A thorough exam reinforces importance of screening
By Kellie Kennedy, RDH, BS
How carefully are you screening for oral cancer with each patient? Do you know that each day 100 new cases of oral cancer will be diagnosed in the United States, and one person every hour of every day will die from it?1 In addition, an increase in new cases has occurred among populations such as nonsmoking men and women under 50 years old who have not typically been at risk in the past. New research has surfaced in the last five years that provides compelling evidence for certain variants of the human papillomavirus (HPV) as a causative agent, joining tobacco, alcohol, sun exposure, and diet as the risk factors associated with new oral cancer cases.2
Considering these alarming revelations, the role of the dental hygienist in oral cancer-related patient education and examinations is more vital than ever.
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Data collected between 2008 and 2011 seem to indicate that oral cancer is on the rise, more aggressively among populations that have not historically been impacted by the disease.
In addition, this data shows that the instances of the disease within the oral environment has shifted from cases associated with tobacco and alcohol (the anterior of the mouth) to the posterior of the oral cavity, which is associated with cases caused by HPV type 16.3 This indicates a dramatic departure from historical data. From a dental hygiene perspective, this switch has real-world implications for screening and patient education.
Oral-health professionals have an obligation to patients to educate them about the very real threat of oral cancer, helping them understand that screening for oral cancer is as important as cervical, prostate, or breast cancer screenings.
Primary risk factors
The National Institute of Dental and Craniofacial Research cites the five most common contributors to oral cancers as:
- Tobacco and alcohol use. Most cases of oral cancer are linked to cigarette smoking, heavy alcohol use, or the use of both tobacco and alcohol together. Using tobacco plus alcohol poses a much greater risk than using either substance alone.
- Infection with the sexually transmitted human papillomavirus (specifically the HPV 16 type) has been linked to a subset of oral cancers at any age.
- Risk increases with age. Oral cancer most often occurs in people over the age of 40.
- Cancer of the lip can be caused by sun exposure.
- A diet low in fruits and vegetables may play a role in oral cancer development.
Dental hygienists are trained to see or feel the precursor tissue changes or the actual cancer while it is still at a very early stage.4 Oral-health providers can emphasize awareness of frequent, normal tissue changes in the mouth. Patients need to be aware of any changes that they notice or feel in their mouths and to inform dental hygienists if they notice something that is not healing or lasting longer than a two-week period.5 It is critical to know how to conduct the intraoral and extraoral examinations thoroughly, what early cancerous lesions may look like, and what the next steps are when a suspicious lesion is located.
A thorough oral cancer exam can take just minutes with your patient in the chair, but needs to be visual and tactile. "Patient positioning, optimum lighting, and effective retractions for accessibility and visibility contribute to the accuracy and completeness."6 Bilateral palpations are a must. Some clinicians also use additional devices to do the exam. They can aid in the thoroughness and visualizing areas of suspicion, but are not a substitute for a tactile and correct visual screening.7
The sequence of the examination presented below is adapted from "Detecting Oral Cancer" by the National Institutes of Health. The examination is conducted with the patient seated. Any intraoral prostheses are removed before starting. The extraoral and perioral tissues are examined first, followed by the intraoral tissues. Keep in mind when doing an oral cancer screening, tobacco and alcohol associated cancers are mostly found on the anterior regions of the mouth and lateral borders of the tongue. HPV16 related oral cancers can be found on the posterior sites of the oral cavity, the oropharynx, the tonsils, and the base of tongue areas.4
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The extraoral examination
- Face: The extraoral assessment includes inspection of the face, head, and neck. Note any asymmetry or changes on the skin such as crusts, fissuring, growths, and/or color change. The regional lymph node areas are bilaterally palpated to detect any enlarged nodes. If enlargement is detected, the examiner should determine the mobility and consistency of the nodes. A recommended order of examination includes the preauricular, submandibular, anterior cervical, posterior auricular, and posterior cervical regions.
Perioral and intraoral soft tissue examination
The perioral and intraoral examination procedure follows a seven-step, systematic assessment of the lips; labial mucosa and sulcus; commissures, buccal mucosa and sulcus; gingiva and alveolar ridge; tongue; floor of the mouth; and hard and soft palates.
