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Running Time: 57 min

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Review neoplasia concepts and statistics Role of the hygienist Etiology and Risk factors for oral cancer Terminology and Description of lesions Abnormal clinical Manifestations Extraoral

Release Date: September 30, 2014

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Did you know that the oral cancer survival rate is around 50%? That means 50% of the patients that get diagnosed with oral cancer don’t make it. Another sad fact is that these statistics haven’t changed in the last 30 years. What is the role of a dental hygienist in helping with the diagnosis and referral of oral pathology lesions? Welcome. My name is Karima Bapoo-Mohamed. I’m a dental hygienist with a private practice at Edmonton, Alberta. I’ve been practicing for about two decades as well as teaching at the University of Alberta for around that time, too. And so I am here today to share with you a wealth of my clinical experiences and knowledge with some slides on some patient cases that we’ve encountered over the last few years. Oral pathology is very much part and parcel of diagnosis and assessment for what we do. And this module today, I would like to review, very quickly, what are some of the neoplasm concepts and some statistics. And more importantly, we, as hygienists, how can we help with that survival rate of 50%? Part of the reason is by the time the lesions are diagnosed, they’re already at Stage 3 or 4 cancer lesions. So is there a role that we, as hygienists, could be doing in our screening and assessment tools? We’re going to discuss the etiology and risk factors, as well, of oral cancer. Go over some terminology and some descriptions. And I have some actual slides to augment the verbal descriptions that I’m going to give you today. And then a large part of the presentation will be on the clinical manifestations of slides. So I plan on spending a large part of time on abnormalities as they may be manifested in the intraoral regions. And when we do find something that we’re not comfortable or not sure about, what do we do? And, of course, finish that segment off with the referral and when and what to refer. So starting out with our first objective, what is neoplasm? As we know that oral and maxillofacial pathology is a science, part of dentistry, and it really deals with the nature, the identification, and the management of any diseases that affect the oral and the maxillofacial facial regions. So when I first started dental hygiene practice, I didn’t even think I needed to know an oral and maxillofacial pathology. And I am sure glad that over the years, I’ve established a relationship. And that would be my recommendation that search out some oral and maxillofacial pathologists in your region, so you have a way of referral for your patients should they need it. And they do a very thorough investigation on not just the clinical manifestations, but they do a whole slew of tests like radiographic, microscopic, biochemical. And there’s all kinds of other examinations to augment the clinical exam that they conduct. I mentioned about the statistics earlier on. And there are some more gory statistics of oral cancer that make up 3% of all the cancers. And what’s really sad, 2% of them are fatal. And I guess, when you hear of the fact that they can be reversed or prevented from progressing, I think we totally have a role to play. We talked about the late detection. 70% of the oral cancers identified are usually in Stage 3 or 4. So as we agreed upon that the early detection, early discovery can actually save patients’ lives. And I have to say in the two decades– I mean, I referral for anything I’m not comfortable with, but from all the referrals, there have been two cases. And these patients still come to see me and are so grateful for having picked it up when we did. And I’ll show you the cases actually later on, too. So really, 25%. There’s a misnomer or the thought that, oh, yeah, if you smoke, you’re going to get oral cancer. Well, more than 25% of oral cancer victims don’t use tobacco or are nonsmokers. So it’s interesting to see, depending on which source you go to, that there are a lot of nonsmokers that are coming up as an incidence for oral cancer, too. When we look at the American Cancer Society, their predictions and estimates, again, for this year is that 37,000 people will get oral cancer in the oral region or oropharyngeal region. And that’s about 7,300 people will die from these cancers a year. That is fairly sad. The other research shows with this society is that the demographics varies, that it’s twice as common in men compared to women. And there’s also been a link with the human papilloma virus recently with oral cancer. So it may start with a little viral lesion but ends up being cancer. So really watch out for those as well, which we will go over. And there is some variations worldwide in the prevalence and incidence of oral cancer and orofacial cancer. 90% of all oral cancer is the squamous cell carcinoma type of cancer. And it not very virulent, which means it doesn’t grow very fast. But it has a very high mortality rate. The reason for that is it can metastasize very easily. And it can actually kill within five years, depending on which stage it’s discovered. So it’s pretty serious stuff. Most oral cancers happen on the floor of the mouth. So we will go over what are the pressure points and where are the key areas we should be watching out for incidence of cancer. And it can be relatively painless. So really, in the earlier stages, patients don’t really have any symptoms. So it behooves us as dental clinicians, the professionals, to really watch out for any changes that we see. Let’s talk terminology. “Neoplasm,” what does that mean? Does that mean it’s a cancer? Neoplasm is actually just showing an abnormal mass or growth of tissue. And it’s abnormal because the cells are dividing and multiplying at an abnormal growth. A neoplasm can be benign. It could be premalignant, or it could be malignant. But neoplasm really refers to any kind of growth. So if you’re referring a patient, if you use the term “neoplasm” for any kind of growth, so that would be the right terminology to use. And this growth is just not coordinated in any way compared to the normal tissue that’s