of all skin cancer deaths are from melanoma.The majority of skin cancers are found on the head and neck. The scope of this problem is significant, as one in five Americans will develop skin cancer. More than one person per hour dies from melanoma. Since 1994, non-melanoma skin cancer has increased more than 300% and melanoma has doubled. Skin cancer accounts for 50% of all diagnosed cancers.

Approximately 90% of oral cancer arises in the epithelial surface layer of oral mucosa , called squamous cell carcinoma. Other types of cancer within the oral cavity include  varieties, such as salivary gland tumors and sarcomas (tumors of bone, nerve, cartilage, fat, muscles or blood vessels) and mucosal melanomas.

As with all cancer, early detection is the key; 99% of skin cancer patients, survive with early detection. Metastasis and mortality as well as scarring and morbidity, are drastically reduced with early detection.

RISK FACTORS

Traditional risk factors for oral cancer include tobacco and alcohol use. When used in combination, they increase risk up to 37-fold. Smokeless tobacco has been linked to cancer of the buccal mucosa (inner cheek tissue). I

n the United States, oral cancer is also seen most frequently in the African American  male population, with an incidence  and death rate of 15.6 and 6.3 per 100,000 of the population, which is double the death rate of staged matched Caucasian patients.

There are several high-risk sites in the oral cavity with a higher rate of malignant transformation for dysplastic areas including the tongue and the floor of the mouth. Cancer of the gingiva (gum tissue) is less common, roughly 10% of all oral cancers.

The average age at diagnosis is 60 years, but a rapidly growing number of younger patients without the traditional risk factors are being diagnosed with HPV- related oropharyngeal tumors ( tonsils and base of the tongue). The presence of the human papillomavirus (HPV), which has been linked to the development of cervical cancer in women, is now considered an independent risk factor for oropharyngeal cancers. The correlation between traditional oral cavity cancer and HPV is still unclear and yet to be defined.

Genetic risks include previous patient history or family history of skin cancer; patients with fair or depigmented skin (albinism, vitiligo), patients  with dysplastic or atypical moles, and patients with multiple moles are all at increased  risk. Patients with a medical history of radiation exposure, immuno-suppressive medications, or burns are also at an elevated risk.

Risks

  • Tobacco use of any kind, including cigarettes, cigars, pipes, chewing tobacco and snuff, among others
  • Heavy alcohol use
  • Excessive sun exposure to your lips
  • A sexually transmitted virus called human papillomavirus (HPV)
  • Tobacco: Tobacco use accounts for most oral cancers. Smoking cigarettes, cigars, or pipes; using chewing tobacco; and dipping snuff are all linked to oral cancer. The use of other tobacco products (such as bidis and kreteks) may also increase the risk of oral cancer. Heavy smokers who use tobacco for a long time are most at risk. The risk is even higher for tobacco users who drink alcohol heavily. In fact, three out of four oral cancers occur in people who use alcohol, tobacco, or both alcohol and tobacco.
  • Alcohol: People who drink alcohol are more likely to develop oral cancer than people who don’t drink. The risk increases with the amount of alcohol that a person consumes. The risk increases even more if the person both drinks alcohol and uses tobacco.
  • Sun: Cancer of the lip can be caused by exposure to the sun. Using a lotion or lip balm that has a sunscreen can reduce the risk. Wearing a hat with a brim can also block the sun’s harmful rays. The risk of cancer of the lip increases if the person also smokes.
  • A personal history of head and neck cancer: People who have had head and neck cancer are at increased risk of developing another primary head and neck cancer. Smoking increases this risk.
  • Quitting tobacco reduces the risk of oral cancer. Also, quitting reduces the chance that a person with oral cancer will get a second cancer in the head and neck region. People who stop smoking can also reduce their risk of cancer of the lung, larynx, mouth, pancreas, bladder, and esophagus.

