SPEAKER HANDOUTS. Friday, February 7, 2014

Transcription

1 Friday, February 7, 2014 SPEAKER HANDOUTS Susan Müller, DMD, MS Empowering Physicians, Nurses and other Non-Dental Healthcare Providers in the Early Detection of Oral and Oropharyngeal Cancer Travis Nelson, DDS, MSD, MPH Empowering Physicians, Nurses and other Non-Dental Healthcare Providers to Screen Children and Adolescents for Oral Diseases

2 Empowering Physicians, Nurses and Other Non Dental Healthcare Providers in the Early Detection of Oral and Oropharyngeal Cancer Faculty/Presenter Disclosure Susan Müller has nothing to disclose Susan Müller, DMD, MS Professor Emeritus Department of Otolaryngology Emory University School of Medicine Disclosure of Commercial Support Goals This program has not received financial support from a commercial entity. This program has not received in-kind support from a commercial entity. Distinguish benign conditions from potentially premalignant or malignant oral lesions Susan Muller, DMD, MS 1

3 Goals Discuss clinical presentation, differential diagnosis of precancerous and cancerous lesions 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 Susan Muller, DMD, MS 2

4 What is oral leukoplakia? Sites of Oral Leukoplakia Leukoplakia is the most common oral precancer (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 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) Petersen PE Oral Cancer prevention and control-the approach of the World Health Organization. 45:454-60,2009; Oral Oncol. Müller S. Oral Precancer. In: Werning JW, eds. Oral Cancer. Diagnosis, Management, and Rehabilitation. New York: Thieme, 2007: Oral Leukoplakia What causes oral leukoplakia? cdc.gov Susan Muller, DMD, MS 3

5 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 Susan Muller, DMD, MS 4

6 As the lesion progresses, rough, scaly areas develop. Chronic focal ulcers may develop and last for months. Actinic Cheilitis 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 rate Chung CH et al. Oral precancerous disorders associated with areca quid chewing, smoking, and alcohol drinking in southern Taiwan. J Oral Pathol Med Sep;34(8): Blanching of the Mucosa Susan Muller, DMD, MS 5

7 Trismus from Betel Nut Use Trismus Patient With Oral Cancer Advanced Oral Cancer in a Betel Nut User Smokeless Tobacco Keratosis Susan Muller, DMD, MS 6

8 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 27 M with a 10-year history of ST use In the last year uses 1½ cans of Skoal daily Rodu B, Jansson C. Smokeless tobacco and oral cancer: a review of the risks and determinants. Crit Rev Oral Biol Med Sep 1;15(5): What is not oral leukoplakia? 6 weeks after stopping ST use Cheek/tongue biting Candidiasis Lichen planus Leukoedema Nicotine stomatitis Aspirin burn Cinnamon reaction Amalgam reaction Susan Muller, DMD, MS 7

9 Tongue Biting Cheek Biting Linea alba associated with pressure, friction, or sucking trauma seen along the occlusal plane Cheek Biting Lip Biting Chronic cheek chewing show thickened, shredded areas with zones or erythema or superficial ulcerations. Susan Muller, DMD, MS 8

10 Aspirin Burn Oral Candidiasis Nicotine Stomatitis Oral Lichen Planus Less common Symptomatic Atrophic erythematous areas with central ulceration Bordered by fine, white radiating striae Susan Muller, DMD, MS 9

11 Lichen Planus Is Lichen Planus a premalignant lesion? Oral Cancer in Patient with Erosive Lichen Planus 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 Erythroplakia Pyogenic Granuloma A red patch that cannot be clinically diagnosed as any other condition. Must exclude other red lesions: mucositis drug reaction candidiasis aphthae herpes non-specific ulcer hemangioma pyogenic granuloma Susan Muller, DMD, MS 10

12 Cinnamon Reaction Aphthous Ulcer Hemangioma Candidiasis Candidiasis Presenting as Median Rhomboid Glossitis Susan Muller, DMD, MS 11

13 Post-Treatment with Antifungal Erythroplakia Usually asymptomatic, and appears as a welldemarcated, 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 Erythroplakia Carcinoma in situ Carcinoma Susan Muller, DMD, MS 12

14 Erythroleukoplakia Head & Neck Cancer Stats Premalignant lesion that has both a leukoplakic (white), and erythroplakic (red) component. 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 oropharyngeal cancer. Oral Oncol Apr-May;45(4-5): Cancer Arising in Erythroplakia Decreasing incidence of oral cancer since 1975 Seer.cancer.gov/statistics Susan Muller, DMD, MS 13

15 Tongue Posterior Lateral Border of Tongue Cancer Increasing incidence of tongue cancer Seer.cancer.gov/statistics Posterior Lateral Border of Tongue Cancer Posterior Lateral Border of Tongue Cancer Susan Muller, DMD, MS 14

16 38 Woman with no Tobacco HX 25 Man with Tongue Cancer 15 Year Old Female Adolescent What s so special about the oral tongue? Susan Muller, DMD, MS 15

17 Why? Tongue.is the tongue becoming the most frequent site of OSCC?.is the tongue the overwhelming site of OSCC in young patients? Oropharynx Increasing tongue and tonsil cancer Seer.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 Susan Muller, DMD, MS 16