surrounding it. And it can persist excessively even after the stimulus has stopped. So this is a growth that’s uncontrolled. And even once the trauma or a stimulus has stopped to it, it will continue growing. What about the types of neoplasms? Well, we mentioned earlier, it could be benign or noncancerous, which is usually very localized. It’s a very circumscribed area that it would grow in. A good example, actually, would be the skin moles. Patients come in with facial moles or skin moles around the hands area. The other thing would be the fibroids that some of your female patients might say. And these are nonmalignant or benign. Premalignant are cells that actually proliferate at the site of the origin, but they don’t really spread. So they’re fairly localized to that area. They’re not cancerous yet, but they could become cancerous. So these are examples, like leukoplakia that we see a lot of the times in our dental exams, as well as any kind of hyperplasia that you may see, which is localized. And of course, the malignant or the cancerous lesions have a very distinctive feature about them. They have abnormal cell growth, a very rapid cell growth as well. And the big thing with the malignant lesions is they have the capacity to actually invade other tissues and metastasize in other areas of distant growth from the origin growth. So these cancers really have the capacity to take over your whole body, and eventually, kill the host. So that’s a quick definition of the neoplasms. I mentioned earlier, what are the common sites we should be vigilant about and really watch out for in the mouth when we’re doing our intraoral exams? Absolutely, the tongue is a key area– the dorsal and the lateral surface of the tongue. The tonsils and the oropharynx. Remember how we have patients say “aah” all the time? What we’re doing is looking for the tonsillar regions to see what’s going on there. Always checking the floor of the mouth with your bidigital palpation, as well as the gums, and sometimes also, actually, the lips and the vestibules around the lip area as well. Not very common, but it can be also salivary glands originated as well. So we have some pictures we’re going to show you a little later on as well. Moving on to the second objective of this module is, then, what is our role? How can we help improve on that 50% survival rate? I feel the most common thing for us to really understand is, what is normal for this patient? And when does it look abnormal? When you think about hygienists and what we do, we are spending focused, concentrated time with our patients for up to an hour most of the times, if not all the times. And maybe we’re seeing them more frequently as well, probably seeing them every three months or six months. So who better than us to really know what exists, what’s normal, and how does it look different from one recall to the next recall? So really a good practice to not only do the comprehensive exam– intraoral, extraoral– but really describe and document the lesions in the chart, so you have a basis of comparison for the next time. We’re going to talk about just what are the common oral lesions that we would normally see. And then how do we monitor and reevaluate? And when do we, then, refer our patient to oral pathologist or for a biopsy? So why do we perform the head and neck exam? Well, it’s a standard of care. We have to provide that standard of care. It’s part of our comprehensive dental care exam. And we’re really observing the normal structures of the mouth, the head and neck area. But what’s more important is, then, the ability to identify what’s abnormal and what’s the variation from what we’ve seen with normal. It helps us actually determine and describe if there is a disease process going on. And if there is disease process, we absolutely want to have an early detection, early discovery strategy, where we prevent the disease from further expanding or metastasizing, and really helping the patients with the survival rate there. These are just common facial moles– very benign, nonmalignant lesions. And I not only document it in my chart; in my private practice, I’ll take pictures. So I have digital pictures of what this looks like on a certain date and may choose to follow up. Doctor’s showing a probe measuring the diameter– I guess, the dimension of the lesion there. So if this is just a facial mole– very common, normal lesion that we would probably encounter in our dental hygiene practice. Yet head and neck exams don’t get done very often. I guess there’s no “billable” code, as far as I know, for head and neck exams only for a dental hygienist. We never have enough time. As it is, we’re always running late, and there’s somebody waiting, and we’re always running behind on the procedures we were supposed to do. So the lack of chair times sometimes makes us jump over and not do a comprehensive intraoral, extraoral exam. And sometimes, hygienists, we’re just not sure. What am I looking for? What’s normal? Is this OK? And because you’re unsure, there may be some misunderstandings of it, and so you’d really rather not deal with it. And maybe that, maybe some other reasons, we don’t really take the time. What I’m hoping is actually, at the end of this module, you will have the confidence and competency to say, yes, I know this is normal, and this doesn’t look right to me. And don’t forget, our objective here isn’t to make you diagnose cancer. My only lament out there is to really make sure we identify anything that’s suspicious-looking or abnormal-looking, and refer the patient out. What are some of the warning signs and symptoms? So really, anything that’s red or white discolorations, patches or lumps in the mouth or around the mouth is something we really want to flag. What about ulcers or sores? Patients get canker sores all the time. How is this different from malignant lesion? And that would be something that doesn’t go away more than three weeks. Normally, canker sores are about two weeks’ time span. And anything that’s longer than two weeks, it’s a cause for concern. And I definitely want to follow up with that and inform the patient about that. Any kind of skin thickening on the lining of the mucosa or around the head and neck area, absolutely we want to follow up. How about teeth that just loosen up, and there’s no real reason for why are they getting so loose? Or