The Intraoral and Extraoral Exam

The purpose of this course is to introduce the protocol for a complete oral cancer examination with proper techniques for both the head and neck and intraoral examinations; to provide patient education information; to provide information on adjunct technologies that may be utilized in lesion detection and; to promote informing all patients that they are receiving a complete oral cancer examination.

In 2018, an estimated 396,937 People were living with oral cavity cancer in the United States. The National Cancer Institute (SEER) 2021 reports an estimate of new cases of oral cavity and pharyngeal cancers to be 54,010 which is 2.8% of all new cancer cases. This amounts to 10,850 of estimated deaths and 1.8% of all cancer deaths. SEER data suggests that 64.8% of patients will survive more than 5 years. Men are two times more likely to develop oral cancer. The average age is 63 and over — with only 20% under 55 years old. White males are more likely to develop cancer followed by black males and Hispanic males. The tongue is the most prominent area followed by the tonsils, oropharynx, gums and floor of the mouth.¹-³

Cancer of the Lung and bronchus is responsible for most full-body cancer deaths with 131,880 people expected to die from these cancers. Colon and rectal cancer is the second most commonly occurring cancer. The oral exam is extremely important in early oral cancer detection, but it is also invaluable in detecting other cancers that may occur elsewhere in the body, but may also exhibit signs within the oral tissues.

The increase in incidence of oropharyngeal cancer in white males is due to an increase in cancers at the base of the tongue and tonsils associated with human papillomavirus (HPV) infections.¹ It is expected that the rate of HPV infections will decrease in the future with the new vaccines that are available currently. Head and neck cancers rank 8th in cancers worldwide with an annual incidence rate of 600,000 individuals.⁴⁶ Studies have shown that visual and tactile examination of the structures of the head, neck and oral cavity are effective in detecting abnormalities occurring within these structures. Therefore, procedures such as the head and neck and intraoral examinations, often referred to as an oral cancer examination or oral cancer screening, are important elements of a complete patient assessment. These examinations should be performed on a routine basis for every patient, not just new patients or those with known risk factors such as the use of tobacco or alcohol, increasing age, or + HPV status.

Current SEER data indicates that over the last ten years, cancer rates in general have decreased. This is attributed to new testing technology, patient awareness, early intervention and a focus on life-style interventions. Only 5% of cancers are due to hereditary factors.² Early detection and treatment normally results in less surgery, less radiation and chemotherapy, and a better quality of life for the patient long-term. Treatment for oral, oropharyngeal and other head and neck cancers diagnosed at later stages is usually associated with more extensive dysfunction and disfigurement than treatment for those same cancers diagnosed in earlier stages. Complications associated with therapy for oral, oropharyngeal and other head and neck cancers include: altered eating and swallowing patterns, salivary gland dysfunction (often total loss of the salivary glands), and loss of hard and soft oral tissues such as teeth, bone, and parts of the tongue, among others. Recent SEER data reports an increase in detection of cancers in the posterior tongue region (Oral Pharyngeal Cancer). The estimate for new United States cases of oral cancer in 2021 is 54,010 with 10,850 deaths. This represents 1.8% of all cancer deaths. With more knowledge by dental professionals, more cancers are being identified and treated early.³ Additionally, the estimate from the American Cancer Society, Inc. 2021 estimates are 1,898,160 new cases with 608,570 deaths going into 2022. Oral cavity and pharynx listed as the number eight most common site in males with 38,800 expected deaths.³

In a 2010 study, Rethman et al. reported there was sufficient evidence-based information to support oral cancer screening by visual and tactile methods as a means to detect cancer in the early stages.⁴ The report further stated that adjunctive screening devices were no more effective in early detection than a thorough visual and tactile exam. In 2009 Watson et al. looked at a group of patients already diagnosed with oral or pharyngeal cancer to determine if oral/pharyngeal cancer screening examinations done in the general dental office were associated with early detection. The researchers found those patients who had a screening examination within the last year were significantly more likely to have an early stage cancer than those who did not have the examination.⁴ Oral exams and screenings continue to be an intricate part of the dental appointment.

