Introduction and Statistics

The National Health and Nutrition Examination Survey (NHANES) for 1997 through 2013, found that approximately 66.2 percent of persons age 2 years and older had seen a dentist during the previous year.¹⁹ While not one hundred percent, sixty-six percent of the population is a significant number of individuals who present at a dental office at least one time per year. Is the dental community providing appropriate oral cancer examinations to these individuals? The American Cancer Society, based on SEER data, predicts that there will be in 2022 54,000 oral cancers detected in the population. With the rise we have seen in cancer of the pharynx, a total of 19,270 is predicted for males and females.²⁰

Although, the public has become more informed about oral cancer in the last decade, the oral cancer exam is not being performed as often as it should be in many cases. The 2020 issues with COVID have caused delayed dental visits, decreased time spent in the dental office and there has been less of an emphasis on the exam probably because of limited appointment time. One of the goals specified in Healthy People 2020 was to have 20% of the adult population receive an oral cancer screening examination within the past year. By 2008 only 18% of the population had received this examination.²⁰ Healthy People 2020 reemphasizes the objective to “Increase the proportion of adults who receive an oral and pharyngeal cancer screening from a dentist or dental hygienist in the past year.”² Studies have found that dental hygienists did not consistently provide oral cancer screening examinations for their patients even though most of them knew it should be done.² In one study less than 25% of hygienists stated they performed the examination at the initial appointment with less than 50% reporting they performed the procedure at recall appointments and almost all reported they did not perform extraoral palpation of nodes and other structures.²¹ The top reasons for not performing this vital service were 1) the dentist does it, 2) it takes too much time, and 3) they did not feel adequately trained.^21,22,23 In March 2004, Case Western Reserve University’s School of Dental Medicine presented the results of a similar survey to the annual research meeting of the American Dental Education Association. They reported that although hygienists placed a high value on oral cancer screening, only 53% actually did the examinations on their patients. A recent study by Tax, et al.(2017) in a cross sectional study investigated whether dental hygienists in Nova Scotia were transferring their knowledge of oral cancer screening into their practice. Although they perceived themselves as knowledgeable, only a small percentage (7%) were performing a comprehensive intra-oral examination. The perceived barriers were: lack of time, the dentists performs the exam and patient compliance. The authors point out that Canada requires hygienists to perform tactile and visual examinations in practice and it is a comprehensive competency requirement for licensure. Studies by Pavao Spaulonci et al. 2018, reported on the knowledge level of newly graduated dentists compared to more senior level dentists on oral cancer knowledge recently in a study conducted in Brazil. The findings indicated that newer graduates exhibited more comprehensive knowledge about oral cancer than their senior colleagues. The junior clinicians appeared to refer suspicious lesions to a dental school for evaluation rather than the senior clinicians. The authors suggest that more continuing education in oral cancer education is warranted.^21,22,23 A recent study in the British Dental Journal found hygiene-therapists/hygienists to be just as competent as primary care dentists when differentiating between oral cancer, potentially malignant disorders and benign lesions.²⁶ Several studies support findings indicating that oral exams are either not performed or poorly performed even when the practitioner is educated or informed. Recent studies by Daley, et al. indicate that dental hygienists had lower knowledge about HPV induced cancer outcomes and that dental providers in general did not discuss HPV prevention with their patients.²⁷A 2007 study found that 92 percent of Illinois dentists reported providing oral cancer screening examinations, but many were not being performed correctly or at the appropriate intervals.²⁸ Additional studies support findings indicating that only 14 percent of dentists perform all aspects of the intraoral and extraoral examinations.²⁹ In 2022, the COVID crises has limited the number of patients seeking dental care and this has been especially true with those patients who are deemed “high risk” such as the elderly. As we know, the aging population may also be at a greater risk for oral cancer.

