speaker handouts - · pdf fileoral‐systemic health day feb 7, 2014 susan muller, dmd, ms 5...

SPEAKER HANDOUTS

Susan Müller, DMD, MSEmpowering Physicians, Nurses and other Non-Dental Healthcare Providers in the Early Detection of Oral and Oropharyngeal Cancer

Travis Nelson, DDS, MSD, MPHEmpowering Physicians, Nurses and other Non-Dental Healthcare Providers to Screen Children and Adolescents for Oral Diseases

Friday, February 7, 2014

Oral‐Systemic Health Day Feb 7, 2014

Susan Muller, DMD, MS 1

Empowering Physicians, Nurses and Other Non‐Dental HealthcareProviders in the Early Detection of Oral and Oropharyngeal Cancer

Susan Müller, DMD, MSProfessor Emeritus

Department of OtolaryngologyEmory University School of Medicine

Faculty/Presenter Disclosure

Susan Müller has nothing to disclose

Disclosure of Commercial Support

• This program has not received financial support from a commercial entity.

• This program has not received in-kind support from a commercial entity.

Goals

Distinguish benign conditions from potentially premalignant or malignant oral lesions

Source: Dr. Susan Muller



Discuss clinical presentation, differential diagnosis of precancerous and cancerous lesions

Goals

Source: Dr. Susan Muller Source: Dr. Susan Muller


Questions to Think About When Evaluating Oral Lesions

• Acute vs Chronic• Multiple vs Single• Location• Duration• Associated pain• Induration

• Other mucosal lesions

• Cutaneous lesions• Systemic diseases• Medications• Any known triggers



What is oral leukoplakia?• Leukoplakia is the most common oral pre-

cancer (potentially malignant oral lesion)• 2.6% worldwide prevalence• 70-95% of oral leukoplakias will not progress to

malignancy• Lesions of long duration have a greater risk of

malignant transformation than those of short duration

Petersen PE Oral Cancer prevention and control-the approach of the

World Health Organization. 45:454-60,2009; Oral Oncol.

Sites of Oral Leukoplakia• More than 2/3 or oral leukoplakia are found at 3

sites: lip vermilion, gingiva, and buccal mucosa• Sites where leukoplakia are most likely to be

associated with pre-cancer/cancer:tongue, lip vermilion and floor of mouth(account for 93% of all leukoplakia associated with dysplasia or cancer)

Müller S. Oral Precancer. In: Werning JW, eds. Oral Cancer. Diagnosis, Management, and Rehabilitation. New York: Thieme, 2007: 8-17.

Oral Leukoplakia


What causes oral leukoplakia?

cdc.gov



Oral Leukoplakia


What causes oral leukoplakia?

Actinic Cheilitis:• Premalignant change of the lower lip

vermilion from long-term or excessive exposure to UV solar radiation.

• Strong male predilection 10:1 (M:F)• Seldom occurs in patients <45 yrs

Actinic Cheilitis• The earliest

clinical changes include atrophy of the lower lip with blotchy pale areas.

• There is blurring of the interface between the vermilion and the skin


Actinic Cheilitis




Actinic Cheilitis

• As the lesion progresses, rough, scaly areas develop.

• Chronic focal ulcers may develop and last for months.


Lip Cancer


Oral Submucous Fibrosis• Chronic, irreversible disease

associated with the use of betel nut, quid, nass, paan and other substances commonly used in India and other South-Central Asian countries

• Early signs include blanching of the mucosa

• Trismus• About 7% malignant

transformation rateChung CH et al. Oral precancerous disorders associated with areca quid chewing, smoking, and alcohol drinking in southern Taiwan. J Oral Pathol Med. 2005 Sep;34(8):460-6.

Blanching of the Mucosa




Trismus from Betel Nut Use


Trismus Patient With Oral Cancer


Advanced Oral Cancer in a Betel Nut User


Smokeless Tobacco Keratosis




Smokeless Tobacco• Smokeless tobacco keratosis has a much

smaller risk of developing cancer than oral leukoplakia that develops in tobacco smokers

• Smokeless tobacco keratosis is routinely reversible after habit cessation

Rodu B, Jansson C. Smokeless tobacco and oral cancer: a review of the risks and determinants. Crit Rev Oral Biol Med. 2004 Sep 1;15(5):252-63

In the last year uses 1½ cans of Skoal daily

27 M with a 10-year history of ST use


6 weeks after stopping ST use


• Cheek/tongue biting• Candidiasis• Lichen planus• Leukoedema• Nicotine stomatitis• Aspirin burn• Cinnamon reaction• Amalgam reaction

What is not oral leukoplakia?



Tongue Biting


Cheek Biting

Linea alba associated with pressure, friction, or sucking trauma seen along the occlusal plane


Cheek Biting

Chronic cheek chewing show thickened, shredded areas with zones or erythema or superficial ulcerations.


Lip Biting




Aspirin Burn


Oral Candidiasis


Nicotine Stomatitis


Oral Lichen Planus• Less common• Symptomatic• Atrophic erythematous areas with central

ulceration• Bordered by fine, white radiating striae




Lichen Planus

Is Lichen Planus a premalignant lesion?

