April and Oral Cancer Awareness Month has just passed; a time when our attention once again turned to this insidious disease. Unfortunately due to over two-thirds of oral and oropharyngeal cancers being discovered in the later stages, only slightly more than half will be alive in 5 years. 1 As a dental hygienist, it is not only our responsibility but a requirement of our standards of practice to perform a thorough visual and tactile extraoral and intraoral examination.
There have been significant changes that have occurred in the landscape of oral and oropharyngeal cancer. There are two distinct etiologic pathways that exist; one the historical risk factors of smoking and alcohol and secondly, the more recent escalating viral transmission related to the Human papillomavirus (HPV). The Human papillomavirus is one of the most common sexually transmitted viruses. In fact, the CDC states that almost every sexually active adult will have a HPV infection in their lifetime. 2 The Special Topic feature of the 2016 Canadian Cancer Statistics was dedicated to HPV-associated cancers 3 (Figure 1). The 2016 HPV topic feature was driven by a media release recognizing that HPV was not just a threat to women {i.e. cervical cancer} but that ‘mouth and throat cancers are rising sharply in men.’ 4 HPV-associated cancers of the mouth and throat are said to surpass the rate of cervical cancer in females. 5 Presently in Canada, 1 in 3 HPV-associated cancers are diagnosed in men with 4 out of 5 oral and oropharyngeal HPV-related cancers being diagnosed in men. Between 1992 and 2012, HPV-related oral and oropharyngeal cancers have experienced a dramatic increase; 56% in males and 17% in females. 4 Eighty percent of HPV-related oropharyngeal cancers are diagnosed in men. 3 Many will not be aware that they have even been infected with the virus and will clear the infection within two years with no evident physical symptoms. This is the typical pathway for the vast majority if they possess a healthy functioning immune system. However for some who have contracted a high risk strain of the virus and have been plagued with persistent infection, the transformation to a malignancy is conceivable.
Figure 1
What are the ‘Toolkit’ Essentials?
The first essential in your ‘toolkit’ is an unwavering resolve to perform a thorough and effective visual and tactile extraoral and intraoral examination on every adult annually. Careful examination and palpation of the head and neck lymph nodes are critical aspects of the extraoral examination. A fixed, palpable, hard, non-tender node may be the first sign of an abnormal development that is not clinically visible or accessible by tactile examination. Typically and in the broadest terms, an infection-related node is most often tender, mobile and associated with a known or recent illness.
“The incidence rate of thyroid cancer is the most rapidly increasing incidence rate among all major cancers not only in Canada but worldwide.” 6 At the present time there is speculation to suggest that more frequent use of superior diagnostic capabilities of medical technology is allowing earlier stage, asymptomatic thyroid cancers to be diagnosed. 7 Another suggested etiologic contributor to the escalation of thyroid cancer is the exposure to diagnostic ionizing radiation that has increased over time promoting the initiation of tumour development. 8 Iodine intake is also under investigation as a possible contributing factor however much debate makes the confirmation of this etiologic factor uncertain at this time. 9
Observation and palpation of the thyroid gland may be done by instructing the client to swallow observing the superior movement. A glass of water may be required to assist the client in swallowing. Comparison of the two lobes may be accomplished by standing to the side of the client and “instructing the client to bend the neck forward and laterally toward the side being examined. Using manual palpation, place one hand on the side on the trachea, then with the other hand gently displace the thyroid tissue to that side of the neck and manually palpate the gland.” 10 Repeat for the other side. The thyroid may also be examined with the client in a supine position allowing for protrusion of the thyroid anatomy. With the close proximity of the thyroid gland to the skin, the supine position affords a visual inspection of the neck area for both enlargement and/or asymmetry.
All areas of the oral cavity need to be visually examined coupled with tactile palpation in a systematic order. The order may be as follows; the lips, labial and buccal mucosa, gingival tissues, tongue (dorsum, lateral borders and ventral surface), floor of the mouth, palatal tissues and oropharynx including uvula and tonsillar areas. The intraoral high risk anatomical areas include the palate, floor of the mouth, tongue and oropharyngeal areas. The palate must be visually examined and palpated. Bimanual palpation of the floor of the mouth is the only way an area of induration may be discovered (Figure 2). Visual examination is not sufficient to examine this very high risk anatomical area of the oral cavity. The tongue is a well-known potential lesion site and warrants careful examination as well. Visual and tactile palpation of the dorsum, lateral borders and the ventral surface of the tongue are required (Figure 3).
