Have We Become Disconnected?

April is Oral Cancer Awareness Month. The objective in sharing my thoughts here is not just to write another article on the horrors of oral cancer, but to incite a much deeper response. The employment of opportunistic oral cancer screenings is an effective means of finding cancer at its early and highly curable stage. Of course, there are shortcomings experienced, particularly when we consider the difficulty in visually accessing the high-risk anatomical areas associated with Human papillomavirus (HPV)-related oropharyngeal cancer. Our professional body possesses a complex arsenal of knowledge and skills to be used in the service of others. The oral cavity is our territory. Oral cancer is our cancer. We own this. Are you connected?

The visual and tactile extraoral/intraoral examination, accompanied by a subjective interview, is the fundamental and baseline requirement of today’s dental practice. Public survey results continually point to a low rate of oral cancer screening being routinely performed. Why? When this disease is in our hands to discover, why are we often waiting for our dental patient to bring our attention to it? By the time a patient does this, it is often too late. Oral cancer screening, especially in today’s world, has never been more important. Our patients deserve and need to know that the historical risk factors of smoking and alcohol are being challenged by a fast-growing etiologic factor that is virally transmitted. HPV is the fastest-growing sexually transmitted infection in North America. The Centers for Disease Control and Prevention states, “HPV infections are so common that nearly all men and women will get at least one type of HPV at some point in their lives.”¹

The Facts
According to the American Cancer Society, there were close to 50,000 Americans diagnosed with oral/oropharyngeal cancer last year, and, worldwide, the problem is astronomically larger.² The ADA reports that squamous cell carcinoma is “the most common malignancy in the oral cavity and oropharyngeal area, accounting for approximately 90% of all cancers of the head and neck.”³ Of those diagnosed, only 50% will be alive in 5 years.

Survival rates have incrementally improved at the same time, which is fueled by the rising incidence of HPV-related oral and oropharyngeal cancers being more receptive to treatment protocols. Dismally, though, the incidence of the disease itself continues to climb. We are simply not making the inroads with this type of cancer as we have with many other cancers. The lucky ones who survive live in daily fear of recurrence; gross disfigurement; severe xerostomic conditions impeding the ability to enjoy life’s simple pleasures; and the scars of a disease that has one of the most brutal treatment regiments, affecting quality of life for the remainder of life. We know this, and we screen for this, and, yet, we are remotely disconnected until it affects our life personally or that of a loved one, friend, or colleague. Then we are connected.

I’ll Never See This in My Practice
A common perception about oral cancer is that it is rare and relatively uncommon to see in clinical practice. Consider the following:

• The US population has 240 million people over the age of 16
• There were 49,670 new cases of oral/oropharyngeal cancer in 2017
• One in 4,831 people will be diagnosed each year with oral/oropharyngeal cancer
• The average practice sees 2,000 patients per year

Therefore, it is reasonable to say that an oral cancer case presents in a given practice approximately once every 2.5 years. There is also oral dysplasia, a precancerous condition, occurring much more frequently. A reasonable estimate is that dysplasia is 20 to 40 times more common than oral cancer, occurring in approximately one in 210 patients. This would equate to 5 to 10 cases of dysplasia per year presenting in a dental practice.

The HPV Profile Has Impacted Dentistry
HPV-related oropharyngeal cancer presents its challenges due to the lack of visual and tactile examination of the high-risk anatomical sites. HPV has an affinity for lymphoid tissues: namely, tonsillar areas, the posterior base of the tongue, and the oropharyngeal area. Keep in mind, the best way to screen for HPV-related oral and oropharyngeal cancers is through the means of a visual and tactile examination, including lymph node palpation. Many of the symptoms related to a developing or recurrent HPV infection are discovered by conducting a patient interview and asking specific questions.⁴ Signs and symptoms are persistent and non-resolving and include those we are most familiar with, such as:

• Any sore or ulceration that does not heal within 14 days
• A red, white, or black discoloration of the soft tissues of the mouth
• Any abnormality that bleeds easily when touched (friable)
• A lump or hard spot in the tissue, usually on the border of the tongue (induration)
• Tissue that is raised above that which surrounds it; a growth (exophytic)
• A sore under a denture that, even after adjustment of the denture, does not heal
• A lump or thickening that develops in the mouth
• A painless, firm, fixated lump felt on the outside of the neck that has been there for at least 2 weeks

The more subtle and often life-saving symptoms that accompany HPV-positive oral and oropharyngeal cancers are critically significant due to the lack of visual acuity. They include, but are not limited to, all of the previously noted, as well as:

• Hoarseness or a sore throat that does not resolve within a few weeks
• Constant coughing that does not resolve after many days
• Difficulty swallowing; a sensation that food is getting caught in the throat
• An earache on one side (unilateral) that persists for more than a few days

The “golden rule,” and one of the most important defining factors regarding referral pathways and management, is persistence. Anything abnormal, new, or different that persists for more than 14 days warrants a referral.