patients saying, yeah, the dentures doesn’t fit quite right to me in the last little while. Investigate that further. Is there any lumps or bumps that’s preventing the dentures from having a precise fit? What about the tongue getting painful or patient complaining of pain when they’re swallowing? Sometimes, there’s even a stiffness of the jaw or pains in the jaw area. Earache is also a symptom and a sign of something going on. Patients who have a dramatic weight loss from one recall to the other, it’s like, what happened? And they’re losing weight for no reason. Definitely, worth an investigation. Sore throats or a hoarse voice that just won’t change over time is absolutely cause for concern as well. Any kind of sensation that something’s trapped. Patients have described it– I feel something. I can’t quite swallow. Something’s trapped or blocking me in my throat. Would absolutely merit an investigation as well. And pain in the neck that won’t go away as well as, of course, any kind of paresthesia or numbness that the patient may feel in the face or the lip or the chin or the neck area. So we’ll move on now to the etiology and the risk factors of oral cancer. What is the etiology of oral cancer? Well, it is the good old DNA. As we know, the deoxyribonucleic acid is a chemical that’s part of our cell. It’s part of our genetic makeup, actually. And that provides directions to the cell functioning for its lifetime. It actually dictates the cell. This is when you’re going to grow. This is when you’re going to reproduce. And this is when you’re going to die. So when you have a change in the structure of the DNA, there is a genetic mutation which actually confuses the cells. And the cells are not getting the proper direction on when to grow. So they grow uncontrollably. And ultimately, they cause a tumor or a growth. Regular cells inside the body actually follow an orderly pattern. But cancer cells, ultimately, can take over in an uncontrolled, expanded way because they just won’t die. This is just a picture, actually an enactment of a tumor growing in the lung tissue of a body here. So what are some of the risk factors? Actually, I have three slides on risk factors, starting with this one, of course. Smoking, we’ve all heard about. And absolutely, there is evidence-based documentation that shows that smoking does have a direct correlation with the incidence of oral cancer. Alcohol intake as well. And here’s the thing. The combination of somebody who uses tobacco and alcohol on a regular basis has a huge multiplier effect, up to 100 times the risk of getting oral cancer. Excessive or prolonged sun exposure, absolutely. Especially in the lip area is a high risk as well for cancer. Next is also nutrition– poor nutrition; lack of antioxidants, fruits, and vegetables in your diet; high consumption of red meat actually; fried foods. These are all risk factors for cancer in general. Your GI disorders. I don’t know about you, but I’m finding every maybe sixth, seventh patient now has reflux esophagitis or some kind of GI tract disorder. And that’s when they are just not comfortable. And the stomach acids are flowing backward. So this acidic environment or back flow is really breeding ground for a lot of the cancerous production and proliferation. Other risk factors, as we mentioned earlier, is the HPV infection that in the mouth and the throat area, sometimes you don’t really even have any symptoms. But just that common virus will sometimes, in a small percentage of patients, develop into oropharyngeal cancer. So very important to get that analyzed and looked at carefully. The prior oral cancer history of a patient is a definite risk factor that I want to monitor this patient very closely. In certain parts of the world, there is a social cultural norm of chewing betel nuts. And that is definitely been proven to be carcinogenic. Gender, again, as some of the stats we showed earlier, it’s twice as common in men than in women. And depending on the source you go to, it says, age-wise, it’s anything 55 and older. So I’ve heard 60 or 62 is the average age when oral cancer is diagnosed. But anything 55 and older. So really, if you have a patient who is male, 55, in your chair, maybe a smoker; right there, you’ve got three, four risk factors already for oral cancer. And maybe drinks as well, that adds to the multiplier effect. And of course, chemical exposure can also be a risk factor for cancer. And big thing with cancer, of course, like any other systemic disease, is host immunity. How happy and healthy is your immune system? And if you have a compromised or weakened immune system for whatever other reasons, chances of you getting oral cancer is a lot higher. There’s also studies on donor stem cells that has been recognized as being formed by the body, and they turned cancerous. So for example, a patient who maybe recently had a kidney transplant or some kind of an organ transplant, that could turn into a cancerous thing. Genetic predisposition, of course, is a risk factor. Good old lichen planus. Remember that white, leafy patches that we see in the mouth is a precursor, actually, to cancer and which should definitely be monitored and watched for our patients. And then there’s a whole bunch of unproven risk factors. You may have a patient in the chair– I heard mouthwashes cause cancer. Is that right? And really, it’s not a proven fact, as far as I know. But these are things that question mark, maybe, could lead to cancer depending on the patient’s immune system. So in a nutshell, I guess those three slides is a lot that gives you a good scope of what are some of the risk factors as we move forward. Let’s talk a little bit about terminology and the descriptions of the lesions before we actually show you the clinical manifestations of it. How do you assess for this? Now, you definitely want to take a very detailed, comprehensive health history of the patient. And then you want to take a history of that specific lesion in terms of, how long has it been there? What was the onset of it? Then you’re going to do the clinical exam, possibly a radiographic exam. And then you may want to send it for a lab, like a biopsy. Or you might have a referral to a pathologist. What the medical exam does for us, actually, is it really will help us disclose any predisposing factors or something that actually makes the patient