Some screenings in years past, have been performed by non-dental or medical providers. Recently in 2020, Otolaryngologists have reported screening of the oral tissues and oropharyngeal areas within community screenings. The screening of 285 patients resulted in referrals to dental, ENT and Primary Physician follow ups. They suggested opportunities for collaborative efforts with other professions.⁷ This is especially important because of the involvement of HPV in increased oral cancer cases. The ACS and the American Dental Association among others continue to recommend oral cancer examinations as a vital element of routine dental examinations.⁸-⁹

The length of time between a patient’s initial consultation with a healthcare provider and a diagnosis of cancer is termed “professional delay.”¹⁰ Professional delay may be caused by inadequate clinical skills and knowledge, a low threshold of suspicion, lack of experience, and the presence of non-specific signs/symptoms. Studies by Yu found a delay of as much as 6 months, much longer than expected, from the time of the initial examination to the diagnosis/treatment.¹¹ In addition to professional delay, patients may delay seeking care themselves for many reasons. A study by Zhang, et al. 2019 listed males, farmers and current smokers as most likely to delay seeing a dental professional. Some common reasons listed for patient delay in seeking treatment are: lack of knowledge of the signs and symptoms of oral cancer leading to a low level of suspicion, no pain, and fear of the dentist.¹²-¹³ Cancer progression is relatively rapid in the oral tissues, and as one would expect, professional and or patient delay results in more late stage diagnoses, more extensive surgery and more radiation and chemotherapy for the patient.

A complete head/neck and intraoral examination is not only important for the early detection of cancer but also for accomplishing a comprehensive assessment of the patient prior to providing dental treatment (Table 1).

Table 1. Objectives of the Head and Neck and Intraoral Examination.

The head and neck examination is often overlooked by busy clinicians but it is as crucial an element of the total cancer examination. A thorough head and neck examination is essential for detecting early skin cancers and enlarged lymph nodes that may indicate cancer metastasis. In addition to cancer, manifestations of systemic disease may be observed during routine dental and oral cancer examinations. With the baby boomers reaching retirement age, the number of patients with chronic disease continues to increase. By 2040 about 22% of all Americans, more than 82 million people, will be older than 65 years old.¹⁵ The knowledgeable dental professional will be able to identify suspicious manifestations and arrange the appropriate referral for evaluation, and follow-up. Although oral cancer is a disease associated with aging, we have seen a continuing increase of oral cancer diagnoses in patients under age 40 with no known risk factors; HPV 16 included in this age group is a significant increase in cancer of the tongue.¹⁷ Current research implicates the human papillomavirus (HPV) as the underlying cause of as many as 72 percent of oropharyngeal squamous cell carcinomas with a predominate increase seen in younger white men.¹⁸ Persistent HPV infections are the leading cause of oral pharyngeal cancers, specifically HPV 16 and 18 that are classified as high oncogenic/high risk types.⁴³ Practitioners who focus on patients at high risk may miss subtle changes in those patients who have no known risk factors or those who do not fit the perceived profile of oral cancer susceptibility such as those who have not smoked or consumed alcohol. With increases of oral cancer in younger age groups, all patients, regardless of age or presence of risk factors, should be examined for oral cancer. In general, cancer in younger populations tends to be much more aggressive and have a poorer prognosis.²⁷ In a study by Rowan, et al. 2015, participants consisting of dental hygienists and dentists reported that only 73% of respondents included the oropharynx in their oral exam. Less than 50% reported the correct location for the greatest increase in cancer with 40% of all groups indicating that a biopsy from the posterior oropharynx should be tested for HPV.⁴² The authors recommend continued education on HPV and oral cancer. In an educational intervention by Shukla et al. 2018, the authors provided a toolkit and a post intervention survey. The researchers concluded that over 91.6% of participants increased their knowledge about HPV. They concluded that the educational process gave participants an opportunity to talk to their patients about HPV and also the HPV vaccination and prevention of the virus.⁴²

The purpose of this course is multifold:

1. to introduce the protocol for a complete oral cancer examination with proper techniques for both the head and neck and intraoral examinations,
2. to provide patient education information,
3. to provide information on adjunct technologies that may be utilized in lesion detection and,
4. to promote informing all patients that they are receiving a complete oral cancer examination.