Table 7: Chairside Oral Cancer Detection Tests Test Method and Rationale
Comments
Toluidine blue
The dye is spread over an area of abnormal tissue. The dye is attracted to cells rich in DNA and RNA (cancer cells, which are rapidly multiplying). The cells are stained blue by the dye. Depending on the type of light and the imaging approach used, optical imaging of oral tissues can detect minimal changes within the tissues, such as changes in architecture and composition, vascularity, and tissue boundary integrity.
Developed in 1875, this dye has been used extensively as a test for mucosal lesions. Sensitivity and specificity in the detection of oral cancer is 78% to 100% and 31% to 100%, respectively. The FDA has approved an auto fluorescence imaging device for early detection of oral neoplasia (2010). Fluorescence imaging devices rely on qualitative observations to detect and delineate neoplastic oral lesions. Reliable screening with these instruments necessitates well- defined and standardized image interpretation criteria and appropriate user training.
Optical imaging
Exfoliative cytology
The lesion is scraped with a stiff brush (brush biopsy) and cells from the scraping are sent to a laboratory that will analyze them for abnormalities.
Note . Adapted from American Cancer Society. Can Oral Cavity and Oropharyngeal Cancers Be Found Early. Last Revised March 23,2021b; Priya.P Saneetha and Babu N. Aravindha. Chair side diagnostic aids in early detection of oral cancer For general practitioners. European journal of Molecular & Clinical Medicine. Volume 07. Issue 10, 2020. https://ejmcm.com; Romano Antonio, Di Stasio Dario, Petruzzi Massimo, et.al., Noninvasive Imaging Methods to Improve the Diagnosis of Oral Carcinoma and its Precursors: State of the Art and Proposal of a Three Step Diagnostic Process. Cancers June 8, 2021. (13) 12, 2864. https://doi.org/10.3390/cancers13122864 Communicating risk and screening process
in age (and typically better overall health), are nonusers of tobacco products, have limited use of alcoholic beverages, and have tumors with a distinct molecular profile which are more sensitive to radiation and chemotherapy all of which bodes well for a better treatment outcome and a reduced chance of a recurrent malignancy (Horakova, et al., 2019; Lechner, et al., 2022). As with all types of cancer, prognosis directly relates to the stage at which the cancer is identified; in general, the earlier the cancer is detected, the better the prognosis. Current screening tests In contrast to cervical cancer, validated screening methods for oral cancer are not available (Sanyalou, 2019). Visual screening is difficult since most of the HPV-positive and obtaining a representative sample given the large surface area of the oropharynx and the presence of crypts (Sanyalou, 2019). Current tests that are used to detect oral HPV infection include polymerase chain reaction (PCR) which can detect HPV DNA and E6/E7 oncoproteins and immunochemistry to detect p16 protein. (Windon et al., 2018). A systematic review of 8 studies for the detection of oral HPV infection via oral rinse or swab produced false-negative results in 28% of the tests which rendered this means of detection questionable in its accuracy and utility (Gipson, et al., 2018). There are no reliable screening methods to determine if HPV presence in the oral cavity or the oropharyngeal region will lead to a malignancy in these areas.
The HPV-oral cancer link necessitates discussion of oral- systemic health issues with patients, including the discussion of sexual behaviors. Many dental providers object to discussing these issues with patients, especially if the patient is a minor, of the opposite sex, or a different age (Wagner & Villa, 2017). Unlike HPV-negative oral cancer, HPV-positive oral cancer is more frequent among non- smokers and individuals with a shorter history of smoking than among heavy smokers (You, et al., 2019). Nevertheless, smoking status should be discussed with patients since smoking negatively affects cancer prognosis and survival rates (Chen, et al., 2020; Gronhoj, et al., 2019). Treatment of HPV-positive oropharyngeal cancer may differ from that for HPV-negative oral cancer. Research shows that HPV-positive oropharyngeal cancers are more sensitive to radiation treatment and may require a lower cumulative dose of radiation compared to HPV-negative oropharyngeal cancers and are thus more responsive to therapy (Taberna, et al., 2017). When compared to HPV-negative cancer, HPV- positive cancer has a more favorable prognosis (Roberts, et al., 2019; Lechner, et al.,2022). The HPV status of the cancer is an independent and strong prognostic factor (Syrjanen, 2018). When compared with HPV-negative oropharyngeal cancer patients, those whose oropharyngeal cancers are HPV-positive have improved overall and disease-free survival rates (Tumban, 2019; Lassen, et al., 2018). The improved prognosis may result in part because HPV-positive patients are typically younger
WORKING WITH HPV-RELATED ORAL CANCER
the stage of disease progression. If radiation therapy is required, compromised teeth should be extracted at least 2-3 weeks beforehand to reduce the risk of odontogenic infections during radiation therapy and for developing osteoradionecrosis after the completion of radiation therapy (University of Florida College of Dentistry, 2022). Interfacing between the oncology group and other providers involved in caring for the patient post-treatment is essential (Yong, et al., 2022).
Treatment for suspicious lesions will depend on the biopsy findings and may include laser removal, standard surgical excision of the lesion, and a combination of chemotherapy with cetuximab combined with intensity-modulated radiation therapy (IMRT) (Taberna et al., 2017). Treatment regimens must be tailored to the unique oncogenic profile of each patient with a consideration of the risks and benefits of any aspect of therapy and the potential for adverse side effects which may be permanent. If the lesion is cancerous, treatment and follow-up procedures will be based on
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