vulnerable by giving a comprehensive exam. 90% of systemic diseases actually can be discovered through just a comprehensive medical exam. In fact, this is such an important topic that we have a separate module dedicated just for assessment for dental hygiene process of care. We need to be familiar with the oral lesions that are associated with some of these common disease processes. And some of these systemic diseases are like congenital heart defects and hypertension. Uncontrolled diabetes is huge, too. That will have oral manifestation as well. Let’s talk about the history of the lesion. As I started saying, this is a good format to follow as to, how long has that lesion been in there? Has it changed in shape or size for you? The patients will be able to say, well, it started like a dot, but now, it looks to me like it’s really big. What’s the characteristics of the lesion? Where did it origin from? Is that where it was first or did it start somewhere else? Just ask those probing questions because the patient will say, come to think of it. And there comes the story. So really think through of how you want to gather that history of the lesion. And a lot of the times, it’s interesting, patients will say, oh, I just bit my tongue. And now, it’s just swollen. And it wasn’t that they bit their tongue, actually the lesion got to a point where it was interfering with their occlusion. And now, they’re symptomatic and telling us about their history of the lesion. But it had probably been there for a long time before. There are systemic symptoms as well, of course, coupled with this topical lesion that the patient may come with. For example, you can certainly ask, have you had any fever or nausea? Is there’s something going on in your body that you’re feeling is just not right? Any kind of abnormal sensation? Any paresthesia, anesthesia kind of a feeling? Any bad taste or smell actually can also lead to some history of the lesion there. And this stage just means trouble swallowing and any swelling or tenderness in any of those areas before even you do your extraoral lesion or have the patient in the supine position. We are moving on to, how do I describe this lesion? What am I seeing? And what is a normal thing to describe it? So we have some clinical slides to augment the descriptive terminology that I’m going to share with you. “Erythroplasia,” of course, is anything that’s red or even has a little bit of red. “Ulceration” is relating to something that looks like an ulcer to us. And of course, the “growth rate,” we really want to understand how fast did it grow for them, from the day 1 to now. How long have you had it for? Does it bleed at all when you press on it? Or does it hurt? And what’s the surrounding tissue look like? Is it firm to touch? Or is it fairly loose and flabby feeling? And does the lesion feel fairly fixated to the submucosa or the underlying tissue? Or does it feel that it’s fairly loose? Something I like to do is I call the ABCD. It’s a lot to remember, but I tell my students just remember the ABCD of oral pathology. And those things relate A for “Asymmetry.” Anything that’s not symmetrical is cause for concern. What about the “Border”? Is it irregular? Is it smooth? Anything that has a border, maybe something you want to monitor. “Color” changes that we talked about. If it’s red or white in color and doesn’t quite match the pink coloration of the mucosa, that’s your C. And then the “Diameter,” as we talked about earlier, measuring with the probe or what have you, that you capture the dimension from one recall to the next recall to see if there’s any changes. So there is a quick summary of the ABCD. If you forget everything else, then remember ABCD of oral pathology. Of course, there are all these descriptions of the lesion. Is it solitary or is there multiple lesions? We talked about location, size, color. Consistency is important. Is it raised or is it flat? And then the symptoms, we’d already talked about. What I’m going to do with the terminology part is I have actual clinical slides of each one of these manifestations that I will now move on to and share. So there is a papule, right there. It’s a small, kind of pointed elevation of the skin and usually doesn’t have any kind of pus coming out of it, but it’s just there– fairly normal, most likely benign. The patients will have had it, and they don’t think it’s much of a deal. But I always take a picture, make a measurement of it, and follow it. Plaque. Now, this we can’t confuse it with dental plaque. This is plaque which is flat. It’s sometimes raised. But it’s a patch of the skin that’s growing somewhere else, for example, the plaque in the aorta. The atherosclerosis is a group of cells that’s growing where it’s not supposed to grow. This is just showing plaque formation on, actually, the eyelids of the patient. And it’s just some slightly raised tissue that’s growing where it’s not supposed to grow. What about a nodule? This is probably the most common intraoral finding you’ll see. It’s just a small rounded mass or a lump. Watch the location of this lump. Sometimes it’s very close to the parotid gland opening. And you could confuse it or discount it, saying, oh, this is the opening of the gland. As it turns out, it was actually a nodule that maybe needed some further investigation. “Cyst” is another term for a raised elevation. The difference between a nodule and a cyst is that the cyst will usually have some kind of a fluid matter being encased in the sac there. Vesicles. You’re familiar with these as well. They are just circumscribed; very, very localized; and they are elevated on the epidermis. And they usually have that blistery kind of look which has fluid in it as well. The herpes simplex virus. We know. 90% of the population actually have been exposed to the herpes virus. But out of the 90%, only 40% will actually display outbreaks. And we all know that the herpes virus is a dormant virus. It lives in the trigeminal nerve ganglion until it’s reactivated. And upon reactivation, it will actually traverse through the trigeminal nerve bundle and then manifest itself clinically in various locations. So watch out for that. And again, the time parameter is really important. How long has that lesion been in there for you? Along the lesion, we also want to talk about vesicles. And this is different from the other vesicles