Oral Cancer Screenings

Early Detection Can Protect Patients.
In 2002, Bruce Paltrow, an acclaimed television and film director and producer, died after suffering for years from complications due to oral cancer. He was 58 years old. After Paltrow’s death, Blythe Danner (an accomplished actress and Paltrow’s wife), partnered with the Oral Cancer Foundation (OCF) to raise awareness for early screening of the disease. In 2006, Danner told ABC News, “Because [the tumor] was hidden way back in [his] throat, it was hard to detect. [If he had] stage I or stage II, he’d still be with us, I think.” Danner emphasized the need for early detection of oral cancer. She said, “Early detection, prevention, it just has to be out there much more, and it hasn’t been out there in the mainstream media.”

Dentists can play key roles in making screenings of oral cancer as common as mammograms and colonoscopies. With massive advertising campaigns in the past few decades, mammograms and colonoscopies have become household terms. The Centers for Disease Control and Prevention (CDC) reports that about 66 percent of women aged 40 and over have had a mammogram in the last two years and 65 percent of adults aged 50 to 75 have had a recent colonoscopy. In contrast, the OCF reports that fewer than 25 percent of those who regularly visit a dentist receive an oral cancer screening. Your patients are likely unaware how pervasive oral cancer is and that you can help them with early screenings. Here are some important facts and risk factors for you to know.

Oral Cancer—The Facts
Oral cancer (any cancer that originates in the mouth or throat) is the sixth most common cancer worldwide. Oral cancer includes mouth cancer, tongue cancer, tonsil cancer, throat cancer, and cancers in the middle part of the throat behind the mouth (the oropharynx). For 2016, the American Cancer Society estimates that about 48,330 people will get oral cavity or oropharyngeal cancer.

More than 8,500 Americans die from the disease each year. The OCF reports that “the death rate for oral cancer is higher than that of cancers which we hear about routinely such as cervical cancer, Hodgkin’s lymphoma, laryngeal cancer, cancer of the testes, and endocrine system cancers such as thyroid, or skin cancer (malignant melanoma).”

When caught early, the five-year survival rate for oral cancer is about 83 percent. This number drops to just 32 percent when the cancer is not discovered until its later stages, after it has begun to spread.

According to the OCF, the death rate for oral cancer has been historically high because it is usually not discovered until late in development. In the early stages, when the cancer is more easily treatable, it is typically painless and symptomless. By the time a patient begins noticing symptoms, the cancer has often spread to the lymph nodes in the neck, and has grown deep into the tissues where it began. At that point, the prognosis is significantly worse.

The key to prevention and successful treatment of oral cancer is early detection. Changes in tissue that signal the beginnings of cancer can be easily seen and felt by a trained medical professional. The best way to screen for oral cancer is a thorough visual and tactile exam. Because an estimated 60 percent of Americans visit dental practices once a year, dental professionals are in a great position to detect early signs of this cancer. Every person who enters a dental office represents an opportunity to catch oral cancer in its early stage.

With shifting at-risk populations, it is now more important than ever to screen as many people as possible. On its website, the OCF reports that, “opportunistic screening of ALL patients must become the norm if the death rate is to be reduced.”

Common Risk Factors
When completing a patient’s health history form, it may be helpful to ask patients about lifestyle choices that may increase their risk for oral cancer. While some factors are out of a patient’s control (such as age and genetics), lifestyle choices are often the biggest factors in increasing the risk of oral cancer. Knowing a patient’s history can help dentists determine whether patients should be screened annually or even more frequently.

