Detecting Oral Abnormalities
Utilizing Advancements in
Technologies
Presented By:
Leslie Gilchrist
Calandra Portalatin
Brigitta Nuccio
Big Bend Area Health Education Center, Tallahassee, FL
West Florida Area Health Education Center, Crestview, FL
Support Oral Cancer Awareness
www.OralCancerFoundation.org
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
Oral Cancer – Patient Education
Know 2 Important Statistics
National Cancer Institute – SEER reports
(Surveillance Epidemiology and End Results)
All 32 measurable forms of cancer
Oral Cancer – Patient Education
Oral Cancer – Patient Education
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
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
Oral Cancer – Research Data
I Don’t 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
Oral Cancer – Research Data
They’re 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
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
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
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.
Oral Cancer - Basic Facts
For those who do survive late stage discovery …
Life may never be the same
Oral Cancer - Basic Facts
The Good News…
When found early, oral
cancer patients have an
80-90% survival rate
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
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
Oral Cancer - Basic Facts
Traditional Risk Factors in North America
Tobacco Use
(including smokeless tobacco)
Oral Cancer - Basic Facts
Traditional Risk Factors in North America
Alcohol Use
(excessive)
Oral Cancer - Basic Facts
Traditional Risk Factors in North America
Previous History of Oral Cancer
20 times higher risk of developing a
second cancer
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
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
Oral Cancer - Basic Facts
Emergent Risk Factors in North America
Why age 17?
According to the CDC’s 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
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
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)
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
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
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…
31
Appropriate Stage for
Discovery & Intervention
Early
Dysplasia
Moderate
Dysplasia
Fluorescence Visualization helps in the identification of clinically
occult oral abnormalities
Severe
Dysplasia
Invasive
Potentially Malignant Disease Stages
Squamous Cell
Carcinoma-In-Situ 32 Carcinoma
(CIS)
(OSCC)
How
Works
34
Examination
Technique
37
Normal Tissue
Patient A
Normal Oral Mucosa Shows
Normal, Green Fluorescence Pattern
Images courtesy of the British Columbia Oral Cancer Prevention Program
38
Abnormal Tissue
Patient B
Oral Lesions May Show as
Irregular, Dark Areas
Images courtesy of the British Columbia Oral Cancer Prevention Program
39
Patient C
An Oral Lesion that Shows
No Change in Autofluorescence
Appearing Pale Green
40
Images courtesy of the British Columbia Oral Cancer Prevention Program
Lichen Planus – VELscope Confirmed Benign
Etiology
41
SCC
42
Moderate Dysplasia
43
Pre-clinical discovery
Left palate : low-grade mucoepidermoid carcinoma
44
18 of the 20
patients showed
dysplasia or
cancer beyond
the clinically
visible lesion
Images courtesy of the British Columbia Oral Cancer Prevention Program
45
Trimira
Identafi 3000 Ultra
Multi-Spectral
Oral Screening System
“Your new weapon in the war against Oral Cancer”
Trimira™
Identafi 3000 Ultra – Complete Screening Kit
Identafi 3000 Ultra
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”
Screening for Oral Cancer
Identafi 3000 Ultra Helps to Visualize
Biochemical and Morphological Changes
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
Oral Cancer – Choosing the Right Technology
The Exam
1. Put the glasses on and begin the
exam with ‘White Light”
Oral Cancer – Choosing the Right Technology
The Exam
The Conventional Oral Exam
(COE) uses only White light to
identify any lesions of interest.
Oral Cancer – Choosing the Right Technology
The Exam
2. Whether suspicious tissue or not, switch
to violet for a second observation
Suspect tissue appears dark
Photo from Enica /
BC here
Oral Cancer – Choosing the Right Technology
The Exam
Violet light enhances normal tissue's natural
fluorescence.
Abnormal tissue does not fluoresce and
appears dark
Oral Cancer – Choosing the Right Technology
The Exam
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
Oral Cancer – Choosing the Right Technology
The Exam
Studies indicate abnormal tissue has a
diffuse vasculature, while normal tissue
vasculature is clearly defined.
