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

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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.

Let's get the word out
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.


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April 2024
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