Diagnosis of Dental Diseases 3

Dentists who encounter a change in the oral mucosa of a

patient must decide whether the abnormality requires
further investigation.
Systematic approach to the assessment of oral mucosal
conditions that are thought likely to be premalignant or an
early cancer.
These steps, which include a comprehensive history, stepby-step clinical examination (including use of adjunctive
visual tools), diagnostic testing and formulation of
diagnosis, are routinely used in daily practice.

A quick look provides insufficient information and

may result in misdiagnosis and improper care.
Although the recommended approach is appropriate for
use in evaluating any mucosal condition.
Leukoplakia is the most frequent form of oral
precancerous lesion and appears in the oral cavity as a
white patch that cannot be rubbed off
It is typically seen in the oral mucosa, lateral borders of
the tongue and floor of the mouth
Erythroplakia appears as red patch and are less
common but have great tendency toward malignant
transformation.
Prevalence less than 1%

A systematic approach to the assessment of a suspicious oral

mucosal lesion
1

History of current illness

onset, location, intensity, frequency, duration
aggravating and/or relieving variables
better, unchanged or worse over time

Medical, tobacco and alcohol history

medical conditions
medications and allergies
tobacco and alcohol (type, frequency, duration)

Clinical examination
extraoral examination
intraoral examination
lesion inspection (adjunctive visual tools such as toluidine blue and direct fluorescence)

Differential diagnosis

Diagnostic tests
biopsy

Definitive diagnosis

Suggested management

During an oral cancer screening examination, if a

suspicious mucosal lesion persists for more than 3 weeks
following removal of local irritants, such as trauma,
infection or inflammation, diagnostic biopsy(ies) or
referral to an oral health care provider with expertise in the
evaluation and management of premalignant or potentially
malignant conditions is recommended.
Tissue biopsy remains the gold standard for diagnosing an
oral premalignant lesion or oral cancer.
A carefully selected, performed and interpreted biopsy is
critical in rendering an accurate diagnosis.

The number of malpractice claims "alleging failure to

diagnose oral cancer" is rising.

These claims rank among the most expensive for the

dentist. These cases can prove difficult to defend, in
part because juries tend to believe the argument that
dental professionals can easily and inexpensively
perform oral cancer screenings on a regular basis.

When diagnosed early the oral cancer survival rate can

be 80% to 90%, but currently only 35% of cases are
caught in time to improve prognosis.

Oral cancer statistics are stark. The Oral Cancer Foundation

estimates 35,000 cases of oral or pharyngeal cancer this year
in the U.S. alone, and estimates approximately 8000 deaths.
50% of those newly identified with oral cancer will not live
past five years after initial diagnosis.
While we often hear about cervical, testicular, and skin cancer
in the media and from health care providers, the chance of
dying from oral cancer is actually greater than any of these
other diseases.
As of 2004, oral cancer is the 6th leading cause of cancer
deaths.
Oral cancer is high among men and eight most common
cancer world wide.

Oral cancers include intraoral melanomas and Kaposis

sarcoma, but most are squamous cell carcinomas.

Early identification of oral cancers and precancers proves

difficult because clinical characteristics of early lesions are
subtle.

Premalignant lesions often present as familiar benign

conditions, and many are not discernable by the eyes alone.

Patient Profile
The patient populations with the highest risk for oral
cancer include people who:
Have a history of oral cancer
Are 40 and over (although oral cancer is increasing in
the 18-49 demographic)
Use tobacco and alcohol
Have premalignant lesions or dysplasia

California Cancer Registry in order to determine

incidence rates of oral squamous cell carcinomas
(OSCCs).The research is the first to examine OSCC
rates of cultural subpopulations within the state.
Black Non-Hispanics and White Non-Hispanics have
the highest incidence rates of cancer of the tongue and
the floor of the mouth.
Of Asian subpopulations, South Asians were most
likely to have cancer of the tongue, with male and
female incidence rates being quite similar in number.

