After an informed public, the dental community is the first line of defense in the early detection of oral cancer. It is important that both private individuals and members of the dental community realize that a visit to the dentist is no longer just about a cleaning, a filling, or a crown. Dental examinations, when properly done, and which include a screening for oral cancer, will save lives.
Unlike many other cancer screening procedures, oral cancer screening has potential for easier public compliance. With oral cancer screening, there is no invasive technique or pain involved, and visits are inexpensive or often free. Educating the public regarding oral cancer and the risk factors for the disease, as well as developing public awareness of the need for annual screening for oral cancer, are primary responsibilities of the dental community.
- Oral Cancer Screening – The Patient Perspective
As lay people, we will not know always know what doctors or dentists are seeing, doing, or thinking as they examine our mouths for oral cancer. Are they going to recognize the early signs? Are they looking where it typically occurs? Are they using all of the tools available to them? We may not know for certain, but there are things that will indicate whether a professional is doing a thorough job or not.
Being informed is the first step in taking good care of yourself, choosing competent care, and recognizing potential problems early. When it comes to finding a medical or dental professional who may save your life by performing an annual screening, you need to be concerned with looking for more than just good personality and chairside manner. Understanding the screening process will help you evaluate if you are in good hands.
Part of a comprehensive exam is answering questions. Your answers may reveal issues that change the examiner’s decisions after the physical exam, or direct him or her to explore a particular area in greater detail. The first thing your medical or dental professional will want to know is if you have experienced any problems or noticed any changes. Be candid. Some of the newer cases of oral, head, and neck cancers have signs and symptoms that are very subtle. In disease caused by the HPV (Human Papilloma Virus), for example, the oral environment may be completely normal in appearance, so your description of symptoms is important. Some of the questions you should expect to hear are:
- Have you noticed any changes in swallowing? Do things seem to stick or catch in your throat when you swallow? This sensation usually is not painful, but becomes more noticeable over time. Most people have a tendency to ignore subtle symptoms like this, especially if they are not painful.
- Have you had any chronic hoarseness? Hoarseness for less than two weeks may indicate a passing infection, but hoarseness over an extended period of time, longer than two weeks, could indicate something more serious.
- Have you noticed or felt any small lumps when feeling the side of your neck while putting on makeup or when shaving? Painful swollen lumps are usually a sign of infection, not cancer. Painless nodes, again something that people tend to ignore, can indicate the metastasis of an oropharyngeal cancer away from the inside of the mouth out into the lymph nodes of the neck.
- Have you had any earaches, particularly only on one side, that refuse to go away? Persistent, unilateral (one-sided) earache can be a red flag.
- Have you or anyone else noticed a change in your voice? Again, similar to hoarseness, there may be changes in how your tongue moves and helps you form certain sounds when you speak, which you may feel and others may hear. The ability to stick your tongue out straight without it veering to the side may also be difficult. Oral cancers that impact the nerves that control the movement of the tongue can be painless and alter your speech in very subtle ways.
These types of questions will help your medical or dental examiner reach helpful and more accurate conclusions about your health. Keep in mind that signs and symptoms alone are often harmless and unrelated to oral cancer. Medical and dental professionals are trained to look for a combination of signs and symptoms to determine the need for further examination.
A good oral cancer exam is both visual and tactile. It takes eyes trained in what and where to look for things, and gloved fingers to feel particular areas as well. Some doctors will use additional devices to do the exam, such as different lights, pre-examination rinses that help them visualize areas of suspicion, or even dye on an area of suspect tissue. Rest assured that while these add to the thoroughness of the exam, a visual and tactile examination with the eyes and fingers only, when conducted by a trained professional, will do a good job of finding oral cancer early if it is done properly.
In addition to asking questions, your doctor or dentist will also be making observations. A good practitioner is sensitive to subtle indicators, such as a slur in your speech, a corner of the mouth that does not move as well as the other, or a slight swelling on one side of your face. A sore on your lip may be obvious, but asymmetry of your features, uncoordinated mouth movements, or drooping may be less noticeable. Some examiners look for these things as you approach, so it may not be apparent that any observations have actually taken place.
After speaking with you, your healthcare provider will conduct a brief manual exam of your face, neck, lips, and mouth to look for any signs of cancer. If you have dentures (plates) or partials, you will be asked to remove them. This is in order to see all the soft tissue areas of the mouth.