• Controversial: Reported frequency of 0.4% to 5% over observation period of .5 to >20 years

• Most occur in sites of atrophic or erosive LP• In some reported cases, LP diagnosis made

only on clinical observation

The clinical manifestations and treatment of oral lichen planus. Dermatologic Clinics, 21: January 2003.

Oral Cancer in Patient with Erosive Lichen Planus


Erythroplakia

• A red patch that cannot be clinically diagnosed as any other condition.

• Must exclude other red lesions:mucositis drug reactioncandidiasis aphthaeherpes non-specific ulcerhemangioma pyogenic granuloma

Pyogenic Granuloma




Cinnamon Reaction


Aphthous Ulcer


Hemangioma


CandidiasisCandidiasis Presenting as Median Rhomboid Glossitis




Post-Treatment with Antifungal


Erythroplakia

• Usually asymptomatic, and appears as a well-demarcated, erythematous macule or plaque with a soft velvety texture.

• Almost all (90%) of erythroplakia exhibit high grade dysplasia, carcinoma-in-situ, or invasive carcinoma.

Erythroplakia

Carcinoma in situ


Erythroplakia

Carcinoma




Premalignant lesion that has both a leukoplakic (white), and erythroplakic (red) component.

Erythroleukoplakia


Head & Neck Cancer Stats• 650,000 patients worldwide are diagnosed with

head and neck cancer each year• 350,000 die from this disease• 90% are squamous cell carcinoma.• The two main causative factors in about 80% of

oral, oropharyngeal, and laryngeal carcinomas are smoking and alcohol use

• >20% are not related to smoking or drinking.

Warnakulasuriya S. Global epidemiology of oral and oropharyngealcancer. Oral Oncol. 2009 Apr-May;45(4-5):309-16.

Cancer Arising in Erythroplakia


Decreasing incidence

of oral cancer

since 1975

Seer.cancer.gov/statistics



Tongue

Seer.cancer.gov/statistics

Increasing incidence of tongue

cancer

Posterior Lateral Border of Tongue Cancer



Source: Dr. Susan Muller Source: Dr. Susan Muller




38 Woman with no Tobacco HX


25 Man with Tongue Cancer


15 Year Old Female Adolescent


What’s so special about the oral tongue?




Why?

….is the tongue becoming the most frequent site of OSCC?

….is the tongue the overwhelming site of OSCC in young patients?

Tongue

Oropharynx

Increasing tongue and

tonsil cancerSeer.cancer.gov/statistics

Oropharyngeal Carcinoma


• The incidence of oropharyngeal SCC has increased from 1973 to 2004 in the US

• We are seeing younger patients with OPSCC who have NEVER SMOKED

• Why? HPV

Eddie VanHalen Brett Butler



What is HPV?

• Genital warts• Laryngeal papillomas• Papillomas• Cervical cancer• Oropharyngeal cancer• Anogenital cancer

---------------------------------------------------------------------------

• Pain• Dysphagia• Otalgia• Neck mass• Foreign body

sensation• Hemoptysis• Weight loss• Voice changes

Oropharyngeal CancerSymptomatology




Asymmetry of Tonsils Oropharyngeal Cancer

Cancer arising at the base of tongue visualized by endoscopic examination


Oropharyngeal Carcinoma

Often the presenting symptom is a neck swelling or mass


PET Scan




HPV Positive Cancers • Younger patients (<60) • Arise from oropharynx -

lingual and palatine tonsils

• Poorly differentiated • Basaloid histopathology • Cystic metastases • Early T stage,

advanced N stage

• Unknown primary • Men > women • Improved survival • Associated with

sexual behavior and intensity of marijuana use, not tobacco or alcohol

Chaturvedi AK, et al. Human papillomavirus and rising oropharyngealcancer incidence in the United States. J Clin Oncol. 2011 Nov 10;29(32):4294-301

What to Look For During Screening

• White areas• Red areas• Sore areas• Pigmented

areas• Lump or

thickening of the soft tissues

What to Look For During Screening

• Difficulty chewing or swallowing, or the feeling that something is caught in the throat

• Ear pain• Difficulty in

moving the tongue or jaw




Oral-Systemic Health Education

for Non-Dental Healthcare Providers

Referral Form Step-by-Step Instructions on Performing a

H&N Exam



Suspicious Lesions

Final Thoughts

• At this time we cannot predict which benign leukoplakias will transform to cancer.

• Current research is underway to try and answer this dilemma.

• Current research is also being conducted to evaluate chemo-preventative agents in the treatment of leukoplakia.

• When in doubt about the malignant potential of an oral lesion – biopsy!


Travis Nelson DDS, MSD, MPH 1

Empowering Physicians, Nurses and other Non‐Dental Healthcare Providers to Screen Children and Adolescents for Oral Diseases

Travis Nelson, DDS, MSD, MPHClinical Assistant Professor

Department of Pediatric Dentistry University of Washington

Faculty/Presenter Disclosure

Travis Nelson has nothing to disclose

Feb. 7, 2014 Travis Nelson DDS, MSD, MPH2

Disclosure of Commercial Support

• This program has not received financial support from a commercial entity.

