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Inside Dentistry

January 2007, Volume 3, Issue 1
Published by AEGIS Communications


Oral Cancer

Allison M. DiMatteo

Your Patients, Your Responsibility

What will you accomplish in 2007? Will this be the year you help save a life? Or will fear, outdated information, and mediocrity lead you to unwittingly contribute to someone’s possibly preventable death? It only takes 1˝ to 3 minutes to scrutinize the head, neck, and soft tissue areas to look for signs of premalignant lesions and oral cancer.1 Just those few minutes could mean a lifetime to one of your patients.

Photo: © Kent Wood/Oxford Scientific/JupiterImages
Invasive squamous cell carcinoma from inside the human lip.

Nearly 8,000 people each year die from oral cancer - about one every hour, 24/7. This year alone, more than 30,000 new cases of oral cancer will be diagnosed in the United States.2 According to A. Ross Kerr, DDS, MSD, chair of the Oral Cancer Consortium and clinical associate professor in the department of oral and maxillofacial pathology, radiology and medicine at New York University College of Dentistry, approximately two thirds of all oral and pharyngeal cancers are detected in advanced stages, when the cancer has already metastasized from the site of local origin to the regional lymph nodes or distant organ systems. At that time, the chances of surviving oral cancer drop significantly, he says.

Overall, approximately 60% of people diagnosed will survive 5 years or more. By staging, the 5-year survival rate for oral cancer is as follows: approximately 80% for local disease (no metastasis); approximately 50% for those with regional metastasis; and approximately 25% for those with distant metastasis. Kerr explains that this works out to 59% overall.

Sadder still, these statistics haven’t improved much in recent decades. Oral cancer continues to ravage people’s bodies and lives because it is so potentially disfiguring and disabling. The typical treatment and rehabilitation costs can range from $100,000 to $200,000 to treat a late-stage oral cancer, estimates Jed J. Jacobson, DDS, MS, MPH, senior vice president and chief science officer of Delta Dental Plans of Michigan, Ohio, and Indiana. In the process of delivering treatment, the oral surgeon most likely will remove a large portion of the tongue and/or jaw, maxillofacial reconstruction could be considerable, and the patient will need to be rehabilitated—all of which makes oral cancer very costly to treat, he says.

“I don’t think there is anything else that could happen to the oral cavity that is more significant that oral cancer,” observes Nelson L. Rhodus, DMD, MPH, professor and director of the division of oral medicine at the University of Minnesota School of Dentistry. “That has become the major emphasis of the American Academy of Oral Medicine, and the #1 priority is the research and development of early detection models for oral cancer.”

Compounding matters is the fact that 50% of the US population doesn’t see a dentist on a regular basis to begin with, notes D. Walter Cohen, DDS, Chancellor Emeritus of Drexel University College of Medicine and Dean Emeritus of the University of Pennsylvania School of Dental Medicine. Those individuals are in underserved communities and are as susceptible to oral cancer, if not more so, than peoplewho do receive regular dental care.

“What we know in retrospect is that we are not accomplishing what we are supposed to be accomplishing,” explains Michael A. Siegel, DDS, MS, immediate past-president of the American Academy of Oral Medicine and professor and chair of the department of diagnostic sciences at Nova Southeastern University College of Dental Medicine. “If it is found early, the survival rate for oral cancer is close to 90%, yet 70% of these cancers are found late.”

These are just a few of the alarming statistics that represent what’s characterized as a very nasty cancer. Oral cancer is responsible for more deaths than melanoma, Hodgkin’s disease, or cervical cancer. It’s the 11th most common cancer worldwide, affecting men and women at about a 2:1 ratio.2,3 And if you think the typical oral cancer patient is someone who’s older, a tobacco user, and an alcohol abuser, guess again; the demographics are changing and oral cancer’s victims are getting younger.

Your fateful contribution to the well-being of your patients lies in your own hands and how you examine each and every one of them from this point forward. Simply stated, the public’s interest in dentistry and cosmetics is an opportunity to examine them for oral cancer and ensure that their soft tissues, head, and neck are healthy foundations for beautiful dentistry. It’s a chance to educate them about strategies to prevent a disease with a gruesome morbidity rate. It’s a chance to be a lifesaver.

So, will 2007 be the year you resolve to perform thorough oral cancer screening examinations on all of your adult patients? Here’s the Inside look at the many compelling reasons why you should and what you need to consider in order to do so.