Manual palpation, or feeling with the hands and fingers, is a very important part of the examination. Before the use of rubber gloves, a hands-on exam of the oral cavity was called a “wet finger” exam. If the examiner uses only a wooden tongue blade or a mouth mirror for your screening, opportunities to detect significant cancer signs may be missed. Many times the tongue blade is put right on an area that needs to be checked. Some professionals are beginning to use adjunctive devices to assist them in doing a thorough screening. These devices, which include various lights, dyes, and even tissue collection brushes, may add to the process, but are not a substitute for a correctly done, white light, visual and tactile screening. The examiner needs to actually feel parts of your tongue and mouth.
With both hands, the examiner will feel the external area under your jaw and the outside of your neck, checking for lumps (enlarged lymph nodes) that may suggest inflammation. If these nodes are painless, but hard and enlarged, and feel like they are fixated in position, it can be a red flag. When feeling the floor or bottom of the mouth, a finger is placed under your tongue, and the fingers of the other hand placed under your chin. Rolling the soft tissues between the two, the examiner can detect enlarged nodes or other hard spots called indurations that may be areas of concern. He or she will then look at and feel the insides of your lips and cheeks to check for possible signs of cancer, or pre-cancerous tissue changes, such as red and/or white patches, or thickened areas.
You will be asked to stick out your tongue so it can be checked for swelling, and abnormal color or texture. The examiner will see if, as the tongue is extended, it deviates to one side or the other, a sign that something is possibly affecting the nerves which control its movement. Using a small piece of gauze, the examiner will then gently pull your tongue to each side in order to fully see its edges, a common location for sores or lesions to occur, and will likely feel the borders of the tongue for hard spots at the same time. A common site for oral cancer to occur is at the base of the tongue where it begins to curve down a person’s throat. This area cannot be visualized well unless the tongue is pulled forward, and the gauze is necessary to do this. The forward pull on your tongue to roll that portion of it up into a more visible position may be a little uncomfortable, but is not painful. The underside of your tongue will also be checked.
Ear, nose, and throat specialists are especially skilled at running a gloved finger across the part of your tongue that is farther back in the throat, feeling for any roughness that could indicate development of a base of tongue cancer. They do this quickly so that it does not elicit a gag reflex. This is a very important part of the tactile exam.
Additionally, your medical or dental professional will visually examine the roof and floor of your mouth, the back of your throat, and the tonsillar pillars on each side. When viewed directly from the front, the opening to the back of your mouth and throat should appear symmetrical and not swollen on either side. This triangular shape, formed by the tonsillar pillars on each side and the tongue on the bottom, is referred to as the trigone. The trigone is symmetrical in most people, but if one side is enlarged and that swelling is also painless, it could be an indication of beginning tonsillar cancer, a common viral-caused cancer, particularly in non-smokers.
When you get home from your screening, take a few minutes to look carefully inside your mouth with a hand mirror. You can also ask your dentist to walk you through a self-exam while you are in the dental office. When you are aware of what your mouth looks like normally, you will be able to recognize changes that may take place between screenings. Regular, monthly self-examinations are particularly important if you have known risk factors for developing oral cancer, such as smoking or using smokeless tobacco. If any changes occur, they need to be brought to the attention of a qualified professional for examination. When you go in for your next dental exam, remember to bring to the examiner’s attention to areas of concern that you may have felt or noticed. This ensures that your concerns will be explored carefully, and your doctor will have an opportunity to evaluate what you have noticed.
Unfortunately, no screening technique for any cancer is one hundred percent effective. An annual visual and tactile exam is not a guarantee that every cancer or precancer will be caught, particularly those that arise from HPV viral infections. However, oral cancer screenings are painless, inexpensive or often free, non-invasive, involve no exposure to anything with possibility of long-term harm, like radiation exposure, and can be accomplished quickly, in just a few minutes, as part of your regular dental visit. If your medical or dental professional does not do this screening automatically, ask for it. If you are not sure whether or not your provider examined you for oral cancer, ask yourself if your tongue was gently pulled out with gauze. That is hard to forget!
Again, signs and symptoms alone are not necessarily of oral cancer concern, but together they may indicate the need to refer you to a specialist, or to have further diagnostic procedures. Early detection is the key to survival. If you are told that you do not need a screening because you are young, a non-smoker, or for other reasons, you are talking to someone who is not current in their knowledge of oral cancer risk factors.