- Lips: Begin examination by observing the lips with the patient's mouth both closed and open. Note the color, texture, and any surface abnormalities of the upper and lower vermilion borders.
- Labial mucosa: With the patient's mouth partially open, visually examine the labial mucosa and sulcus of the maxillary vestibule and frenum and the mandibular vestibule. Observe the color, texture, and any swelling or other abnormalities of the vestibular mucosa and gingiva.
- Buccal mucosa: Retract the buccal mucosa. Examine first the right then the left buccal mucosa extending from the labial commissure and back to the anterior tonsillar pillar. Note any change in pigmentation, color, texture, mobility, and other abnormalities of the mucosa, making sure that the commissures are examined carefully and are not covered by the retractors during the retraction of the cheek.
- Gingiva: First, examine the buccal and labial aspects of the gingiva and alveolar ridges (processes) by starting with the right maxillary posterior gingiva and alveolar ridge and then move around the arch to the left posterior area. Drop to the left mandibular posterior gingiva and alveolar ridge and move around the arch to the right posterior area.
Secondly, examine the palatal and lingual aspects as had been done on the facial side, from right to left on the palatal (maxilla) and left to right on the lingual (mandible).
- Tongue: With the patient's tongue at rest, and mouth partially open, inspect the dorsum of the tongue for any swelling, ulceration, coating, or variation in size, color, or texture. Also, note any change in the pattern of the papillae covering the surface of the tongue and examine the tip of the tongue. The patient should then protrude the tongue, and the examiner should note any abnormality of mobility or positioning.
With the aid of mouth mirrors, inspect the right and left lateral margins of the tongue. Grasping the tip of the tongue with a piece of gauze will assist full protrusion and will aid examination of the more posterior aspects of the tongue's lateral borders. Then examine the ventral surface. Palpate the tongue to detect growths.
- Floor: With the tongue still elevated, inspect the floor of the mouth for changes in color, texture, swellings, or other surface abnormalities.
- Palate: With the mouth wide open and the patient's head tilted back, gently depress the base of the tongue with a mouth mirror. First inspect the hard and then the soft palate. Examine all soft palate and oropharyngeal tissues. Bimanually palpate the floor of the mouth for any abnormalities. All mucosal or facial tissues that seem to be abnormal should be palpated.
What to look for
Dr. Esther Wilkins breaks down the five basic forms of early cancer appearance in the textbook, "Clinical Practice of the Dental Hygienist." The characteristics that she describes include:
- White areas vary from a filmy, barely visible change in the mucosa to heavy, thick, heaped-up areas of dry keratinized tissue.
- Fissures, ulcers, or areas of induration in a white area are most indicative of malignancy.
- Leukoplakia is a white patch or plaque that cannot be scraped off or characterized as any other disease. It may be associated with physical or chemical agents and the use of tobacco.
- Lesions of red, velvety consistency, sometimes with small ulcers.
- Erythroplakia is a term used to designate lesions of the oral mucosa that appear as bright red patches or plaques that cannot be characterized as any specific disease.
- Ulcers may have flat or raised margins.
- Palpation may reveal induration.
- Papillary masses, sometimes with ulcerated areas, occur as elevations above the surrounding tissues.
- Other masses may occur below the normal mucosa and may be found only by palpation.
- Brown or black areas of pigmentation may be located on mucosa where pigmentation does not normally occur.
If any of these suggested suspicious lesions are identified, a procedure for follow-up should be a part of the protocol. It is advised to have the dentist biopsy immediately, use a cytologic smear, or have the patient referred to a specialist for additional diagnosis and biopsy.6 Documentation is our legal responsibility. Note in the patient's chart every detail of the examination, as well as size, color, and location of lesion. Note all lifestyle habits with referral or recommendations for follow-up.
On average, we see our patients every six months, which may be more than the patient sees their general physician. It is our duty to make sure our patients are treated with the highest standard of care at every maintenance appointment, which includes a detailed oral cancer exam.
KELLIE KENNEDY, RDH, BS, is a clinical instructor at New York University. She also has been a practicing dental hygienist in Manhattan since 2009. She can be contacted at [email protected].
6. Wilkins, Ester M., BS,RDH,DMD., Clinical Practice for the Dental Hygienist. Publisher: Lippincott Williams & Wilkins Published January 30th, 2012