• This program has not received in-kind support from a commercial entity.

Feb. 7, 2014 Travis Nelson DDS, MSD, MPH3

What about her teeth?

Source: Dr. Travis Nelson



57% of Canadian children aged 6-11 have had tooth decay

Health Canada. Summary report on the findings of the oral health component of the Canadian Health Measures Survey. No., May, 2010Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 5

The prevalence of decay exceeds 90% in some indigenous Canadian communities.


But you can just fill the cavities, right?


Not when the teeth look like this.

Source: Dr. Travis NelsonFeb. 7, 2014 Travis Nelson DDS, MSD, MPH 8



And…would she sit still for a shot and a half-hour of drilling….4 times?


So we end up here.


The first dental visit: Whose responsibility is it?

First Screening by First Birthday

• American Academy of Pediatrics (AAP)

• American Academy of Family Physicians

(AAFP)

• American Academy of Pediatric Dentistry

(AAPD)

…. by dentist or medical provider?



Healthy Primary Teeth

Source: Dr. Travis Nelson Source: Dr. Travis Nelson




Spaces are OK




White Spot Lesions


White spot caries lesions typically form at the gum line


Not the edge of the incisor

Cavitated Lesions


As the cavities increase in size the teeth become fragile.Cavitated Lesions




Make sure to check the posterior aspects of the teeth.


Parulis


Localized Abscess


Cellulitis can form rapidly




How do you do the oral exam?


Let’s be honest…you don’t have time for this

So you need to leverage your:

• Position• Team• Existing messages

Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 26

1. Risk Assessment2. Bacterial Transmission3. Fluoride4. Diet5. Referral


Caries Risk Assessment

Caries vs Cavities(A Disease Process) (A Hole)




Risk Factors

Fisher-Owens et al.

Which are the strongest predictors of caries?

Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health 2004;21:71-85

Socioeconomic Status

Poor Diet

Previous Caries Experience

Bacterial Transmission from Mother to Infant

Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatr Dent 2006;28:106-109; discussion 192-108.



Mutans Streptococci

www.saishika.jpFeb. 7, 2014 Travis Nelson DDS, MSD, MPH 33

The Window of Infectivity

Decrease Bacterial Load


Systemic Fluoride



Fluoride Sources

Nelson, T.M. The Key to Caries Prevention. Dimensions of Dental Hygiene. July 2011; 9(7): 48-50, 52-53.

0

5,000

10,000

15,000

20,000

25,000

H2O Rinses Toothpaste PrescriptionToothpaste

Varnish

Fluoride Parts/Million

How good is OTC

toothpaste?

Brushing reduced decay by over 50%

How good is fluoride varnish?Up to 46% Caries reduction

Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. In: Cochrane Database Syst Rev, England, 2002.

Obesity



Dental Caries

15.6%

Percent of children ages 6-19 years with untreated dental caries

2007-2010 CDC Oral Health Facts

The foods you already recommend are great for teeth!

Photo Credit: Walmart Corporate


Frequency

WA State ABCD program

Normal Meals vs. Snacking/Grazing

Benefits of Breastfeeding



What the AAP Recommends:

• Exclusive breastfeeding for about the first six months of a baby's life…

• followed by breastfeeding in combination with the introduction of complementary foods until at least 12 months of age…

• and continuation of breastfeeding for as long as mutually desired by mother and baby.

Breastfeeding and the use of human milk. Pediatrics. 2012 Mar; 129(3):e827-41.

As teeth erupt frequent feeding can increase risk for decay


Snacking Smartly Front of Referral Form Reverse Side of Referral Form



The Impact of a Referral

Milgrom P, Ludwig S, Shirtcliff , RM, Smolen D, Sutherland M, Gates PA, Weinstein P. Providing a dental home for pregnant women: a community program to address dental care access. J Public Health Dent. 2008 Summer; 68 (3) : 170-3

Smile Survey 2010, The Health of Washington’s Children

• The rate of untreated decay in low-income WA preschoolers was cut in half from 2005 to 2010

• Projected treatment costs avoided are $525/child based on average Medicaid restoration costs

Into the Mouths of Babes: North Carolina’s Program

• Children enrolled in the program have fewer caries-related treatments

• Children with four or greater IMB visits experienced, on average, a 17% reduction in dental-caries-related treatments

• The IMB program is effective in reducing oral health related costs

Pahal BT, Rozier RG, Stearns SC, Quinonez RB. Effectiveness of preventive dental treatments by physicians for young medicaid enrollees. Pediatrics 2011; 127:e632-89.

Checklists

1. Risk Assessment2. Bacterial Transmission3. Fluoride4. Diet5. Referral




Caries Risk Assessment

Caries vs Cavities(A Disease Process) (A Hole)


Bacterial Transmission

Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatr Dent 2006;28:106-109; discussion 192-108.

Fluoride

Thank You!

[email protected]


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