Management strategies for oral potentially malignant disorders

Author: Joel M. Laudenbach, DMD

Oral potentially malignant disorders (OPMDs) include oral leukoplakia (OL), oral erythroplakia, oral submucous fibrosis, oral lichen planus, proliferative verrucous leukoplakia, and actinic keratosis. Once an OPMD has been clinically diagnosed, execution of management strategy is critical. When formulating the strategy, healthcare providers should consider histopathology, lesion characteristics (ie, surface texture, unifocal, multifocal), lesion location in the mouth (ie, tongue, floor of mouth), patient risk factor assessment, and a detailed medical/cancer history.

In this newly published article, Nadeau and Kerr[1] detail various parameters surrounding evaluation and management of OPMDs. The authors make it clear that OPMDs are challenging, each with their own nuances regarding risk for malignant transformation. For example, when OL is unifocal, nonhomogeneous, nodular, or verrucous, there is a much higher chance of the OL becoming dysplastic (12.63-fold) or demonstrating a focus of carcinoma (8.9-fold) when compared with homogeneous types of OLs.[1]

Provider knowledge of these variables is critical when counseling patients about their diagnosis and management options and when selecting interventions along with follow-up care. Although progression to malignancy is difficult to predict with OPMDs, clinicians can account for multiple risk factors such as smoking/alcohol status, high-risk location in the oral cavity, and size of lesion (>200 mm2) to help formulate a tailored management plan for each patient. Consultation with an oral pathologist to discuss the histologic appearance in the context of specific patient history and lesion characteristics can provide additional perspective and/or recommendations.

Modifiable oral cavity cancer risks related to tobacco and heavy alcohol use should be communicated to patients with OPMDs so that they are able to make changes that may lead to regression/disappearance of certain lesions such as OL. Providers confronted with patients who use tobacco and/or heavy alcohol can integrate recommendations for cessation of tobacco[2] and alcohol[3] because they are both established, independent, causative agents for oral cavity cancer and OPMDs.

Available treatment strategies for OPMDs include surgical removal/ablation, photodynamic therapy, and surveillance. The authors make a clear point with supportive studies that traditional surgical excision of dysplastic OPMDs may decrease malignant transformation (MT) risk, yet it does not fully eliminate that risk and, in some instances, has not changed the MT risk when compared with surveillance alone. Appropriate surgical margin identification for OPMDs is clinically challenging. The authors note that smaller excisional margin sizes (1-2 mm) without marginal histologic assessment are common surgical management goals for OPMDs.[1]

Nadeau and Kerr carefully outline updated considerations for all OPMDs. Healthcare providers involved in screening, diagnosing, referring, and/or managing patients with OPMDs should be well versed in standards of care, including baseline biopsy goals, tobacco/alcohol cessation, currently available interventions, and surveillance care.

Clinicians should also develop a local team of practitioners who are experts in diagnosis and management of OPMDs to help patients obtain the best opportunity for positive outcomes. I encourage readers with interest to retrieve and review the full article by Nadeau and Kerr as a strategy to update your knowledge base and to continue to improve overall morbidity, mortality, and survival rates related to OPMDs.

1. Nadeau C, Kerr AR. Evaluation and management of oral potentially malignant disorders. Dent Clin North Am. 2018;62:1-27.

2. US Preventive Services Task Force. Final recommendation statement. Tobacco smoking cessation in adults, including pregnant women: behavioral and pharmacotherapy interventions. September 2015. Accessed March 1, 2018.

3. US Preventive Services Task Force. Final recommendation statement. Alcohol misuse: screening and behavioral counseling interventions in primary care. May 2013.
/RecommendationStatementFinal/alcohol-misuse-screening-and-behavioral-counseling-interventions-in-primary-care Accessed March 1, 2018.

March, 2018|Oral Cancer News|

HPV leads to increase In head and neck cancer In men

Author: Bianca Castro

The number of men diagnosed with head and neck cancer caused by human papillomavirus has skyrocketed. This report found that 11 million men and 3.2 million women in the United States are infected with some type of oral HPV and oncologists say it’s leading to more head and neck cancer in men.

“From the 1970’s to today, the prevalence of this HPV-related head and neck cancer has increased by three to five percent per year from then until now, and it is continuing that same rate,” said Oncologist Jerry Barker, Jr., M.D. at Texas Oncology.

“This is a silent epidemic. Most patients who are exposed to this virus, they don’t know it. They’ll never have symptoms from it, but some of those patients will move on to develop a cancer,” said Dr. Barker.

Jeff Busby, of Weatherford, is one of those patients. The aerospace engineer and owner of Busby Quarter Horses says he was diagnosed with throat cancer in February of 2016. His wife Andrea, who documented their journey here, says they were both shocked.

“We were just busy living life. You don’t ever think that shoe is going to drop,” said Andrea.

Jeff says the symptoms began as pain in his ear which lead to pain in his throat. Nine months later, he had a biopsy done on what was a mass in his neck.

“I had just been toughing it out and my partner said, ‘hey, you can’t just tough these kinds of things out. You’ve got to go get this checked out,'” said Jeff.

“It was the cancer putting pressure on and radiating nerve pain to the ear. There was nothing wrong with the ear whatsoever,” said Jeff.

A biopsy revealed Jeff had throat cancer caused by the human papillomavirus, the most common sexually transmitted infection.

