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Oral Cancer: Stop Assuming and Start Screening by Alison Stahl, RDH, BS and Neil Gottehrer, DDS

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Interprofessional collaboration for optimal patient health and wellness has never been more important, especially with advancements related to electronic health records. With so many specialties, whole-body health is often fragmented by specific body systems and therefore, for better or worse, the roles and responsibilities of providers are intertwined.

Recently I saw my physician for a routine physical. The nurse checked my vitals, height and weight, and made sure my medication list on file was up to date. The nurse also asked if I had any specific concerns for the doctor. The physician listened to my heart and lungs, pressed on my abdomen, palpated my thyroid and asked me to say "ahh." The visit concluded with a flu shot and an order for routine blood work. This sounds like a fairly typical exam from a family practitioner, right?

Before leaving, I asked the doctor if there was a reason he didn't check more of the lymph nodes of my head and neck, or examine my back for suspicious moles. He replied that he would have if I mentioned a concern, but knew from my medical history responses that I see a dentist and dermatologist regularly.

He said, "Those providers are checking these structures for abnormalities."

I thought, "Are they?" The last time I visited the dermatologist, she addressed the one concern and did no other screening beyond the face. I don't know about you, but I can't see my own back well enough to know if I should be concerned about any moles there. Thankfully, my dentist and hygienist perform a comprehensive head and neck exam. But my question to other dental providers is, "Do you screen?" Or do you, like my physician, assume that if a person sees another health-care provider, that he or she is doing the comprehensive extraoral and intraoral exams?

Detection and prevention
Helping our patients achieve a beautiful smile goes well beyond aesthetics and oral hygiene. Oral cancer is dentistry's cancer, and the suffering endured by our patients who face this disease is often debilitating. We can make a difference by actively engaging our patients during our routine exams—educating them about current risk factors, trends and healthy lifestyles, and teaching self-examination. According to the Oral Cancer Foundation, one person dies from oral cancer every hour of every day. "When found at early stages of development, oral cancers have an 80 to 90 percent survival rate."1 But we must look be looking and feeling for abnormalities in order to detect it!

The high morbidity rate of 43 percent at five years is primarily attributed to the cancer's late stage at the time of diagnosis. Dental professionals have an opportunity to change these statistics by screening all patients and also teaching them how to do self-exams. This leads to chances of early discovery; treatment interventions at this stage will result in more favorable outcomes as well as an improved quality of life for survivors.

Does your screening protocol include extraoral palpation of the lymph nodes and glands of the head and neck region?2 Through my involvement with the OCF, I've had the opportunity to interview quite a few oral cancer survivors and asked them if their provider did comprehensive screenings. I've been surprised to hear how many of these people recall the dentist or hygienist looking at their tongue (which is great), but none of them noted the administration of the extraoral portion of the exam. Palpation of the lymph nodes and glands of the head and neck region should not be overlooked and is a vital part of the comprehensive screening exam. Tenderness is typically associated with an active infection; however, swollen, non-tender lymph nodes that have been present more than two weeks are especially concerning and could signify malignancies.

Although tobacco use (in all of its forms) and alcohol are still major risk factors for oral cancer, HPV-related cancers are on the rise, affecting many younger, non-smoking adults. HPV-positive cancers most often reside in the tonsils, back of the oropharynx, or base of the tongue. They may not be visible during an intraoral exam, so in addition to extraoral palpation, it is imperative that we also ask patients pertinent questions that may indicate the need for further follow-up exams or testing.

Patients should be asked if they've experienced any difficulty with swallowing, change or hoarseness in voice, persistent cough, or unilateral ear pain that lasts more than a few days, as these can all be warning signs or symptoms of disease. Any sore that does not heal within 14 days should also be tested for a definitive diagnosis. "Watching it" for any longer than that is negligent and may pose liability concerns under legal scrutiny. Referral to an oral surgeon and/or ENT should be documented under these conditions.

April is Oral Cancer Awareness Month
Please make a commitment to spread awareness, and help put an end to the devastating outcomes associated with late-stage detection of this disease. Need a refresher? View an online video at: https://www.youtube.com/watch?v=zPRDeFxDO5M

It's never too late to start incorporating this potentially lifesaving exam into your practice. Insurance coding includes this evaluation in the description of the periodic exam. CDT 2015 defines the 0120 procedure (Periodic Oral Evaluation — Established Patient) as follows: "An evaluation performed on a patient of record to determine any changes in the patient's dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening, where indicated, and may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately."