18 What is HPV? Genital warts Laryngeal papillomas Papillomas Cervical cancer Oropharyngeal cancer Anogenital cancer Oropharyngeal Cancer Symptomatology Pain Dysphagia Otalgia Neck mass Foreign body sensation Hemoptysis Weight loss Voice changes Susan Muller, DMD, MS 17

19 Asymmetry of Tonsils Oropharyngeal Cancer Cancer arising at the base of tongue visualized by endoscopic examination Oropharyngeal Carcinoma PET Scan Often the presenting symptom is a neck swelling or mass Susan Muller, DMD, MS 18

20 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 Chaturvedi AK, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol Nov 10;29(32): Unknown primary Men > women Improved survival Associated with sexual behavior and intensity of marijuana use, not tobacco or alcohol 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 Susan Muller, DMD, MS 19

21 Oral-Systemic Health Education for Non-Dental Healthcare Providers Referral Form Step-by-Step Instructions on Performing a H&N Exam Susan Muller, DMD, MS 20

22 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! Susan Muller, DMD, MS 21

23 Empowering Physicians, Nurses and other Non Dental Healthcare Providers to Screen Children and Adolescents for Oral Diseases Faculty/Presenter Disclosure Travis Nelson has nothing to disclose Travis Nelson, DDS, MSD, MPH Clinical Assistant Professor Department of Pediatric Dentistry University of Washington Feb. 7, Travis Nelson DDS, MSD, MPH Disclosure of Commercial Support What about her teeth? 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, Travis Nelson DDS, MSD, MPH Travis Nelson DDS, MSD, MPH 1

24 57% of Canadian children aged 6-11 have had tooth decay The prevalence of decay exceeds 90% in some indigenous Canadian communities. Health Canada. Summary report on the findings of the oral health Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 5 component of the Canadian Health Measures Survey. No., May, 2010 But you can just fill the cavities, right? Not when the teeth look like this. Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 8 Travis Nelson DDS, MSD, MPH 2

25 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? Travis Nelson DDS, MSD, MPH 3

26 Healthy Primary Teeth Healthy Primary Teeth Healthy Primary Teeth Spaces are OK Travis Nelson DDS, MSD, MPH 4

27 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 Travis Nelson DDS, MSD, MPH 5

28 Parulis Make sure to check the posterior aspects of the teeth. Localized Abscess Cellulitis can form rapidly Travis Nelson DDS, MSD, MPH 6

29 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 Caries Risk Assessment 1. Risk Assessment 2. Bacterial Transmission 3. Fluoride 4. Diet 5. Referral Caries vs Cavities (A Disease Process) (A Hole) Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 27 Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 28 Travis Nelson DDS, MSD, MPH 7

30 Risk Factors Fisher-Owens et al. Which are the strongest predictors of caries? Bacterial Transmission from Mother to Infant Socioeconomic Status Poor Diet Previous Caries Experience 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 Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatr Dent 2006;28: ; discussion Travis Nelson DDS, MSD, MPH 8

31 The Window of Infectivity Mutans Streptococci Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 33 Decrease Bacterial Load Systemic Fluoride Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 35 Travis Nelson DDS, MSD, MPH 9

32 25,000 20,000 Fluoride Sources Fluoride Parts/Million How good is OTC toothpaste? 15,000 10,000 5,000 0 H2O Rinses Toothpaste Prescription Toothpaste Varnish Brushing reduced decay by over 50% Nelson, T.M. The Key to Caries Prevention. Dimensions of Dental Hygiene. July 2011; 9(7): 48-50, How good is fluoride varnish? Up to 46% Caries reduction Obesity Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. In: Cochrane Database Syst Rev, England, Travis Nelson DDS, MSD, MPH 10

33 Dental Caries 15.6% The foods you already recommend are great for teeth! Percent of children ages 6-19 years with untreated dental caries CDC Oral Health Facts Photo Credit: Walmart Corporate Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 42 Frequency Benefits of Breastfeeding Normal Meals vs. Snacking/Grazing WA State ABCD program Travis Nelson DDS, MSD, MPH 11

34 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. As teeth erupt frequent feeding can increase risk for decay Breastfeeding and the use of human milk. Pediatrics Mar; 129(3):e Snacking Smartly Front of Referral Form Reverse Side of Referral Form Travis Nelson DDS, MSD, MPH 12

35 The Impact of a Referral 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 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 Summer; 68 (3) : Smile Survey 2010, The Health of Washington s Children 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 Checklists 1. Risk Assessment 2. Bacterial Transmission 3. Fluoride 4. Diet 5. Referral Pahal BT, Rozier RG, Stearns SC, Quinonez RB. Effectiveness of preventive dental treatments by physicians for young medicaid enrollees. Pediatrics 2011; 127:e Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 52 Travis Nelson DDS, MSD, MPH 13

36 Caries Risk Assessment Bacterial Transmission Caries vs Cavities (A Disease Process) (A Hole) Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 53 Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatr Dent 2006;28: ; discussion Fluoride Thank You! Feb. 7, 2014 Travis Nelson DDS, MSD, MPH 56 Travis Nelson DDS, MSD, MPH 14