Jeff was likely exposed in his teens or 20s, but now decades later, created a cancer with one of the most gruesome treatment protocols. He needed surgery to remove his bottom teeth and part of his jaw, 35 radiation treatments and six rounds of chemotherapy.

“I couldn’t let any of my energy go towards feeling sorry for myself because I had to have every amount of energy I had to beat this thing,” said Jeff.

Jeff had never heard of HPV before, while Andrea says she thought it was linked to only cervical cancer.

While pap smears screen for cervical cancer, there is no screening for hpv-related head and neck cancer and that may be part of the reason rates of hpv-related head and neck cancer has surpassed the rate of hpv-related cervical cancer.

There is way to stop the epidemic. The HPV vaccine is recommended for children as early as 11-years-old and young adults as old as 26 years of age. However, according to this study, in Texas, only 35 percent of children get the vaccine.

“Somewhere along the way, these vaccines developed the idea that they had to do with human sexuality and preventing a sexually transmitted disease, but in reality, they are designed to prevent cancer. These are cancer vaccines,” said Dr. Barker.

“If you could just see what some of our patients have to go through to cure one of these cancers, you would run to get the needle in the arm to prevent that from happening to one of your children.”

At 55, Jeff never had the chance to benefit from the vaccine, approved for use in 2006. He’s now cancer free and in some ways, he says, life is better than before cancer.

“I thank God for this challenge and I still wouldn’t change it today. I wouldn’t take it all away because I didn’t think I could be closer to the Lord or to my wife and I certainly have a much better relationship with both,” said Jeff.

He and Andrea are focused on raising vaccination rates and preventing the kind of cancer battle they fought from from happening to someone else.

“There are so many parents that even hear about but still choose not to do it. It’s beyond me. I can’t understand that,” said Jeff.

“Whether it gets a kid vaccinated or somebody sitting on their couch goes, ‘I have ear pain when I swallow. I should go to the doctor.’ That’s why we are doing this,” said Andrea.

The Centers for Disease Control estimates that most Americans have some type of HPV strain but not all strains lead to cancer. Some of the symptoms are head and neck cancer include ear pain, difficulty swallowing and a painless lump on the side of the neck.

January, 2018|Oral Cancer News|

Blood-borne HPV antibodies indicate head, neck cancer prognosis

Author: provided by Brown University

People with head and neck cancers with evidence of human papillomavirus (HPV) infection generally have a better prognosis than people without evidence of infection. A new study in JAMA Oncology suggests that to produce a strong, reliable prognostic signal, all that’s needed is a blood serum test for two specific HPV antibodies, rather than lab work on a biopsy. Further, the researchers said, the study shows that this blood-based biomarker is predictive of outcome for all types of head and neck cancer.


The human papillomavirus causes not only cervical cancer but also cancers of the head and neck. Credit: National Cancer Institute

“What this adds is that it helps us know how best to measure clinically the HPV contribution to this disease,” said study senior author Karl Kelsey, a professor of epidemiology and of pathology and laboratory medicine at Brown University. Kelsey collaborated with lead author Heather Nelson of the University of Minnesota Masonic Cancer Center in making the findings.

Moreover, Nelson, Kelsey and their colleagues wrote, referring to the common HPV16 strain of the virus: “These data are among the first to demonstrate a convincing relationship between HPV16 and improved patient survival for tumors of the larynx and oral cavity.”

Appraising antibodies
The study examined blood serum samples and five-year survival rates among more than 1,000 Boston-area head and neck cancer patients diagnosed between 1999 and 2011. Overall, those who tested positive for antibodies to the oncogenic HPV proteins E6 or E7 were less likely to die during the five year follow-up period after diagnosis compared to those who tested negative for the antibodies. Based on the analysis, the researchers estimated that those with evidence of an immune response to HPV were 25% less likely to die during the course of follow-up compared to those with no immune response to HPV.

The study’s purpose was to determine whether the antibodies provide a reliable indication of prognosis. In ongoing trials, doctors are testing whether patients with HPV-associated cancers can be treated less aggressively—and hopefully with fewer negative side effects—than people with non-HPV-associated cancers, Kelsey said. If trials prove successful, then it will be particularly important to determine whether cancers are HPV-associated.

“The assessment of a patient’s HPV status likely will affect treatment,” he said. “That’s why there’s real interest in getting it right; for instance, how do you test?”

Better prognosis across the board
Prior studies have focused primarily on the role of HPV in the oropharynx—the area of the throat right behind the mouth. An important contribution of the current study, Nelson said, is demonstration that an immune response to HPV is important for all forms of head and neck cancer, although the benefit does show some variance based on the exact cancer location. Those patients with an HPV immune response with tumors located in the oropharynx and larynx had a similar risk of dying during the follow-up period, though the reduced risk was slightly attenuated for those patients with tumors located in the oral cavity.

The results didn’t depend significantly on whether people had high or low levels of the antibodies, so long as they had some, the researchers found, though testing positive for both E6 and E7 was better than for just one.

The reduced chance of dying by five years carried through for people who tested positive for the antibodies even if they consumed tobacco and alcohol. But the worst prognoses in the study were among smokers whose cancers could not be traced to HPV.

In all, the findings controlled for the statistical influences not only of tobacco and alcohol exposure, but also of age, race, gender, education and how far advanced the cancer was.

