Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 62-65

Effectiveness of a New Technique for Oral Cancer Screening – A Pilot Study


1 Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences, Department of Public Health Dentistry, Mangalore, India
2 Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences, Department of Oral & Maxillofacial Pathology and Microbiology, Mangalore, India
3 Goa Dental College and Hospital, Department of Public Health Dentistry, Goa, India
4 Yenepoya (Deemed to be University), Yenepoya Dental College, Department of Oral & Maxillofacial Pathology and Microbiology, Mangalore, India

Date of Submission07-Feb-2022
Date of Decision08-May-2022
Date of Acceptance11-May-2022
Date of Web Publication05-Aug-2022

Correspondence Address:
Urvashi Ashwin Shetty
Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences, Department of Oral & Maxillofacial Pathology and Microbiology, Mangalore
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jofs.jofs_43_22

Rights and Permissions
  Abstract 

Introduction: Screening programs with the use of specific diagnostic tools in asymptomatic patients are useful in identifying suspicious oral lesions and aid in the early diagnosis of oral cancer. The objective of the present study was to compare the oral rub and rinse technique with the conventional exfoliative cytology in the screening of oral malignant and potentially malignant diseases. Materials and Methods: An oral cancer screening program was conducted in the Dakshina Kannada district of Karnataka, India. The oral rub and rinse technique was performed on patients who had red/white lesions in the oral mucosa followed by the conventional exfoliative cytology. Scalpel biopsy was performed to confirm for presence or absence of malignancy in cases wherever indicated. Descriptive statistics (frequency and percentage) were used in the present study. Results: A total of 848 subjects were screened for oral cancer and precancer. About 112 participants had premalignant/malignant lesions and biopsy was performed on 30 subjects. Of these, 27.7% were Class I smears, 39.3% were Class II smears, 22.3% were Class III smears, 4.5% were Class IV smears, and 6.2% were unsatisfactory using the conventional technique, whereas the oral rub and rinse technique showed 26.8% Class I smears, 42.9% Class II smears, 19.6% Class III smears, 6.2% Class IV smears, 0.9% Class V smears, and 3.6% unsatisfactory. Conclusion: Although both the techniques could detect malignancy, the oral rub and rinse technique showed better cellular clarity and sample adequacy when compared to conventional exfoliative cytology, which makes it a practical tool in resource-challenged settings.

Keywords: Cytology, early diagnosis, mouth neoplasm, oral cancer screening


How to cite this article:
D’Cruz AM, Shetty P, Shetty UA, Bola VK, Prabhu VD. Effectiveness of a New Technique for Oral Cancer Screening – A Pilot Study. J Orofac Sci 2022;14:62-5

How to cite this URL:
D’Cruz AM, Shetty P, Shetty UA, Bola VK, Prabhu VD. Effectiveness of a New Technique for Oral Cancer Screening – A Pilot Study. J Orofac Sci [serial online] 2022 [cited 2022 Aug 7];14:62-5. Available from: https://www.jofs.in/text.asp?2022/14/1/62/353475




  Introduction Top


Oral and oropharyngeal cancers comprise about 2% to 10% of all cases of cancers in the body and are the sixth most common cancer worldwide. The majority of the oropharyngeal cancers are squamous cell carcinoma.[1] About 300,000 new cases are reported annually worldwide, of which 80,000 cases are diagnosed annually in India.[2] It is the most common cancer in men in India and ranks first. Among females, it is the third most common cancer.[3]

Early stages of oral cancer have a better prognosis than the advanced stages, but unfortunately they are usually detected at advanced stages (stage III and IV] due to which the prognosis may be very poor. The survival rate is very poor, with the average of 5-year survival rate being 50%.[1]

Early diagnosis of oral cancer is a priority health objective, in which oral health professionals may play a pivotal role. Detection should lead to less damage from cancer therapy and a better prognosis. Screening programs that identify asymptomatic patients with suspicious oral lesions and the use of specific diagnostic tools in asymptomatic patients with suspicious oral lesions to identify potentially malignant/malignant oral lesions in asymptomatic patients are two main approaches for the early detection of oral dysplasia and cancer.[3]

