Signs & Symptom
Figure 1. VELscope examination. The
clinician shines the blue excitation light into the
patients oral cavity and looks through the Handpiece.
Figure 2. Illustration of VELscopes
principle of operation.
Figure 3. Representative examples of
direct visualization under both white light and VELscope
examination - photos courtesy of the British Columbia
Oral Cancer Prevention Program.
No apparent lesion
Normal fluorescence pattern
Irregular, dark area visible
under fluorescence visualization. Biopsy-confirmed
Irregular, dark area visible
under fluorescence visualization. Biopsy-confirmed
Carcinoma in Situ (CIS)
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Every hour of every day in America
someone dies of Oral Cancer. Oral Cancer is the sixth
most common diagnosed form of cancer in the United States.
Presently 30,000 patients are diagnosed annually with
oral cancer. The 5-year survival rate is only 50%, accounting
for 8,000 deaths each year. Oral Cancer risk factors
include tobacco use, frequent and/or excessive alcohol
consumption, a compromised immune system, past history
of cancer, and the presence of the HPV virus. Recently
however 25% of all newly diagnosed cases have been in
patients under the age of forty with none of the known
risk factors. Oral Cancer is one of the few cancers
whose survival rate has not improved in the past 50
years. This is due primarily to the fact that during
this time we have not changed the way we screen for
this disease (a visual and manual examination of the
oral cavity, head, and neck).
Oral Squamous Cell Carcinomas (OSCC)
make up over 90% of all oral cancers, and because of
its appearance it has been difficult to differentiate
from the other relatively benign lesions of the oral
cavity. Early OSCC and potentially malignant lesions
can appear as a white patch (leukoplakia, or as a reddened
area (erythroplakia), or as a red and white (erythroleukoplakia)
mucosal change under standard white light examination.
However, these cellular changes are often non-detectable
to the human eye (even with magnification eyewear) under
standard lighting conditions. Often, when the lesion
becomes visible, it has advanced to invasive stages.
The high mortality rate is directly related to the lack
of early detection of potentially malignant lesions.
When diagnosis and treatment are performed at or before
a Stage 1 carcinoma level, the survival rate is more
The cancers which have seen a major
decline in the mortality rate have included colon, cervical,
and prostate cancer and the primary reason is early
detection and screening.
We can make a difference in the oral
cancer mortality rate.
Early screening, diagnosis, and
treatment planning saves lives.
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Understanding the causative factors
of cancer will contribute to prevention of the disease.
Age is frequently named as a risk factor for oral cancer,
as most of the time it occurs in those over the age
of 40. The age of diagnosed patients may indicate a
time component in the biochemical or biophysical processes
of aging cells that allows malignant transformation,
or perhaps, immune system competence diminishes with
age. However, it is likely that the accumulative damage
from other factors, such as tobacco use, are the real
culprits. It may take several decades of smoking for
instance, to precipitate the development of a cancer.
Having said that, tobacco use in all its forms is number
one on the list of risk factors. At least 75% of those
diagnosed are tobacco users. When you combine tobacco
with heavy use of alcohol, your risk is significantly
increased, as the two act synergistically.Those who
both smoke and drink, have a 15 times greater risk of
developing oral cancer than others.
Tobacco and alcohol are essentially
chemical factors, but they can also be considered lifestyle
factors, since we have some control over them. Besides
these, there are physical factors such as exposure to
ultraviolet radiation. This is a causative agent in
cancers of the lip, as well as other skin cancers. Cancer
of the lip is one oral cancer whose numbers have declined
in the last few decades. This is likely due to the increased
awareness of the damaging effects of prolonged exposure
to sunlight, and the use of sunscreens for protection.
Another physical factor is exposure to x-rays. Radiographs
regularly taken during examinations, and at the dental
office, are safe, but remember that radiation exposure
is accumulative over a lifetime. It has been implicated
in several head and neck cancers.
Biological factors include viruses
and fungi, which have been found in association with
oral cancers. The human papilloma virus, particularly
HPV16 and 18, have been implicated in some oral cancers.
