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Oral Cancer Screening
Poster Title: Oral Cancer Screening
Submitted on 29 Feb 2020
Author(s): Dr.Esraa Mostafa Fouad, Associate professor Dr. Shaimaa Omar zayed
Affiliations: Master Degree student at oral and maxillofacial pathology Cairo University, Associate professor at oral and maxillofacial pathology Department Cairo University
This poster was presented at 2nd annual oral and maxillofacial pathology scientific day, Cairo University
Poster Views: 665
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Poster Information
Abstract:  Rationale:
American Cancer Society for 2020 predicts about 53,260 new cases of oral cancer and estimates about 10,750 mortal cases.(1)Head and Neck Cancers accounts 5% of all Tumors and about 50% of head and neck Tumors occur specifically in the oral cavity.(2)Survival rate of oral cancer mainly depends on the stage of cancer that have been diagnosed at.The early detection of oral cancer will enhance the Treatment, survival rate and quality of life.Screening is the process of evaluating asymptomatic patients if they have potentially malignant or malignant lesion. Oral cancer screening is composed of 4 steps Visual examination, Selection of the area for biopsy, Cytological or Histological biopsy, Analysis of the exfoliated cells. Nowadays there is many oral cancer screening methods that should be investigated to have the most accurate and precise one to get a definite efficient clinical routinely examination for oral cancer.
The aim of this poster is to have a clear organized map for oral cancer screening clinical steps with recommendations for research gaps.
 Oral Cancer Screening Map:
I. Tissue investigation:
1. Visual examination(3)
• Palpation and Visual inspection
 Mandible chin and jaw bones
 Temporomandibular joint (TMJ jaw hinge)
 Larynx (voice box moves with swallowing)
 Anterior auricular lymph node (Infront of ears)
 Posterior auricular lymph node (behind ears)
 Occipital lymph node (back of the neck)
 Parotid gland (salivary gland mid of cheeks)
 Submental lymph node
 Submandibular lymph node
 Sternocleidomastoid muscle (large muscle side of neck)
 Thyroid gland (butterfly shaped gland in the neck)
 Supra clavicular lymph node (next to collar bone, related to breast tissue)
 Lip inside and outside
 Labial mucosa and frenum (soft tissue inside lip)
 Alveolar ridges (Gum & bone top and bottom)
 Parotid gland duct or small opening mid cheek)
 Retromolar pads on bottom gum tissue behind 2nd or 3rd molar
 Maxillary tuberosity on top gum tissue behind 2nd and 3rd molar
 Floor of the mouth, underside of tongue tissues ducts and muscle under tongue
 Submandibular and submental gland under chin and tongue.
 Lateral and base of tongue sides and back of tongue (Pull the tongue forward to evaluate it)
 Tongue
 Hard and soft palate (roof of mouth)
 Uvula anterior and posterior pillars back of throat
 Palatine tonsils and posterior wall of the pharynx (back of throat)

2. Selection of the area(4)
• Tissue (Vital) stains
 Toluidine blue stain (TB)
 Methylene blue stain (MB)
 Lugol’s iodine stain
 Rose Bengal stain
• Light Based Aids (LBA)
 Tissue fluorescence imaging (VELscope, Identafi 3000, OralID, Bio/Screen, Dental Oral Examination (DOE) Dentlight Kit(24))
 Tissue reflectance chemiluminescence (Microlux/DL, Orascoptic DK, Vizilite plus)

3. Diagnosing the area selected
• Cytological techniques
 Oral brush biopsy (Oral CDx)
• Histological techniques
 Incisional biopsy
 Excisional biopsy

4. Analysis of the exfoliated cells or incisional biopsy
• Oral brush with computer-based analysis
• Laser captured microdissection
• Imaging techniques
 PET Scan(4)
 Fibro-optic fluorescence microscope(2)
 High resolution micro-endoscope (HRME)(6)
• Molecular Analysis(4,5)
 Gene alteration (DNA Analysis)
 Epigenetic alteration
 Viral genome
 Biomarkers
 Tumor markers
 Proliferation index & AgNoR
II. Fluid investigation:
• Saliva based oral cancer diagnosis

