Medical history sheets which include lifestyle questions and soft tissue assessment charts can save a lot of time for dentists. Mouth maps will help with soft tissue monitoring. It will also help to flag up patients who are ‘at risk’ as shown on their records.
  • History and physical examination. Includes risk factor analysis and exposure to carcinogens.
  • Head and neck examination: Direct visualization, mirror examination, manual palpation and toluidine blue staining.
  • Laboratory tests: CBC liver function.
  • Radiology: CT or MRI of head and neck, chest X-ray, dental films, bone scan when indicated.
  • Pathology: Incisional biopsy, excisional biopsy, fine needle aspiration biopsy, molecular markers, flow cytometry.
  • Panendoscopy: T- stage schematic tumour map, evaluate for second malignancies.
  • Pre-therapy consultation with: Radiation oncology, medical oncology, head and neck surgery, reconstructive surgery, dental oncology, speech pathology and psychosocial service.
  • Multidisciplinary Tumour Board: Finalize staging and formulate treatment plan.

Screening is the process by which practitioner evaluates an asymptomatic patient to determine if he or she is likely or unlikely to have a potentially malignant or malignant lesion. This can be done by a conventional oral examination.

Conventional/Routine Oral Examination

To ensure completeness, a soft tissue examination needs to follow a pattern. Work out a logical sequence and then stick to it. Since your first step will be a general appraisal of the patient’s well-being, it could make sense to start with soft tissues, before moving on to examination of the teeth and gums. But this is a personal choice - carry out the examination in an order that you are comfortable with and that you find easy to explain to the patient. Use gloved fingers or preferably, two mouth mirrors to retract the tissues. The visual inspection should be supplemented by palpation of any suspicious area and the submandibular and cervical lymph nodes.

Any intraoral prostheses (dentures or partial dentures) are removed before starting the inspection. The extraoral and perioral tissues are examined first, followed by the intraoral tissues.

I. The Extra Oral Examination
  • Face:The extra-oral assessment includes an examination of the face, head and neck. The face, ears and neck are observed, noting any asymmetry or changes on the skin such as crusts,fissuring, growths and/or colour change. The regional lymph node areas are bilaterally palpated to detect any enlarged nodes and if detected, their mobility and consistency are checked. A recommended order of examination includes the preauricular, submandibular, anterior cervical or auricular and posterior cervical regions.
II. Perioral and Intraoral Soft Tissue Examination:The perioral and intra-oral examination procedure follows a seven-step systematic assessment of the lips; labial mucosa and sulcus; commissures, buccal mucosa and sulcus,gingiva and alveolar ridge, tongue, floor of the mouth and hard and soft palate.

  • Lips: Observe the lips with the patient's mouth both closed and open. Note the colour, texture and any surface abnormalities of the upper and lower vermilion borders.
  • Labial Mucosa: With the patient's mouth partially open, visually examine the labial mucosa and sulcus of the maxillary vestibule and frenum and the mandibular vestibule. Observe the colour, texture, and any swelling or other abnormalities of the vestibular mucosa and gingiva.
  • Buccal Mucosa: Retract the buccal mucosa. Examine first the right then the left buccal mucosa extending from the labial commissure and back to the anterior tonsillar pillar. Note any change in pigmentation, colour, texture, mobility and other abnormalities of the mucosa, making sure that the commissures are examined carefully and are not covered by the retractors during the retraction of the cheek.
  • Gingiva: First, examine the buccal and labial aspects of the gingiva and alveolar ridges (processes) by starting with the right maxillary posterior gingiva and alveolar ridge and then move around the arch to the left posterior area. Drop to the left mandibular posterior gingiva and alveolar ridge and move around the arch to the right posterior area. Second, examine the palatal and lingual aspects as had been done on the facial side, from right to left on the palatal (maxilla) and left to right on the lingual (mandible).
  • Tongue: With the patient's tongue at rest and mouth partially open, inspect the dorsum of the tongue for any swelling, ulceration, coating or variation in size, colour or texture. Also note any change in the pattern of the papillae covering the surface of the tongue and examine the tip of the tongue. The patient should then protrude the tongue and the examiner should note any abnormality of mobility or positioning.

    With the aid of mouth mirrors, inspect the right and left lateral margins of the tongue. Grasping the tip of the tongue with a piece of gauze will assist full protrusion and will aid examination of the more posterior aspects of the tongue's lateral borders. Then examine the ventral surface. Palpate the tongue to detect growths.