Figure 2
Figure 3
The v-shaped groove on the dorsum of the tongue referred to as the sulcus terminalus separates the oral cavity from the oropharyngeal region. To examine the oropharyngeal area it is recommended to place the mouth mirror (mirror side down) or tongue depressor on the midline of the dorsum of the tongue instructing the client to take a deep breath in and say ‘ah’.
Visual access to a number of these high risk areas has always presented its challenges. Once again, superior visual acuity with the use of magnification and headlights may make the difference between seeing something and missing it entirely (Figure 4). A new product to emerge is an all-in-one illuminated tongue depressor, Throat Scope™. The device enables illumination right at the site of examination whether it be viewing the floor of the mouth, retracting the tongue or depressing the tongue to gain visual access to the posterior regions of the oral cavity and oropharynx. Throat Scope™ also enables the client to perform a self-examination of the oral cavity illuminating many of the difficult areas to visually access (Figure 5).
Figure 4
Figure 5
The second essential in your ‘toolkit’ is knowledge. As primary oral health care professionals, dental hygienists have the capability along with the responsibility to employ oral cancer screening examinations. A systematic, thorough and effective screening has a profoundly positively impact on the ability to discover oral cancer in its earliest stages. Current knowledge of palpation techniques as well as identifying risk factors, signs and symptoms related to both non-HPV and HPV-associated oral and oropharyngeal cancer is critical to meet the needs of today’s population.
Symptoms of oral cancer to be aware of include however are not limited to:
- Bleeding in the mouth or throat or sore that does not heal within 14 days including under a denture or appliance
- Discoloration of the soft tissues; red, white, mixed or black
- An indurated or hard area, lump or thickening detectable visually or through palpation of soft tissues
- Continual lymphadenopathy; firm, fixed, non-tender and present for more than two weeks with no known etiology
- Unexplained weight loss
The more subtle symptoms that may accompany HPV-related oropharyngeal cancer include however are not limited to:
- Recurrent sore throat or persistent infection that does not resolve completely within 2 weeks or respond to antibiotics
- Hoarseness or change in speech; slurred speech
- Tongue that tracks to 1 side when stuck out
- A unilateral earache that persists
- Continual lymphadenopathy; firm, fixed, non-tender and present for more than two weeks with no known etiology
- A feeling like something is caught in the throat; continual cleaning of the throat
Our responsibility does not end in our chairside conversation and protocols. It is our mandate to translate knowledge to our dental hygiene clients. Does your practice have sufficient educational materials to empower your client to understand the importance of both the annual head and neck examination including the oral cancer screening as well as doing a periodic self-examination? The CDHA has developed a number of resources for your practice as well as educational materials for your client. Links to downloadable materials both from the CDHA and others are listed at the end of the article.
The Oral Cancer Foundation provides a number of marketing tools that inform your clients that your practice is dedicated to performing an oral cancer screening and making every attempt to discover oral cancer in its earliest stages (Figure 6). The Oral Cancer Foundation is a non-profit charitable organization dedicated to providing current scientific literature to the dental community, supporting oral cancer patients, their families, and contributing to funding ongoing research.
The 3rd essential in your ‘toolkit’ is improving the oral cancer screening examination through the exploration of employing an adjunctive screening device to complement the white light examination. Adjunctive screening devices employing direct fluorescence visualization such as VELscope, OralID or Identafi enable the clinician to view tissue changes beneath the surface where white light examination is unable to assist. With over two-thirds of oral cancers discovered in the later stages, it is clear that we need to utilize every capability possible to discover oral cancer in its earlier stages. The VELscope Vx system employs seamless smart technology capturing images, storing and emailing as required through the use of a magnet attached iPod touch (Figure 7).
