Detecting Oral Abnormalities

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• Detecting Oral Abnormalities
• Utilizing Advancements in
• Technologies

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• Presented By
• Leslie Gilchrist
• Calandra Portalatin
• Brigitta Nuccio
• Big Bend Area Health Education Center,
  Tallahassee, FL
• West Florida Area Health Education Center,
  Crestview, FL

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www.OralCancerFoundation.org
Support Oral Cancer Awareness
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Oral Cancer - Basic Facts
The Reality of Oral Cancer

• One person dies every hour of every day of Oral
  Cancer
• Oral Cancer - 9th highest death rate among all
  32 categories of cancer
• The mortality rate in the U.S. is higher than
  that of cancers which we hear about routinely
  such as breast, cervical, Hodgkin's, prostate,
  liver, testes, kidney, thyroid and colon
  National Cancer Institute/SEER Report
• 2007 and 2008 - incidence Oral Cancer increased
  over 11 in the U.S.
• One of few cancers actually increasing each year
• At 11 growth rate - 87,961 patients will die
  over the next 5 years

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Oral Cancer Patient Education
Know 2 Important Statistics National Cancer
Institute SEER reports (Surveillance
Epidemiology and End Results) All 32 measurable
forms of cancer
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Oral Cancer Patient Education
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Oral Cancer Patient Education
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Oral Cancer Research Data
True or False
The majority of patients referred to an Oral
Surgeon or ENT for suspected oral cancer biopsy,
are referred by a dental health provider
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Oral Cancer Research Data
False
In 2008, Primary Care Physicians referred 310,000
patients with abnormal oral tissue lesions to
Oral Surgeons or ENT Dentists referred 220,000
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Oral Cancer Research Data
I Dont Believe It!

• My Family Doctor looks in my mouth for maybe
  three seconds how can they be finding the
  majority of oral cancer?
• -Industry Professional

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Oral Cancer Research Data
Theyre not
most patients are finding it themselves!

• Patients go to their Primary Care Physicians for
  sore throats and cold sores.
• 62 of Oral Cancer is found by the patient in
  stage 3 or 4

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Oral Cancer Research Data
Patients think dentists are about teeth!

• A very small percentage of patients understand
  that annual check-ups are about more than
  cavities and cleanings
• According to the ADA only 15 of patients report
  any knowledge of having an oral cancer screening

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Oral Cancer - Basic Facts
What Patients Need to Know
Dentists and Hygienists are in the best position
to be front line detectors for early stage Oral
Cancer Oral cancer can frequently prosper without
producing pain or symptoms the average patient
might recognize
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Oral Cancer - Basic Facts
Late Stage Discovery can be very costly
As a result there is a high risk of producing
second, primary tumors before the first tumor is
ever detected Oral Cancer often goes undetected
until it has already metastasized to another
location.
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Oral Cancer - Basic Facts
For those who do survive late stage discovery

• Life may never be the same

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Oral Cancer - Basic Facts
The Good News
When found early, oral cancer patients have an
80-90 survival rate
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Oral Cancer - Basic Facts
The Bad News
40 of those diagnosed with oral cancer will die
within five years because the majority of these
cases will be discovered as a late stage
malignancy
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Oral Cancer - Basic Facts
Traditional Risk Factors in North America
Age The majority of oral cancer occurs in
patients 45 years or older, which means all 84M
Baby Boomers are at risk
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Oral Cancer - Basic Facts
Traditional Risk Factors in North America
Tobacco Use (including smokeless tobacco)
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Oral Cancer - Basic Facts
Traditional Risk Factors in North America
Alcohol Use (excessive)
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Oral Cancer - Basic Facts
Traditional Risk Factors in North America

• Previous History of Oral Cancer
• 20 times higher risk of developing a second
  cancer

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Oral Cancer - Basic Facts
Emergent Risk Factors in North America
Undetermined New research shows up to 40 of
all oral cancer cases effect individuals without
any history of tobacco, alcohol use, or any other
significant lifestyle risks
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Oral Cancer - Basic Facts
Emergent Risk Factors in North America
Sexually Transmitted HPV Represents the fastest
growing oral cancer population with a 5 fold
increase in incidence under the age of 45 Means
all patients over the age of 17 should be
screened annually
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Oral Cancer - Basic Facts
Emergent Risk Factors in North America
Why age 17? According to the CDCs Advisory
Committee on Immunization Practices in
recommendation of the new HPV vaccine Gardasil
for cervical cancer prevention We recommend
ages 11 and 12 because most girls have not had
sex at that age. She adds By 15 years of age,
about 25 of American young people have become
sexually active. And by age 17, 50 have already
done so. -revolutionhealth.com
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Oral Cancer - Basic Facts
What is HPV? (Human Papilloma Virus - Warts)

