Author: Jo-Anne Jones, RDH
Source: ‘Oral Health Journal (www.oralhealthjournal.com)

If you have ever had a diagnosis from a medical doctor that leaves your life temporarily hanging in the balance, you will truly appreciate the emotional impact the diagnosis of oral cancer has on an individual.

For those that unfortunately receive this type of news, death may be very prolonged and extremely painful both mentally and physically. Unfortunately, this is the second year in a row in which there has been an increase in the number of occurrences, this time of about 11% over the previous year. 1

Here are the facts… the five-year survival rate from oral cancer has not significantly improved in the past 30 years, remaining at approximately 50-59% More than 34,000 (35,310 cases estimated in 2008 involving the oral cavity and pharynx2)Americans will be diagnosed with oral or pharyngeal cancer this year. It will cause over 8,000 deaths, killing roughly one person per hour, 24 hours per day. Of those 34,000 newly diagnosed individuals, only half will be alive in 5 years. This is a number which has not significantly improved in decades. The death rate for oral cancer is higher than that of cancers which we hear about routinely, such as cervical cancer, Hodgkin’s lymphoma, laryngeal cancer, cancer of the testes, endocrine system, thyroid, or skin cancer (malignant melanoma). If you expand the definition of oral cancers to include cancer of the larynx, for which the risk factors are the same, the number of diagnosed cases grows to 41,000 individuals, and 12,500 deaths per year in the US alone. Worldwide the problem is much greater, with over 400,000 new cases being found each year. The ratio of men to women diagnosed with oral cancer is 2:1. As the population ages, the ratio evens out to 1:1.3

There has been an eerie commonality that exists amongst a percentage of those individuals who have fallen prey to this disease. Non-smoker, non-drinker, healthy life style; diagnosis: oral cancer. The profile of an oral cancer victim is surprisingly unpredictable. Approximately 25% of all newly diagnosed cases of oral cancer do not fall into the typical profile associated with alcohol and tobacco usage.

Mounting scientific evidence though reveals that oral cancer possesses two distinct etiologies. One which we have been keenly aware of for decades is through usage of tobacco and alcohol and the other appears to be linked via the HPV virus exposure to the HPV-16 virus (human papilloma virus), the same one which is responsible for the vast majority of cervical cancers in women. 4 This may begin to explain the ‘unknown’ etiology and the bizarre atypical profile that accounts for 25% of diagnosed cases of oral cancer.

The HPV related sites of occurrence appear to be on the tonsillar area, oropharynx and the base of the tongue. Non-HPV positive tumors occur more frequently on the lateral/ventral portion of the tongue, floor of the mouth, soft palate, buccal mucosal tissue and the gingival/alveolar ridges with the lower lip accounting for the highest incidence of squamous cell carcinoma. The lower lip accounts for 30-40% of all oral carcinomas. It is much more common in males than females, occurring most commonly in patients who are in their fifth to eighth decade of life. 5

Emerging trends reveal that the incidence of HPV positive tumors occur most frequently in younger groups particularly white males who are non-smokers, whereas tobacco related malignancies are not as prevalent. The HPV group is the fastest growing segment of the oral cancer population. 4

Early detection is key

The overall five year survival rate for oral and oropharyngeal cancer is 52%. When oral cancer is found early though, this survival rate can be as high as 82%.2 At this time, the majority are found as late stage cancers, and this accounts for the high death rate.

As members of the health care profession, dental hygienists are in a prime position to greatly impact the early detection of oral cancer. Our dental clients need to understand that this examination is not considered to be elective, but mandatory. We need to educate our clients to be keenly tuned into the health of their mouth and to identify anything unusual or persistent such as;

• A sore or lesion in the mouth that does not heal within two weeks.

• A lump or thickening in the cheek.

• A white or red patch on the gums, tongue, tonsil, or lining of the mouth.

• A sore throat or a feeling that something is caught in the throat.

• Difficulty chewing or swallowing.

• Difficulty moving the jaw or tongue.

• Numbness of the tongue or other area of the mouth.

• Swelling of the jaw that causes dentures to fit poorly or become uncomfortable.