Figure 6
Figure 7
Lastly, conduct your oral cancer screening as if a life depended on it. Your commitment to performing an effective and thorough extraoral and intraoral examination may save a life. There is no greater gift in this world that one human being can give to another.
Acknowledgements
The author would like to acknowledge and thank the Canadian Dental Hygienists Association for permission granted to use images from the online course “Oral Cancer Screening for Today’s Population” for educational purposes.
Disclosure
The author serves in the capacity as an opinion leader/consultant for Orascoptic, LED Dental Inc. and in an advisory position for Throat Scope.
Resources
CDHA Video – What to expect from an oral cancer screening examination http://www.dentalhygienecanada.ca/DHCanada/Your%20Oral%20Health/Oral_Cancer_Awareness/DHCanada/Information/Oral_Cancer.aspx
CDHA Fact Sheet and Quick Quiz http://www.dentalhygienecanada.ca/pdfs/education/OCS_FactSheet_2015.pdf
CDHA Oral Cancer Early Detection Flyer
CDHA Oral Cancer Screening for Today’s Population booklet – http://files.cdha.ca/Education/Courses/Oral-Cancer-4page-booklet.pdf
CDHA Oral Cancer Screening for Today’s Population (2015) – Online self-study http://www.cdha.ca/cdha/Education/Online_Courses/Oral_Cancer_Screening_for_Today_s_Population/CDHA/Education/Courses/Oral_Cancer_Screening.aspx
Oral Cancer Foundation Information Resource http://oralcancerfoundation.org/wp-content/uploads/2017/03/Oral-Cancer-and-HPV-Facts-2017.pdf
Health Canada ‘SMILE’ booklet – To obtain printed copies of the document (limit of 50 copies per order), contact publications@hc-sc.gc.ca
Lexi-Comp Reference Library “Oral Soft Tissue Diseases” www.lexi.com/dentistry (Promo code: RDHC01)
Oral Cancer Foundation professional products – http://www.ocfstore.org/Professional_Products_s/2.htm
http://www.velscope.com/education/downloads-center/
References
1. Oral Cancer Foundation. http://oralcancerfoundation.org/facts/
2. Centers for Disease Control and Prevention. Human Papillomavirus (HPV) https://www.cdc.gov/std/hpv/stdfact-hpv.htm
3. Canadian Cancer Statistics 2016. Special Topic HPV-Associated Cancers
4. Canadian Cancer Society. HPV not just a threat to women: mouth and throat cancers rising sharply in men. Media Release October 19, 2016. https://www.cancer.ca/en/about-us/for-media/media-releases/national/2016/canadian-cancer-statistics-2016/?region=bc
5. Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus and rising oropharyngeal cancer in the United States. J Clin Oncol 29(32):4294-301, 2011.
6. Pellegriti G, Frasca F, Regalbuto C, Squatrito S, Vigneri R. Worldwide increasing incidence of thyroid cancer: update on epidemiology and risk factors. J Cancer Epidemiol. 2013;1–10.
7. Kent WD, Hall SF, Isotalo PA, Houlden RL, George RL, Groome PA. Increased incidence of differentiated thyroid carcinoma and detection of subclinical disease. CMAJ. 2007;177(11):1357–61.
8. How J, Tabah R. Explaining the increasing incidence of differentiated thyroid cancer. CMAJ. 2007;177(11):1383–4.
9. Zimmermann MB, Galetti V. Iodine intake as a risk factor for thyroid cancer: a comprehensive review of animal and human studies. Thyroid Research 20158:8
10. Dental Hygiene Theory and Practice. 2nd Edition. Darby ML, Walsh MM. Extraoral and Intraoral Clinical Assessment, Ch. 12.
About the Author
As a successful entrepreneur and international, award winning speaker, Jo-Anne has been selected as one of DPR’s Top 25 Women in Dentistry and is a returning 2017 Dentistry Today CE Leader for the 7th consecutive year. Jo-Anne is president of an educational and clinical training company and a sought after writer for leading dental journals and publications across the U.S., Canada, and the UK. Her frank and open style of lecturing complemented by the provision of clinical resources has earned many loyal followers. She may be contacted at jjones@jo-annejones.com