in that this is also circumscribed, but it’s got a crusting going on with it, too. Very similar to something like chickenpox that we would see. And then there is the oral lesions as well. That is very large vesicles, like so. Macule is just a patch of skin that has a discoloration on it. It is usually elevated. And it can be caused actually from various diseases as well. So again, that comprehensive medical exam. Erosion. Look at this, just raw-looking breakage of the buccal mucosa. And this was complementary, actually, with the gingival tissue there, too. First time I’ve seen something along the gingival margin that’s eroding like that. Ulceration, absolutely. This is, again, a mucous membrane issue where the tissue just disintegrates and it forms. It can be painful as well. This is, again, from a patient recently, intraorally. And we’ll talk about the causes for ulceration later on, too. Aphthous stomatitis. Here you go. These are canker sores again. They are recurrent. The etiology is really unknown, but usually, they are associated with a lot of stress, some trauma. Nutritional deficiencies can do it. Hormonal imbalances. And of course, patients notice when they go to smoking cessation, sometimes they end up with a lot of ulcerations in their mouth. It’s usually intraoral and pretty much in the movable parts of your soft tissue. It’s typically a single lesion, but a lot of times, you can end up with multiple lesions. We’ll now move on to the abnormal clinical manifestations. What I’ve done is segment it in different areas. So I’m going to start with the hands and the nails, and then move on to the different extraoral, intraoral areas. When we look at some of the high-risk areas actually in the oral cavity especially, the lateral and ventral border of the tongue, the dorsal border, is really, really critical for checking it all closely. The floor of the mouth, that basal area, really make sure you’re thorough with your bidigital palpation. The tonsillar area and your pharynx as well as the soft palate also are high risk for squamous cell carcinoma. What are some of the common lesions? We have a whole bunch here that we’re going to go through with some slides that we’re going to augment it. Again, how do we actually examine these lesions? Well, two key ways we go about it in our dental hygiene practice is to visualize it. And so we want to look at where it’s located, what does the color look like, what is the size and the surface characteristics of it. But then beyond just looking at it, we’re actually in there with our gloved fingers and feeling the surface texture of this lesion. We want to look at the consistency. Is it soft or firm? Is it underrated? Is it fixed or is it moving? And is it hurting the patient when we touch it? So with the extraoral examination, we really want to look at variations from the normal. And I’m going to start with actually the patient’s hands area. These are actually three lifesaving minutes that you can incorporate in your daily dental hygiene routine that can be lifesaving for sure. Look at the patient’s hands. I’m really looking at the dorsal aspects of the patient’s hand and what is normal and what’s not normal. A lot of the times, patients with arthritis, you will notice with rheumatoid or osteoarthritis that there is the metacarpals and carpals which have the bumps and the swelling. And sometimes, you can see it at the ulna stage as well, which is so severe. We also want to check their fingernails. Believe it or not, the fingernails have a story to tell. And the color of the fingernails, they will really give us a clue on whether the patient is maybe anemic or there’s some other hematologic situation or problem going on with that patient. So really watch out for that. Again, the proviso is we’re not diagnosing here. We’re just looking at what’s normal and how can we assist or flag things for the patient without being a cause for worry. How about something that shows up like this? The patient says, yeah, it just appeared. And I don’t know, it’s not going away. I thought it would go away. This is a cause for concern. Definitely, you want to have patients having that taken a look at. Clubbing of fingernails. We’ve all heard about that– how there is this convexity on the fingernails. And studies show that may be linked with actually cardiac diseases. So a lot of systemic diseases may have things like this. Spoon-shaped finger. Actually, right here you can see this patient has this little divot or depression on their fingernails. This is actually right out of a textbook showing excessive clubbing or spoon shape of fingernails. And this is sometimes linked with, actually, iron deficiency or anemia. So good idea to have the patient getting that checked out. What about half and half fingernails where you can see the color demarcation between the white and in the dark part of the fingernail? And this is sometimes associated with patients on hemodialysis or renal transplants. So really, the fingernails have a story to tell us for sure. Splintered fingernails, for example, have been linked with bacterial endocarditis, scurvies, psoriasis, some nutritional deficiencies. So get that looked and watched. And this is something you could be doing very innocuously just as you seat the patient or putting the bib on the patient or watching the patient. This slide, of course, shows the virus infection of measles. Now, let’s move on to the face and neck area, which is pretty much where we are at and where we live. What about the skin on the face? When we’re doing our extraoral exams, I’m really curious to see if there is any lumps or bumps. Is it bilateral? And is there any cause for, actually, pain or paralysis that the patient might be mentioning? So this is just showing a unilateral swelling. And it’s very close to the parotid gland area. That’s abnormal. And it’s been there, and the patient was just walking around because there’s no pain. I think we’re such a pain-driven society. We’re guilty of that. Our patients are guilty of it. Unless something hurts, we’re not going to go do something about it. But we should actually be following up with this. This is just showing the angioedema. It’s bilateral. You can see the puffiness and the swelling on this patient’s face. And it’s actually related to congestive heart failure in some cases, to real diseases as well. We’re all