Exfoliative cytology for dental students

A.Beeula MDS

1. EXFOLIATIVE CYTOLOGY DR.A.BEEULA 1 ST MDS DEPT.OF ORAL PATHOLOGY CHETTINAD DENTAL COLLEGE AND &RI

2. SYNOPSIS Definition Rationale History of Exfoliative Cytology, in oral cavity Indications & Contraindications Materials required Sites for smear & its preparation Types of Smear & procedure Staining & interpretation Advantages & Disadvantages Conclusion References

3. DEFINITION Exfoliative cytology is the microscopic examination of shed, desquamated cells from body surfaces or cells harvested by rubbing or brushing a lesional tissue surface. Also, includes cells harvested from mucous membranes and body fluids.

4. DOES SALIVA CONTAINS CELLS? yes

5. HISTORY: 1843 Walshe Cancer cells in sputum 1851 Lebert Alterations of cells size in cancer cytology 1860 Beale Cancer cells drawn from oropharynx 1927 Dudgeon Direct smear technique 1943 Papanicolaou and Traut Routine test in cervical cancers

6. HISTORY OF ORAL EXFOLIATIVE CYTOLOGY 1890 Miller Epithelial cells and leucocytes in saliva 1939 Orban and weinmann Cellular contents of saliva in patients with dental caries 1940 Ziskin and kamen et al Use of exfoliative cytology in oral cavity 1951 Miller and Montgomery EC in normal mucousa 1951 Montgomery and hamm EC method of diagnosing oral cancer 1963 sandler Methods of obtaining smears

7. INDICATIONS Hesitant dentist or patient for biopsy Large or multiple lesions Difficulty in biopsy Microbial infection - herpes or candida Follow up - Recurrence An innocuous lesion

8. CONTRAINDICATIONS Obvious cancererous lesion Unreliable patient A sub-mucosal lesion Dry or crusted lesions such as in lip

9. SITES FOR SMEAR Buccal mucosa Junction of hard and soft palate Dorsum of the tongue Floor of the mouth Lower labial region

10. MATERIALS REQUIRED Microscopic slides Cell harvesting instruments: Wooden/metal spatula Cytobrush Tooth brush Fixative Slide marking pen Clinical report form

11. PREPARATION OF THE TISSUE SITE NO wiping/drying Debris or slough  wet gauze used to clean Tender lesion  L.A application Exudates  treated like blood smear

12. SMEAR TAKING/HARVESTING CELLS

13. PAPANICOLAOU STAINING Hematoxylin  nuclei  blue/black Light green sf  cytoplasm  blue/green OG-6  keratinizing cells  pink/orange Eosin y  squamous cells , nucleoli , RBC’s  red/pink

14. INTERPRETATING THE SMEAR Class 1 (normal) Only normal cells are observed Class 2 (atypical) Presence of minor atypia due to inflammation. No signs of malignancy. Class 3 (intermediate) Wider atypia with severe dysplasia , carcinoma-in-situ or cancer Class 4 (suggestive of cancer) Shows few epithelial cells with malignant changes. Biopsy is mandatory. Class 5 (positive for cancer) Cells shows characteristic malignant changes. Biopsy is mandatory.

15. NORMAL CELL CYTOLOGY Anucleated Orthokeratinized sq. cells polygonal cytoplasm stains orange to yellow Superficial cells show pyknotic nuclei

16. ATYPICAL CELL IN CYTOLOGY Proportionate enlargement Colonization bacteria in cytoplasm Viral infection- ballooning degeneration and Inclusion bodies. giant nuclei and multinucleated Cells seen Fungal infection- yeast cells and hyphae

17. CELLS IN CARCINOMA Nuclear abnormalities increased nuclear size irregular shapes multinucleated abnormal mitosis nuclear hyper chromatism altered nuclear cytoplasmic ratio degenerative changes of the nuclei Cytoplasmic abnormalities scanty cytoplasm vacuolization and inclusions altered staining Cell as whole enlargement bizarre shapes

18. RECENT TRENDS IN EXFOLIATIVE CYTOLOGY ViziLite plus with Tblue VEL Scope Microlux Oral CDX

19. MICROLUX DL SYSTEM After noting any white lesion during routine examination, simply ask the patient to rinse with microlux DL 1% acetic acid solution for 60sec Then use microlux and repeat the examination Since acetic acid dehydrates the cytoplasm of the lesion, the refractive properties of the lesion is changed Under diffuse light it become more visible The irregular takes up the whitish hue with contrast to surrounding tissues, helps to identify the abnormalities easily and requires further testing

20. VELSCOPE SYSTEM

21. DIAGNOSTIC TEST Diagnostic test and newer smear collecting instruments were deviced to aid in harvesting the adequate cells for microscopy Cytobrush liquid based cytology oral CDX

22. LIQUID BASED CYTOLOGY

23. METHODS IN DEVELOPMENT Laser capture microdissection Lab-on-a-chip sensor technique DNA image cytometry Saliva based oral cancer diagnosis Molecular analysis Microscopy spectroscopy

24. LASER CAPTURE MICRODISSECTION

25. DNA IMAGE CYTOMETRY Measures the malignant potential of cells by the DNA ploidy The program, identifies the deviations in the cellular DNA content This method has 100% sensitivity and specificity

26. SALIVA BASED ORAL CANCER DIAGNOSIS Used to measure specific salivary macromolecules and proteomic or genomic targets It determines the prognosis of oral cancer and for monitoring post therapy status

27. MOLECULAR ANALYSIS Combined with liquid based cytology- visualization of the malignant cells using antibodies against cytokeratin AE1 and AE3 Nuclear organizer regions (NOR) measures the proliferation of the cells and thereby differentiates the reactive lesions from non-neoplastic lesion Protein-chip arrays (SELDI) is a recent technique of monitoring the lesions based on expression of protein levels

28. USES OF ORAL EXFOLIATIVE CYTOLOGY Early detection and control of oral cancer ,microbial diseases ( candidiasis, viral infections) and dermatological lesions Assessment of nutrition iron deficiency Forensic dentistry (age and sex identification) Study of conditions like D.M, smoking, pregnancy and agening Prediction of cellular response of tumour to radiation

29. ADVANTAGES Non- invasive, painless Minimal skills Patient compliance Cost effective Performed in large number Minimal instruments required Early diagnosis of lesion Can be used in patients with systemic disorders were biopsy is contraindicated Easily done at the chairside

30. DISADVANTAGES False negative results Only an adjuvant Contamination Low sensitivity Inadequate sampling Not usable in non epithelial lesions

31. CONCLUSION Exfoliative cytology is a non-invasive and pain free , non-aggressive and rapid technique. All the dentist can perform the technique , because of this there is a big challenge for cytology to become a routine procedure in patients with oral mucosa problems.

32. REFERENCES Shafer’s text book oral pathology Ogden GR et al. Oral Exfoliative cytology: review of methods of assessment. J Oral Path Med 1997; 26: 201-205. Neville, Damm , Allen and Bouquot ; Oral and maxillofacial pathology 2nd edition by Elsevier 2002 www. Google .com