• Most common virus group in the world today
  affecting the skin and mucosal tissue
• Over 100 different types
• Different types infect different parts of the
  body
• Most HPV's are common, harmless, and treatable

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Oral Cancer - Basic Facts
What does this have to do with Oral Cancer?
Two types of HVP are sexually transmitted and
have a direct link to cancer The FDA estimates
that 70 of all cervical cancers are associated
with HPV-16 or 18 These same two HPV's also
manifest themselves in the mouth (oropharynx
region)
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Oral Cancer - Basic Facts
They are difficult to see
These are a serious problem and cause growths
that usually appear flat and are nearly invisible
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Oral Cancer - Basic Facts
The latest research is compelling and shows HPV
is poised to become the leading cause of Oral
Cancer!

• University of Michigan found out of 42 oral
  tumors two thirds were positive for HPV
• John Hopkins University in a recent study
  indicated HPV will over take tobacco and alcohol
  to become the number one cause of oral cancer
  within 10 years
• New England Journal of Medicine Oral HPV
  infection is strongly associated with
  oropharyngeal cancer among subjects with or
  without the established risk factors of tobacco
  and alcohol use.

HPVhelp.org
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Oral Cancer Early Detection is the Key
Screening with diagnostic aids can provide
additional information
These products definitely work for finding HPV
and many other types of tissue abnormalities
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Fluorescence Visualization helps in the
identification of clinically occult oral
abnormalities
Appropriate Stage for Discovery Intervention
Early Dysplasia
Moderate Dysplasia
Severe Dysplasia
Invasive Squamous Cell Carcinoma (OSCC)
Potentially Malignant Disease Stages
Carcinoma-In-Situ (CIS)
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Direct Tissue Fluorescence Visualization
Receptor (Eye)
Specific Excitation Wavelength Intensity
Light
Emission (Fluorescence) Filters
Fluorescence
Reflectance
Absorption Excitation
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Normal (Healthy) Tissue Fluorescence

• Shining an excitation light on the tissue causes
  it to emit fluorescence
• Color is characteristic of combination of the
  fluorophores in the tissue

Schematic representation of tissue fluorescence
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Abnormal Tissue Fluorescence

• Changes in tissue fluorescence can help determine
  areas where molecular/structural changes have
  occurred

Schematic representation of tissue fluorescence
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Examination Technique
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Normal Tissue
Patient A

• Normal Oral Mucosa Shows
• Normal, Green Fluorescence Pattern

Images courtesy of the British Columbia Oral
Cancer Prevention Program
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Abnormal Tissue

• Oral Lesions May Show as
• Irregular, Dark Areas

Images courtesy of the British Columbia Oral
Cancer Prevention Program
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Patient C
An Oral Lesion that Shows No Change in
Autofluorescence Appearing Pale Green
Images courtesy of the British Columbia Oral
Cancer Prevention Program
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Lichen Planus VELscope Confirmed Benign Etiology
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SCC
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Moderate Dysplasia
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Pre-clinical discovery
Left palate low-grade mucoepidermoid carcinoma
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18 of the 20 patients showed dysplasia or cancer
beyond the clinically visible lesion
Images courtesy of the British Columbia Oral
Cancer Prevention Program
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Photo- documentation
Dental Learning Centers VELscope Kit
MagnaVus Video Microscope
PhotoMeds Lens Adapter
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TrimiraIdentafi 3000 UltraMulti-SpectralOral
Screening System

• Your new weapon in the war against Oral Cancer

Trimira
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Identafi 3000 Ultra Complete Screening Kit
Identafi 3000 Ultra
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Oral Cancer Choosing the Right Technology
Identafi 3000 Ultra Provides More Information
The combination of all three Multi-Spectral
wavelengths provides the clinician with more
visual information and increased confidence for
recommending biopsies that yield fewer False
Positives
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Identafi 3000 Ultra Helps to VisualizeBiochemical
and Morphological Changes
Screening for Oral Cancer

• Neoplastic Lesions
• Genetically Altered Cells
• Hyperplasia
• Dysplasia
• In Situ Cancer
• Invasive Cancer
• Reactive Lesions (inflammation)
• Trauma from physical irritation or abuse
• Chemical irritation
• Medication side effects
• Allergic responses
• Thermal damage
• Fungal, viral, or bacterial irritation
• Systemic conditions with oral manifestations

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The Exam
Oral Cancer Choosing the Right Technology

• Put the glasses on and begin the exam with White
  Light

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The Exam
Oral Cancer Choosing the Right Technology
The Conventional Oral Exam (COE) uses only White
light to identify any lesions of interest.
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The Exam
Oral Cancer Choosing the Right Technology

• 2. Whether suspicious tissue or not, switch to
  violet for a second observation
• Suspect tissue appears dark

Photo from Enica / BC here
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The Exam
Oral Cancer Choosing the Right Technology

• Violet light enhances normal tissue's natural
  fluorescence.
• Abnormal tissue does not fluoresce and appears
  dark

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The Exam
Oral Cancer Choosing the Right Technology

• 3. If you see dark spots or suspicious tissue
  with violet, switch to Amber and look for an
  increase in redness or blood vessels surrounding
  the area

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The Exam
Oral Cancer Choosing the Right Technology

• Studies indicate abnormal tissue has a diffuse
  vasculature, while normal tissue vasculature is
  clearly defined.

