Point of Care the “Point of Care” Section Answers Everyday Clinical Questions by Providing Practical Information That Aims to Be Useful at the Point of Patient Care
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Point of Care The “Point of Care” section answers everyday clinical questions by providing practical information that aims to be useful at the point of patient care. The responses reflect the opinions of the contributors and do not purport to set forth standards of care or clinical practice guidelines. This month’s articles were written by speakers at the Pacific Dental Conference, to be held in Vancouver, B.C., from March 6 to 8, 2008. For more information on the conference, visit www.pdconf.com. Q U E S T I O N 1 What do I need to know about oral cancer screening? Background The BC OCPP team has embraced this chal- ral cancer is a devastating disease: approx- lenge through a multifaceted program incorpor- imately 3,200 new cases and 1,050 deaths ating research, education and care. This program Ofrom oral cancer occur each year in provides the scientific groundwork for oral cancer Canada.1 Regrettably, many cases are diagnosed screening using a standardized clinical approach late and require aggressive treatment. Today, 50% in conjunction with screening tools that include toluidine blue staining and direct fluorescence vis- of oral cancer patients die within 5 years of diag- ualization using a number of devices including the nosis. Those who survive often endure significant VELscope (LED Dental Inc., White Rock, B.C.). disfigurement, impairments in oral function and Toluidine blue has a long history of use as a compromised quality of life. Of further concern, vital stain to identify oral cancers and has been global survival rates have changed little over the used sporadically in dental practice for many years. last 3 decades.2 Research from an ongoing longitudinal study con- It is firmly believed that early detection of oral ducted at the British Columbia Cancer Agency has cancer can significantly reduce oral cancer deaths shown that oral premalignant lesions that stain 3 and morbidity. The British Columbia Oral Cancer with toluidine blue are 6 times more likely to be- Prevention Program (BC OCPP) team thinks come oral cancers than those that do not (Fig. 1b). that dentists are ideally positioned to make this This finding supports a new role for this vital stain happen. Oral cancer is frequently preceded by an in identification of high-risk oral lesions.5 identifiable premalignant lesion — a white patch Using evidence-based techniques, the BC or, less frequently, a red patch — and progres- OCPP team is working toward understanding the 4 sion from dysplasia to cancer occurs over years. value of direct fluorescence visualization in the This allows clinicians the opportunity to detect management of oral dysplasia and oral cancer. early changes in the oral mucosa and intervene. The team has used this technology in its highly However, a major challenge has been differenti- specialized clinics to follow about 600 patients for ating between benign and precancerous or early more than 3 years.6 This experience has provided cancerous mucosal changes when there are often sufficient evidence of added value to warrant use of no distinctive clinical features that distinguish the this technique in specialized referral clinics for the conditions (Fig. 1a). management of oral dysplasia or in the follow-up a b c Figure 1: A painless, diffuse, red and white lesion on the left lateral area of the tongue of a 35-year-old man with a history of tobacco chewing. Diagnostic biopsy identified carcinoma in situ. (a) Lesion viewed with conventional white light showing a diffuse, predominantly white lesion. (b) Lesion viewed following application of toluidine blue showing a focal region of dye uptake. (c) Lesion viewed with direct fluorescence visualization showing loss of fluorescence. ���JCDA • www.cda-adc.ca/jcda • November 2007, Vol. 73, No. 9 • 797 ––––––– Point of Care ––––– of treated oral cancer patients (Fig. 1c). Efforts are THE AUTHORS being made to understand its use in community settings where evidence is still being collected. Dr. Michele Williams is clinical professor in the faculty of dentistry, University of British Columbia, Management Advice and staff in the oral oncology department, British Columbia Cancer Agency, V���������������������ancouver, B.C��������.