HPV is a common, sexually transmitted virus, which infects
about 40 million Americans. There are about 80 strains
of HPV, most thought to be harmless. But 1% of those
infected, have the HPV16 strain which is a causative
agent in cervical cancer, and now is linked to oral
cancer as well. There are other risk factors which have
been associated with oral cancers, but have not yet
been definitively shown to participate in their development.
These include lichen planus, an inflammatory disease
of the oral soft tissues.
There are studies which indicate a
diet low in fruits and vegetables could be a risk factor,
and that conversely, one high in these foods may have
a protective value against many types of cancer.
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Signs & Symptoms
One of the real dangers of this cancer,
is that in its early stages, it can go unnoticed. It
can be painless, and little in the way of physical changes
may be obvious. The good news is however, that your
dentist or doctor can see or feel the precursor tissue
changes, or the actual cancer while it is still very
small, or in its earliest stages. It may appear as a
white or red patch of tissue in the mouth, or a small
indurated ulcer which looks like a common canker sore.
Because there are so many benign tissue changes that
occur normally in your mouth, and some things as simple
as a bite on the inside of your cheek may mimic the
look of a dangerous tissue change, it is important to
have any sore or discolored area of your mouth, which
does not heal within 14 days, looked at by a professional.
Other symptoms include; a lump or mass which can be
felt inside the mouth or neck, pain or difficulty in
swallowing, speaking, or chewing, any wart like masses,
hoarseness which! lasts for a long time, or any numbness
in the oral/facial region. Other than the lips, the
most common areas for oral cancer to develop are on
the tongue and the floor of the mouth. Individuals that
use chewing tobacco, are likely to have them develop
in the sulcus between the lip or cheek and the soft
tissue (gingiva) covering the lower jaw (mandible).
In the US, cancers of the hard palate are uncommon,
though not unknown. The base of the tongue at the back
of the mouth, and on the pillars of the tonsils, are
other sites where it is commonly found. If your dentist
or doctor decides that an area is suspicious, the only
way to know for sure is to do a biopsy of the area.
This is not painful, is inexpensive, and takes little
time. It is important to have a firm diagnosis as early
as possible. It is possible that your general dentist
or medical doctor, may refer you to a specialist to
have the biopsy performed. This is not cause for alarm,
but a normal part of referring that happens ! between
doctors of different specialties.
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Historically, it has been difficult
to determine which abnormal tissues in the mouth are
worthy of concern. The fact is, the average person routinely
has conditions existing in their mouths that mimic the
appearance of pre-cancerous changes, and very early
cancers of the soft tissues. One study determined that
the average dentist sees 3-5 patients a day who exhibit
soft tissue abnormalities, most of which are benign
in nature. Even the simplest things, such as a canker
sore (herpes simplex), the wound left by accidentally
biting the inside of your cheek, or sore spots from
a poorly fitting prosthetic appliance or denture, all
at first examination, share similarities with dangerous
lesions. Some of these conditions cause physical discomfort,
others are painless. The question is which ones deserve
action, and which ones bear watching and waiting?
There has been a tendency to watch
these areas over an extended period to determine if
they are dangerous or not. Unfortunately, this philosophy
leads to a situation in which a dangerous lesion may
continue to prosper and grow into a later stage, hard
to cure cancer. Any sore, discoloration, induration,
prominent tissue, irritation, hoarseness, which does
not resolve within a two week period on its own,
with or without treatment, should be considered suspect
and worthy of further examination or referral. Besides
a routine visit to the dental office for regular examinations,
it is the patient's responsibility to be aware of changes
in their oral environment. When these changes occur,
they need to be brought to the attention of a qualified
dental professional for examination. The dental professional
needs to be current in the knowledge base necessary
to make a proper diagnosis, and be competent in the
proper screening procedures to identify oral cancer.