SYMPTOMS

Oral cancer can present with  many different symptoms. Often , a non-healing ulcer (wound), whether or not it is painful, is the first presenting symptom. Onset orofacial pain may be a predictor from the transition from oral pre-cancer to cancer.. Screening patients with new-onset orofacial pain may lead to a diagnosis of early detection of head and neck cancer. Other symptoms that should raise suspicion of oral cancer include; white or red spots, bleeding mouth sores, increase mouth pain, loose teeth, poor- fitting dentures, non-healing extraction socket, ear pain, lip or tongue numbness, difficulty/ painful swallowing, change in speech or a lump in the neck. it is important to remember that any white/red lesion in the mouth that has not healed  within three weeks shoud be evaluated by a general dentist or oral and maxillofacial surgeon.

APPEARANCE OF PRE-CANCERS AND CANCERS

Most oral cancers present clinically as mucosal ulcerations. Clinical examination can show signs of mucosal changes  that, with time, might develop into oral cancer. Pre-cancers have been organized according to color;  Leukoplakia (ie, white), Erytroplakia (ie, red), and erytroleukoplakia (ie,white and red). Leukoplakia is generally associated with an incidence of malignant change in 1% to 3% of cases. Erytroleukoplakia is associated  with a 25% incidence of malignant chenges. The identification of precancerous lesions must be  monitored by the dentists or surgeons for long-term follow up. Many precancerous lesions of the oral mucosa will never develop into cancer; however, their recognition is essential so that they can be biopsied and monitored as needed.

ORAL CANCER SCREENING

 The first pert of clinical examination includes  a visual screening of the head, neck and oral cavity for any suspicious lesions. The second part of the clinical examination is palpation, extended to include lymph nodes, and skin lesions of the head and neck region, also oral cavity.

It is widely accepted that Stage at diagnosis affects the prognosis of oral cancer at five years. The earliest stages conveys the best prognosis, least treatment burden and highest quality of life. As a routine care with your dentist or physician, a  screening examination for oral cancer can easily be accomplished as part of that visit.

Visual and Tactile Examination — a conventional oral examination using visual and tactile techniques remains the gold standard for detecting oral lesions. Clinical Examination — Routine examination is recommended to identify oral mucosal changes suggestive of dysplasia or early invasive squamous cell carcinoma. The clinical examination will address direct inspection of oral cavity for high-risk sites including the posterior-lateral tongue, ventral tongue and floor of the mouth, lips , salivary glands, the buccal mucosa, the teeth and gingiva. Indirect mirror evaluation is important to evaluatef the oropharynx, soft palates, and uvula. Examination of the neck is equally important, with particular attention to the lymph nodes of the five oncologic levels of the neck ( Level I- submandibular and submental nodes; level II-upper jugular nodes; level III-middle jugular nodes; level IV-lower jugular nodes; level V-posterior triangle nodes) oral cancer primarily involves Levels I,II and III

ADJUNCTIVE SCREENING AIDS

 Detecting oral cancer at an early stage  would have a better prognosis, resulting in a better quality life for the patient. Adjunctive tests may help detect the type of oral lesions at the time of the screening, however, the biopsy will remain a strong tool of certain diagnosis. These adjuncts include devices based on the following technologies:

Tissue Reflectance

Such  devices as Microlux; Orascopic DK; and VisiLite Plus, utilize a light source that emits similar blue-white light or at near 440 nanometers. The oral cavity is examined following an oral rinse with 1%acetic acid . Abnormal mucosa is reported to appear distinctly white when illuminated by this wave-length.

Autofluorescence

The manufacturer of VELscope claims that normal tissue appears pale green when illuminated with the viewed through a light source and filter set contained in the handpiece. This appearance is caused by the phenomenon of autofluorescence, which results in a darker appearance as compared to adjacent normal tissue.

Autofluorescence and Tissue reflectance

Identafi 3000 combines these two technologies with the assertion that as a result, the clinician may recognize mucosal abnormalities that would otherwise go unnoticed.

Transepithelial cytology

This device marked as the OralCDx Brush Test is intended to help clinicians evaluate the clinical importance of lesions discovered that do not suggest a high index of suspicion.Very poplar method  to use in dental practices, these device has been increase awareness of the clinician’s responsibility to perform routine oral cancer examinations. However, we have to realize that  each year about 40% of the people in the United States do not visit a dentist. In additions, individuals at greater risks for developing oral cancer are more likely to seek medical care rather than dental care. 
Oral Cancer – Diagnosis Part 2
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