familiar with Bell’s palsy. It’s paralysis of half the mouth. Stroke would also show that. And I have a couple of patients with very mild form of Bell’s palsy. And again, the big thing is to have them smile is when you’re able to really see the discrepancy and the asymmetry. Extraoral exam. We want to look at the skin and any alterations, any changes in their pigmentation. And I’m very curious to know, is it generalized? Is it localized? Is it perioral? Here’s a situation where a patient had glasses on forever and says, oh, this is just from the nose pads of my glasses. Now, when I’m doing the extraoral exam and seeing the patient now, I’m removing their prescription glasses that they came home with and checking. And this is just at the bridge at the nose. And look at this. Basal cell carcinoma is what that was diagnosed as. So was this case here. So really important to make sure you remove the eyeglasses and check around that area. This is just showing a malar rash on the facial area. This is not very normal-looking. The melanoma. This is absolutely a very advanced case of melanoma from a textbook picture that I’m showing you here. What about pigmentation? Most people have freckles and fairly normal for them. Looks like it’s some crazy disease, but actually, usually can be very normal. And in this case, the pigmentation is very localized to the peripheral tissue area. Pigmentation can also be around the extremities as well. And so hands and feet would be part of that, too. Lupus-based red tissue is absolutely a manifestation there as well that you can see on the face. Very classic lupus look. Redness of the skin. Any kind of rash-looking of the skin, definitely be something that we want to monitor, watch, and keep it there. So let’s move on now to the nose, ears. I want to talk about, actually, the nose area next. This is what’s normal. And this is why it’s very important to have a normal documentation of your mouth. And this is just showing swelling on the one side of the nasolabial cyst. So really watch out for that. Ears. Actually, this is a gout deposit on the upper surface of the ear. And this is on the earlobe area which turned out to be basal cell carcinoma. So really, you’re doing yourself a service. It takes an extra few minutes, but really be alert and watchful. And once you get experience, it goes by really quick. Neck area, you want to examine again for any asymmetry, any deviation from the normal, any pain, or anything that feels like it’s a paresthesia-related tenderness. You want to investigate that. What’s interesting between the benign and the malignant growth is that benign is fairly slow-growing. And if a tissue is fairly freely moving and there’s not a lot of invasion of that tissue, it’s probably not very painful for the patient, chances are that it’s a benign lesion. Whereas, the malignant one is often painful. By that time, it’s probably progressed to that Stage 3 or 4. What are some of the types of neck masses that we would encounter in our day-to-day dental hygiene practice? Well, some of them can be congenital. Some of them are actually new and now forming. Some have been part of the infection that they have acquired, and now has a neck mass that manifested itself. Some of them, of course, can be trauma-related. And sometimes, it’s very inflammatory. Or it’s just idiopathic for the patient. They just have these masses there. So these are some congenital manifestations– just born with it. And it’s very normal for them to have had that since birth. And these are, again, showing other benign neck masses, neoplasms around the neck area. This, you almost have to have the patient turn their head sideways to discover this area here. And as you can see, around the angle of the mandible. Moving on to the salivary gland area, you can see that there is a huge mass of growth happening around here. And there is one on the neck area here. Surprisingly, it wasn’t tender for this patient at all. There you go. These are malignant neoplasms of the neck and fairly advanced as you can see from these cases here. These are some more neck manifestations of infectious diseases, actually. This is actually from a cat scratch that got infected. So good old cat, play with the cat, and got scratched, got an infection, and there you have it. This patient presented with a lump in that neck area. These are just some inflammatory-related neck bones, as you can see in this area here. So let’s move on now. We’ve done the face, we’ve done the skin, and we’ve done the ears and the neck. We’re now going to move on to the intraoral areas. And let’s investigate closely the lips, the buccal mucosa, the vestibule. We’re also going to look very closely at the tongue, the floor of the mouth, and also the hard palate, the tonsillar areas as well. Very important to do that intraoral exam, if you’re not doing it– that three-minute lifesaving tip of actually checking the buccal mucosa by doing the lip and the cheek roll, doing the digital palpation on the floor of the mouth. Do that palate check as well as the tongue and the gauze check. Have the patient say “aah” and check their tonsils and tonsillar region as well. And definitely be checking the neck area for any other lesions or bumps. Document what’s normal. That’s really, really important. This may look like, oh, my god! What is this foreign lesion going on? This is just some bimandibular tori that the patient has– always has had them. The documentist or the dentist or another hygienist is picking up the chart. You know that this is a normal manifestation for a patient. And tongue piercing, of course. How are we going to do the screening? Well, there’s a simple and systematic way of actually following it in a visual and a palpable way. There is also adjunct methods, like you’ve heard of the VELscope and some of the other agents that actually may be helpful as well. But again, the clinical examination a visual and palpitation examination is still the gold standard for examination. Here we go. Looking at the tissue, this is very soft and friable. This tissue is actually picking up the tolonium chloride. And so it looks very suspect to us. Definitely want to get that flagged because this is not just periodontal disease. This is way beyond what periodontal disease would be. Again, “how long has that lesion being in there?” is my question for the patient. Remember