Screening programs for oral cancers may be an excellent platform for raising public awareness regarding behavioral risk factors associated with the occurrence of oral cancer such as tobacco and alcohol.[4] Several screening aids have been reported in the literature with varied results of efficacy, such as conventional oral examination, exfoliative cytology, brush biopsy, vital staining methods (toluidine blue, Lugol’s Iodine, etc.), and Light-based detection methods (ViziLite, Velscope, etc.).[5] Screening programs for detection of oral potentially malignant and malignant diseases need to be carried out using simple, cost-effective, noninvasive screening aids. The conventional exfoliative cytology methods, although simple, cost-efficient, and noninvasive, have disadvantages such as low sensitivity (i.e., a high proportion of false negatives), inadequate sampling, procedural errors, and the need for a subjective interpretation of findings.[6] Mulki et al reported a new technique ‘the oral rinse’ and compared diagnostic agreement between oral rinse–based smears and conventional smears. They concluded that both smears were diagnostically reliable; however, the oral rinse-based method showed an overall improvement in sample adequacy and cellular clarity. The study was carried out in clinically diagnosed and confirmed cases. There is a need to determine the efficacy of this new technique in the screening of the population for oral cancer and precancer. Hence, the present study was conducted to compare the oral rub and rinse technique with the conventional exfoliative cytology in the screening of oral malignant and potentially malignant diseases.


  Materials and Methods Top


An oral cancer screening program was conducted in various dental camps held in Dakshina Kannada district of Karnataka, India. All adult patients attending the camps who signed the informed consent were included. Patients with a known history of malignancy and treated for cancers (surgery, chemotherapy, radiotherapy) were excluded from the study. Ethical approval for this study (NU/CEC/2016-17/052) was provided by the Central Ethics Committee, Nitte (Deemed to be University), Mangalore, Karnataka on 20-04-2016.

Sample collection

A proforma collected sociodemographic details of the patients following which oral and dental screening was carried out. The oral rub and rinse technique was performed on patients who had red/white lesions in the oral mucosa followed by conventional exfoliative cytology. The patient was asked to rinse their mouth with water to clear any debris. Using firm finger pressure, the lesion was rubbed for 30 seconds by the clinician’s gloved finger. The patient was then asked to swish the mouth with 10 mL of 1% phosphate-buffered saline (pH 7.2) and expectorate into a sterile, labeled container.[7] Following the oral rub and rinse technique, the conventional exfoliative cytology was performed. A moistened wooden spatula was used to perform conventional exfoliative cytology. The lesion was scrapped and smeared onto a labeled glass slide.[8] The slides were then fixed with absolute alcohol and stained using the Papanicolaou (PAP) stain. Both the oral rub and rinse samples and slides of conventional exfoliative cytology were transported to the Oral Pathology lab. The oral rub and rinse samples were transported in cooler boxes with ice gel packs. The oral rub and rinse samples were centrifuged at 1000 rpm for 5 minutes in the laboratory to obtain a cell plug. After discarding the supernatant fluid, the cell plug was pipetted and smeared onto the labeled glass slides, fixed using absolute alcohol, and stained with PAP stain. The results obtained from both the techniques were compared. Scalpel biopsy was performed to confirm for presence or absence of malignancy in cases wherever indicated.

Smear assessment

All slides were assessed by one trained pre-calibrated cytopathologist who was not aware of the type of technique by which the material was collected.

Based on the above specified parameters, cytologic specimens were classified as follows:[8]

Class I (normal): Only normal cells are observed.

Class II (atypical): Presence of minor atypia but no evidence of malignant changes.

Class III (indeterminate): Wider atypia that may be suggestive of cancer, but they are not clear-cut and may represent precancerous lesions or carcinoma in situ. A biopsy is recommended.

Class IV (suggestive of cancer): A few cells with malignant changes or many cells with borderline characteristics. A biopsy is mandatory.

Class V (positive for cancer): Cells that are obviously malignant. A biopsy is mandatory.

For analysis, Classes I and II were considered negative and Classes III to V positive.

Biopsy

Wherever indicated, an incisional biopsy was performed and sent for histopathological analysis. The results were classified as negative or positive. Negative lesions included inflammatory lesions and acanthosis. Positive lesions included dysplasia (mild/moderate/severe), carcinoma in situ, oral lichen planus, oral submucous fibrosis, proliferative verrucous leukoplakia and verrucous carcinoma, and squamous cell carcinoma (well/moderate/poorly differentiated). Results from biopsy were considered as the gold standard of diagnosis.