Oral cancer screenings performed by a dental professional must include a systematic visual examination of all the soft tissues of the mouth as well as external palpation of all lymph nodes of the face, oral regions and the neck and close examination of the lips. The tongue needs to be examined while manually extended observing the posterior third and the attachment to the floor of the mouth. A bi-manual palpation of the floor of the mouth is bilaterally required as well as a digital examination of the borders of the tongue. Observation of the roof of the mouth as well as the back of the throat and the tonsillar pillars form another integral part of the examination. A comprehensive oral examination is both visual and tactile.

We have fortunately seen a great drop in the mortality rate of cervical cancer through the utilization of routine cervical cancer screening in which a smear of exfoliated cells is specially stained and examined under a microscope for pathological changes. There are still a percentage of false positives however highly insignificant when compared to the decrease in mortality rate of 70-80%.

Science has made great progress

As a female medical patient, I am certainly well aware of the need for an annual cervical cancer screening. I understand that this screening is in my own best interests knowing that early detection of cellular changes is the key. As a professional body, we as dental hygienists tend to be hesitant to inform our clients that we are performing an oral cancer screening examination. Even though it may be carried out, the client is often unaware of exactly what we are looking for. We need to communicate the need for an oral cancer screening examination advising that it is designed to promote early detection of abnormal tissue changes.

A survey conducted by the American Dental Hygienists Association in 2006 reported that of 1,505 subjects surveyed, only 453 reported having been examined for oral cancer. Of that same group, 506 indicated that they did not have an examination, and 532 were not sure whether or not an oral cancer examination was performed.

Great strides are now being made in the world of dentistry to enable detection of suspect tissues in the oral cavity. With the use of VELscope by LED Dental Inc. the operator can use the principle of tissue fluorescence to help identify suspect tissue. VELscope has the potential to bridge the gap between a visual examination and an invasive biopsy. VELscope is a noninvasive, pain-free method of helping to identify abnormal mucosal changes that may be hard to detect or even invisible otherwise. Through the use of a visible and safe blue light (400-460 nanometres), the clinician is able to clearly see the distinction of normal vs. abnormal tissue through a change in the normal fluorescence pattern. The light will excite the tissue from the surface of the epithelium through to the basement membrane and into the stroma beneath causing it to fluoresce. Abnormal tissue typically appears as an irregular, dark area that stands out against the otherwise normal green fluorescence pattern of surrounding healthy tissue (Figures 1 and 2).

The argument exists that there may be a lack of clarity in distinguishing between abnormal and normal tissues by detecting the more common benign abnormal tissues. Loss of fluorescence will be evident in benign conditions such as apthous ulcers, lichen planus, benign migratory glossitis and pemphigoid. This is where the clinician exercises the compilation of all components of the client examination and history and applies critical thinking. Proper training and skill in communicating with the dental client are integral to incorporation of this device into the routine oral cancer screening examination. VELscope is intended as an adjunctive screening tool to the visual examination, not a diagnostic tool.

The profession of dental hygiene requires a commitment to life long learning. The incorporation of any new technology requires evidence based decision making and a strong commitment to training. As a colleague, I would challenge you to examine your present means of assessment for your clients and critically evaluate the level of care you are presently providing. If you have any part in early detection of this insidious disease, it will be a job well done. Saving lives… all in a day’s work.

References:
1. www.oralcancerfoundation.org/

2. American Cancer Society. Cancer Facts & Figures. 2008. Atlanta: American Cancer Society; 2008

3. www.oralcancerfoundation.org/facts/

4. www.oralcancerfoundation.org/hpv/index.htm

5. Sapp, J. P. Eversole, L. R., Wysocki, G. P. Contemporary Oral & Maxillofacial Pathology. 2nd Edition. Ch. 6 Epithelial disorders, p. 190-191

6. Hein C, Kunselman B, Frese P. Preliminary findings of consumer-patient’s perceptions of dental hygienists’ scope of practice/qualifications and the level of care being rendered. American Dental Hygienists’ Association Annual Session. June 2006.

7. Gurenlian, J. The Role of the Dental Hygienist in Oral Cancer Screening, Education, and Management. The Inside Summit on Oral Cancer Discovery and Management 2007;3(2):21-2.

Jo-Anne Jones is an international lecturer, author and owner of her own consulting business, Practice Smart. Working closely with the corporate sector, she remains active as a lecturer, researcher and key opinion leader focusing on best clinical practices and the enjoyment of best treatment outcomes.