 Oral Cancer Screening Methods:
1. Toluidine Blue Stain (TB)
• Other Names: (7)Tolonium chloride (Ora Test)
• 1st Discussed By: (7) Abbott Laboratories
• Year: (7)1949
• Structure: (8)
o 1gm Toluidine blue powder
o 10ml of 1% Acetic acid
o 4.19ml absolute alcohol
o 86ml distilled water
o PH: 4.5
• Mechanismit is a vital dye that stain Nucleic Acid
• Technique(9)
o Rinse Twice with water (20sec each)
o Rinse with 1% Acetic Acid
o Dry the area gently with gauze
o Apply toluidine blue on cotton swab
o Rinse again with Acetic acid and then with water
• Interpretation(7)
o (+ve) Suspicious malignancy = Dark Blue
o (+ve) Premalignant Lesion = Light Blue
o (-ve) No Stain retained
2. Methylene Blue Stain (MB)
• Other Names: Methylthioninium chloride
• 1st Discussed By: Paul Ehrlich
• Year: 1887
• Structure:
MB system had 2 bottles
o Bottle A: Dye rinse solution(1% methylene blue + 1% Malachite + 0.5% eosin+ Glycerol+ Dimethyl Sulfoxide)
o Bottle B: Pre & Post rinse solution (1% Lactic acid and Purified water(10) or 1% Acetic acid and Purified water(11))
• Mechanism: ithas the ability to stain Acidic parts of the cell ex. DNA
• Technique:(12)
o Rinse with 1% Lactic Acid & Distilled water (Bottle B) (30sec.)
o Dry the area gently with gauze and power air to ensure no saliva contamination.
o Apply the dye (Bottle A) by cotton bud or rinse for (30sec.) then expectorate.
o Rinse again with 1% Lactic Acid & Distilled water (Bottle B) (30sec.)
• Interpretation:
o (+ve) Deep Blue stain
o (-ve) Wide, Shallow, Faint blue stain.
3. Lugol’s Iodine Stain
• Other Names: (13)
o Iodine-Potassium Iodide (I2KI)
o Strong Lugol’s Solution
o Markodine
o Aqueous Iodine Solution
• 1st Discussed By: (7)French Physician “Jean Lugol”Till the end of 19th century it was used as Antiseptic.
• Year: (7)1829
• Structure: (7)
5gm Iodine (I2) + 10gm Potassium Iodide + 100ml Distilled water
• Mechanism: (7)
o It stains Glycogen containing Squamous epithelium where
o Strongly stained with iodine = fully differentiated i.e: well differentiated= Keratinized surface = high Glycogen = “+ve response”
o Failed to stain = immature metaplastic squamous epithelium i.e: undifferentiated = No Keratin formation = No Glycogen = “-ve response”
o It is restricted for diagnosis of Oral Non-Keratinized Mucosa (Buccal, Vestibular, Ventral Surface of the Tongue, Floor of the Mouth.
• Technique: (14)
o Rinse with water &dry with air
o Surrounding the area with 20ml of 10% Lugol’s Iodine Solution with Cotton buds (let it in contact for 2mins)
o Rinse with water again
• Interpretation
o (+ve) doesnot stain or pale (Dysplastic tissue)
o (-ve) Brown color(Normal Tissue)

4. Rose Bengal Stain
• Other Names: (15)4,5,6,7,Tetrachloro-2,4,5,7,TetraIodo derivate of Fluorescein. Rose (Flower) Bengal (Region)
• 1stPrepared by: Ghnem
• Year: 1882
• Structure: (15)1% Rose Bengal Stain
• Mechanism: (16)it stains the desquamated ocular epithelial cells, dead cells, or degenerated cells.
• Technique(15)
o Rinse with distilled water (1min)
o Apply 1% RosenBengal Solution with cotton
o Rinse with distilled water (1-2mins)

• Interpretation(15)
o The intensity of staining was matched with shade guide using Adobe Photoshop CS3
o Grade I= Hyperkeratosis
o Grade II= Mild Dysplasia
o Grade III = Moderate dysplasia
o Grade IV = Severe Dysplasia.

5. ViziLite & ViziLitePlus
• Other Names: Chemiluminescence
• 1stApproved By: FDA
• Year: ViziLite (2002), ViziLitePlus (2004)
• Structure: (17)
o Vizilite: it composed of disposable capsule formed of outer shell of flexible plastic containing Acetyl Salicylic Acid and an inner glass vial containing Hydrogen Peroxide. Where Bent to mix the content together producing bluish-white light with Wave length (λ)(430-580nm) last for 10mins.
o Vizilite Plus: it consists of combination of Chemiluminescence and Toluidine blue that selectively stain acidic substances such as DNA.
• Mechanism:(18)
o The technique referred to Magnified Chemiluminescence Visual examination (MCE)
o As the emission of light with limited emission of heat (Luminescence) as a result of chemical reaction.
o Chemiluminescence has two types (Luminol based & Peroxy-Oxalate Based)
o Vizilite is Peroxy-Oxalate Based
• Technique:
o Rinse with 1% Acetic Acid for (1min)
o Followed by examination of oral cavity by Light (430-580nm) λ
• Interpretation
• Normal Mucosa will absorb the light while the dysplastic cells will reflect it cause scattering.