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Oral Cancer Choosing the Right Technology
What you will normally see
At least we hope
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Identafi 3000 Ultra Clinical Examples
What you will hopefully never see
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Identafi 3000 Ultra Clinical Examples
What you will hopefully never see
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Identafi 3000 Ultra Clinical Examples
What you will hopefully never see
SCC
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Oral Cancer Choosing the Right Technology
Case 2

• Family History Her father is deceased with a
  history of colon cancer. Her paternal
  grandmother is deceased with a history of lung
  cancer, and a paternal uncle is deceased with a
  history of throat cancer.
• Social History She has a 15-pack-year history of
  tobacco use and quit smoking cigarettes in
  2001. She continues to smoke cigars occasionally
  and is currently going through tobacco
  treatment.
• Diagnosis History of oral leukoplakia and now
  with squamous cell carcinoma of the left palate
  which is early invasive, mostly for carcinoma in
  situ.

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Identafi 3000 Ultra Clinical Examples
Case 3

• Family History  Family history is positive for
  cancer
• Social History  The patient denies any history
  of alcohol, tobacco or drugs
• Diagnosis  Invasive squamous cell carcinoma of
  the right oral tongue/floor of mouth

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Oral Cancer Choosing the Right Technology
Identafi 3000 Ultra Provides More Information
The combination of all three patented
Multi-Spectral wavelengths provides the clinician
with more visual information and increased
confidence for recommending biopsies that yield
fewer False Positives
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Identafi 3000 ultra Bacteria Applications
Adjunctive applications for Dentists and Dental
Hygienists
Courtesy, Dr. M. Romer, ATSU ASDOH
Courtesy, Dr. M. Nichols, Bering Omega Dental
Clinic
Courtesy, Dr. M. Romer, ATSU ASDOH
Identafi 3000 is also intended for use to help
identify bacteria, yeast, fungus, candidacies ,
plaque, tartar, gingivitis, and other bacterial
infections
Courtesy, Dr. M. Nichols, Bering Omega Dental
Clinic
Courtesy, Dr. M. Nichols, Bering Omega Dental
Clinic
Courtesy, Dr. M. Nichols, Bering Omega Dental
Clinic
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Oral Cancer Surgical Applications
Bay Correctional Facility 5400 Bayline
Drive Panama City, FL 32404
Bay Correctional Facility 5400 Bayline
Drive Panama City, FL 32404
Adjunctive applications for OMS and ENT
Courtesy, Rebecca Rae Richards-Kortum, Ann M.
Gillenwater, M.D., F.A.C.S.
Courtesy, Rebecca Rae Richards-Kortum, Ann M.
Gillenwater, M.D., F.A.C.S.
Identifi 3000 is also intended for use to help
identify diseased tissue around clinically
apparent lesions enhancing the ability to choose
biopsy sites and margins for surgical incision
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Identafi 3000 ultra Camera Assembly
Photo - Documentation
RT3-23000
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Chemiluminescence

• Normal epithelium absorbs ViziLite illumination
• Abnormal epithelium
• Leukoplakias appear white
• Red lesions appear darker than surrounding tissue

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Oral Mucosal Response
Mild dysplasia
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Chemiluminescence
Without ViziLite
With ViziLite
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The Power of Blue

• Toluidine Blue Staining Identifies Lesions with
  High Probability of Malignant Transformation
• Metachromatic Dye of the Thiazine Group Used as a
  Nuclear Stain due to its Binding to DNA
• Identifies Cells which are Undergoing LOH
• Cells which Uptake Toluidine Blue are 600 More
  Likely to Undergo Malignant Transformation.
  (Cancer Research 65,8017-8021, Sept 1, 20005)

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• Components of TBlue630 Oral Lesion Marking
  System
• 1 acetic acid solution swab
• TBlue630 swab (.5 Zila Tolonium Chloride)
• 3. 1 acetic acid solution swab

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TBlue630 Stained Lesion
Before Lesion is difficult to see and define
After Lesion is easy to view, document and
evaluate. Measure the stained lesion and document
the staining pattern
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Better Screening Saves Lives

• OUR portion of the patients total body health WE
  are responsible for. NOBODY else looks!
• It shouldnt be a matter of Should we screen?
  It should be a question of WHICH screening tool
  best suites our practice?
• Choose a system that works in your practice and
  make it your standard of care policy to screen
  every patient!

