Core Concepts

Core Concepts in Oral Cancer Education:
What Every Oral Health Professional Should Know

Compiled by Hillel Ephros, DMD, MD
Diplomate, American Board of Oral and Maxillofacial Surgery
Academic Fellow, American Academy of Oral Medicine

Objectives

Dentists should be able to:

  1. perform a competent oral cancer examination;
  2. describe oral lesions of local and systemic etiology;
  3. identify oral lesions that should raise the suspicion of malignancy;
  4. appropriately select and consider using diagnostic adjuncts to assist in oral cancer early detection;
  5. describe an approach to managing questionable and suspicious oral lesions;
  6. develop and implement an office protocol for oral cancer screening;
  7. discuss the role of the dentist in the comprehensive management of oral/head & neck cancer patients;
  8. articulate the ethical and medical/legal responsibility of dentists to screen for oral cancer, especially in high risk populations.

1. The stakes: dentists should be able to articulate the differences between the survival and quality of life for the typical stage III or IV patient and for an individual whose oral cancer is detected in its earliest stages.

  • a. significance of lesion size
  • b. significance of lesion thickness
  • c. significance of regional spread and metastases

2. The risk factors: dentists should be able to list the major risk factors for oral squamous cell carcinoma (SCCA).

  • a. burnt tobacco products (cigarettes, cigars and pipe smoking)
  • b. heavy alcohol consumption
  • c. HPV for a subset of oral cancers
  • d. possible associations with immunosupression, family history, diet and other suspected factors

3. The high risk sites: dentists should be able to describe the high risk sites for oral SCCA in the USA.

  • a. Highest risk : Floor of mouth, soft palate complex and lateral tongue
  • b. Less concern: Gingiva and buccal mucosa (inside of cheeks and lips)
  • c. Least concern: Dorsum of tongue and hard palate

4. The earliest appearance: dentists should be able to identify suspicious lesions.

  • a. abandon the dogmatic and counterproductive overemphasis on leukoplakia
  • b. focus on the challenges of finding subtle red lesions on a red/pink background as well as lesions with more obvious white components
  • c. any persistent alteration of normal mucosa is suspect if unresolved >2 weeks

5. Diagnosis: dentists should be able to discuss diagnostic techniques.

  • a. benefits and concerns related to brush biopsy
  • b. the indications and limitations of other adjuncts
  • c. toluidine blue and how it may be utilized
  • d. the need for an obsessive search for lesions in the high risk population

6. Responsibility: dentists should be able to identify who is responsible for diagnosing early squamous cell carcinoma (SCCA)

  • a. most physicians are inadequately trained and have neither the time nor the interest in conducting a meticulous examination of the oral soft tissues
  • b. dentists are better prepared but as yet, unremunerated and often inadequately motivated to elevate oral cancer screening to the same level as other dental procedures
  • c. other primary care providers (PA, APN) may be good candidates for training

7. Treatment: dentists should be able to describe how oral cancer patients are treated

  • a. early lesions are treated with surgery or radiation
  • b. when must the neck be treated?
  • c. when are radiation therapy and chemotherapy used?

8. Complications: dentists should be able to discuss complications of the disease and its treatment

  • a. surgery
  • b. radiation and chemotherapy
  • c. additional primary lesions in the upper aero/digestive tract

9. Behavior: dentists should be able to discuss methods for influencing the behavior of their patients

  • a. smoking cessation
  • b. avoiding excessive alcohol intake
  • c. seeking routine examination

10. Demographics and racial disparities: dentists should be able to describe the subpopulations at elevated risk and the huge disparities between the races regarding oral cancer

  • a. incidence
  • b. stage at diagnosis
  • c. mortality

Articles

Importance of Radiation Oncologist Experience Among Patients With Head-and-Neck Cancer Treated With Intensity-Modulated Radiation Therapy (IMRT)
American Society of Clinical Oncology, 2016

Epidemiology of Human Papillomavirus–Positive Head and Neck Squamous Cell Carcinoma
Journal of Clinical Oncology, September 8, 2015

Rising Population of Survivors of Oral Squamous Cell Cancer in the United States
Cancer, May 1, 2016

HPV Infection in the Head and Neck Region and Its Stem Cells
Journal of Dental Research, 2015

Oral Cancer Care Struggles with Three Misconceptions 
by Jo-Anne Jones, RDH, MS
Dentistry Today, April 2016

Cancer Prevention and Treatment: The Dental Hygienists Role
by Cathy Draper, RDH, MS
Access Magazine, Nov 2010

HPV Vaccine Provides Protection at Multiple Sites, Even Among Some Previously Exposed
American Association for Cancer Research, April 2015

My Journey with Cancer: A Dental Hygienist’s Perspective
by Jennifer Cicci, RDH
CDHA Oral Health Canada Magazine, Spring 2015

Researchers Discover Genetic Fingerprint of HPV Virus in some Head and Neck Cancers
Oral Cancer Foundation, January 2015

Failure to Diagnose and Delayed Diagnosis of Cancer: Medicolegal Issues, The Journal of the American Dental Association, December 2009

Oropharyngeal Cancer Epidemic and Human Papillomavirus, Emerging Infectious Diseases
Centers for Disease Control and Prevention, November 2010

Can Saliva-Based HPV Tests Establish Cancer Risk and Guide Patient Management? Mark W. Lingen, DDS, PhD Section Editor, Oral and Maxillofacial Pathology, September 2010

Human Papillomavirus and Survival of Patients with Oropharyngeal Cancer  The New England Journal of Medicine, July 2010

Oral Cancer Screenings A Must, Say Malpractice Attorneys
Oral Cancer Foundation, March 2011

Other Resources

AAOM Clinician’s Guide by A. Ross Kerr, David Lederman, Hillel Ephros. A concise education on early detection of oral cancer. Includes detailed photographs. Downloadable version of the AAOM Clinician’s Guide.

Issue of the OMS Clinics of North America, guest edited by Hillel Ephros, DMD, MD. Contributions from a wide variety of clinicians on psychological issues in dentistry and oral and maxillofacial surgery. Includes a chapter by Albert Wu and his Johns Hopkins’ associates about how to talk with patients and families when adverse outcomes occur. Another chapter deals with end of life issues and focuses on ethical questions related to advanced oral cancer.

For more information visit the Oral Cancer Foundation.