The data obtained were tabulated in MS Excel for Windows and descriptive statistics was done using the SPSS Version 17.0 (SPSS Inc., Chicago).


  Results Top


A total of 848 subjects were screened for potentially malignant and malignant lesions. [Table 1] summarizes the age and gender distribution of the study participants. Most of the participants (29.2%) were in their third decade. About 65.9% of the study participants were males. Of the 848 participants, 112 had premalignant/malignant lesions. Of these, 27.7% were Class I smears, 39.3% were Class II smears, 22.3% were Class III smears, 4.5% were Class IV smears, and 6.2% were unsatisfactory using the conventional technique, whereas the oral rub and rinse technique showed 26.8% Class I smears, 42.9% Class II smears, 19.6% Class III smears, 6.2% Class IV smears, 0.9% Class V smears, and 3.6% unsatisfactory [Table 2].
Table 1 Age and gender distribution of the study participants

Click here to view
Table 2 Comparison of conventional exfoliative technique and oral rub and rinse technique

Click here to view


Out of the 112 study subjects, a biopsy was performed on 30 subjects. Most cases were epithelial dysplasia (30%), followed by leukoplakia (20%), hyperkeratosis (20%), carcinoma in situ (10%), squamous cell carcinoma (6.7%), verrucous carcinoma (6.7%), erythroplakia (3.3%), and verrucous hyperplasia (3.3%) [Table 3].
Table 3 Histopathology results of biopsy specimen

Click here to view



  Discussion Top


Despite advances in diagnostic and therapeutic modalities in the management of OSCC, the patient prognosis remains poor. Early diagnosis and prompt treatment help in improving patient outcomes. The present study attempts to evaluate the effectiveness of the oral rub and rinse technique over conventional exfoliative cytology in population screening of oral potentially malignant and malignant disorders.

There are several diagnostic adjuncts that are used alone or with conventional oral examination for screening of oral cancer and precancer such as exfoliative cytology, brush biopsy, vital staining methods, chemiluminescent techniques, and saliva-based diagnostic tests. However, scalpel biopsy is mandatory for confirmation of diagnosis and hence is considered the gold standard.[9],[10] Exfoliative cytology is the microscopic examination of the desquamated cells of the oral mucous membrane.[11] In normal oral epithelium, there is a continuous exfoliation of superficial epithelial as a part of the physiological turnover process. However, the deeper cells are strongly adhered to the basal epithelium. In the case of malignancy, the deeper cells become loose and exfoliate along with superficial cells.[7]

The results of the present study show that both the oral rub and rinse technique and the conventional exfoliative cytology could detect malignancy. Besra et al. in their study had reported that exfoliative cytology had a sensitivity of 95.91% and specificity of 99.17%.[12] Salih et al. reported an overall sensitivity of 79.5% and specificity of 100%.[13] Mulki et al. in their study reported that both the exfoliative cytology and the oral rub and rinse technique were diagnostically reliable. However, the oral rinsebased method had better cellular clarity.[7],[14]

Although scalpel biopsy followed by histopathology is considered the gold standard for diagnosing oral malignant and premalignant lesions, it may not be feasible to perform scalpel biopsy in all suspected cases in rural setup/screening camps. In spite of having red and white lesions, few barriers exist to perform biopsy at camps, such as lack of skilled clinicians, patient discomfort, and lack of armamentarium for transporting biopsy specimens at the campsite.[15] The oral rub and rinse technique being a noninvasive method has its advantages over biopsy. Like the exfoliative cytology, it can be used in anxious patients who refuse a surgical biopsy and in patients in whom biopsy may be contraindicated. The oral rub and rinse technique is a type of exfoliative cytology. The difference is in the collection of samples and preparation of smears. When centrifuged, the exfoliated epithelial cells collect at the bottom of the tubes forming a cell plug. Smears prepared out of this cell plug are better in quality than the smears prepared with the traditional method. Since the slides are prepared in the laboratory, only the tubes with 1% phosphate-buffered saline can be taken to the field for sample collection and can be stored in ice lined sample collection box till further processing. Hence, elaborate equipment and materials needn’t be taken to the field for screening.