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• BRIEF
• INTERVENTION

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Smokeless Tobacco - Two Basic Forms

• Snuff

• Chewing Tobacco

• Finely ground tobacco packaged in cans or
  pouches.
• Sold in dry and moist forms

• Long strands of loose leaves, plugs, or twists of
  tobacco
• Commonly called plugs, wads, or chew

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• Alternative Smokeless Tobacco Products - Come
• in many forms
• Snus
• Exalt and Revel (pouches of snuff)
• Ariva and Stonewall (tobacco lozenges)

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Tobacco Marketing

• Marketing of Smokeless Tobacco Products
• Tobacco companies
• Make and sell smokeless products that can be used
  in non-smoking areas
• Provide free samples and coupons
• Promote smokeless tobacco as an effective way to
  quit

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Tobacco Marketing

• Two Major Problems with Smokeless
• Tobacco Marketing
• Ads encourage smokers to use their products
• Increased usage in the teen population

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You Can Make A Difference

• Research shows that YOU can have a significant
  influence on your clients decision to quit by
  recommending that they stop using tobacco

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Clinical Practice Guideline (2008 Update)

• Can assist health professionals with implementing
  office systems to assist tobacco users

• Encourage staff to perform tobacco use assessment
  s and brief interventions at every visit

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• MAKE TOBACCO USE TREATMENT
• A PRIORITY
• Brief interventions (less than three minutes)
• Societal and environmental factors
• Cost-effective
• Can reduce fatality rate

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Brief Intervention 2As AND R

• ASK gt ADVISE gt REFER
• Ask about tobacco use
• Advise those who use to quit
• Refer to a tobacco quit-line and/or provide
  cessation treatment options

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Brief Intervention - Ask

• Ask clients at every visit about
• tobacco usage
• Do you smoke, chew or use other
• forms of tobacco?

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Brief Intervention - Advise

• Advise patients who use tobacco products to quit
  This will double the chances that they will try
  to
• quit.
• Quitting tobacco is the single most important
  thing you can do for your health. I have some
  resources to help you.

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Brief Intervention - Refer

• Refer patients to community resources or to
  the Florida Quit For Life Line for help in
  quitting tobacco.
• Here are some organizations that can help you
  quit.
• The ______Quit Line can provide you with support
  to help you make a quit attempt.
• Our clinic works with the _________. They can
  help support you in your quit attempt.

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CLIENT NOT READY TO QUIT ?

• Provide information resources (i.e. brochures,
  flyer for the next tobacco cessation class, etc.)
• Let the client know that you are there to help
  when they are ready to quit.

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Encourage Nicotine Replacement Therapy

• Nicotine Replacement Therapy (NRT)
• Great choice, especially when used in combination
  with group sessions or counseling
• Helps the client manage withdrawal symptoms so
  they can focus on the emotional and mental
  aspects of the addiction
• Most effective at the beginning of the attempt to
  quit

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Types of NRT

• Over the Counter

• Prescription

• Patches
• Gum
• Lozenge
• Nasal Spray
• Inhaler

• Buproprion (Zyban)
• Varencline (Chantix)

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Make Brief Interventions A Success

• Acknowledge the difficulty of smoking.
• Stress the benefits of quitting.
• Give a clear recommendation to quit.
• Take advantage of teachable moments.
• Be caring, empathetic, and positive.

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Resources

• National Organizations and Web Sites
• Centers for Disease Control and Prevention
• Office on Smoking Health
• Telephone 1-800-CDC-INFO (1-800-232-4636)
• Website www.cdc.gov/tobacco/quit_smoking/in
  dex.htm
• Kill The Can
• (Online support for Smokeless Tobacco
  Users)
• Website www.killthecan.org

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Resources

• National Organizations and Web Sites (contd)
• National Cancer Institute
• Telephone 1-800-4-CANCER (1-800-422-6237)
• Website www.cancer.gov
• Nicotine Anonymous
• Telephone [phone]
• Website www.nicotine-anonymous.org
• Smokefree.gov (Information on State
  Telephone-Based Programs)
• Telephone 1-800-QUITNOW
• Website www.smokefree.gov

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Contact Information

• Big Bend Area Health Education Center (Big Bend
  AHEC)
• 325 John Knox Road
• Building M, Suite 200
• Tallahassee, FL 32303
• Telephone [phone]

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Contact Information

• West Florida Area Health Education Center (West
  Florida AHEC)
• 1455 S. Ferdon Blvd.
• Suite B-1
• Crestview, FL 32536
• Telephone [phone]