Relates to broader advances
Kelsey said the findings could help bring head and neck cancer treatment closer into line with two emerging practices of fighting the disease: personalized medicine and immunotherapy.

“To me, personalized medicine really reflects using all the information you can glean about an individual tumor to treat it appropriately,” Kelsey said. “Here HPV is an example of a causal factor that delineates the mechanism of the tumor suppressor genes that drive the tumor and that gives you insight into the differences in the tumor.”

Meanwhile, the study might help shed light on why immunotherapy—in which the body’s immune system is marshaled to attack cancer—appears to help for some head and neck cancers, Kelsey said. It may not be coincidence, for instance, that the prognosis is better among people whose cancers are associated with a virus that promotes a robust immune response, in the form of antibodies, than among people without a viral cause for their cancer.

If HPV-related cancers can indeed be treated differently, Kelsey said, then serum-based testing to determine the role of the virus could soon be available, too.

December, 2016|Oral Cancer News|

Patient survives stage IV, inoperable throat cancer in clinical trial

Author: staff

It took a white lie to get David Polisini, 79, to a doctor in 2004, after months of being unable to swallow.

“Two of my daughters, Toni and Susie, showed up on my back porch and told me to put my jacket on,” he says. “They told me we were just going for a ride, but the next thing I knew, we were pulling into the Clermont Mercy Hospital.”

Polisini says tests ordered in the emergency room uncovered a tumor in his throat.

“It was the size of a golf ball,” he says, adding that he then scheduled an appointment with his primary care physician, Francis Dumont, MD. “I was then referred to an ear, nose and throat physician within his group who said I needed to see someone at the University of Cincinnati (UC) Cancer Institute.”

A biopsy was performed, and a diagnosis was confirmed—it was Stage IV cancer.

“I began seeing Dr. (Bill) Barrett who explained that I would need to go through very aggressive radiation along with chemotherapy five days a week for three months,” he says. “I’d drive myself every day to every visit in my little Miata. The therapy really zapped my strength, but I’m here because of it.

“I really don’t think I realized how much trouble I was in with Stage IV inoperable cancer, but I knew I had to do what I had to do to get through it.”

The radiation and chemo regimen was a Phase III clinical trial at UC, studying the effects of the use of both radiation and chemotherapy for advanced head and neck cancers.

Besides his family, Polisini credits Barrett, chair and professor of the UC Department of Radiation Oncology and director of the UC Cancer Institute, as well as the staff and care providers at the Barrett Center, where he received treatment, with being a tremendous support.

“Dr. Barrett was there with me every step of the way,” he says. “He was so dedicated to helping me, as were the other nurses and staff at UC. I’m just so impressed with everyone who works there. They stood by me the whole time, and more than 10 years later, I’m doing fine, and the cancer hasn’t come back. To me, Dr. Barrett is an angel come to Earth.”
The clinical trial seems to have worked, and Polisini, who lives in Clermont County, says that while he has a primarily liquid diet, he doesn’t regret a thing.

“By golly, I’ll trade the ability to eat with the ability to get up every morning,” he says. “I have the energy to do the things I want and have to do. I go to the ‘Y’ every other day to exercise. I do my own house and lawn work. I just put a new floor on my front porch. I can only do these things because of the outstanding treatment I received at the UC Cancer Institute and the Barrett Center.”

And he warns others to not ignore symptoms, like he did.

“If you have something wrong, see a doctor right away, unlike I did,” he says. “I’m just thankful for my daughters and Dr. Barrett for helping me.”

March, 2016|Oral Cancer News|

Hopkins team shows methylation-specific ddPCR may help predict head and neck cancer recurrence

Author: Madeleine Johnson

Oncologists probe the margins of surgical sites to detect epigenetic indicators that can anticipate cancer recurrence. But deep surgical margin analysis with biopsy can alter the site making it challenging to return to the exact spot if there is a problem. It also takes only a few rogue cancer cells to cause a recurrence and these may be missed by histological techniques.

Researchers at Johns Hopkins University School of Medicine have now developed a method using Bio-Rad’s Droplet Digital PCR platform that is amenable to molecular methods and only requires a tiny sample from the surgical margin.

Specifically, in a study published this week in Cancer Prevention Research, scientists examined an epigenetic signature of PAX5 gene methlyation previously determined to be specific to cancer, and found that it could be used to predict local cancer recurrence after tumor removal for head and neck squamous cell carcinoma, or HNSCC.

In a prospective study of 82 patients, if the tumors had methylated PAX5 then the presence of residual methylated cells in the surgical margins was a predictor of poor locoregional recurrence-free survival. And among patients on subgroup of patients who did not receive radiation treatment after surgery, the ddPCR method increased detection of the PAX5 maker from 29 percent to 71 percent.

Compared to conventional methylation analysis, the ddPCR method also reduced the number of false negatives. Importantly, the authors noted in the study that the method can be performed within three hours by one person. Thus, it might be completed before the reconstruction phase of a typical operation, allowing surgeons to resect the margin of the surgical site if methylated cells are detected.

The authors concluded that future personalized oncology workflows could also employ methylation arrays or methylation sequencing to pre-operatively define a patient’s methylome and design a panel of primers and probes that could be used in intraoperative surgical margin assays.

A spokesperson at Bio-Rad noted that an increasing number of researchers are using the firm’s digital PCR platform for methylation studies.