Together, We Can Make a Difference
Early discovery is key! The 5-year survival rate is 83% when the disease is discovered locally and a dismal 36% once the cancer has metastasized. This is precisely why it is vitally important to effectively manage and refer any persistent problem that does not resolve in a period of 14 days. A definitive diagnosis must be established to effectively manage and treat the condition. Thankfully, most of these persistent issues will not be cancer. However, are we prepared to take this chance by not following through?

Dedicate Your Practice to the Early Discovery of Oral Cancer
The following checklist provides an opportunity for you to critically self-evaluate your practice. Ensuring that the items in this checklist are in place will significantly increase the ability of you and your team to discover this insidious cancer in its earlier stages. Your practice should:

• Update extraoral and intraoral cancer screening methods to take into account the fastest growing etiologic factor being HPV
• Promote awareness and the solicitation of feedback through a patient interview on the subtle signs and symptoms that often accompany the HPV profile
• Employ regular opportunistic head and neck examinations that include oral cancer screenings on all adults at a minimum of once per year
• Have clinical team members use magnification and, preferably, a dedicated headlight to assess oral mucosal tissues
• Have team awareness of management strategies for the referral of any lesion that persists for more than 14 days
• Palpate key lymph node sites extraorally, as well as use intraoral tactile palpation techniques on all soft tissues within the oral cavity and accessible oropharyngeal areas
• Have an awareness that the risk for oral and oropharyngeal cancer extends beyond the historic heavy alcohol drinker and smoker
• Provide patient educational materials on all oral/oropharyngeal risk factors, including HPV

There are many credible resources that we have open access to as a professional body. Our professional associations, including the Oral Cancer Foundation (OCF), offer peer-reviewed literature and evidence-based information that provide a wealth of available knowledge. There are also a number of educational resources available to distribute to our patient population.

A global campaign, “Check Your Mouth,” launched this past January. A collaboration between the OCF and Throat Scope (the makers of the world’s first all-in-one illuminated tongue depressor), the campaign follows a successful, proven self-examination model used for melanoma and breast cancer. The hope is to facilitate earlier discovery by encouraging the general public to perform self-examinations at home. Learn more about this project at checkyourmouth.org.

With the aid of printed materials provided to the patient, dental professionals can reinforce the importance of self-examination and self-referral between regular dental appointments. Educational materials are available to the dental community upon request from the OCF Store, located at ocfstore.org.

Too many lesions are being discovered too late. We can never underestimate the impact of our reach and, essentially, our ability to not only improve the quality of lives but save lives through earlier discovery. April is Oral Cancer Awareness Month. We own this. What is your practice plan?

References

1. Centers for Disease Control and Prevention. Genital HPV Infection – Fact Sheet. https://www.cdc.gov/std/hpv/stdfact-hpv.htm. Updated November 16, 2017.
2. American Cancer Society. Cancer Facts & Figures 2017. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2017.html.
3. American Dental Association. Oral Health Topics – Oral and Oropharyngeal Cancer. https://www.ada.org/en/member-center/
   oral-health-topics/oral-cancer. Updated February 22, 2018.
4. The Oral Cancer Foundation. Oral Cancer Facts. https://oralcancerfoundation.org/wp-content/uploads/2017/03/Oral-Cancer-and-HPV-Facts-2017.pdf.

Ms. Jones is a dental-hygienist-turned-educator, an international award-winning speaker, and was named a Dentistry Today CE Leader in 2018 for the eighth consecutive year. While preparing to present her research on HPV-related oropharyngeal cancer to her national association, a family member received a diagnosis of late-stage HPV tonsillar cancer, succumbing to the disease 16 months later. Ms. Jones proudly partners with the Oral Cancer Foundation in conveying the urgent need for changing the way in which we screen for oral cancer to meet the needs of today’s population. She can be reached at via email at
jjones@jo-annejones.com or by visiting jo-annejones.com.

Disclosure: Ms. Jones is an advisor to the launch of Throat Scope in North America and has a financial interest in the product.

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