6. Microlux/DL(17)
• Other Names: chemiluminescence
• 1stApproved By:FDA
• Year: 2005
• Structure: This device diffused blue white LED Light source and a fiber optic light guide.
• Mechanism: Same Principle as ViziLite
• Technique:
o Rinse with 1% Acetic Acid
o Oral examination with Light (460-555nm) Wave length (λ)
• Interpretation
Dysplastic tissue appears white

7. VELscope
• Other Names: -
• 1stApproved By: FDA
• Year: 2006
• Structure: (17)
It uses 120W Lamp and a series of philters & reflectors producing light with Wave length (λ) (400-600nm)
• Mechanism:(19)
o The light emitted reaches oral mucosa and excites endogenous Autofluorescence substance called “Flurophores”
o It uses blue light with a special λ that Penetrates the epithelial layer and basal layer reaching the stroma.
• Technique:
o Rinse with 1% Acetic Acid
o Oral examination with Light (400-600nm) Wave length (λ)
• Interpretation: (19)
o Normal tissue gives the fluorescent blue color (Autofluorescence)
o Abnormal dysplastic tissue gives Dark Green reaching Black

8. Identafi 3000(17,20)
• Other Names: TRIMIRA
• 1stApproved By: FDA
• Year: 2009
• Structure:
o It is a probe like device.
o It has 3 light sources of different Wave lengths (λ): white, Violet (405nm), Green-amber (545nm).
• Mechanism:
o White: provides classical visual examination
o Violet: excites endogen fluorophores enabling assessment of mucosa by Autofluorescence. Like (VELscope)
o Green amber: Through the reflectance spectroscopy excites hemoglobin molecules in the blood with the aim to visualize the vasculature.
• Technique:
o Rinse with 1% Acetic Acid
o Oral examination with one of the Different LightWave lengths (λ)
• Interpretation
By using Violet light
o Normal tissue gives the fluorescent blue color (Autofluorescence)
o Abnormal dysplastic tissue gives Dark Green reaching Black
By using Green amber light:
o Micro vascular parameters are examined by detecting the number of mucosal blood vessels
9. Orascoptic DK(21)
• Other Names: -
• 1stApproved by: FDA
• Year: 2005
• Structure:
It composed of LED Light Source with transillumination instrument and lighted mirror instrument.
• Mechanism: same principle as Microlux/DL and ViziLite
• Technique:
o Rinse with 1% Acetic Acid for (60sec)
o Tissue illuminated by the Orascoptic Diagnostic Kit
• Interpretation
o Dysplastic Tissue appeared white in a dimly lighted room

10. Oral Brush Biopsy (Oral CDx)
• Other Names:Oral CDx
• 1stDeveloped At: 1999 to investigate oral lesion suspicion for dysplasia or cancer
• The Oral CDx Kit composed of: (23)
o Stiff bristle brush
o Fixative (alcohol/ Polyethylene Glycol)
o Glass Slide
o Container for sending samples to Laboratory
• Technique:(22)
o After selection of the area
o The Brush placed on the area to be investigated rotate it in one spot until it produces hemorrhagic spot or reddening (This sample representing the whole epithelium thickness)
o The sample applied on the Glass slide fixed and sent to the Laboratory to be stained by Giemsa Azur eosin methylene blue solution, dried, covered with Entellan and coverslip.
o While in Liquid Based Cytology:After cell collection the Oracellex Brush fixation is carried out by separating the brush from the applicator and placing it in to fixation liquid in the collection Vial.
• Interpretation(23)
o The Analysis will be done by light microscope or by computed based imaging system (CBS).
o The CBS:
(-ve): without epithelial dysplasia.
(Atypical): uncertain diagnostic meaning.
(+ve): definite dysplastic features (carcinoma)
(Inadequate): Not enough specimen.

 Conclusion:
Randomized Clinical Trials with Proper Sample Size Testing the Sensitivity and Specificity for each Screening Method is strongly Recommended to reach a Confident Standard Guideline for Oral Cancer Screening.
Summary: The Aim of this poster is to have a Clear Organized Map for Oral Cancer Screening Clinical Steps.References: 1. American Cancer Society, Cancer Facts & Figures 2020,Atlanta, Ga.,Key Statistics for Oral Cavity and Oropharyngeal Cancers, 2020.
2. Clinical Policy Bulletins, Oral Screening and Lesion Identification systems Review, Aetna, 2019.
3. Danglas.L, Making oral cancer screening a routine part of your patient care, British Dental Association, 2015.
4. Torras.C, Escoda.C, Techniques for early diagnosis of oral squamous cell carcinoma: Systematic review, Med Oral Patol Oral Cir Bucal Journal, May ,2015.
5. Strome.A, Kossatz.S, Zanoni.D, Rajadhyaksha.M, Patel.S, Reiner.T, Current Practice and Emerging Molecular Imaging Technologies in Oral Cancer Screening, SAGE Publications, VoL.17, 2018.
6. Vila.P, Park.C, Piece.M, Goldstein.G, Levy.L, Gurudutt.V, Polydorides.A, Godbold.J, Teng.M, Genden.E, Miles.B, Anandasabapathy.S, Gillenwater.A, Kortum.R and Sikora.A, Discrimination of Benign and Neoplastic Mucosa with a High- Resolution Microendoscope (HRME) in Head and Neck Cancer,
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