Question: Should Dental Practitioners Perform a Cancer Exam on Every Patient?
Emily Boge, RDH, BS, MPAc
The short answer—absolutely. A visual oral cancer screening on every patient, every time is standard operating procedure because it is painless, quick, and essentially free to complete.
Here in Iowa, I see many farmers who were not educated on the importance of sunscreen. My visual oral cancer screening includes scanning the patient’s face and lips, and also viewing behind the ears, the top of the head, and around the neck. I palpate for “lumps or bumps” and check for asymmetry. A visual extra-oral cancer screening not only provides a valuable service to the patient, but it opens the door to conversation about extra- and intraoral cancers and the importance of SPF protection. I then turn my attention inside the mouth, turning on my head lamp to look for redness, white patches, ulcerations, or irritated areas. I follow a specific sequence: top to bottom, side to side, and under and over (the tongue). Using the same sequence for each patient helps to assure I do not miss anything.
In the past, other providers have shared with me that an oral cancer screening is only to be completed on “high-risk” patients. Although I understand this thought process, I respectfully disagree. By screening all patients—young and old, smokers and nonsmokers, snuff chewers and non–tobacco users, alcohol users and those who refrain from alcohol, those having a family history of oral cancer and those that do not—the clinician not only gets accustomed to the process, but incorporates that process into the sequence of that day’s appointment. He or she also gets better at explaining the purpose of the screening and the occurrence of disease.
Although research may not show a direct relationship between cancer screenings and prevention of oral cancer, early detection has been shown to decrease the oral cancer mortality rate on a global scale. Does the visual oral cancer screening alone determine what areas should and should not be excised? I do not believe so. My intention is to simply scan the areas, photograph what needs to be recorded, measure my findings, and document those findings in the written chart for future comparisons. The doctor determines what course of action is taken when an area of concern is noted. He or she also completes his or her own visual oral cancer screening, taking a second look at every patient, every time. Providing the most comprehensive care to the population I serve is my mission. And for the cost of two 2x2 pieces of gauze (one for myself and one for my doctor), at $0.0003 total cost, I challenge you to do the same.
John R. Kalmar, DMD, PhD
This is a trick question. It implies that a cancer exam is somehow different or separable from the regular or routine exam that dental practitioners provide all new patients and patients who present for periodic recall evaluation. But this routine exam, also known as the comprehensive oral examination, doesn’t just look for oral cancer. It is intended “to detect the presence of any oral abnormality…including those of neoplastic, infectious, reactive/inflammatory or developmental origin.”1 In practice, infectious and inflammatory diseases such as caries, canker sores, and gingivitis are far more common and detected routinely by dentists the world over. Yet despite their relative rarity, oral cancer or precancerous lesions have potentially more serious and even lethal consequences. Early detection of these lesions is essential to early diagnosis, which may improve disease-specific survival.1,2
So the better question is this: Should every dental practitioner who performs a comprehensive patient exam know the risk factors, risk sites, and risk features of oral cancerous and precancerous lesions? Absolutely! It is generally accepted that the use of cigarettes and alcohol increase the risk for oral cancer, up to 15-fold in patients who both smoke and drink. Although much attention has been focused recently on human papillomavirus (HPV) and oropharyngeal cancer, current evidence suggests that less than 10% of oral cancer is HPV-related. High-risk sites for oral cancer include the ventral and lateral surfaces of the tongue, floor of mouth, and the anterior tonsillar pillars. High-risk clinical presentations include sharply defined, non-homogenous leukoplakic lesions; mixed red/white lesions; or erythroplakic lesions; areas of persistent ulceration; and indurated lesions.
Recently, routine comprehensive examinations have been recommended for low-risk patients on an annual basis; however, a shorter interval may be warranted with high-risk patients.3 Dental practitioners who recognize the signs of oral cancer and precancerous lesions can help their patients by clearly recording and communicating any findings, discussing treatment options (including biopsy) and by subsequent follow-up as indicated. Oral precancerous or cancerous lesions don’t occur in every patient, but every patient deserves to know that such lesions were among the many possible conditions that were carefully considered by their dentist or dental hygienist during each routine comprehensive oral exam.
1. Rethman MP, Carpenter W, Cohen EE, et al. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc. 2010;141(5):509-520.
2. Kalmar JR. Advances in the detection and diagnosis of oral precancerous and cancerous lesions. Oral Maxillofacial Surg Clin North Am. 2006;18
3. Li L, Morse DE, Katz RV. What constitutes a proper routine oral cancer examination for patients at low risk? Findings from a Delphi survey. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116(5):e379-e386.
About the Authors
Emily Boge, RDH, BS, MPAc, is currently a health sciences public administration Master’s degree candidate at Upper Iowa University and has practiced dental hygiene since 2003. She is also the owner of Think Big Dental, a consulting and writing firm specializing in the education of health professionals regarding the importance of dental care.
John R. Kalmar, DMD, PhD, is associate dean for academic affairs and program director, oral and maxillofacial pathology at The Ohio State University College of Dentistry in Columbus, Ohio. He is also president of the American Academy of Oral and Maxillofacial Pathology.