1. Tobacco
Tobacco usage tops the list of risk factors. In the past, about 75 percent of people aged 50 years and older who were diagnosed with oral cancer were tobacco users. Today, the Cancer Treatment Centers of America (CTCA) reports that “About 80 percent of people with oral cavity and oropharyngeal cancers use tobacco in the form of cigarettes, chewing tobacco or snuff.” Even exposure to secondhand smoke increases the oral cancer risk. A 2009 study in Cancer Epidemiology, Biomarkers & Prevention reported an 87 percent increase in oral cancer risk for people who had never smoked but had been exposed to smoke at work or at home.
2. Alcohol
Heavy use of alcohol, particularly when combined with smoking, also increases the risk of developing oral cancer. The CTCA reports that “About 70 percent of people diagnosed with oral cancer are heavy drinkers.”
3. Diet
According to the National Institute of Dental and Craniofacial Research, diet may also play a role in increasing cancer risk. A diet low in fruits and vegetables may be a factor in cancer development.
4. Sun Exposure
Sun exposure is also a major risk factor, particularly for cancers that appear on the lips. With increased use of sun protection in recent years, the incidence of this particular oral cancer has decreased. But this risk factor may still apply for individuals who spend a lot of time outdoors for work or recreation.
5. Age
Age is also a risk factor; the average age for an oral cancer diagnosis is 62 years old, and two-thirds of those diagnosed are over than the age of 55. Oral cancer is also more common in men than women.
6. Human Papillomavirus (HPV) Infection
The demographic statistics for oral cancer are beginning to shift. In recent years, younger, non-smoking patients are the fastest growing segment of the oral cancer population. This change is due to a newly emerging risk factor: HPV.

Many strains of HPV are harmless, several cause warts, and a few are linked to cancer. One strain, HPV16, is linked to oropharyngeal cancer. In 20- to 30-year-old men and women, cases of oral cancer caused by HPV16 are beginning to replace cases of cancer caused by tobacco products.

Additionally, while men have historically been diagnosed with oral cancer six times more often than women, in recent years the gap has shrunk dramatically. Men are still twice as likely to have oral cancer as women, but the statistics may continue to change as HPV-related cancers rise.

The Dentist’s Role
Currently, most patients report feeling symptoms (pain, a mass, bleeding, otalgia, or dysphagia) before receiving a screening from a dentist or a doctor. But often, once symptoms appear, it’s too late to treat the cancer easily.

A screening takes just a few minutes, and can reveal abnormalities that could develop into cancer long before symptoms appear. With the main cause of oral cancer shifting to HPV16, it is difficult to determine which populations are at greatest risk.

The dentist’s first responsibility is to educate his or her patients about oral cancer—particularly the risk factors and any early signs and symptoms. Alongside raising awareness, “the dental community is the first line of defense in early detection of the disease,” according to the OCF. To fulfill this role, the OCF recommends that dentists add routine cancer screenings to their regular exams, at least on an annual basis. Patients who are at a higher risk should be screened more often, if possible.

Oral cancer screening is quick, painless, inexpensive, non-invasive, and effective. Therefore, offering oral cancer screenings is a great way to add value to a dental practice and build trust with patients. Patients get peace of mind about a growing cancer threat, and the confidence that their dentist cares about their overall health.

Conducting a Screening
Dental professionals do not need any special training or qualifications to perform oral cancer screenings. As in all dental procedures, patients should feel comfortable and informed about the process. Explain to patients what you plan on doing and why you are doing it—not only to put them at ease but to provide them the tools to conduct basic self-examinations as well (which further increases the chance of detecting any abnormalities early). Encourage patients to perform a brief self-examination at least once a month, looking for any abnormalities (you can find directions for oral cancer self examinations online through the American Dental Hygienists’ Association). When conducting an exam on patients, the OCF suggests that it is important to listen, look, and feel.

Listen
Ask patients the following questions:
1. Have you noticed any changes in swallowing? Do things seem to stick or catch in your throat when you swallow? (Difficulty swallowing can indicate the development of oral cancer at the base of the tongue.)
2. Have you had any chronic hoarseness? (Hoarseness lasting more than two weeks may indicate something more than an ordinary infection.)
3. While putting on makeup or shaving, have you noticed or felt any small lumps on the side of your neck? (Many people ignore painless lumps, but they may indicate the spread of cancer from the inside of the mouth into the lymph nodes.)
4. Have you had any earaches that seem to persist, particularly unilateral ones?
5. Have you or any of your friends noticed a change in your voice? (Oral cancer can subtly affect nerves that control the movement of the tongue, causing changes in voice and speech.)

While patients answer these questions, listen not only to the answers but also the sound of the patient’s voice. Is it hoarse and raspy? Changes in the voice can indicate growths in the throat or base of the tongue.