How to know if you have had a proper
oral cancer screening
There are two separate issues, discovery
and diagnosis. Discovery is the result of a thorough
visual and manual examination. A protocol for a comprehensive
oral cancer screening appears elsewhere in this section
of the web site. It includes a systematic visual examination
of all the soft tissues of the mouth, including manual
extension of the tongue to examine its base, a bi-manual
palpation of the floor of the mouth, and a digital examination
of the borders of the tongue, and the lymph nodes surrounding
the oral cavity and in the neck. New diagnostic aids,
including lights, dyes, and other techniques are beginning
to appear on the marketplace. While making the discovery
process more effective, it is still possible to do a
comprehensive examination through a proper visual and
Once suspect tissues have been detected,
the only way a definitive diagnosis of oral cancer may
be made is through biopsy. Given the large number of
tissue abnormalities a dentist sees every day, it is
not logical, nor practical, that each one of these be
biopsied. The first question which may help in the determination
of which abnormality bears closer examination, is how
long has the suspect condition been present? Any condition
that has existed for 14 days or more without resolution
should be considered suspect and worthy of further diagnostic
procedures or referral. Certainly, it is common knowledge
that two of the most prevalent lesions that mimic oral
cancer, are the herpes simplex ulceration, and aphthous
ulcerations, each resolving of their own accord in approximately
10-14 days. Perhaps that sentence should be underlined,
since one of the most common diagnoses received with
referred patients to a major university cancer pathology
department is "an atypical herpeti! c/aphth ous
lesion" These all too frequently turn out to be
squamous cell carcinomas, which have been under observation....
for several months.
Still, it would seem impractical at
these early timelines to engage in biopsy. A oral biopsy
brush is available that makes this decision to get an
early diagnosis through biopsy easier to make. Simple,
painless, and accurate diagnosis of soft tissue abnormalities
can be obtained through its use.
Note that this system is not designed
to provide the kind of information, specifically cellular
architecture, that would be obtained through a punch
or incisional biopsy. But it will provide an answer
to the question of whether malignancy exists or not,
through a quick, minimally invasive, and inexpensive
procedure. Should positive results be returned through
this system, the brush biopsy must be followed by a
conventional biopsy procedure for confirmation. The
strong argument for the brush biopsy is that it eliminates
the waiting and watching of a suspicious lesion, while
it develops from a highly treatable and curable, early
stage localized cancer, into a life threatening late
stage malignancy. Positive identification of oral cancers
at the earliest stages, result in the best prognosis
for cure and long-term survivability.
Creating awareness, discovery, diagnosis,
and referral. When it comes to oral cancer and saving
lives, these are the primary responsibilities of the
dental community. The most important step in reducing
the death rate from oral cancer is early discovery.
No group has a better opportunity to have an impact
than members of the dental community.
An important message about oral cancer from the
American Dental Association
Now precancerous cells can be detected-years before oral cancer can start. See your dentist regularly and ask about a brush test for oral spots.
What You Can Expect as Part of Your Routine Exam:
- Your dentist and hygienist look for spots in your mouth.
- If a spot is observed, your dentist may recommend further testing.
- A brush test sample is then sent for computer-assisted laboratory analysis.
- Even if a lab identifies abnormal cells, they can typically be removed-years before they can harm you.
If a brush test finds unhealthy cells, they can typically be removed, years before they can penetrate the basement membrane and become oral cancer.
What you should know:
- Most People Will Have tiny white or red spots in their mouth at one time or another.
- See your Dentist Regularly for a thorough oral exam. Although the vast majority of these spots do not contain unhealthy cells, your dentist may recommend further testing.
- Even If A Lab Identifies abnormal cells, they can then typically be removed-years before they can harm you.
For more information please visit www.ada.org
ADA American Dental Association
America's leading advocate for oral health
The OralCDx brand of brush test is an adjunct to the professional oral examination in the early detection of oral precancer. This test is not a substitute for a scalpel biopsy which should continue to be utilized to evaluate suspicious oral lesions. The ADA has no financial interest in this product. This brochure is part of an educational programs supported by a grant from Oral Cancer Prevention International, Inc, provider of the ORalCDx brand of brush test. For more information please visit www.ada.org
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