Exodontia.Info
Oral Cancer - Oral Screening
Why Screen?

The stage that Oral Squamous Cell Carcinoma (OSCC) is diagnosed has a bearing on the outcome of OSCC; oro-
pharyngeal cancers
have relatively ‘silent’ symptoms which may not be present during the early stages of the
disease, which is possibly why the stage of disease at diagnosis has not altered in the last 40 years despite public
education.

For this reason, there is an interest in the early identification of
OSCC yet the case for formal screening
programmes does not meet the criteria established by the
UK Screening Committee.

The Cochrane review on oral screening for OSCC found that overall there is not enough evidence to decide
whether screening by visual inspection reduces the death rate for oral cancer and there is no evidence for other
screening methods
.

A
GDP can expect to see at least a couple of mouth cancer lesions during their practising lifetime.  Obviously, this
is an average statistic affected by geographical location and social class of clientèle, much like the statistics for
caries (tooth decay).

Nevertheless, to miss such a diagnosis could have a significant effect upon a patient’s health, quality and longevity
of life and, of course, might leave the clinician open to criticism by the patient, and possibly give rise to medico-
legal concerns.

One of the main problems with oral screening is limited accessibility to the dental office.

High risk groups are those less likely to have access to an NHS dentist and therefore less likely to have regular
dental appointments.

These patients, many of whom are elderly, are less likely to schedule regular visits to the dentist due to financial
constraints, a lack of adequate facilities or indifference towards their oral health.

Oral Cancer Screening

For oral cancer, where large numbers of patients are already seeing a dentist, an 'opportunistic screening'
approach is generally advocated.

'
Opportunistic screening' is less systematic but very much more cost-effective than population screening. If an
opportunistic screening strategy is to be successful, all dentists should carry out the necessary soft tissue
examination alongside hard tissue examinations.

Screening for oral cancer and pre-cancer becomes part of the routine examination.  In practice, this will normally
be at the beginning of each new course of treatment.
ViziLite® is an oral cancer screening tool that may help the clinician more easily visualise suspicious lesions.  It is
not a diagnostic tool.  

In the UK, it is sold by
Panadent.  Checking their website, there seems to be a patchy take up over England;
seemingly most of the
GDP practices are based in Essex.  Possibly not to be sensationalist, not many of practices
using this system, advertise their
oral cancer screening facility.

Kit contents:

•        
Chemi-luminescent device
•        30 ml acetic acid
•        Light stick holder / retractor
Last Updated 1st January 2020
Useful Websites:

The Oral Cancer Foundation

The Mouth Cancer Foundation

Homestead Schools, Inc (Dental)

National Institute for Health Research (NIHR)

CancerHelp UK

International Agency for Research on Cancer / World Health Organisation

Emedicine.com

Medscape.com

Oral Cancer LDV

Oral Cancer Recognition Toolkit


Useful Articles:

BDA Occasional Paper 2000.  Opportunistic Oral Cancer Screening.

Department of Public Health and Epidemiology, University of Birmingham 2000.  The clinical effectiveness of
toluidine blue dye as an adjunct to oral cancer screening in general dental practice.  A West Midlands
Development and Evaluation Service Report.

BDJ 2003.  Oral Cancer Prevention & Detection in Primary Healthcare.

Oral Oncology 2003.  The effectiveness of community-based visual screening and utility of adjunctive diagnostic
aids in the early detection of oral cancer

Agency for Healthcare Research and Quality 2004.  Screening for Oral Cancer. A Brief Evidence Update for the
U.S. Preventive Services Task Force.

J Med Screen 2006.  Does the ‘Inverse Screening Law’ apply to Oral Cancer Screening & Regular Dental Check-
ups?

Oral Oncology 2007.  Review.  Critical Evaluation of Diagnostic Aids for the Detection of Oral Cancer.

Am J Dent 2008.  Review Article.  Oral Cancer - Current & Future Diagnostic Techniques

JADA 2008.  Adjunctive Techniques for Oral Cancer Examination & Lesion Diagnosis.  A Systematic Review of
the Literature.

JADA 2008.  Oral Rinses may help detect HPV-positive Head & Neck Cancers

Bulletin of the World Health Organization 2009.  Cost-effectiveness of Oral Cancer Screening - Results from a
Cluster Randomized Controlled Trial in India.

Family Practice 2009.  Conducting Oral Examinations for Cancer in General Practice - What are the barriers?

Evidence-Based Dentistry 2009.  Editorial.  Should we screen for Oral Cancer?

BDJ 2009.  A qualitative study examining the experience of primary care dentists in the detection & management
of potentially malignant lesions. 1. Factors influencing detection

J Dent Res 2010.  A community-based RCT for oral cancer screening with toluidine blue.

JADA 2010.  Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas.

JADA 2010.  For The Dental Patient...Detecting Oral Cancer Early

DHHS, NIH & NIDCR.  Detecting Oral Cancer - A guide for health care professionals.ppt

Screening.nhs.uk 2010.  Evaluation of Screening for Oral Cancer against NSC Criteria.

Evidence-Based Dentistry 2010.  Clinical Recommendations for Oral Cancer Screening

Evidence Based Dentistry 2010.  Editorial.  Seek, don’t screen for Oral Cancer.

Evidence-Based Dentistry 2010.  Does Toluidine Blue Detect More Oral Cancer

Cochrane Database of Systematic Reviews 2010.  Screening programmes for the early detection and prevention
of oral cancer.

