By Mark E. Hyman, DDS, MAGD
As the close relationship between physical and oral health is more clearly understood, dentists find themselves at the forefront of the battle against oral cancer through early detection. Recent presidential debates brought national attention to the significant increase in the incidence of HPV cancers. While most of our patients know that human papillomavirus (HPV) is linked to cancer of the cervix, they may not know that HPV is involved in many other types of cancers, including 60% of oropharyngeal cancers. Performing thorough evaluations during each appointment gives us an opportunity to educate patients about the disease and its risk factors, help them identify symptoms, and, quite possibly, save their lives.
The death rate associated with oral cancer is particularly high — not because it is hard to discover or diagnose, but because the cancer is routinely discovered late in its development. Oral cancer is particularly dangerous because in its early stages the patient may not notice it. It frequently develops without producing pain or any symptoms the patient might readily recognize. It is insidious because it has a high risk of producing additional tumors.
Patients who survive a first encounter with the disease have up to a 20 times higher risk of developing a second cancer. Countering that bad news is the fact that oral cancer is 90% curable when it is found early.
Risk factors for oral cancer include tobacco and alcohol use, being male, and being over 60 years old. African-Americans with less access to care are also at high risk. Our office makes a note if a patient mentions other lifestyle factors that present risks for oral cancer, such as drug use, family history, and multiple sex partners. Consideration of sexual behavior is crucial because the increase in the incidence of oral sex in adolescents contributes to the unprecedented spread of HPV in America today.
The components of a thorough evaluation have advanced, along with the technological innovations we have experienced through the years. Whatever form of diagnostic technology is available to you, the key is making sure that you have a firm policy to promote regularly scheduled imaging. Our practice has a stringent radiology policy for all patients. This was established as a result of a tragic situation in which a patient, and dear friend of mine, was diagnosed with ameloblastoma of the mandible at a late stage. He subsequently underwent a hemi-mandibulectomy to save his life.
We did a panorex on him in 1989 and a full series in 1999, and without an established radiography schedule, we took bitewings for seven years. When he visited in 2006, we diagnosed the cancer. While we followed the best practice protocols, I carry deep regret that in those days we did not schedule full-mouth radiographs more frequently. We now have a concrete policy in which we perform annual bitewings, and we alternate our other forms of radiography every three years.
In our experience, the most low-tech method can also be the most effective in diagnosing oral cancer. At the beginning of each patient’s appointment, we update their medical record for changes in health or habits. We ask if there have been any changes in their mouth since their last appointment. If they mention any of the typical symptoms for oral cancer, like sores that bleed and don’t heal, swelling of the tongue or throat, red or white spots, or tiny marks that look similar to canker sores, we are on high alert.
Our evaluation includes checking soft tissue by separating the lips and inspecting the tongue thoroughly. The lateral border of the tongue and the floor of the mouth are the most common locations for the lesions that indicate oral cancer.
I use a wet 2x2 gauze to manipulate the tongue, and I palpate the cheeks and neck to detect lumps. If I find a lesion, I may biopsy it or send it to one of my oral surgeon colleagues for consideration. It is extremely important that all results are followed up in writing and promptly communicated to patients. An incomplete chain of custody can create serious problems for everyone.
We usually diagnose oral cancer at least once a year. Fortunately, it has always been at an early enough stage that our patients are able to treat the disease and make a complete recovery. While we may occasionally get some pushback from patients about our rigorous radiograph schedule, when we explain the benefits of early detection of oral cancer, they always see the value.
Mark E. Hyman, DDS, MAGD, practices full time in Greensboro, N.C. He is an adjunct associate professor at the UNC School of Dentistry, a Pankey Institute Instructor, and an international dental speaker. You may contact Dr. Hyman to speak for your study club or dental meeting via email at [email protected].
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