“There seems to be increasing success in applying ddPCR to measurements of methylation, as judged from an uptick in recent publications,” George Karlin-Neumann, the director of scientific affairs at Bio-Rad’s Digital Biology Center, told GenomeWeb in an email.

He cited another recent study that examined so-called “field cancerization,” or the presence of clonally-related cells in the mucosal area surrounding a tumor that have malignant potential and carry cancer-associated genetic or epigenetic alterations.

That work, published in Epigenetics in July, looked at colorectal cancer and showed MethyLight ddPCR was able to achieve a significantly lower limit of detection than the same technique using standard PCR. The author of that study told GenomeWeb that ddPCR could help detect the one or two cells with cancerous epigenetic changes out of a field of thousands.

This increased sensitivity over conventional qPCR is “translating into better clinical sensitivity and specificity with methylation biomarkers, bringing us closer to the possibility of their clinical implementation,” Karlin-Neumann said.

He further noted another recent study, published in Diabetes, which showed absolute measurements of methylated and non-methylated preproinsulin cell-free DNA in blood could provide a better association with Type 1 diabetes than ratio measures.

This result “plays to the strengths of ddPCR’s ability to make absolute measurements, rather than just relative ones.”

Raleigh, North Carolina-based biopharmaceutical company Islet Sciences is also using the methylation status of cell-free DNA to track pancreatic beta cell death. That firm licensed a ddPCR-based epigenetic method from a lab at Yale University, and representatives told GenomeWeb last year that Islet is working to commercialize the assay.

Viresh Patel, global marketing director at Bio-Rad’s Digital Biology Center, told GenomeWeb in an email that the firm is not currently marketing methylation applications specifically, but Bio-Rad continues to work with customers on assay design, sample compatibility, and data analysis.

“This is an emerging application for ddPCR which we expect to gain momentum as researchers continue to publish their breakthrough research,” Patel said.

August, 2015|Oral Cancer News|

For the war against oral cancer, what’s in your arsenal?

Author: Dennis M. Abbott, DDS

The face of oral cancer has changed: No longer is oral cancer a disease isolated to men over 60 years of age with a long history of smoking and alcohol consumption. Today, the demographic for the disease includes younger people of both sexes with no history of deleterious social habits who are otherwise healthy and active. It spans all socioeconomic, racial, religious, and societal lines. In other words, oral and oropharyngeal cancer is an equal opportunity killer. Today, as you read this article, 24 people in the US will lose their battles with oral cancer. That is one person for each hour of the day, every day of the year. Each of those lost is someone’s sister, a father’s son, a small child’s mommy, or maybe even a person you hold dear to your heart. The truth is, oral and oropharyngeal cancer has several faces . . . and each of those faces is a human being, just like you and me. So how can we, as dental professionals, be instrumental in the war against oral and head and neck cancer?

Views of the oropharynx, the base of the tongue, and the epiglottis, taken with the Iris HD USB 3.0 intraoral camera using different points of focus. Photos courtesy of the author.

Views of the oropharynx, the base of the tongue, and the epiglottis, taken with the Iris HD USB 3.0 intraoral camera using different points of focus.
Photos courtesy of the author.

The answer, as with most other cancers, lies in early detection. When oral and oropharyngeal cancer is detected early, the five-year survival rate can be as high as 80% to 90%. The harsh reality is that most oral and head and neck cancers are only found at late stages after the cancer has advanced—often to the lymph system. As a result, the chance of the person living for five years after diagnosis falls to approximately 55%.

As dentists and dental hygienists, we—like it or not—are on the front line of this war. We often have the opportunity to see potential cancer patients more frequently than our medical colleagues do, and we are trained to see abnormalities inside the mouth and in the head and neck region. (This is a huge part of the solution!) Many of my medical colleagues tell me that they do not have the training to see what I can see in the mouth. But I do not have the training to practice oncological medicine like they do. The truth is, it takes all of us doing our jobs to care and manage the individual person—not just the teeth, not just the liver, not just the breast, but the whole patient.

Years ago, we could almost profile who would or would not be likely to present with oral cancer. It was always the “Marlboro man”—that guy who was older, drank alcohol frequently, and had a smoking pack-year history that was two or three times his age. But those days are long gone. With the recent understanding that the human papillomavirus (HPV), the most common sexually transmitted infection in the United States, is an etiological factor for oral and oropharyngeal cancer, virtually everyone is a potential cancer patient. As such, everyone should be screened. While the individual with classic risk factors still remains at risk for developing oral cancer, many who present with HPV-related oral and head and neck cancers have no other discovered risk factors, other than exposure to HPV and an immune system that, for reasons still unknown, will not adequately clear the virus without repercussions.

It is believed that 80% to 90% of all Americans have been exposed to HPV at least once in their lifetimes. Most people manage to clear the virus through the immune system’s normal defense function within six to seven months; in some patients, however, damage takes place at the cellular level that may take months, years, or even decades to manifest as cancer. The majority of HPV-related oral and head and neck cancers present in areas that are difficult for us as dental professionals to visualize, such as the tonsils, the base of the tongue, the oropharynx, the posterior pharyngeal wall, and the larynx. That, however, does not give us an excuse not to screen in these areas . . . we just have to think outside of the box and get creative about how we screen.