BDJ 2010.  The Reality of Identifying Early Oral Cancer in the General Dental Practice

JADA 2010.  Detecting Oral Cancer Early

Vital 2011.  Making oral cancer screening a routine part of your patient care.   Part 1

Vital 2011.  Making oral cancer screening a routine part of your patient care.   Part 2

BDA 2011.  Early Detection of Oral Cancer.  A Management Strategy

BJOMS 2011.  Management of Oral Carcinoma.  Benefits of early Pre-Cancerous Intervention

JADA 2011.  Rise in Oral Cancer Linked to HPV, Study Shows

JADA 2011.  The Connection between HPV & Oroparyngeal Squamous Cell Carcinomas in the US.  Implications
for Dentistry

BDJ 2012.  Microscope Created For Early Oral Cancer Diagnosis

BDJ 2016.  Letters to the Editor.  Mouth Cancer.  Extending the RULE

BDJ 2018.    Screening for Mouth Cancer - The Pros & Cons of a National Programme

BDJ 2018.  Mouth Cancer - Presentation, Detection and Referral in Primary Dental Care

1.        Patient rinses with 1% acetic acid for 1 minute
2.        
Chemi-luminescent device activated & placed in ‘light stick’ holder.
3.        Dim room lighting
4.        Visually inspect oral cavity using device
5.        Record any findings and refer the patient if necessary

How ViziLite® Works

Normal epithelium (skin) absorbs the light and appears dark; abnormal tissue reflects light and appears bright
white.  Based upon the current suggested usage for these devices, it is unclear what added benefit they would
provide to the practicing clinician.
Toluidine Blue
  • Meta-chromatic dye
  • Stains nuclear DNA
  • 1% aqueous solution followed by 1% acetic acid to de-colourise the oral lesion
  • ‘Abnormal’ tissue retains the blue dye

Tolonium chloride or toluidine blue, is a stain that like Vizilite, is used as a screening device to help the clinician
more easily visualise suspicious lesions.

Overall,
toluidine blue appears to be good at detecting carcinomata but is positive in only ~50% of lesions with
dysplasia.  In addition, it also frequently stains common, benign conditions such as non-specific ulcers.

A systematic review concluded that there is no evidence that
toluidine blue is effective as a screening test in a
primary care setting.

The high rate of false positive stains and the low specificity in staining
dysplasia likely outweigh the potential
benefits of any additional cancers detected at this time.
All 3 layers (basal, intermediate and superficial layers) of epithelium are included / OralCDx® results come back
as
negative (no cellular abnormalities), positive (definitive cellular evidence of epithelial dysplasia or carcinoma) or
atypical (abnormal epithelial changes warranting further investigation).

Negative lesions require the same careful clinical follow-up as negative histologically sampled lesions.  Atypical and
positive lesions require scalpel biopsy and histology analysis.

A report is sent with results for any specimens with
atypical or positive findings.  The report contains histological
slides of the specimen and the
oral pathologist's report.


Disadvantages:

Often used inappropriately by the dentist.  For example, some use it on
papillomata.

Cells are seen out of context, which can result in misinterpretation.  For example, if the
Brush Test is used to
collect cells from a patient who has
lichen planus and the cells are spread out on a slide, they will be out of
context and will be read as atypical.
Cancers 2012 - Vision Paper, that by 2012, a pilot scheme should have been held in > 1 'spearhead PCT' to
screening. This might include:


  • setting up of a dedicated Head & Neck Clinic every 3 - 4 months to which over-50's in high risk groups are
    invited

  • links to specialists in secondary care, for example, sending digital photos for advice prior to a decision to refer
    although there are concerns about the feasibility of producing good enough quality photos

  • posters in pharmacies offering mouth checks for ulcers

Also, action should have been taken with the manufacturers of products designed for self-medication of
oral ulcers
and related conditions for the medication carton to carry a clear health warning about
oral cancer.  This will need to
be managed carefully to avoid large numbers of the “worried well” overwhelming services.

Finally, the
CRS opined that due to the problems of 'dental capacity' (which are outside the scope of the CRS to
resolve), it may not be feasible to focus
opportunistic screening with dentists.  As a response to this perceived
lack of capacity, it was thought that
GP's and practice nurses (who often see high risk groups for other issues such
as high blood pressure) and
pharmacists (who are often consulted about mouth ulcers) might be able to take up
the slack.

Training issues and financial incentives would need to be considered as would the advantages / disadvantages of
screening being carried out by non-medical personnel


Opportunistic Oral Cancer Screening

This was published by the British Dental Association in 2000.

This is quite comprehensive.  It covers:

  • Oral cancer screening - obligations and opportunities
  • Risk factors
  • Talking to patients about oral cancer
  • Administration
  • Examining the head, neck and soft tissue
  • Using tolonium chloride
  • Putting screening into practice

If you were considering offering this type of screening service, it is well worth looking at.

It can be downloaded from here.


Oral Cancer Screening 'Visual Aids'

To augment the GDP’s visual check of the mouth, there are a number of 'aids' to flag up suspicious areas.

These include:

  • ViziLite & MicroLux DL
  • Tolonium chloride (Toluidine Blue)
  • OralCDx® brush biopsy
  • Exfoliative cytology

Toluidine blue
has been used for a number of years.  ViziLite & OralCDx® are quite new.  Exfoliative cytology is
included for the sake of completeness but I don’t believe many
GDP practices do this.  This tends to be done in
hospitals.

Most studies show that the various aids can help but when used for screening, economically, it is too expensive for
the number of lesions correctly picked up.

VELscope, OralCDx® and Toluidine Blue staining have high false positive rates when they are used to screen
routinely for
oral cancer.

It would be inefficient to allocate scarce healthcare resources to the routine use of these devices for
oral cancer
screening
.

These devices may be beneficial in
opportunistic screening programmes or in cancer referral clinics when the pre-
test probability of
oral cancer is likely to be above 10%.

Further research is needed to determine at which pre-test probabilities, these adjunctive diagnostic devices would
be cost-beneficial for the screening of
oral cancer.