Comprehensive screenings take only a few minutes, yet they have the potential to save the life of your patient. Our patients are counting on us to be their partners in oral health. We are entrusted with this responsibility and should view it as an opportunity to elevate our profession through education and interprofessional collaboration, accepting with pride the vital role we play in overall health and wellness.

References
  1. Oral Cancer Foundation: www.oralcancer.org
  2. Wolters Kluwer Health: http://pmtwww.uptodate.com/contents/image?imageKey=PI/55189&topicKey=PI%2F691&source=outline_link


Alison Stahl is an adjunct clinical supervisor at William Rainey Harper College and practices clinically for a general dentist in Glenview, Illinois. As a regional coordinator for the Oral Cancer Foundation, she also advocates for oral cancer awareness and early detection through opportunistic screenings. She has launched initiatives in her state to raise awareness about oral cancer by coordinating an annual walk/run and a multitude of free public screening events. Stahl is a recipient of the 2014 Sunstar Award of Distinction and the 2013 Young Dental Caring Clinician Award for her work related to these outreach efforts.



You know the statistics by now. According to the National Cancer Institute, about 43,500 people in the United States will be newly diagnosed with oral cancer this year. This number includes those cancers that occur in the mouth itself, on the lips and in the oropharynx. The sad thing is that next to skin cancer, oral cancer is the most visible form of cancer.

When diagnosed in later stages, the oral-cancer survival rate is 50 percent. Many who survive must endure painful, disfiguring and expensive surgery. The late film critic Roger Ebert, who battled both thyroid and salivary-gland cancers, was a high-profile example of this. His Esquire Magazine post-surgery photo in February 2010 shocked people, yet increased public awareness of the disease. Conversely, when detected early, the survival rate for oral cancer is more than 90 percent. It could be argued that no other medical professional has the potential to directly influence the reduction of cancer mortality statistics like we do.

Oral cancer is no longer the disease of hard-drinking, heavy-smoking, middle-aged and older men. The definition of an at-risk adult is skewing younger, due to the common practice of oral sex and the potential risks presented by the oral HPV 16-18 virus.

This virus is proving to be an unfortunate equalizer in that more young women are now at risk for oral cancer than ever before. Every adult should receive a thorough oral-cancer exam on an annual basis. It takes only five minutes, and the exam is easily integrated into an existing hygiene protocol.

I found something! Now what?
After implementing a consistent and comprehensive screening protocol, it's only a matter of time before you see something that doesn't look right. Is it a temporary lesion or premalignant? This is the type of decision that causes dentists the most angst and one that, quite frankly, many of us were not trained for—especially when it comes to communicating our concerns to the patient.

We tremble at the thought of having to tell someone that he or she may have oral cancer. So what do most dentists do if they see something odd? Many default to a biopsy. In some ways this is akin to punting in football. Yes, it is better to be safe than sorry, but wouldn't it be better to be more certain that the recommended biopsy is needed?

Why is it that well over 90 percent of biopsies turn out negative? It is not a reflection upon the efficacy of the procedure, as biopsies remain the gold standard for evaluating the malignancy of a tissue sample. It is because so many needless biopsies are performed, which greatly skews the results. Moreover, biopsies are invasive, often painful, and scare the patient.

What if you could be more certain about your biopsy referrals? Wouldn't that be a major improvement in our oral-cancer-screening protocol? Enter salivary diagnostics.

The SaliMark OSCC salivary biomarker test for oral cancer can serve as a valuable addition to the dental clinician's armamentarium for discovering oral cancer disease. SaliMark OSCC aids in the identification and early detection of oral lesions and abnormalities at the highest risk for cancer by analyzing the patient's saliva to detect the presence of molecular RNA biomarkers specific to OSCC. Salivary testing is the next logical procedural step after identifying a suspicious lesion. This painless, noninvasive test can accurately quantify whether or not you need to refer your patient to a specialist for consideration of a biopsy. The test has a sensitivity rating of more than 95 percent and has a negative predictive value of more than 99 percent in typical screening populations.

Conclusion
Oral cancer is a deadly, disfiguring disease that has a high survival rate when detected early. Today's dental teams have a variety of tools at their disposal to help them identify suspicious lesions that may be early-stage oral cancers. The latest breakthrough is a salivary test that will prove to be invaluable in quantifying the risk of suspicious lesions, therby improving early detection while reducing the number of negative biopsies. However, early detection of oral cancer starts with performing an exam on every adult patient.

Neil Gottehrer is a board-certified, practicing periodontist and the chief dental officer of PeriRx LLC, a developer of breakthrough, noninvasive, oral-diagnostic technology that will help clinical professionals detect and treat diseases sooner and enhance the practice of wellness management.



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