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Check, Please! by Dr. Shahrooz Yazdani

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Categories: Oral Pathology, Pharmacology, and Cariology;
Check, Please! 

The importance of preventive screening in oral cancer management

by Dr. Shahrooz Yazdani

For anyone, a dreaded diagnosis from their health practitioner is the scary word that starts with the letter C: cancer. I would say dentists are lucky because our patients’ early-stage and localized oral cancer survival rates are very high (75%–93%).1 Once oral abnormalities are detected and cells can be biopsied for proper diagnosis, you can develop a treatment plan and likely reassure your patient that their health scare will be surmountable.

However, many forms of oral cancer go undetected because of patients’ compounding health and socioeconomic factors. Their prognosis is further affected by treatment plans and how their body responds. The duality of oral cancer diagnosis means that preventive dentistry and early detection are even more paramount to decreasing morbidity and mortality rates among patients.


Risk factors below the surface
Risk factors such as tobacco and alcohol use, genetics and HPV diagnosis can put patients at increased risk for oral cancer.2 While education can help redirect a patient’s oral health trajectory, I think it is worth illustrating just how important it is for dental practitioners to listen to each patient’s history and be diligent about detecting compounding risk factors that are more easily glossed over.

In my more than 25 years of experience in dentistry, I saw more oral cancer in two years doing a hospital residency at Carolinas Medical Center in North Carolina than in the subsequent 23 years in private practice. A couple of obvious reasons for this:
  • In residency, we were responsible for doing rounds and oral exams on patients undergoing stem cell transplants, bone marrow transplants, organ transplants, cancer treatment, etc. These patients were on significant immunosuppressant therapy and/or chemotherapy. It is well known that immune suppression increases the risk of cancer cells running unchecked.
  • In our residency, the hospital largely served the indigent population, who could not afford dentistry and had no dental insurance. Socioeconomic status significantly affects oral and overall health, including cancer risk.
What I took away from these experiences is that first, we must be extra vigilant when examining patients who are or have a history of being immunosuppressed. Whether the immunosuppression is caused by another cancer diagnosis elsewhere in the body or another condition, this should ring the alarm bells for a cautious oral cancer screening. Second, understanding the social history of your patients is just as important as understanding their physical health history. Through this more holistic approach, practitioners can more easily identify those who are at higher risk for oral cancer and screen accordingly.


Comprehensive exam, early detection
Despite the example above being in reference to hospital work, these facts are just as true for private practice. At my practice, we perform an oral cancer screening during every comprehensive and recall exam, starting with an extraoral exam to evaluate the tissues of the head and neck and proceeding to an intraoral exam. The intraoral exam consists of evaluating all internal soft tissues, including cheeks, lips, tongue, the floor of the mouth, roof of the mouth, back of the throat and all gingiva.

I recently noticed a lesion in a the mouth of a patient who used to be a smoker but hadn’t smoked in several years. I referred the patient to an oral surgeon, who removed the lesion. The diagnosis was carcinoma in situ. If the lesion had not been detected and removed, it would have spread and the patient’s long-term’s prognosis would have been grim. With the diagnosis and removal, however, there is a minimal risk of recurrence.

The main takeaway here is the importance of regular screening. Even if the patient no longer has the risk factors for oral cancer, historical risk factors can still increase the risk (although lessened) for these patients down the road.


A routine exam reveals a separate issue
Similarly, one of our associates, Dr. Mary Claire Bates, was performing a routine exam when she came across a mass in the patient’s cheek that turned out to be lymphoma.

As Bates recalled, “During this exam, we were checking for any abnormalities in the patient’s cheeks and lips, as we always do. The lesion noted during this exam was approximately 1 centimeter, circular, firm and nonmovable. The patient reported that palpation of the mass was not tender at that time. She had never noticed it herself and this was the first time our office was seeing her, so we had no previous records for her.

“At that time, because of the nature of the mass, we decided to send the patient to an oral surgeon for a biopsy. She was promptly seen by an oral surgeon in the Ottawa area and had the lesion biopsied; the results came back as a lymphoma. The patient then met with an oncologist for further investigation and testing, at which point they found additional cancer in her body. The doctors told the patient this cancer was separate from the lymphoma and likely wouldn’t have been discovered until much later without these additional tests. She came back after her initial biopsy to tell us this news and thanked us for being so thorough. She’s still undergoing treatment.”

This case reiterates just how sneaky this disease can be—but also that oral cancer can often be easier to detect than cancer in other, nonvisible parts of the body. “I think it’s always better to be safe than sorry,” Bates said, emphasizing the importance of dentists in private practice referring to specialists. For many forms of cancer, a biopsy is needed to confirm the diagnosis, and with a disease as unpredictable as cancer, that early diagnosis can make all the difference.


Conclusion
We know not every lesion is cause for major concern, but every abnormality deserves proper due diligence. Whenever an abnormality or lesion is presented, we can do follow-ups and see if anything heals on its own. From the point the patient first presents with a condition in our chair, we can take measurements and photos and compare changes before making the necessary referrals. With these proper records, the specialist will be well informed to help investigate the patient’s case further.

I have seen firsthand how effective and lifesaving it can be to identify potential oral cancer and make appropriate referrals. I’ve had a couple of patients thank me for saving their lives because the cancers were spotted when they were still in the early stages. I’ve also known individuals who had oral cancer that was undetected by their dentists, leading to major disfigurement. Thorough and intentional oral cancer screening is a tremendous way to bring great value to our patients. When you do so, don’t forget to tell the patient what you are doing, or you’ll miss the opportunity for the patient to understand how valuable you are to preserving their health.

References
1. Survival statistics for oral cancer. Canadian Cancer Society. Retrieved April 1, 2024, from cancer.ca.
2. Risk factors for oral cancer. Canadian Cancer Society. Retrieved April 1, 2024, from cancer.ca.

Author Bios
Dr. Shahrooz Yazdani Dr. Shahrooz Yazdani is the CEO and director of Yazdani Family Dentistry, which includes two practices in Ontario. Yazdani earned his DDS with honors from the University of Toronto, then completed a two-year residency. He has completed more than 1,000 hours of comprehensive CE through the Kois Center and a 330-hour implant and bone grafting course through Ti-Max in Toronto. He opened Yazdani Family Dentistry in 2001 and later expanded to a third location, Costello Family Dentistry.
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