Consultants Corner: Oral Cancer Exam

April 2022 was designated Oral Cancer Awareness Month. As dentists and Registered Dental Hygienists, it is very important to incorporate an oral cancer exam into your patient's comprehensive and periodic oral exams.

An estimated 25 percent of oral cancer patients have no known risk factors for oral cancer. Alcohol and tobacco remain the greatest risk factors (and using them in combination increases the risk 15 times over the use of one or the other). While smoking and tobacco use are still major risk factors, the fastest-growing segment of oral cancer patients is young, healthy, nonsmoking individuals due to the connection to the Human Papillomavirus (HPV) virus. Infection with the sexually transmitted HPV virus has been linked to a subset of oral cancers. 

Oral cancer affects almost twice as many men as women.

The best way to detect oral cancer early is to perform a screening at every dental visit. The intraoral examination should include the assessment of the following oral structures.

Buccal mucosa: Move the buccal mucosa away from the teeth and gingiva to visualize the vestibule. Examine one side and then the other. Be sure to examine the entire buccal mucosa from the labial commissure back to the anterior tonsillar pillar. Next, gently pinch the cheek between your fingers and thumb as this allows you to palpate the buccal mucosa for any hidden masses.

Tongue: Ask the patient to stick out his or her tongue and move it from side to side. Note any masses, ulceration, or swelling. Observe the dorsum of the tongue, noting any discolorations, irregularities, or limitations to movement, all of which may be a sign of cancer. One of the most common sites of oral cancer is on the lateral border of the tongue, and it should be evaluated completely. This area is best viewed by pulling the tongue forward. Palpate the dorsum and lateral margins of the tongue, paying special attention to any masses or firm/fixated areas. Finally, have the patient touch the roof of the mouth with the tip of his or her tongue. This will allow the examiner to inspect the ventral surface of the tongue.

Floor of the mouth: Inspect this area while the tongue is elevated. Wrap a piece of gauze around the tip of the tongue and pull the tongue gently forward and to one side. With the other hand, use a tongue blade or gloved finger to push the middle of the tongue up and out of the way. Notice the frenulum in the midline and the ducts from the submandibular glands symmetrically on either side. Also note the sublingual glands. Next, insert a gloved finger beneath the tongue, and another under the chin on the exterior skin, and bimanually palpate the submandibular glands and the entire submental region. Keep in mind that this one of the most common places for oral cancers.

Hard and soft palate: Have the patient open wide and tilt his or her head backward to provide an adequate view of the hard and soft palate. Red spots, white spots, ulcerations, rough areas, asymmetry, growths, or other masses may be the first sign of a cancer in this area.

Tonsils: Ask the patient to open wide, relax, and slowly breathe in and out saying, “Ahh.” This relaxes the tongue and offers a view of the oropharynx. It may be necessary to press down on the back of the tongue to get a full view of the oropharynx.

The lips: The lips should be evaluated with the mouth open and closed, noting any abnormalities in symmetry, contour, color, or texture. Attention to the vermilion border of the lower lip is warranted as this is a prime site for oral cancers. First, inspect the inner surface of the lower lip. The labial mucosa should be smooth and uniform in color. Notice the frenum of the lip in the midline. Note any signs of smokeless tobacco use (ulcers, red or white discolorations, texture variations) on the labial mucosa. With the lip still retracted, one can also inspect the gingivolabial sulcus and the gingival mucosa. Next, palpate the lip with your thumb and index finger, noting any firm or nodular submucosal areas. Repeat these steps for the upper lip.

Approximately 54,000 people in the U.S. will be newly diagnosed with oral cancer this year. Every day, 132 new people in the US will be newly diagnosed with oral cancer. Oral and pharyngeal cancer (cancer of the upper throat) collectively kills nearly one person every hour of every day of the year. Of the people newly diagnosed with these cancers, only about 60% will live longer than 5 years. Moreover, many who do survive suffer long-term problems such as severe facial disfigurement or difficulties eating and speaking. The death rate associated with oral and pharyngeal cancers remains particularly high due to the cancer being routinely discovered late in its development.