Public ignorance of oral cancer, its symptoms and risk factors and how it can be detected early does not help the situation. For example, many patients are unaware they have had an oral cancer examination even when one has been completed because the practitioner may not inform them that the procedure has been performed.²³ Studies by Patton et al. 2004,³⁰ found that 29% of a North Carolina population consisting of 1,096 respondents reported having had an oral cancer screening examination only after the procedure was described to them. Almost 84% of patients surveyed by Johns and reported in the Journal of Dental Hygiene in Fall 2001 stated they had never had an extraoral examination.³¹

In a publication in JADA, a report by the American Dental Association, guidelines for clinicians (specified as dentists), the panel recommends that clinicians perform an oral exam on every patient. A list of clinical pathways for the clinician in evaluating potentially malignant disease, good practice statements and the evaluation of potentially malignant disorders and oral squamous cell carcinomas of the oral cavity are reported in this publication Lingen, M, et al. October, 2017.³⁰ The panel of experts recommended that patients with suspicious lesions need to be referred to those who perform biopsies and adjunct techniques such as: autofluorescence, tissue reflectance and vital staining and cytologic testing are not more effective than a comprehensive oral exam. However, in patients who decline biopsy and refuse a referral, cytologic adjuncts could give the clinician more information and perhaps persuade the patient to seek further treatment through a biopsy or referral to a specialist. The panel suggests immediate biopsy in unexplained, suspicious lesions and referral to a specialist who performs such biopsies when they cannot be performed in the present clinic/office.

The publication recommends that the oral exam should be addressed by the dentist, but hygienists are well-versed in tissue management and spend a substantial amount of time with patients and especially the patients who are seen multiple times in a practice for tissue maintenance and recare appointments. A team approach is recommended and an oral exam takes very little time with large advantages when viewed by multiple professionals even in the same office or clinic. With the surprisingly high rates of oral cancer, the oral exam is never wasted time and very often will provide large benefits to the patient. Other studies conducted by Tomar et al. surveyed the oral cancer screening experiences of adult patients in Florida and the self-reported frequency of performing oral cancer screening examinations by dentists/dental hygienists in Florida. Less than 20% of adults over age 40 reported having a screening examination while the dentists and hygienists reported they screened almost all of their over age 40 patients.³²

Education regarding the risk factors related to oral cancer is crucial in reducing the risk for all patients including those patients who consume alcohol, use tobacco products and for those who maintain a poor quality lifestyle. Teaching patients to become cognizant of changes in their oral tissues empowers them to become an active participant in their own health and to perhaps discover an early lesion between dental visits. A study of North Carolina dental hygienists by Bigelow, et al. found hygienists play a key role in prevention not only in detecting precancerous and malignant lesions early but also in educating patients to avoid risk factors.³³

Two major reporting agencies in the United States are the American Cancer Society (ACS) and The National Cancer Institute, Surveillance, Epidemiology and End Results Program (SEER). Oral squamous cell carcinoma (SCCA) comprises 90% of all oral cancers. Comprising the remaining 10% are cancers of the salivary glands, sarcomas and other cancers classified as rare.¹ According to current SEER data 2021, approximately 54,010 cases of oral cavity and oral pharynx cancer will be diagnosed in the United States of which more cases will be found in men and this is twice that of oral cancer found in women.³⁴ According to SEER data the median age at diagnosis for oropharyngeal cancer is approximately 63 years of age and the five year survival rate in the United States is approximately 66.9% all stages combined. At the current time only 31% of cases are diagnosed at a localized stage which has the highest 5-year survival rate of 83%. SEER data estimates 10,850 deaths from oropharyngeal cancers will occur in 2021. This is 1.8% of all new cancer cases.³³

Head and neck cancers have multifactorial etiologies. In addition to increasing age and use of tobacco and alcohol, sun exposure, genetic predisposition, viruses such as HPV and HIV, and inadequate nutrition, play a role in the development of head and neck cancer. Alterations in host immunity, chronic inflammation associated with some mucosal diseases, and exposure to radiation or carcinogens also play a role in the development of head and neck cancers.³⁵ Patients with known risk factors should be examined at every visit, encouraged to perform self-exams and to report any observed abnormality. One study conducted in Maryland found that current and former smokers were no more likely to have had an oral cancer examination than anyone else in the general population.³⁶ Knowing the health history of the patient should be even more of a reason to focus on the susceptibility of certain individuals.