Areas of greatest risk

Oral cancers can occur on any mucosal site. Typically, they
occur in a U-shaped zone from the tonsillar pillars and lateral
soft palate, to the lateral tongue, and ending at the anterior
floor of the mouth.
The relative incidence rates of oral squamous cell
carcinomas are as follows:
Tongue - 25%
Lower Lip (vermilion) - 30-40%
Floor of mouth - 20%
Oropharynx/soft palate - 15%

Alcohol use is implicated as a synergistic cofactor with

tobacco. Alcohol alone increases the risk of oral
cancers 6 times, according to the Centers for Disease
Control.
When used with tobacco, however, the risk of
squamous cell carcinomas increases dramatically.
In addition to tobacco and alcohol use, Human
Papillomavirus strain 16 (HPV16) has been reported in
18.9% of oropharyngeal cancers and 3.9% of oral
cavity cancers.
The Human Papillomavirus was found in 25% of
patients, and of that subset, 90% of the tissues tested
positive for HPV16

Signs and Symptoms

Common symptoms of oral cancer include:
Patches inside the mouth or on the lips that are white
(leukoplakia), a mixture of red and white
(erythroleukoplakia), or red (erythroplakia)
A sore on the lip or in the mouth that will not heal
Bleeding in the mouth
Loose teeth
Difficulty or pain when swallowing
Difficulty wearing dentures
A lump in the neck
An earache
Advanced lesion characteristics

TNM

It is important to realize that the TNM

staging

system

is

simply

an

anatomic

staging system that describes the anatomic

extent of the primary tumor as well as the
involvement of regional lymph nodes and
distant metastasis.

T Staging for Tumors of the Lip and Oral Cavity

TX: Primary tumor cannot be assessed

T0: No evidence of primary tumor
Tis Carcinoma in situ
T1: Tumor 2 cm or less in greatest dimension
T2: Tumor more than 2 cm but not more than 4 cm in greatest
dimension
T3: Tumor more than 4 cm in greatest dimension
T4a: Lip Tumor invades through cortical bone, inferior alveolar
nerve, floor of mouth, or skin of face (ie, chin or nose)*
Oral Cavity: Tumors invades through cortical bone into deep
extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus,
and styloglossus), maxillary sinus, or skin of face
T4b: Tumor involves masticator space, pterygoid plates, or skull
base and/or encases internal carotid artery

TABLE 9 N Staging for All Head and Neck Sites

Except the Nasopharynx and Thyroid

Nx: Regional lymph nodes cannot be assessed

N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest
dimension
N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not
more than 6 cm in greatest dimension; or in multiple ipsilateral lymph
nodes, none more than 6 cm in greatest dimension; or in bilateral or
contralateral lymph nodes, none more than 6 cm in greatest dimension
N2a: Metastasis in a single ipsilateral lymph node more than 3 cm but not
more than 6 cm in greatest dimension
N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm
in greatest dimension
N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6
cm in greatest dimension
N3: Metastasis in a lymph more than 6 cm in greatest dimension

TABLE 12 M Staging for Head and Neck

Tumors

Mx: Distant metastasis cannot be assessed

M0: No distant metastasis
M1: Distant metastasis

Carcinoma-in-situ lesion: involves the full thickness

of the epithelium, but cancerous cells have not broken
through the basal membrane.
When
the cancer or cells invade past the
basamembrane, the lesion is either a carcinoma or
sarcoma.
Most are oral squamous cell carcinomas.

Diagnostic Aids and Tests

The chair side adjuncts and tests available include lightbased detection systems, fluorescence visualization, and
brush cytology.
Advancements in saliva testing are also showing positive
initial results.
Ideally, an adjunct or test has high sensitivity and
specificity, meaning few false positives and false
negatives, respectively.
The proportion of subjects with positive test results for the
disease determines sensitivity.
The proportion of subjects clear of the disease, and also
test negative, determines specificity.