Visual inspection combined with palpation remains the essential foundation of screening for oral and oropharyngeal cancers, but where visualization is difficult—such as with the base of the tongue and the lower oropharynx—knowing and asking the right questions can become critically important for identifying potential concerns:
“Are you noticing any unusual hoarseness?”
“Are you having any difficulty swallowing?”
“Do you ever have a sensation as though something is caught in your throat?”
“How long has that tonsil been inflamed?”
“Have you noticed any sinus or allergy issues since that tonsil has been enlarged?”
While these questions may seem unrelated to teeth, they are not unrelated to oral health. Simply asking the right questions can open a dialogue of discovery that may lead to the detection of an oropharyngeal cancer early. And early detection is the key to beating the disease and maintaining a good quality of life during the survivorship years.

Technology-based adjunctive devices to assist the dental professional in the early detection of oral cancer have existed in the market for the past 10 to 15 years. Much has been written about fluorescence and reflective technologies, which help the examiner to detect subtle changes in tissue through the usage of light in the violet and yellow ranges of visible light, respectively. Examination with these wavelength-specific devices enhances visualization by highlighting changes in the oral mucosa and vasculature. Usage of these adjuncts has also demonstrated value in enabling clinicians to better understand the size of affected tissue surrounding suspected lesions. As such, these may be useful in selecting a field for biopsy that may produce clear, or noncancerous, margins.

Since the completion of the Human Genome Project (HGP) in 2003, there exists a more clearly defined understanding of how diseases such as cancer affect our cells at the nucleic acid level and how genetic mutations can serve as risk factors or catalysts for cancerous changes in cells. Technology used in the HGP has also provided insight into the genotyping of viruses, leading to a sharper picture of how viral interaction with our genetic code can lead to disease. Today, the dentist and dental hygienist have this technology readily available to move their practice into the era of personalized health.

Salivary tests, such as the MOP (Molecular Oral Testing) by PCG Molecular, take advantage of innovative, advanced genetic testing to establish the risk or presence of oral or oropharyngeal squamous cell carcinoma. MOP does this by evaluating cellular abnormalities in the oral cavity and oropharynx, DNA damage associated with oral and oropharyngeal cancer, and the presence of HPV. With this information, the clinician can better determine the appropriate course of action for the patient.

Sometimes striving to provide the best possible patient care means thinking outside of the box to use technology designed for one purpose and discovering a new application to meet an unanswered need. Most of us are at least familiar with intraoral cameras, and many of us have them in our offices. Using the magnified imagery of a quality intraoral camera and a high-resolution monitor, this tool is a favorite device for illustrating the need for proposed treatment and for establishing patient trust. But what if we could use those images to possibly save a life?

The Iris HD USB 3.0 intraoral camera by Digital Doc LLC has catapulted intraoral photography into the high-definition age. Using the Iris HD precision optical lens array and an advanced HD sensor from Sony, the Iris HD USB 3.0 provides unmatched 720p-resolution clarity that is perfect for the magnification and photographic capture of suspicious areas discovered during a thorough head and neck examination/oral cancer screening. Because of the size of the camera head, the device even makes it possible to examine areas of the oropharynx that were previously difficult for dentists and hygienists to visualize.

Of course, the camera cannot substitute for laryngeal endoscopy, especially if cancer inferior to the epiglottis is suspected, but the camera’s ability to see beyond the palatopharyngeal arch is an improvement over an angled dental mirror. Most patients can tolerate the necessary posterior placement of the camera to capture an oropharyngeal image either by breathing through the nose or with placement of a topical anesthetic on the posterior soft palate and uvula to suppress the gag reflex.

Regardless of the power of the technology, the ultimate skill in detecting early-stage oral and oropharyngeal cancer lies in the eyes, hands, and brain of the examiner. Careful inspection, knowledge, discernment, and experience are the real tools of the professional for acquiring and processing all of the available data and for correctly fitting the puzzle pieces into a picture that illustrates either health, concern with reason for reevaluation, or the need to biopsy the area in question. When reevaluation is required, no more than two weeks should elapse between the initial examination and follow-up, as time is of the essence in proceeding to treatment should the suspicious area indeed be cancerous.

Responsibility to the patient does not end with an abnormal screening result. The dental professional should have a plan in place to either biopsy or refer. The dental professional should biopsy only if he or she is well-experienced in the removal of suspected cancerous lesions. Otherwise, the patient should be referred to an oral/maxillofacial surgeon, periodontist, otolaryngologist, or head and neck surgeon who is comfortable with and experienced in the safe and effective biopsy of a potentially cancerous area. It is most often the case that only one opportunity to obtain a diagnostic tissue sample exists, so the skills of the doctor performing the biopsy should be without question. Every effort should be made to ensure that the patient is seen promptly for biopsy and that the pathology results are returned and shared with the patient expeditiously. Delay can be detrimental to the survival of a patient with oral or oropharyngeal cancer.

Should a screening result from your office lead to a diagnosis of oral or oropharyngeal cancer, be prepared to counsel and educate your patient about what to expect in his or her cancer journey. Learn about and be prepared to meet the unique dental and oral health needs of patients with oral and head and neck cancers, and become equipped to continue care for your patients throughout their treatment and into survivorship. For all of the destruction and hardship that cancer brings, it can form unbreakable bonds, between doctor and patient and between dentist and physician.

