Title	Dental radiograph as an opportunistic screening tool for a colorectal cancer syndrome
Clinical Question	Does dental radiograph serve as an opportunistic screening tool for early detection of extraintestinal manifestations of Familial Adenomatous Polyposis (FAP) in children and adults?
Clinical Bottom Line	Incidental findings on dental radiographs could serve as screening tools for systemic diseases and syndromes. The attention should be raised when gene mutation, congenitally diseases or familial colorectal cancer are reported by patients during the medical history questionnaire. For patients with risk of FAP, the Dental panoramic radiographic score (DPRS) is inexpensive, and reinforce the referral for the further clinical investigation, gene mapping and colonoscopy of these patients and families. It should be considered as a valid tool in detecting the early presence of the disease. (The dental-radiographically-detectable extraintestinal manifestations of FAP)
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 766398 Thakker et al./ 1995 153 patients with and without gene mutation or linkage. A third group of clinically low-risk adults. Gold standard-controlled diagnostic study Key results By applying the proposed weighted score system (DPRS) in a sample combining FAP-affected (n=85), unaffected by linkage/mutation (n=49) and low-risk patients (19), this study validated the proposed methodology. Dental panoramic radiographs were used against the reference standard for FAP. The radiologist evaluators were blinded to the disease. The score system lists and weights the incidental findings. The 82% sensitivity and 88% specificity in addition to the reliability tests validated the method efficacy in 79%. The predictive positive value ranged from 96% – 92% and negative predictive value from 66% to 74% depending on the group, the efficiency of the test was declared as being in average 80%. 28887722 Septer et al./2018 68 female children Case Control Study Key results From out of the affected children (n=22) and matched control (n=46) investigated, the most frequent dental anomalies linked to the APC mutation were osteomas (77%) and sclerosis (44%), both p=0.0001. The evaluators were not blinded due to the fact that the genetic study status of the participants, the reference standard for the disease (genetic mutation status) was known before the panoramic radiograph imaging. The study showed association of gene mutation and dental anomalies in females from 9 – 15 years old. They emphasized the risk of undiagnosed FAP patients if these oral anomalies are not investigated and the benefits of screening the dental radiographs leading to an early detection of colorectal cancer. 26331960 Almeida et al./2016 1635 patients, 20 studies qualitatively assessed and 16 included in the meta-analysis. Meta-Analysis Key results Key Results: Due to the fact that FAP is a rare condition, the studies included in this systematic review were basically designed as case controls and case series (confirmed by the high heterogeneity I2=97.2% CI:96-97 and p=0.001). The total sample size was 1635, a reasonable number of affected individuals. An extensive search strategy including electronic databases, grey literature, reference lists and expects were pursuit. The level of evidence was low due to the studies’ design, and the risk of bias considered moderate to high. The attention was raised to mucosal lesions; however, these findings were not consistently reported by the included studies. The frequency of osseous lesions was 65% (osteomas of the jaw and skull). The dental anomalies incidence around 35% comprising odontomas, supernumeraries, and unerupted teeth.
Evidence Search	((familial adenomatous polyposis OR Gardner syndrome OR FAP)) AND (dental radiography OR dental panoramic OR panoramic OR oral manifestations OR dental phenotype)
Comments on The Evidence	Validity: The studies are valid and their methodology replicable. Thakker et al. developed a useful screening tool to score the abnormal dental findings, the diagnostic parameters such as sensitivity and specificity were high and easy to be applied by the general dentists or dental hygiene without increasing cost or chair-time. Septer et al. investigated children (10yo), they emphasize the importance of surveillance and early detection of colorectal cancer oral manifestations. At last, the meta-analysis assessed several studies that despite being considered weak evidence in the hierarchy of research evidence (case series and case reports) brought together a reasonable amount of FAP patients (n=1635). The majority of the dental anomalies such as osteomas, sclerosis and root alterations were consistent between all studies. Perspective: These studies emphasize the extra-intestinal manifestations of colorectal cancer. The dental anomalies, commonly considered incidental findings, appear around 10 years before the clinical evidence of the intestinal polyps and the dental professional should be aware of these correlations. Since the gene mutation affects families, it is important to early detect, refer and map genetically these patients reducing the morbidity. The colorectal cancer is considered a public health issue, FAP patients are rare; however, easily detected by dental radiographs due to the numerous abnormal radiograph findings.
Applicability	The selected studies aimed to disseminate the screening tools for FAP. The sample and imaging modality of the studies were representative of the patients the oral health care professionals see on a daily basis. Surveillance of incidental findings should be promoted by dentists and hygienists. The opportunistic screening of abnormalities in routinely taken panoramic radiographs may be implemented since there is no cost and radiation harm involved. It is important to propagate such scoring systems (DRPS) to assist on the screening of suspected patients. The earlier detection and referral prevent the development and promote awareness to the dento-osseous manifestations of colorectal cancer.
Specialty	(Public Health) (Oral Medicine/Pathology/Radiology) (Endodontics) (General Dentistry) (Oral Surgery) (Orthodontics) (Pediatric Dentistry) (Prosthodontics) (Restorative Dentistry) (Interprofessional CATs)
Keywords	Familial Adenomatous Polyposis, FAP, Gardner Syndrome, Desmoid tumor, Adenoma
ID#	3342
Date of submission	11/16/2018
E-mail	pereirac@uthscsa.edu
Author	Camila Pacheco-Pereira
Co-author(s)
Co-author(s) e-mail
Faculty mentor	Thomas II S Deahl
Faculty mentor e-mail	DEAHL@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available