The oral rub and rinse method have a few advantages over the conventional exfoliative cytology, such as better quality smears and better clarity of cells, thus ensuring better detection of dysplastic features. Moreover, multiple smear slides can be prepared from a single sample when compared to conventional exfoliative cytology. Also, the cell pellet obtained can be used as a source of salivary DNA and hence can be used in molecular studies. A technique that must be useful as a screening tool should be simple, noninvasive, painless (hence acceptable to the people), and replicable. The oral rub and rinse technique fulfills the above criteria.

Although both the techniques could detect malignancy, the oral rub and rinse technique showed better cellular clarity and sample adequacy when compared to conventional exfoliative cytology, which makes it a potentially practical tool in resource-challenged settings. However, it needs to be kept in mind that oral rub and rinse technique should not be used as a substitute for scalpel biopsy and histopathological examination.

Acknowledgment

The authors would like to thank all the study participants for their cooperation in conducting this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol 2009;45:309–16.  Back to cited text no. 1
    
2.
Coelho KR. Challenges of the oral cancer burden in India. J Cancer Epidemiol. 2012;2012:701932. doi: 10.1155/2012/701932.  Back to cited text no. 2
    
3.
Mehrotra R, Gupta DK. Exciting new advances in oral cancer diagnosis: avenues to early detection. Head Neck Oncol. 2011 Jul 28;3:33.  Back to cited text no. 3
    
4.
Agar NJM, Patel RS. Early detection, causes and screening of oral cancer. JSM Dent 2014;2:1039.  Back to cited text no. 4
    
5.
Reddy GS, Rao KE, Kumar KK, Sekhar PC, Prakash Chandra KL, Ramana Reddy BV. Diagnosis of oral cancer: the past and present. J Orofac Sci 2014;6:10–6.  Back to cited text no. 5
  [Full text]  
6.
Diniz Freitas M, García García A, Crespo Abelleira A, Martins Carneiro J, Gándara Rey JM. Applications of exfoliative cytology in the diagnosis of oral cancer. Med Oral 2004;9:355–61.  Back to cited text no. 6
    
7.
Shaila M, Shetty P, Pai P. A new approach to exfoliative cytology: a comparative cytomorphometric study. Indian J Cancer 2016;53:193–8.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Rajendran A, Sivapathasundaram B. Shafer’s Textbook of Oral Pathology. 7th ed. Elsevier India; 2012.  Back to cited text no. 8
    
9.
Brocklehurst P, Kujan O, O’Malley LA, Ogden G, Shepherd S, Glenny AM. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database Syst Rev 2013;(11):CD004150. doi: https://doi.org/10.1002/14651858.CD004150.pub4  Back to cited text no. 9
    
10.
Macey R, Walsh T, Brocklehurst P et al., Diagnostic tests for oral cancer and potentially malignant disorders in patients presenting with clinically evident lesions. Cochrane Database Syst Rev. 2015;2015 May 29(5):CD010276.  Back to cited text no. 10
    
11.
Sivapathasundharam B, Kalasagar M. Yet another article on exfoliative cytology. J Oral Maxillofac Pathol 2004;8:54–7.  Back to cited text no. 11
  [Full text]  
12.
Besra K, Samantaray S, Pathy PC, Das PK, Panda S, Rout N. Efficacy of oral exfoliative cytology in diagnosis of oral cancer. Int J Med Sci Public Health 2017;6:896–900.  Back to cited text no. 12
    
13.
Salih MA, Bushra MO, El Nabi AH, Yahia NA. Comparison between exfoliatve cytology and histopathology in detecting oral squamous cell carcinoma. Saudi J Oral Sci 2017;4:46–50.  Back to cited text no. 13
  [Full text]  
14.
Pereira T, Kesarkar K, Tamgadge A, Bhalerao S, Shetty S. Comparative analysis of oral rinse-based cytology and conventional exfoliative cytology: a pilot study. J Can Res Ther 2018;14:921–5.  Back to cited text no. 14
    
15.
Yang EC, Tan MT, Schwarz RA, Richards-Kortum RR, Gillenwater AM, Vigneswaran N. Noninvasive diagnostic adjuncts for the evaluation of potentially premalignant oral epithelial lesions: current limitations and future directions. Oral Surg Oral Med Oral Pathol Oral Radiol 2018;125:670–81.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
References
Article Tables

 Article Access Statistics
    Viewed34    
    Printed4    
    Emailed0    
    PDF Downloaded4    
    Comments [Add]    

Recommend this journal