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Dr David Murchison

Commentary—Screening Aids for Oral Squamous Cell Carcinoma: Are They Really Aids?

1/12/2018 David F. Murchison, DDS, MMS, Clinical Professor, Department of Biological Sciences, The University of Texas at Dallas; Adjunct Professor, Department of Diagnostic Sciences, Texas A&M University College of Dentistry

In addition to evaluating patients for infectious, inflammatory, or developmental disorders, part of a comprehensive dental/oral examination focuses on detecting potential malignant lesions of the oral cavity. The Journal of the American Dental Association recently published an evidenced-based systematic review by an expert panel updating screening recommendations for oral squamous cell carcinoma. 2  The report particularly addresses newer adjunctive screening aids that are increasingly being marketed to primary care physicians and dentists to identify malignant oral lesions.

The panel reviewed published literature on outcomes to determine the accuracy of these tests and devices and evaluate the risk and benefits of screening, including clinical outcome and patient peace-of-mind, versus the risks of potential false-positive results (eg, unnecessary worry, unnecessary intervention). 1, 2   Oral lesions present on the lateral border of the tongue were pointedly specified in the article as high risk for oral squamous cell carcinomas (non-human papilloma virus-related). 2

Current commercially available adjuncts typically involve one of the following

  • Autofluorescence: Examination using a blue light that may induce fluorescence in potentially malignant tissue
  • Tissue reflectance: Examination using a blue-white LED light after rinsing the mouth with a mild acetic acid solution to enhance lesion visibility
  • Cytologic tests: Conventional cytology done via swabbing or transepithelial brush harvest of  specimens from suspicious lesions
  • Salivary tests: Tests on oral swish samples for DNA and other biomarkers possibly suggestive of malignancy

The visualization tests may be done with or without vital staining (application of a dye such as toluidine blue).

The overall take away from the expert panel is that there is insufficient evidence that the commercially available adjunctive devices based on the above methodologies improve the detection of potentially malignant lesions beyond that of a conventional visual and tactile examination. Salivary tests were of such low sensitivity and specificity that the panel advised use only in a research setting. Furthermore, there was insufficient evidence that these devices improved patient compliance or aided patient education. 1

The panel recommended that patients with no visible or palpable lesions on standard examination have no screening tests. Those with visible lesions that appear malignant or suspicious for malignancy should be referred for biopsy. Visible lesions that appear innocuous should be followed and biopsied if they progress or persist. The exceptions to this recommendation are few but include possibly doing cytology on selected patients, 2 including those who

  • Decline a biopsy
  • Live in rural areas with limited access to care

The previous guideline had included cytology for treatment planning if patients were medically compromised and unable to withstand surgical procedures, or had physical or intellectual disabilities. 1

Until new technologies improve the effectiveness of early detection for oral cancers, thorough visual and tactile oral examination, comprehensive medical history review for risk factors for oral cancers (eg, tobacco use, heavy alcohol consumption, previous respiratory or upper digestive tract cancer, increasing age, some inherited diseases) continue to be the recommendation. 1,,2  The panel concluded that no available adjuncts demonstrated sufficient diagnostic test accuracy to support their routine use as triage tools during the evaluation of lesions in the oral cavity. The gold standard for suspicious lesions remains timely surgical biopsy with subsequent histopathological examination.

References

  1. Rethman MP, Carpenter W, Cohen EEW, et al:  Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. JADA 141(5):509–520, 2010.
  2. Lingen MW, Abt E, Agrawal N, et al: Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity. JADA 148(10):712–727, 2017.
Dr David Murchison

Commentary—Screening Aids for Oral Squamous Cell Carcinoma: Are They Really Aids?

1/12/2018 David F. Murchison, DDS, MMS, Clinical Professor, Department of Biological Sciences, The University of Texas at Dallas; Adjunct Professor, Department of Diagnostic Sciences, Texas A&M University College of Dentistry

In addition to evaluating patients for infectious, inflammatory, or developmental disorders, part of a comprehensive dental/oral examination focuses on detecting potential malignant lesions of the oral cavity. The Journal of the American Dental Association recently published an evidenced-based systematic review by an expert panel updating screening recommendations for oral squamous cell carcinoma. 2  The report particularly addresses newer adjunctive screening aids that are increasingly being marketed to primary care physicians and dentists to identify malignant oral lesions.

The panel reviewed published literature on outcomes to determine the accuracy of these tests and devices and evaluate the risk and benefits of screening, including clinical outcome and patient peace-of-mind, versus the risks of potential false-positive results (eg, unnecessary worry, unnecessary intervention). 1, 2   Oral lesions present on the lateral border of the tongue were pointedly specified in the article as high risk for oral squamous cell carcinomas (non-human papilloma virus-related). 2

Current commercially available adjuncts typically involve one of the following

  • Autofluorescence: Examination using a blue light that may induce fluorescence in potentially malignant tissue
  • Tissue reflectance: Examination using a blue-white LED light after rinsing the mouth with a mild acetic acid solution to enhance lesion visibility
  • Cytologic tests: Conventional cytology done via swabbing or transepithelial brush harvest of  specimens from suspicious lesions
  • Salivary tests: Tests on oral swish samples for DNA and other biomarkers possibly suggestive of malignancy

The visualization tests may be done with or without vital staining (application of a dye such as toluidine blue).

The overall take away from the expert panel is that there is insufficient evidence that the commercially available adjunctive devices based on the above methodologies improve the detection of potentially malignant lesions beyond that of a conventional visual and tactile examination. Salivary tests were of such low sensitivity and specificity that the panel advised use only in a research setting. Furthermore, there was insufficient evidence that these devices improved patient compliance or aided patient education. 1

The panel recommended that patients with no visible or palpable lesions on standard examination have no screening tests. Those with visible lesions that appear malignant or suspicious for malignancy should be referred for biopsy. Visible lesions that appear innocuous should be followed and biopsied if they progress or persist. The exceptions to this recommendation are few but include possibly doing cytology on selected patients, 2 including those who

  • Decline a biopsy
  • Live in rural areas with limited access to care

The previous guideline had included cytology for treatment planning if patients were medically compromised and unable to withstand surgical procedures, or had physical or intellectual disabilities. 1

Until new technologies improve the effectiveness of early detection for oral cancers, thorough visual and tactile oral examination, comprehensive medical history review for risk factors for oral cancers (eg, tobacco use, heavy alcohol consumption, previous respiratory or upper digestive tract cancer, increasing age, some inherited diseases) continue to be the recommendation. 1,,2  The panel concluded that no available adjuncts demonstrated sufficient diagnostic test accuracy to support their routine use as triage tools during the evaluation of lesions in the oral cavity. The gold standard for suspicious lesions remains timely surgical biopsy with subsequent histopathological examination.

References

  1. Rethman MP, Carpenter W, Cohen EEW, et al:  Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. JADA 141(5):509–520, 2010.
  2. Lingen MW, Abt E, Agrawal N, et al: Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity. JADA 148(10):712–727, 2017.