  • Floor: With the tongue still elevated, inspect the floor of the mouth for changes in colour, texture, swellings or other surface abnormalities.
  • Palate: With the mouth wide open and the patient's head tilted back, gently depress the base of the tongue with a mouth mirror. First inspect the hard and then the soft palate. Examine all soft palate and oropharyngeal tissues. Bimanually palpate the floor of the mouth for any abnormalities. All mucosal or facial tissues that seem to be abnormal should be palpated.
Early stage lesions often are asymptometric and may mimic other conditions, whereas others may not be readily evident in routine examination. Malignent and benign lesions may not be clinically distinguishable, the dentist cannot predict the biological relevance of lesions on the basis of physical features alone. The following screening aids assist dentist with the detection of early cancerous changes or for the assessment of the biological relevance of mucosal lesion.

1. Toluidine blue stain

Toluidine blue (also known as tolonium chloride) is a vital dye that may stain nucleic acids and abnormal tissues. It has been used for decades as an aid to the identification of mucosal abnormalities of the cervix as well as in the oral cavity. It has been valued by surgeons as a useful way of demarcating the extent of a lesion prior to excision. Toluidine blue has been used for several decades as a means of identifying clinically occult lesions in patients whose oral mucosa may otherwise be normal – that is, as a screening test or adjunct.

  • The topical application of toluidine blue to a suspicious area helps identify the presence of dysplastic or carcinomatous lesions. But to verify the premalignant status of an oral lesion a biopsy is required.
  • It may be that toluidine blue selectively stains for acidic tissue components and thus binds more readily to DNA, which is increased in neoplastic cells.
  • Toluidine blue has been recommended for use as a mouthwash or for direct application on suspicious lesions; its value comes from its simplicity, low cost, noninvasiveness and accuracy.
  • Clinicians can use toluidine blue to help select an appropriate biopsy site within a large lesion or monitor high-risk patients who have been previously diagnosed with a premalignant or malignant lesion.
  • Toluidine blue is an adjunct to biopsy, not a replacement for it.

2. Brush biopsy

The Brush Biopsy (CDx Laboratories, Suffren, NY) was introduced as a potential oral cancer case-finding device in 1999. It was designed for clinical lesions that would otherwise not be subjected to biopsy because the level of suspicion for carcinoma, based upon clinical features, was low. When an abnormal result is reported (atypical or positive), the clinician must follow-up with a scalpel biopsy of the lesion, as the use of brush cytology does not provide a definitive diagnosis.

3. Exfoliative cytology

A procedure to collect cells from the lip or oral cavity. A piece of cotton, a brush or a small wooden stick is used to gently scrape cells from the lips, tongue, mouth or throat. The cells are viewed under a microscope to find out if they are abnormal.

4. Chemiluminescence (reflective tissue fluorescence)

Chemiluminescence has been used for many years as an adjunct in the examination of the cervical mucosa for “acetowhite” premalignant and malignant lesions. Recently, this technology has been adapted for use in the oral cavity and is currently marketed under the names ViziLite Plus and MicroLux DL. These products are intended to enhance the identification of oral mucosal abnormalities. With both systems, the patient must first rinse with a 1 percent acetic acid solution followed by direct visual examination of the oral cavity using a blue-white light source. ViziLite Plus uses a disposable chemiluminescent light packet, while the MicroLux unit offers a reusable, battery- powered light source. The 1 percent acetic acid wash is used to help remove surface debris and may increase the visibility of epithelial cell nuclei, possibly as a result of mild cellular dehydration. Under blue-white illumination, normal epithelium appears lightly bluish while abnormal epithelium appears distinctly white (acetowhite). ViziLite Plus also provides a tolonium chloride solution (TBlue), which is intended to aid in the marking of an acetowhite lesion for subsequent biopsy once the light source is removed.

5. Velscope

The Velcope is a portable device that allows for direct visualization of the oral cavity and is being marketed for use in oral cancer screening. Under intense blue excitation light (400 to 460 nm) provided by the unit, normal oral mucosa emits a pale green autofluorescence when viewed through the selective (narrow- band) filter incorporated within the instrument handpiece. Proper filtration is critical, as the intensity of the reflected blue-white light makes it otherwise impossible to visualize the narrow autofluorescent signal. In contrast, abnormal or suspicious tissue exhibits decreased levels of normal autofluorescence and appears dark by comparison to the surrounding healthy tissue.

Early-stage oral cancer can be cured, but most oral cancers generally spread to lymph nodes or other areas by the time they are found.

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