Oral Cancer – Choosing the Right Technology
What you will normally see
At least we hope…
Identafi 3000 Ultra – Clinical Examples
What you will hopefully never see
Identafi 3000 Ultra – Clinical Examples
What you will hopefully never see
Identafi 3000 Ultra – Clinical Examples
What you will hopefully never see
SCC
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.
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
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”
Identafi 3000 ultra –Bacteria Applications
Adjunctive applications for Dentists and Dental Hygienists
Courtesy, Dr. M. Romer, ATSU ASDOH
Courtesy, Dr. M. Romer, ATSU ASDOH
Courtesy, Dr. M. Nichols, Bering Omega Dental Clinic
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
Bay Correctional Facility
5400 Bayline Drive
Panama City, FL 32404
Oral Cancer – Surgical Applications
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
Identafi 3000 ultra – Camera Assembly
Photo - Documentation
RT3-23000
Trimira™
Chemiluminescence
Normal epithelium absorbs ViziLite illumination
Abnormal epithelium
Leukoplakias appear white
Red lesions appear darker than surrounding tissue
Oral Mucosal Response
Mild dysplasia
Chemiluminescence
Without ViziLite
With ViziLite
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)
Components of TBlue630 Oral Lesion Marking System
1. 1% acetic acid solution swab
2. TBlue630 swab (.5% Zila Tolonium Chloride)
3. 1% acetic acid solution swab
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
Better Screening Saves Lives
• OUR portion of the patient’s total body health
WE are responsible for. NOBODY else looks!
• It shouldn’t 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!
BRIEF
INTERVENTION
Smokeless Tobacco - Two Basic Forms
Snuff
- Finely ground tobacco
packaged in cans or
pouches.
- Sold in dry and moist
forms
Chewing Tobacco
- Long strands of loose
leaves, plugs, or twists of
tobacco
- Commonly called “plugs”,
“wads”, or “chew”
Alternative Smokeless Tobacco Products - Come
in many forms:
• Snus
• Exalt and Revel (pouches of snuff)
• Ariva and Stonewall (tobacco lozenges)
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
Tobacco Marketing
Two Major Problems with Smokeless
Tobacco Marketing
• Ads encourage smokers to use their products
• Increased usage in the teen population
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
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
MAKE TOBACCO USE TREATMENT
A PRIORITY
• Brief interventions (less than three minutes)
• Societal and environmental factors
• Cost-effective
• Can reduce fatality rate
Brief Intervention: 2As AND R
ASK > ADVISE > REFER
• Ask about tobacco use
• Advise those who use to quit
• Refer to a tobacco quit-line and/or provide
cessation treatment options
Brief Intervention - Ask
Ask clients at every visit about
tobacco usage…
“Do you smoke, chew or use other
forms of tobacco?”
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.”
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.”
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.
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
Types of NRT
Over the Counter
• Patches
• Gum
• Lozenge
• Nasal Spray
• Inhaler
Prescription
• Buproprion (Zyban)
• Varencline (Chantix)
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.
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/index.htm
• Kill The Can
(Online support for Smokeless Tobacco Users)
Website: www.killthecan.org
Resources
National Organizations and Web Sites (cont’d)
• National Cancer Institute
Telephone: 1-800-4-CANCER (1-800-422-6237)
Website: www.cancer.gov
• Nicotine Anonymous
Telephone: 1-877-879-6422
Website: www.nicotine-anonymous.org
• Smokefree.gov (Information on State Telephone-Based Programs)
Telephone: 1-800-QUITNOW
Website: www.smokefree.gov
Contact Information
Big Bend Area Health Education Center (Big Bend AHEC)
325 John Knox Road
Building M, Suite 200
Tallahassee, FL 32303
Telephone: 850-224-1177
Contact Information
West Florida Area Health Education Center (West
Florida AHEC)
1455 S. Ferdon Blvd.
Suite B-1
Crestview, FL 32536
Telephone: 850-682-2552