Don’t be afraid to reach out to your counterparts in the medical community and bridge the gap between medicine and dentistry in your area. Form alliances with head and neck surgeons, radiation oncologists, medical oncologists, and oncology nurses. Let them know about your skills and the services and technology available in your office that place you on the front line of this war on oral cancer. Take time to understand your medical colleagues’ role in treating the disease and become familiar with the technology they are using to save lives and diminish the long-term effects of oral cancer treatment. We are, after all, fighting the same war, and we’re all on the same side. It is all of us against oral and oropharyngeal cancer, with the needs and health of that one patient we’re fighting for leading us in the battle.

About the author:
Dennis M. Abbott, DDS, is the founder and CEO of Dental Oncology Professionals, an oral medicine-based practice dedicated to meeting the unique dental and oral health needs of patients battling cancer. In addition to private practice, he is a member of the dental oncology medical staff at Charles A. Sammons Cancer Center at Baylor University Medical Center in Dallas. Dr. Abbott is also the founder of the American Academy of Dental Oncology and serves as a consultant to the national American Cancer Society in the development of oral monitoring guidelines for post-treatment cancer survivors. Dr. Abbott lectures internationally on the topics of dental oncology and oral cancer.

Mouth cancer survivor: Dental check ups saved my life

Author: Elaine McLaren

“Nobody particularly enjoys visits to the dentist and I’m no exception, but I’ve always looked after my teeth and have never missed a six-month check. So that day back in May 2009, I wasn’t expecting there to be any problems. I hadn’t been in any pain or discomfort, so I was surprised when the dentist voiced his concern.

‘There’s a white patch on the side of your tongue,’ he told me through his mask. ‘It’s probably nothing but you should get it checked out by your GP, just to be on the safe side.’

Examination over, I sat up in the chair as he explained what he thought it could be – a condition called leukoplakia, which was harmless in its mild form and often disappeared without the need for treatment.

So when, a few days later, I was sitting opposite my GP, I was shocked to hear the condition was closely linked to mouth cancer.

My heart sank at the mere mention of the word. Just seven years earlier, I’d lost my dad to lung cancer.

My thoughts immediately turned to my own children, Grace, who was then only eight, and Daniel, five, and whether they’d have to go through the same trauma as I had with Dad.

As quickly as the notion had entered my head, I brushed it aside. I was only 38 then, I didn’t smoke or drink heavily and I ate healthily. Nothing made me a high risk.

But that still didn’t stop my heart pounding as I sat in the hospital waiting to see the consultant a few weeks later. Opening my mouth wide once again, I steeled myself for the worst possible news.

When he told me I had nothing to worry about, I could have cried with relief.

But its habit of developing into something far more sinister meant that wasn’t the end. I was sent for a biopsy to check for irregular cells and continued to see the consultant for check-ups, then discharged 18 months later. I could finally start to relax and believe it was over.

My dentist wasn’t quite so laid-back. As an expert in mouth cancer, he kept a close eye on it, taking photographs every time I saw him to make sure he could track the changes. It became a routine part of my visits and something I barely even thought about, until five years later I started to notice a difference myself.

All of a sudden, the patch started to rub against my teeth, whereas I’d never noticed it before. It started to get red and aggravated and every time I ate spicy foods, an agonising, searing pain would shoot through my tongue.

As luck would have it, I already had an appointment with my dentist booked, so I decided to see him before doing anything else. I was hoping he would tell me it was nothing, but in my heart I knew that wasn’t the case. Sure enough, he took one look at it and recommended I went back to see the GP.

Just weeks later, I was once again sitting in the familiar surroundings of the consultant’s office. I knew from his straight-faced, stilted reaction – so different to the casual reassurance I’d had before – that it was much more serious.

His voice was calm and steady as he told me I would need another biopsy, but I could tell he thought the worst. I had the procedure two days before Christmas 2013 and though I tried to think positively, telling myself that I’d been worried before and it had turned out to be nothing, the truth was I was terrified.

I spent the entire festive season putting on a happy face and trying to make everything as normal as possible for the children when, inside, all I could think about were the impending results. Every waking moment, I worried about the outcome.

When I returned to the consultant early in the new year, I thought I’d prepared myself for what he was about to say. When I eventually heard the words, ‘You have mouth cancer,’ it turns out I wasn’t prepared at all.

Though I’d known deep down that it was coming, it hit me like a bolt out of the blue as if I’d never expected it at all. As the words began to sink in, it came as such a huge shock that he was talking about me.

I’d always assumed it was a disease that only affected older men who smoked heavily. How wrong I’d been. Mercifully, and thanks to the diligence of my dentist, mine had been caught early enough to give me a great chance. I felt incredibly lucky. I was going to beat this.

But just as I was counting my lucky stars, fate dealt me another blow. A routine MRI scan revealed a mass on my right lung. It couldn’t be diagnosed with a biopsy because of its position, so I had no choice but to leave it there until they’d dealt with the cancer in my mouth.

I was determined to get through it and get back to being a mum again.

In January last year, I had a 10-hour operation to remove the cancer in my tongue and have it rebuilt with tissue and a vein from my arm, which was then grafted with skin from my tummy.

As soon as I recovered, in March last year, I was back in theatre again for a four-hour operation to remove the mass on my lung, which did turn out to be cancerous.

