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Practical Clinical Oral Pathology

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Practical Clinical Oral Pathology Practical Clinical Oral Presenter Disclosure Pathology Dr. Kahn has no financial interest / arrangements that could be perceived September 15, 2012 as a realtflitfittl or apparent conflict of interest in the context of the subject of this Michael A. Kahn, DDS Professor and Chairman, Dept. Oral and presentation. Maxillofacial Pathology Tufts University School of Dental Medicine Boston, MA 02111 MAK MAK Topics/Objectives – The Lineup Description of Oral Soft Tissue Lesions • AM Session • PM Session – Describe lesions – Differential diagnoses • Site – Adjunctive screening and current tx and – GidliGuidelines for management – Part 2 • Morphology observing & referring – Emerging role of HPV • Color – Differential diagnoses – Update on BRONJ and current tx and • Size management ––PartPart 1 • Texture MAK MAK Site • Perioral skin • Edentulous alveolar • Lips ridge • Tongue • Retromolar pad • Floor of mouth • TiTrigone area • Gingiva • Hamular notch • Vestibule • Maxillary tuberosity • Buccal mucosa • Soft and hard palate • Oropharynx MAK MAK 1 Site Site MAK MAK MAK MAK Soft Tissue Lesion Morphology - Basic Types Elevated Lesions • Elevated ––AAbove the plane of mucosa • Blisterform – contains a body • Depressed flu id; “blister” – Below the plane of mucosa ––VesicleVesicle - 0.5 cm in diameter • Flat ––BullaBulla - > 0.5 cm in diameter – Even with the plane of mucosa ––PustulePustule – 0.5 cm and > 0.5 cm; – Detectable by change in color filled with pus MAK MAK 2 Elevated Lesions Depressed Lesions • Most are ulcers – Number - single vs. multiple • Nonblisterform – no fluid • Separate vs. coalescing – PlPapule - 050.5 cm in diame ter – Outline - regular vs. irregular – Margin - raised vs. smooth – Nodule - > 0.5 cm and 2 cm in diameter – Depth - superficial vs. deep • 0.3 cm vs. > 0.3 cm – Tumor - > 2 cm in diameter – Diameter – Plaque – usually > 0.5 cm in diameter • 0.5 cm vs. > 0.5 cm MAK MAK Depressed Lesions Flat Lesions • Other examples • Macule ––ScarScar – Circumscribed area of abnormal color –Pit or blind pouch change • Tongue Lesion – special case – Not a macule – Loss of dorsum papillae – Single or multiple • Irregular or regular outline MAK MAK Flat Lesion – Tongue MAK MAK 3 Color • 4 Primary Endogenous Pigments ––OxyhemoglobinOxyhemoglobin - Red ––ReducedReduced hemoglobin - Blue ––MelaninMelanin - Brown ––CaroteneCarotene - Yellow MAK MAK Color Incidence (%) – a component of the lesion • Red – 80% • Black ––7%7% • Pink – 50% • Brown ––5%5% • White – 50% • Translucent • Red and White – 34% ––PinkPink • Blue – 13% ––BlueBlue • Purple ––8%8% ––RedRed or purple • Gray ––7%7% MAK MAK MAK MAK 4 Red/Purple • Intravascular Red/Purple – Dilation - hyperemia – Proliferation – hamartoma, neoplasm • Extravascular • Extravascular – Extravasated (discoloration) – macule and elevated – Extravasated (discoloration) – • Hematoma macules – thin, spreading, diffuse; – Collection of blood become darker, more purple – Becomes elevated over time • Petechia ––0.10.1-- 0.2 cm in diameter – Becomes darker, purple, over time • Purpura ––0.30.3 - 2.0 cm in diameter • Ecchymosis – > 2.0 cm in diameter MAK MAK Size Consistency • Expressed as greatest diameter • Fixed vs. movable in length and width • Indurated • Use normal structures as point • Firm vs. doughy vs. fluctuant of reference to aid estimate with rebound • Metric units • Crepitus ––CentimetersCentimeters and fractions thereof MAK MAK Miscellaneous Terminology • Ulceration vs. erosion • Keratosis • Sessile vs . pedunculated • Smooth vs. rough – Papillary; papillomatous – Verrucous; verrucoid MAK MAK 5 Deaths from Oral and Oropharyngeal Incidence of Oral and Oropharyngeal Carcinoma Carcinoma • ~ 7,850 annually (est. 2012) • ~ 40,250 (est. 2012) • 2:1 male to female • 3% new cancers in men • 1 death every 60 minutes, 24/7 • 2:1 male to female • Relative 5-year survival rate = 61% ••WhiteWhite - 63% • Rate more common in African-African-AmericansAmericans • Black - 42% • 1 new case every 20 minutes, 24/7 ••MModestodest overall improvement • 54% (’74(’74--’76)’76) • Relatively constant rate for 25 years • 55% (‘83(‘83--’85)’85) • 59% (’95(’95--’00)’00) Siegel R, et al. Cancer Stats, 2012. Ca Cancer J Clinic 2012;62(1):10-29 MAK Siegel R, et al. Cancer Stats, 2012. Ca Cancer J Clinic 2012;62(1):10-29 MAK Grading Dysplasia Time to travel? 