Look
While talking with patients, take note of facial asymmetry, masses, skin lesions, facial paralysis, swelling, or temporal wasting. It may be helpful to have a baseline photograph of the patient to compare, to make it easier to notice changes over time.

Feel
As you examine the oral cavity, mouth, and throat, it is important to feel each area to look for masses or abnormalities.

Keep Records and Follow Up
A cancer screening is only as good as the records you keep. Use a mouth map to document areas that seem abnormal in any way. In the record, include the size, shape, color, surface texture, consistency, location, and any previous trauma of the area in question. Any area that seems suspicious should be monitored for two weeks. If it persists for longer than two weeks, refer the patient to an oral surgeon or another specialist for further testing.

Diagnostic Aids
No device or diagnostic test can replace a thorough visual and tactile exam performed by a dental professional. However, when used as adjuncts to an exam, certain tools may be helpful, depending on the needs and scope of each individual dental practice. Diagnostic aids are just that—aids. The devices are intended to help dentists and other specialists in analyzing and interpreting test results.

Toluidine Blue Staining: Toluidine blue staining uses a blue dye that is supposed to stain cancerous oral lesions, making them easier to spot. In studies, its effectiveness is mixed, and it has a high rate of false positive results.

Tissue Reflectance: Tissue reflectance uses an acetic acid rinse that patients swish for one minute to remove the glycoprotein barrier. The dentist then activates a light stick containing hydrogen peroxide to produce a blue/white light source. Under this light source, normal tissue appears blue while abnormal tissue appears white with brighter and sharper margins. This is intended to make it easier to identify abnormal tissue. However, studies so far have not shown that tissue reflectance is any more effective than the naked eye.

Narrow Emission Tissue Fluorescence: This technique uses only light, without a rinse. It requires a specialized machine that uses a blue light to highlight abnormal tissue. Initial results using this technology are promising, but studies are limited.

Brush Cytology: If an abnormal area is found, brush cytology can evaluate the area. Cells from the suspect area are gently scraped and tested for malignancy. Brush cytology cannot provide a definitive diagnosis, but it may help dentists determine whether to refer a patient to an oral surgeon or another specialist for a biopsy based on the results.

Insurance
Most dental insurance plans cover some level of oral cancer screening as part of a routine dental examination. In some cases, a medical insurance plan may cover the screening since cancer is considered a medical condition rather than a dental one.

Screening for oral cancer is an important part of the dental professional’s responsibility to her or his patients. Conducting a thorough cancer screening typically takes less than five minutes, and has the potential of adding years to a patient’s life.

For more information and support, including sample marketing materials and downloadable fact sheets, release of liability forms, and referral forms, go to www.oralcancerfoundation.org.

References
Bouquo, J.E. “Oral Cancer Detection Equipment.” Inside Dentistry 7, no. 7. Accessed November 30, 2015. https://www.dentalaegis.com/id/2011/08/2011-technology-update-oral-cancer-detection-equipment.
Giesey, Nicole. “Oral Cancer Screening Update.” RDH Magazine. Accessed November 30, 2015. http://www.rdhmag.com/articles/print/volume-33/issue-3/features/oral-cancer-screening-update.html.
“Oral Cancer.” American Dental Association. Accessed November 30, 2015. http://www.mouthhealthy.org/en/az-topics/o/oral-cancer.
“The Oral Cancer Foundation.” The Oral Cancer Foundation. Accessed November 30, 2015. http://www.oralcancerfoundation.org.
“Oral Cancer Risk Factors.” Oral Cancer Risk Factors: Tobacco, Alcohol, Others. Accessed November 30, 2015. http://www.cancercenter.com/oral-cancer/risk-factors/.
“Oral Cavity and Oropharyngeal Cancer.” Oral Cavity and Oropharyngeal Cancer. Accessed November 30, 2015. http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/index.
“Paltrow Family Honors Dad’s Memory by Advocating for Cancer Awareness.” ABC News. Accessed May 16, 2016. http://abcnews.go.com/GMA/Health/story?id=1891663.