������� Email: In the specialized BC OCPP affiliated clinics, [email protected]. the team employs a standardized step-by-step approach to the evaluation of any mucosal le- Dr. Catherine F. Poh is clinical assistant professor sion suspected to be premalignant or potentially in the faculty of dentistry, University of British 7 Columbia, and staff in th oral oncology department, malignant. British Columbia Cancer Agency, Vancouver, B.C. • Patient history — including family history of head and neck cancer, habits and lifestyle, signs Dr. Lewei Zhang is professor and director of oral and symptoms medicine oral pathology in the faculty of dentistry, • Visual inspection (general) — including extra- University of British Columbia, Vancouver, B.C. oral and intraoral examinations • Visual inspection (specific) — location, size, colour, texture and outline of identified Dr. Miriam R. Rosin is professor and director of the British Columbia Oral Cancer Prevention Program, lesion(s) British Columbia Cancer Agency, Vancouver, B.C. • Visualization aids — direct fluorescence vis- ualization; toluidine blue application The authors have no declared financial interests in any company • Clinical photos — all visible lesions manufacturing the types of products mentioned in this article. • Diagnostic biopsy — as indicated It is critical to note that toluidine blue staining References and direct fluorescence visualization are not diag- 1. Canadian cancer statistics 2007. Toronto: Canadian Cancer Society/National Cancer Institute of Canada; 2007. Available: www. nostic in all settings. The impression is that these cancer.ca/vgn/images/portal/cit_86751114/36/15/1816216925cw_ techniques are complementary to and not a re- 2007stats_en.pdf (accessed 2007 Oct 17). placement for a comprehensive history and con- 2. Cancer facts & figures 2005. Atlanta: American Cancer ventional visual and manual examination of head Society; 2005. Available: www.cancer.org/downloads/STT/ CAFF2005f4PWSecured.pdf (accessed 2007 Oct 17). and neck. The value of these techniques depends 3. Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara on the knowledge and training of the operator S, Mathew B, and others. Effect of screening on oral cancer mor- in their use and interpretation. Training and ex- tality in Kerala, India: a cluster-randomised controlled trial. Lancet perience are important as a variety of benign and 2005; 365(9475):1927–33. common mucosal changes may result in staining 4. Rosin MP, Cheng X, Poh C, Lam WL, Huang Y, Lovas J, and others. Use of allelic loss to predict malignant risk for low-grade with the application of toluidine blue or show loss oral epithelial dysplasia. Clin Cancer Res 2000; 6(2):357–62. of fluorescence. These alterations are not restricted 5. Zhang L, Williams M, Poh CF, Laronde D, Epstein JB, Durham to potentially malignant or malignant disease. As S, and others. Toluidine blue staining identifies high-risk primary oral premalignant lesions with poor outcome. Cancer Res 2005; always, good clinical judgement is indicated in all 65(17):8017–21. circumstances. The challenge to the dental profes- 6. Poh CF, Ng SP, Williams PM, Zhang L, Laronde DM, Lane P, and sion will be to ensure that all adult patients receive others. Direct fluorescence visualization of clinically occult high-risk a regularly scheduled comprehensive oral cancer oral premalignant disease using a simple hand-held device. Head Neck 2007; 29(1):71–6. screening examination. Working together with a 7. Poh CF, Williams PM, Zhang L, Rosin MP. Heads up! — A call strong commitment to change, dentists have the for dentists to screen for oral cancer. J Can Dent Assoc 2006; opportunity to make a dramatic difference. a 72(5):413–6. A special edition of JCDA on oral cancer screening and early detection of oral cancer is planned for the spring of 2008. This edition will contain detailed information on the resources developed by the British Columbia Oral Cancer Prevention Program team, including practical and time-efficient clinical practice guidelines that incorporate these techniques into an already busy dental practice. The BC OCPP team will also be giving a presentation on this topic at the Pacific Dental Conference on Thursday, March 6 (session repeated Friday, March 7). 798 ���JCDA • www.cda-adc.ca/jcda • November 2007, Vol. 73, No. 9 • ––––––– Point of Care ––––– Q U E S T I O N 2 What is the role of the physiotherapist in managing the patient with complex temporo- mandibular disorder? Background of the jaw, painful clicking, grating sounds or emporomandibular disorder (TMD) is a syn- sudden changes in occlusion. Patients will self- drome that is often misdiagnosed or even ig- refer to physiotherapists if they have other symp- Tnored by medical professionals. It may cause toms, such as headaches or neck and shoulder headaches, earaches, facial pain or sinusitis, and pain, which often lead to a diagnosis of TMD. the afflicted are often left to suffer the sequelae of ssessment to Determine the Patho- chronic pain. The etiology of TMD is multifactorial: physiology of TMD and Related Pain trauma (a direct blow to the jaw or the result of a motor vehicle accident), stress,1 forward head Subjective assessment includes a TMD ques- posture or dental work. TMD can also be psycho- tionnaire, questions about past and present life history, direct triggers, such as dental work, in- somatic,2 which means that effective treatment creased stress, symptom behaviour (time of day, should be directed at the mind as well as the body. posture), medications, related medical history and Physiotherapists are university-trained body other investigative tests. specialists, who are educated in pathology, Physical assessment includes an upper quad- anatomy, physiology and kinesiology. In short, rant scan to determine which area and tissue re- they are able to assess and treat the muscles and quire further investigation.