25-25-4545 days (dep. on site) mild moderate severe & invasive in-situ -ca MAK MAK Concept and Degrees of Epithelial Dysplasia Screening Mild ------>> Moderate ------>> “The examination of a group of Severe ---->> InIn--situsitu--carcinomacarcinoma usually asymptomatic ---- > Invasive squamous cell carcinoma (super fic ia l, then individuals to detect those with deep) a high probability of having or However, the process does developing a given disease” not always progress through each step! The American Heritage® Stedman's Medical Dictionary MAK MAK 6 What Cancer Screening Statistics What Cancer Screening Statistics Really Tell Us Really Tell Us • Counterintuitive Emerging Realization • Sources of Bias (Confounders) – More screening does not necessarily – Lead time bias translate into fewer cancer deaths (and • Cancer found earlier but diagnosis does some can do more harm than good) nothing to change the course of the disease – Survival = how long a person lives after a • Inherent in analysis comparing survival after cancer diagnosis detection (5-(5-yearyear survival data) • But improvement in survival does not imply that the test saves lives because of bias MAK MAK What Cancer Screening Statistics Really Tell Us • Sources of Bias (Confounders) – LengthLength--biasedbiased sample • Screening is more likely to pick up slower growing, less aggressive cancers – Preclinical period when detected by screening is longer (sojourn time) – Extreme example = over diagnosis MAK MAK What Cancer Screening Statistics Really Tell Us • Randomized trials – Reliable way to know if screening test saves lives • Reduction in cancer deaths in people assigned to screening compared with people assigned to a control group • Screening test can only save lives if it advances the time of dx and earlier tx is more effective than later tx • Improvement in 55--yr.yr. survival ≠ test saves lives • Improvement in mortality data = test saves lives MAK MAK 7 Oral Cancer Diagnosis and Screening Aids • Tissue Reflectance and Vital Dye - Chemiluminesce • Vizilite Plus® with TBlue® • Surgical Biopsy (Tolmar/Zila) • Scalpel • Punch • MicroLux DL (AdDent) • Laser • Orascoptic DL Basic • Cytology (Orascoptic) • Exfoliative smear • Visual Optical Fluorescence (narrow • BrushTest ® (aka brush band imaging) biopsy) (Oral CDx) • VELscope® (L.E.D. Dental) • LiquidLiquid--basedbased SurePath®(BD) • DentLight DOE (DentLight) • Salivary Screening • OraRisk ® HPV (Oral DNA • Sapphire Plus LD (Dent(Dent--Mat)Mat) Labs) • Tissue Reflectance, Fluorescence • Salivary Biomarker Test and White Light (Advanced Lab Services) • Identafi 3000 Ultra® (Star Dental) MAK MAK Cancer Screening and Diagnostic Protocols Exfoliative Cytology Conventional Adjunctive Biopsy and Cytology Screening Screening (Dx) Techniques Diagnosis Breast Needle Manual Mammogram Biopsy Incisional Biopsy Prostate Manual PSA Prostate Biopsy 630 Histological Oral *ViziLite Plus TBlue l DentLight DOE Analysis Visual & Sapphire Plus LD Incisional Palpation or Punch VELscope Vx Liquid or Biopsy Identafi BrushTest Cytology OraRisk HPV Cervix Pap smear Incisional or Punch Speculite + Pap Visual Biopsy Colposcopy * Also MicroLux DL and Orascoptic DK Basic MAK MAK BrushTest SurePath Liquid-Liquid-BasedBased Brush Cytology •$9.95 – dentist purchased kit • $100-200 - billed to patient by dentist • $95 - billed to patient by Oral CDx MAK MAK 8 LiquidLiquid--BasedBased Brush Cytology LiquidLiquid--BasedBased Brush Cytology Conventional Smear LiquidLiquid--BasedBased MAK MAK sm ® OraRisk HPV by OralDNA Labs OraRisksm HPV by OralDNA® LABS • Indications – Traditional risk factors, sexually active, • Mixed terminology of head and neck cancer, family hx of oral cancer, signs and oral cancer, oropharyngeal ca, ororespiratory symptoms of oral ca, suspicious oral cancer, oral and throat cancers lesion • “A test looking for a disease” – Lingen, M. • Non-invasive, easy-to-use • ? - Establish increased risk for HPVHPV--relatedrelated – Gargle/swish with sterile saline for 30 oral cancer seconds, expectorate into funnelfunnel--toptop $200 – dentist purchased – What does HPV positive really mean that is tube, ship, receive report kit $70 – billed to patient by clinically significant • HighHigh--oror low-low-riskrisk type by PCR OralDNA labs – Cannot predict in whom the virus will persist – Positive test w/no lesion • ? - Determine appropriate referral and – Repeat in 6 months; positive again, monitoring conditions refer to OS or ENT MAK MAK Oral Cancer Saliva Test? ALS - Salivary Biomarker Test • Advanced Laboratory Service’s Saliva Biomarker Test • Screening over age of 18 • Method – No tobacco , nicotine gum, liquids meds 24 hours prior – No eat, drink, oral hygiene 30 min. prior – No current infection or RT – Rinse with water and wait 5 minutes – Fill test tube with 5 mL of saliva MAK MAK 9 Toluidine Blue Vital Staining • Salivary Biomarkers Examined • First touted in 1970s • IL-8 screening • Basic metachromatic dye (tolonium • If negative, low risk group chloride) that stains nuclear material of • If positive, high risk group ---> malignant lesion then IL -6IL6, IL-1 screening • If positive - - - - - > biopsy • Nuclei of cancerous cells have increased DNA
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