what is normal? And then here we have a premalignant change in the labial mucosa of this patient. Make a note of it and document it, and actually take a picture of it as well. This is squamous cell, actually carcinoma of the lips. And you can see how it’s changed from something that was very benign-looking to something that actually looks raw and unhealthy. Labial mucosa. Really make sure you are retracting the labial mucosa and looking for any abnormalities like this bump. And the patient says, oh, I probably just bit it. And they want to try and say that it’s something that maybe it doesn’t need any further investigation. But really, I feel it’s our ethical, legal, moral, professional obligation to inform the patient of our findings. And then what they do with it, of course, is their choice. But it is our obligation to document and inform. Again, this is showing a pyogenic granuloma right in this area, in the interdental papilla area. They discount it as, oh, it’s part of the periodontal disease. It’s not definitely needing some more examination. Melanosis, absolutely. Change in pigmentation. Tobacco smokers, absolutely, will evidence some change in pigmentation. Usually, it’s reversible if it’s not malignant. But keep an eye on them and watch out as to where it is and how it’s growing. This is a manifestation from use of tobacco. And you know how you have a contact time that’s increased by having it in the vestibule of the buccal mucosa or the labial mucosa. And this is what the changes that happen in the tissue from this heavy carcinogenic. Buccal mucosa, absolutely. We want to look closely at the fibroma here. See, again, this is at a very strategic location because it’s close to where the parotid gland opening is. But it’s actually a fibroma of a different sort. This is just at the corner of the lip there. We want to keep an eye on it. Again, that tongue we talked about– the dorsal aspect of the tongue. We want to look at all the papillae and look at the filiform, the fungiform, the circumvallate at the back there. And are they smooth and shiny, or are they looking like they may not be looking quite right? Lateral border, absolutely. There’s some fibroma or some squamous cell carcinoma going on here. Interestingly, patients, most of the time, feel they just bit their tongue, and so they discount any lesion that persists beyond three weeks. And, oh, I just bit my tongue. So really follow up with that. Xerostomia, of course, will be very evident in the mouth as the dry mouth and the tongue will have deep fissures and grooves that we want to watch out for. What about this area right here? Look at that foliate papilla. And that’s quite prominent and visible there. Definitely want to keep an eye on that. When you have the patient say “aah,” you want to look at the uvula and the tonsillar region here. And look what we found in the ventral and the dorsal part in the very posterior region of the tongue right there. So really important to make sure patient sticks out the tongue. This is what’s called a “cancer horseshoe.” And it can be an a shape of a horseshoe, I suppose. Very painful lesion for patients usually. So it’s there at this stage, it’s probably been there for quite a while. And if it’s diagnosis of cancer horseshoe, survival rates are less than five years usually. The tongue can be heavily coated, but then you add tobacco use to it, you can have some really crazy things happening. Very prominent circumvallate. But look at how coated the tongue is here. Again, this is another horseshoe manifestation of cancer that’s showing here. What about geographic tongue? Is that cancerous? Well, it can be. It’s usually benign. But the thing with geographic tongue, of course, is it moves. It’s very migratory lesion. It’s more common in females. Most of the readings that I’ve done showed the etiology. We don’t know what causes it and what the symptoms are for it. It can sometimes be a little painful. But look at this slide here. This is actually manifestation of geographic tongue, but it’s ectopic. It’s not on the tongue. It’s areas other than the tongue. So just be aware of that as well. It’s geographic tongue manifesting somewhere else. Hard palate, absolutely. We want to take our little mouth mirror and check the rugae and the hard palate and the soft palate. As you can see, there is some defect here in the incisive canal– some kind of cyst that’s growing. And the patient just thought that they burnt their mouth with hot pizza one day, and that’s what’s going on there. But it turned out to be needing investigation for sure. Nicotine stomatitis has a different palate manifestation, as we all know. And of course, with the vasoconstriction, there is just not enough circulation going on. And this is a fairly severe case of nicotine stomatitis. And it’s very chronic, long-term exposure. And it’s a combination of not just the tobacco, but it’s actually the heat from the tobacco as well that’s causing the nicotine stomatitis. And it’s usually painless, so patients aren’t motivated to do anything about it. Usually, it’s benign. It’s not pathological. But something to definitely watch out for. Flora of the tongue. For sure, we want to really take a close look at this surface here. And there is a hemangioma right there on the ventral surface of the tongue. Leukoplakia. I guess it’s probably one of the more common premalignant lesions we see in the intraoral region. 85% of these oral lesions are precancerous. So really want to watch out for any changes that go on with this manifestation. Leukoplakia, again, showing some more manifestations. This is just that white lacy area that you see. Sometimes, it can be a red area like so. Tobacco use can give you a black hairy tongue as well, as you can see. And this patient probably has loss of taste sensation as well based on this issue here. And of course, halitosis is a big part of it. Leukoedema on the cheek. Again, it’s from the use of excessive tobacco. This is a high incidence actually in cigar smokers. We should talk about Candida infections as well. As we know, it’s the yeast infection. 