The fastest growing segment of the oral cancer population is young, non-smoking individuals who come into the disease from the HPV16 virus, which also causes cervical cancers. It is the most common sexually-transferred infection in the U.S., and the CDC (Centers for Disease Control and Prevention) has said that between 50%-80% of the entire U.S. population will have an HPV infection at some point in their lifetime. People with HPV infections have no symptoms, and may never know that they have been exposed or that their body has cleared it and recovered. Therefore, if you are old enough to have engaged in sexual contact, you are old enough to need an annual oral cancer screening. It is the patient’s responsibility to routinely visit the dentist , and to be aware of and report any changes in the head, neck, and mouth to the medical or dental professional.
- Discovery and Diagnosis
When it comes to oral cancer and saving lives, awareness, discovery, diagnosis, and referral are the primary responsibilities of the dental community. Annual opportunistic oral cancer exams are a must. They should not be considered a postponable elective procedure. The most important step in reducing the death rate from oral cancer is early discovery, and no group has more opportunity to have an impact on this than members of the dental community.
Dental and medical professionals must be current in the knowledge base necessary to make a proper diagnosis, and be competent in the proper screening procedures to identify the possibility of oral cancer. At the very least, persistent abnormalities need to be identified by general dental professionals and sent for referral and biopsy when warranted.
The average person routinely has conditions existing in their mouths that mimic the appearance of pre-cancerous changes or very early cancers of the soft tissues, therefore, it can be difficult to determine which abnormal tissues in the mouth are worth of concern. One study determined that the average dentist sees three to five patients a day who exhibit soft tissue abnormalities, the vast majority of which are benign in nature. Even basic lesions, such as a canker sore (herpes simplex), a wound from accidentally biting the inside of your cheek, or sore spots from a poorly fitting prosthetic appliance or denture, can, on first examination, share similarities with more dangerous lesions. Some of these conditions cause physical discomfort, others are painless. The question is which ones deserve action, and which ones bear watching and waiting?
There is a tendency to watch areas over an extended period of time to determine if they are harmless or not. Unfortunately, this can lead to situations in which a cancerous lesion is allowed to continue growing, and becomes a later-stage, harder-to-cure cancer. For this reason, any sore, discoloration, induration, prominent (exophytic) tissue, irritation, hoarseness, complaints of difficulty in swallowing, or unilateral earache that does not resolve within a two-week period, with or without treatment, should be considered suspect and require further examination or referral.
Once suspect tissues have been detected, or red flag issues revealed in a patient’s oral history, the only way a definitive diagnosis of oral cancer can be made is through biopsy. Given the large number of tissue abnormalities a dentist sees every day, it is not logical, nor practical, that each one of these is biopsied. In fact, two of the most prevalent lesions that mimic oral cancer are the herpes simplex ulceration and aphthous ulcerations, each resolving of their own accord in approximately 10-14 days. One question that can help determine which abnormalities bear closer examination, is how long the suspect conditions have been present? Any condition that has existed for 14 days or more without resolution is in need of further diagnostic procedures or referral. In addition, oral cancers seldom, if ever, present bilaterally in the oral environment, nor do they routinely appear on the midline. While these guidelines are not absolutes, they can aid in determining which abnormalities are of immediate concern.
While this process creates a continuous chain of custody and referral during the discovery and diagnostic process, patients with positive findings will continue to need dental care. As they prepare for treatment and for management of oral issues before treatment begins, as well as during and after the treatment process, the dental professional is a core part of the team that will see to their needs as a cancer patient. When it comes to oral cancer and saving lives, these are the primary responsibilities of the dental community.
Despite advances in surgical techniques, radiation therapy technology, and the addition of combined chemotherapy and radiation therapy to the treatment regimen, survival data has not shown appreciable change in decades. Five-year survival data reveal overall disease-specific survival rates of less than 60%, although those that do survive often endure major functional, cosmetic, and psychological burden due to dysfunction of the ability to speak, swallow, breathe, and chew. The goal is to discover oral, head and neck cancers early, before patients present complaining of a mass, bleeding, pain, otalgia (earache), or dysplasia (Difficulty swallowing).
A thorough, systematic examination of the mouth and neck need only take a few minutes and can detect these cancers at an early, and curable, stage. Errors in diagnosis are most often ones of omission, and therefore the importance of a systematic approach to the oral, head and neck cancer examination should not be overstated.
Source: Oral Cancer Foundation
Now its your turn, why don’t you tell us when was the last time you had oral cancer screening? And how was your procedure?
I read each and every comment.
Haider Maitham, DDS / Bondistry