Both of the operations were a success and I’m finally getting my life back on track. I know I’ve got the vigilance of my dentist and the fact that I visited him regularly for the fact that it was caught early enough and I can put it all behind me. If it wasn’t for him, I could still be living with a cancer I didn’t even know was there.”

Throat cancer survivor celebrates life after trans-oral robotic surgery

Author: staff

When Charlie Guinn sits down to eat with his lovely wife of 39 years, he thoroughly enjoys each bite. It’s not just the food; the entire experience is a celebration. Just over a year ago, Mr. Guinn learned that he had stage IV throat cancer. For him, just surviving would have been an accomplishment — so swallowing again at a meal with a loved one is truly something special.

The American Cancer Society estimates that in 2013 over 41,000 people in the U.S. were diagnosed with cancer of the oral cavity and pharynx and almost 8,000 died from the disease. But Mr. Guinn would be the first to say that he is one of the lucky ones. He is one of the first patients to undergo trans-oral robotic surgery (TORS) at the University of New Mexico Hospital. And the results have been stunning.

Mr. Guinn first discovered the lump in his throat while shaving. When it was still there a week later, he went to an urgent care center where he was immediately referred to an Ear, Nose and Throat physician. The physician ran a number of tests including a biopsy. When the results came back, the physician referred Mr. Guinn to Nathan Boyd, MD, at the University of New Mexico Cancer Center. It had been only a week and a half from that fateful visit to urgent care.

Mr. Guinn recalls, “When I first got there to see Dr. Boyd, one of the nurses told me, ‘You really hit the lottery because you have some of the finest doctors working on you.’ And I agree. Dr. Boyd is one of the most fantastic people I’ve ever met.” Dr. Boyd, an Assistant Professor in the Department of Surgery, Division of Otolaryngology at the UNM School of Medicine, is one of the first two physicians in New Mexico to offer TORS. The other physician, Andrew Cowan, MD, PhD, is also an Assistant Professor in the Department of Surgery, Division of Otolaryngology at the UNM School of Medicine and initiated and launched the surgical program in early 2013.

After his initial consultation with Dr. Boyd, in which he learned about his surgical options, Mr. Guinn consulted with two other physicians at the UNM Cancer Center that same day. He met with his oncologist, Elizabeth McGuire, MD, an Associate Professor in the Department of Internal Medicine, Division of Hematology/Oncology; and with his radiation therapy physician, William Thompson, MD, a Staff Physician in the Department of Internal Medicine, Division of Hematology/Oncology.

The physician team took Mr. Guinn’s preferences into account and agreed to offer him the TORS procedure. Dr. Boyd explained to Mr. Guinn that they would need to complete at least one exploratory surgery first. Mr. Guinn agreed. He recalls that meeting with a laugh and says, “Dr. Boyd told me, ‘My goal for you is, in one year, to have a [Blake’s] Lotaburger with cheese and green chile.’”

Three weeks later, Dr. Boyd completed three TORS procedures on Mr. Guinn and the tumor was out. But because the tumor cells had spread to the lymph nodes, even bursting one of them, Mr. Guinn’s UNM Cancer Center physician team decided to recommend chemotherapy and radiation as a preventive measure to make sure no cancer cells were lurking. Mr. Guinn did not like the additional treatments but knew they were necessary. “The worst experience for me was the radiation,” he says. He experienced some third-degree burning during his course of treatment, but has healed now. He shrugs off the experience saying it’s nothing compared to what burn victims go through.

His chemotherapy experience was a little better. Mr. Guinn didn’t feel like eating very much and he lost weight. “That was the positive of all this,” he laughs. “I do not recommend the diet, but it was the greatest thing.” Another side effect was his hair changing color. “I didn’t lose my hair. I’ve been silver and grey since my late 20s and now my hair is black. At first, I was mad.” But, he’s now accustomed to the darker hair.

Mr. Guinn reflects on what the experience of the past year has brought him. “It’s made me understand what other people go through and what their families go through,” he says. “And I realize that it’s not talking about it but just asking: How are you feeling? What can I do for you?”

Additionally, he and wife have gotten closer. “We’ve been married for 39 years. And we never thought we could get closer.” They are planning a celebratory vacation together.
Finally, Mr. Guinn credits his recovery to his faith, positive attitude, and the people around him who helped him keep that positive attitude. His family was with him at every single appointment. His family and friends sent their prayers and cards, meals, and other helpful items. And his entire treatment team at the UNM Hospital and the UNM Cancer Center gave him the confidence that he would pull through. “Ever since I met Dr. Boyd, not once did I think I was going to die,” he says. “I tell people, you don’t need to go anywhere. These people will take good care of you.”

At his latest visit recently, Mr. Guinn gave Dr. Boyd a gift card to Blake’s Lotaburger. He laughs as he recalls the look on his surgeon’s face. “I told him, ‘Have one on me!’

March, 2014|Oral Cancer News|

Shedding light on oral cancer

Author: staff

A team of Indian cancer researchers led by Dr Narayanan Subhash has developed a simple, non-invasive spectral imaging system that holds the possibility of rapid, inexpensive mass screening. Even in the hands of non-clinical staff, it is capable of real-time discrimination of healthy oral tissue from pre-malignant and malignant tissues with accuracy comparable to the gold standard histopathology of a biopsy sample.