Recent discoveries associating oral HPV infection (especially HPV 16 and HPV 18) with the dramatic increase of HPV-related oropharyngeal cancers worldwide have researchers scrambling to determine the impact this will have on the future. Some are predicting an epidemic of HPV-related oropharyngeal cancers in the coming years.^34,37 Chaturvedi, et al. estimate that by 2020 human papilloma virus (HPV) associated oropharyngeal squamous cell cancer cases may surpass the annual number of cervical cancers; the majority of these oral cancers being found in men.¹⁸ We are all aware of the vaccinations available for preventing HPV-related cervical cancer in women and genital warts in both men and women, but current research is focused on whether these vaccines might prevent oropharyngeal cancers as well. Recent acceptance and recommendation by the ADA 2018, has extended the focus and commitment of dental professionals in promoting the vaccine. The organization cites the American Academy of Pediatric Dentistry in issuing a 2017 policy statement on the HPV vaccination. The academy encourages education and counseling of patients on the health risk of HPV and providing information about the current vaccination against HPV. The FDA approved a supplemental application for Gardasil 9 (HPV 9 valent-vaccine, recombinant; Merck & Co., Inc extending the age group for both males and females to aged 27-45 years old.^44,45 They have already determined that HPV-related cancers affect the base of the tongue, tonsils and other pharyngeal tissues that includes the nasopharynx significantly more often than tissues in the oral cavity proper and that they are affecting a younger population often with no history of tobacco or alcohol use.^34,37 SEER data notes that HPV is associated with 70% of oral cancers. There are over 40 HPV types that may cause oral cancer. White males are most often affected followed by Black males, American Indian, Hispanic, and Asian men.^1,2 Research has shown that HPV-related oropharyngeal/tonsillar cancer has a better prognosis than cancers not related to HPV. While there seem to be more questions than answers on this topic, it is up to the dental professional to remain informed and to be cognizant of the fact that early detection of any of these cancers can be accomplished by practitioners who are actively looking for them. The Oral Exam is still, by far, the most effective way of detecting an early oral cancer.^3,30

SIGNS THAT SHOULD GET YOUR ATTENTION WITH REGARD TO ORAL HPV INFECTION: (based on SEER data)^1,2

• A sore throat that is persistent

• A noticeable lump in the nose, neck throat, mouth, oral tissues or lips

• The patient complains of trouble breathing, speaking, chewing, swallowing, opening the mouth, jaw or moving the tongue

• Ear Pain

• A change in the voice

The dental professional is in an excellent position to assist the patient in obtaining and maintaining total health. By providing information on health related topics and referring patients to specialists such as oral pathologists & Oral medicine specialists, dermatologists, internists, nutritionists and others, we can assist the patient in obtaining quality healthcare. Dentists and hygienists are in a prime position to talk to patients, assess oral tissues (which are a good indicator of total health), and provide health related information to our patients. Dental hygienists have more one-on-one contact time with patients than most other health care providers and can spend more time providing education even while providing treatment. Many patients have established regular 6 month or yearly recall or maintenance appointments increasing the probability for lesions to be detected early if the dental professional looks for them. In addition, the dental operatory is engineered to provide the best possible visualization of the oral cavity and surrounding structures. We have better light sources than are available to most other practitioners allowing us to better visualize oral tissues and the patient chair enables us to position the patient for optimum access.

The study by Cotter et al., published in the Fall 2011 Journal of Dental Hygiene, concluded that greater emphasis should be placed on the importance of the oral cancer assessment in dental hygiene education and that practicing hygienists should avail themselves of continuing education in oral cancer assessment.²¹