90% of them are origin of the yeast. And there are different types of causes. There’s research that shows uncontrolled diabetics usually are more likely, of course, to have Candida or fungal infections of the toes. But absolutely in the mouth area, it would be a yeast infection. Patients with HIV, cancer patients can have Candida infections as well. Hormonal changes in pregnant women can also make you predisposed to Candida infections. Smokers, ill-fitting dentures– these are all some of the causes for Candida infections. And actually, even babies can end up with a Candida infection passing on from their moms. Smokers are absolutely at high risk for periodontal disease. So this is the impact of smoking that can be created from the changes in intraoral tissues. So having seen the visual of all the possible things that could go wrong, when do we refer? And what do we refer for? Again, to reiterate, you want to refer a sore in the mouth that doesn’t heal spontaneously and has been there for about three weeks or more. Any lump or thickening on the cheek, which is growing actually quite rapidly, is a source of concern. White or red patches on the gums, on the tongue, the lining of the mouth, anywhere it doesn’t belong there should definitely put our antennas up. Soreness or a feeling or something feels like it’s caught in the throat, as patients would describe it. Difficulty in chewing or swallowing or sometimes even breathing because their airways could be getting compressed from these lesions. Difficulty in actually moving their jaw or their tongue. So very important when we do the extraoral exam, check for the range of motion of that patient. Numbness on the tongue or any other area of the mouth, as well as the swelling of the jaw. And sometimes, it will be a partial or a full denture that just doesn’t fit anymore. Some of the diagnostics that we can get done is CBCT, for example, where they can investigate a radiolucency further to see if it has a sharp border, is it a cyst, how large it is, and really the periphery of it. There’s lots of dyes out in the marketplace as well which will actually help with the diagnosis. A lot of times, my course of action is to send it for a biopsy, refer it to oral pathologist, or really have an oral surgeon to take a close look at it. Sometimes, it’s ENT specialist, but then the doctor can take it to that next level. This is just showing a picture of them taking a little bit of fluid to see if there is any malignant cells in that area there. So again, at the cost of repeating myself, any hyperkeratotic change on the surface that’s persistent, has been there over three months, and if the lesion is interfering with the local function, usually that’s when the patient is now in your chair, saying they’re in trouble or suffering from it. And important to know also that it may not just be a cancer lesion– what you’re seeing in the mouth actually is probably related to some systemic diseases because people can have some systemic diseases that actually have oral manifestations. So maybe what you are discovering is an undiagnosed systemic disease. So there is another great service you can give your patients as well. And again, when you refer to your specialists, now you have the vocabulary and the terminology to know what to say and how to say it. And this way, it will expedite the actual treatment of it. I have a couple of case studies before I end my module. This is a 51-year-old patient in the chair. And they presented themselves with these slightly tender areas on the lips on an extraoral exam. And when I deflected the labial mucosa, there were these little lesions here. So this was definitely something I referred out, and it is under investigation. What about this case here? 55-year-old lady sometimes had this, but hadn’t quite noticed these white changes, these white lacy tissue. Looks like leukoplakia to me. And typical response, she’s on some drug for blood pressure but really doesn’t remember the name and takes it sometimes, doesn’t take it sometimes. So really, this is the cause. This wasn’t there originally. So I’m curious to know now what is going on there. So here we are at the end of our journey on oral pathology. We started out with talking about what “neoplasm” means. What are some of the statistics? And there’s some pretty sad facts out there on oral cancer diseases. What is the role, then, of us as hygienists in early detection, early discovery, and really, early referral of these patients? And then we went through all the risk factors of what could possibly cause oral cancer. We described some of the cancer lesions and went over the terminology of it. And then we actually showed clinical slides on different areas which are extraoral as even the fingernails and hands and skin of the patients, to really take a close look at that, and when to refer our patients. I would like to end the presentation with the bird philosophy or the team philosophy, as I call it. We all heard about birds that fly in formation. It’s interesting to me that birds that fly in formation of a V shape actually cover twice the distance than any bird flying alone. It’s amazing. And I guess it’s the way they are positioning themselves with the wings, where the lift of the wings of a bird in front of you actually helps you move further up faster. This was interesting to me that they actually take turns being the leader. So I guess the bird at the front of that V is taking the brunt of the wind force. And so everyone will take a turn being the leader. When this bird gets tired, it moves to the back. And the next one in line gets to be the leader. And we’d always hear these birds honking away, especially the Canadian geese– now, they’re coming back– is they’re honking constantly. The reason for that is they’re telling you, hey, way to go. You’re doing a great job. It’s amazing to me that these are just birds. They take care of the sick. If one bird falls, guess what? Another bird will stay behind with him till that bird gets better or passes, and then they’ll join another flock. And so the message there is this is an animal which has a brain the size of– I am told a green pea is how big their brain is. Yet they are so sophisticated in the ability to work together. So when we are in our silos of dental hygiene practice, in our cubicle with our patients, and as alone as we may feel, we are part of that bigger V. We do have access for referrals to a whole slew of interdisciplinary professionals that we should use on. Thank you for joining me for the Oral Pathology module. Thank you. Bye-bye.

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