The core of the novel Diffuse Reflectance Imaging System (DRIS) is an Andor Luca-R EMCCD camera, which captures monochrome images of the patient’s mouth at 545 and 575 nm.

Andor’s SOLIS software computes a ratio image (R545/R575) of the area under investigation and generates a Pseudo Colour Map (PCM) where blue designates healthy tissue, red denotes dysplastic/pre-malignant tissue and yellow identifies malignant tissue.


This allows rapid visual differentiation of oral lesions and identification of regions with pre-malignant characteristics.


“Since mortality from oral cancer is particularly high, early detection, diagnosis and treatment is vital in increasing the survival rate of those with the disease,” says Dr Subhash. “Our imaging method has the great advantage of non-invasively scanning entire lesions and their surrounding areas and automatically categorising these oral lesions into normal/clinically healthy, pre-malignant, and malignant tissue in real-time.

“It also delineates the boundaries of neoplastic changes and locates sites with the most malignant potential for biopsy, thereby avoiding unnecessary repeated biopsies and delay in diagnosis. What’s more, imaging the entire region may also help the surgeons to identify the margins of the lesion that cannot be easily visualised by the naked eye during surgical interventions.”

Orla Hanrahan of Andor added: “The Luca-R EMCCD camera is well-equipped to handle this demanding role. It is built around a monochrome, megapixel frame transfer EMCCD sensor to deliver single photon detection sensitivity and unrestrained QE (65% max) in a TE cooled, USB 2.0 camera platform.”

February, 2014|Oral Cancer News|

Noninvasive oral cancer test eases patient fears

Author: Donna Domino, Features Editor

A new, noninvasive cytology test for oral cancer, ClearPrep OC, is being offered free to dentists. The test, aimed at “watch and wait” lesions, is less expensive than biopsies and less frightening for patients, according to Resolution Biomedical, the company that is commercializing it.

The chairside oral cancer test — which can be ordered directly from the company — is designed to be a diagnostic option for assessing lesions when a biopsy is not warranted or the patient fears getting a biopsy, according to Donald Williams, MD, chief medical officer of Resolution Biomedical.

The test involves a cyto-brush sampling method that measures gross changes in the nuclear DNA content of oral epithelial cells, providing information about the precancerous or cancerous state of a lesion, the company explained. The samples are sent to medical testing labs, and the report is sent to the dentist within four to five days, the same time frame as biopsies. Dentists send the samples to the company, which prepares the slides and sends them to labs, which prepare a diagnostic report for the dentists.

“It’s a way to triage patients where something may be suspicious but the patient is balking about getting a biopsy,” Dr. Williams told “It could be leukoplakia lesions or thrush instead of an indication of a neoplasm. It rules out biopsies without an invasive process.”

When dentists refer patients to periodontists to get biopsies of suspicious lesions, many patients don’t follow through on the recommendation because they find it a daunting procedure, Dr. Williams noted.

“Some patients think, ‘I’ve had this for years and it hasn’t killed me, so I don’t want to be biopsied,’ ” he said. “It’s kind of frightening to say you’re going to have a piece of meat cut out of your mouth.”

The most logical application is for worrisome lesions that are likely benign, Dr. Williams said.

Ongoing clinical trial
Resolution Biomedical conducted about five validation studies of the ClearPrep OC test in general practices over six months, Dr. Williams said. It is now being tested with Southern California dentists.

In addition, the test is in the second phase of a trial study with cancer patients in the City of Hope cancer research hospital in Duarte, CA. ClearPrep OC and saliva samples will be taken, and p16 stains will be done on the biopsy specimens. All the modalities then will be combined before a blind match is done. The company plans to do a joint publication based on the results with the University of California, Los Angeles, Dr. Williams said. The test was primarily designed for gynecologic cytology pap tests, but Resolution Biomedical realized it also had potential to detect oral cancer.

The company does not plan on doing an official launch of the product, which has no marketing restrictions since nongynecologic cytology tests are an established medical practice, according to Dr. Williams. As a result, the test does not require U.S. Food and Drug Administration clearance or need to be Clinical Laboratory Improvement Amendments (CLIA)-certified, he said.

While the test is being provided for free to dentists, patients and labs pay $60 to $125 — much less than biopsies, which range from $400 to $500, according to Dr. Williams. It is usually covered by insurance, and dentists can charge a collection fee for the process, including interpreting the final report, according to Dr. Williams. Company revenues will be derived from the testing labs it uses for analysis.

“Biopsies are invasive, expensive, and painful,” said company CEO Mike Friedl. “This is an intermediate way to rule out stuff while you’re still at the dentist rather than going to a specialist.”

The test is especially suitable if the condition is simply a treatable condition, such as a fungal change, and doesn’t require a trip to see a specialist, Friedl noted. Since the human papillomavirus (HPV) is now associated with many oral cancers, the company tests for it if the sample shows any degree of atypism.

Sol Silverman Jr., DDS, a professor of oral medicine in the University of California, San Francisco (UCSF) School of Dentistry and head of one of the oral medicine clinics at UCSF, called the ClearPrep test a good adjunctive diagnostic technique.

“Cytology has been around a long time, and it’s very high-quality,” Dr. Silverman told “Any technique that will accelerate the recognition of dysplasia is important. Early detection is still our best approach to good survival results.”

March, 2013|Oral Cancer News|