Various diagnostic modalities for oral cancer detection

Visual examination
Excision biopsy and Histopathology
Oral brush biopsy (OralCDx)
Toluidine blue
Light-based detection systems
Chemiluminescence (ViziLite Plus; Microlux/DL, Orascoptic-DK)
Tissue fluorescence imaging (VELscope)
Tissue fluorescence spectroscopy
Biomarkers
DNA-analysis
Laser capture microdissection

Light-based Detection Systems

Light-based
detection
systems
use
several
chemiluminescence, bluewhite
LED, and autofluorescence as light sources.
They are designed to detect possible abnormalities in
the epithelial tissue that are not necessarily visible to
the naked eye.

Chemiluminescent Light and Blue-White LED Systems

Each of these systems employs a 1% acetic acid rinse to

dislodge foreign matter, and to make cell nuclei in the
epithelium more prominent.
The patient rinses with the acid for 30-60 seconds. Then,
with dimmed lights, a dental professional visually examines
the oral cavity with the light source.
Abnormal epithelium will appear exceedingly white
(acetowhite). Under the light, normal epithelial tissue reflects
a light bluish color.
The test itself takes approximately five minutes, and can be
performed by licensed dentists, hygienists, physicians, and
nurses.
The light can actively illuminate for ten minutes.

ViziLite Kit
Kit

contents:

Chemiluminescent
device
30 ml acetic acid
Light stick
holder/retractor

Image used with permission from Dr. Mark Bride, DDS, ViziLite, Zila Pharmaceuticals, 2004

How ViziLite Works

Normal epithelium absorbs the light and appears dark

Abnormal tissue reflects light and appears bright white
Images used with permission from Dr. Mark Bride, DDS, ViziLite, Zila Pharmaceuticals, 2004

Tolonium Chloride
Toluidine blue
Phenothiazine
Metachromatic dye
Stains nuclear DNA
1% aqueous solution followed by 1% acetic
acid to decolorize lesion
Abnormal tissue retains the blue dye

OraTest

Zila Pharmaceuticals, Inc.

Exfoliative Cytology
Microscopic examination of cells
Spread on slide
Fixed
Stained

Exfoliative Cytology

Image used with permission from Dr. Mark Bride, DDS, ViziLite, Zila Pharmaceuticals, 2004

Brush placement

Image used with permission from Dr. Jane Eisen, DDS, OralCDx, CDx Laboratories, 2004

Slide Preparation
Immediately spread on
slide
Rotate brush- spread
material along entire
slide
Use all fixative
Air dry 20 minutes

Image used with permission from Dr. Jane Eisen, DDS, OralCDx, CDx Laboratories, 2004

OralCDx Results
Negative:

No cellular abnormalities

Positive:

Definitive cellular evidence

of epithelial dysplasia or
carcinoma

Atypical:

Abnormal epithelial
changes warranting further
investigation

Imaging

Diagnosis of oral cancer usually by surgical

or fine needle biopsy.

Imaging techniques are used to determine

the extent of the disease and detect
recurrent disease following therapy

Imaging Techniques

CT: Computed tomography

MRI: Magnetic resonance imaging

PET: Positron emission tomography

Referral Sites

Where do you refer a patient if

oropharyngeal cancer is suspected?

Oral surgeons
Oral pathologists
Otolaryngologists
Head and neck cancer centers

Early detection of oral premalignant lesions and early

neoplastic changes may be the most effective means to
improve survival and quality of life for oral cancer patients.
Early detection and diagnosis of oral neoplasti changes is the
best way to improve patient outcomes.
Conventional oral examination is based on visual inspection
under normal white light and palpation of suspicious lesions,
usually performed by dentists or physicians.
A variety of diagnostic aids and adjunctive techniques are
commercially available, such as toluidine blue and the
ViziLite.
Data indicate that alternative diagnostic techniques can
improve diagnostic performance in high-risk populations, but
there is little evidence to support their effectiveness in lowrisk populations.