DAWDLING OVER DETECTION

Surveys have suggested a low use of oral cancer examinations despite their noninvasive nature. In 2003, an article was published reporting that less than 15% of people surveyed said they received an oral cancer examination during a 12-month period.4 It was concluded that to increase detection of oral cancer, extensive educational and media campaigns for the public as well as health care providers to identify risk factors and the availability of and need for these examinations is required.4

“Dentists are not doing themselves a favor by not talking about what they’re doing,” Siegel says. “There’s an educational component to this whereby patients learn what it is to receive good, thorough care.”

Brian Hill, founder and executive director of the Oral Cancer Foundation, explains that having auxiliaries in the dental office initiate conversations with patients about oral cancer, the screening process, and what they’ll look for has helped motivate people to move past the “can’t talk about cancer” issue. The sequential progression of the conversation—from front desk staff to hygienist to dentist—reinforces for the patient that an oral cancer screening is something they want to have.

In fact, in 2002, an article in the Journal of the American Dental Association indicated that more clinicians should include comprehensive oral cancer screenings in their oral examinations. Also, they should explain to patients what they are doing when they provide these screenings.5

The reason why some dentists choose not to perform an oral cancer screening examination depends on who you ask. Some say it’s simply a shortcut; there’s not enough time in the appointment or the patient doesn’t fit the mold of the classic at-risk candidate (See Not the Usual Suspects, this page). Others say it’s because there’s no separate financial renumeration specifically for the oral cancer screening exam. The “c” word may just not be something they planned on having in their dental vocabulary, or there may be a lack of confidence in performing the exam or knowing what to do with something suspiciousonce it’s found.

“The trick is not to know what to do with it,” Siegel points out. “The trick is to find it [the premalignant lesion] and refer it.”

The National Institute of Dental and Craniofacial Research (NIDCR) has provided funding to collect baseline data on oral cancer knowledge, practices, and opinions among dentists and dental hygienists. According to NIDCR Director Lawrence Tabak, DDS, PhD, this research has shown that most practitioners lack an appropriate knowledge about oral cancer. Subsequent focus groups with dentists identified a list of the barriers to providing oral cancer examinations and how best to improve their diagnostic skills.

YOU’RE RESPONSIBLE - CHECK FOR SIGNS & SYMPTOMS

According to Cohen, a number of dentists are very careful in their examination procedures and check all of the oral tissues—including the cheeks, lips, tongue, palate, and gum tissue. They also check radiographs for changes.

Michael Kahn, DDS, professor and chairman of the department of oral and maxillofacial pathology at Tufts University School of Dental Medicine, explains that examining the extraoral and intraoral head-and-neck soft tissues involves bilateral visual and palpation inspection of the pre- and postauricular facial region; the anterior and posterior cervical chain of lymph nodes, thyroid gland, and remaining major salivary glands; three anatomical regions of the upper and lower lip and their commissures; and the buccal mucosa.1 Then, the examination should proceed to the maxillary and mandibular attached gingival and corresponding alveolar mucosa and vestibules; the hard palate and soft palate complex; the oropharynx, especially the posterior pharyngeal wall; the dorsum, lateral border, ventral surface, and base of the tongue; and bilateral inspection of the floor of the mouth after drying thoroughly.1

Of course, there may be some clinicians who might think that their role in dentistry is exclusively limited to crown-and-bridge or cosmetic veneers. Siegel puts this mindset into perspective for his students by reminding them that if they only provide patients with beautiful smiles but neglect to perform an oral cancer examination and “miss the threatening lesion, it makes for a good open viewing.”

“We are in a health care profession. I won’t argue that psycho-social image and self-image aren’t important, but if someone has a tumor and my profession misses it, who is going to find it?” Siegel asks. “You’ve got to look.”

Even with careful examination using the naked eye, gloved finger and palpation, magnification, and incandescent operatory light, subtle tissue surface changes that could signal the earliest stages of oral cancer can be missed. For this reason, clinicians should consider using some of the ancillary and adjunctive screening or diagnostic tools to supplement the examinationprocess, suggests Kahn.

“You have to recognize that based on the law of optics, even an expert at times may miss certain lesions,” Kahn explains. “Therefore, if you’ve got a wavelength of light, certain vital chemical dye, or any other process that might be a marker for early cancer, you’ve got to consider that in addition to your naked eye.”

Siegel’s examination process is simple: start with a mirror, a light, and your eyes. If you find something, you have the choice of using a brush biopsy to sample the cells, chemiluminescence to make the lesion more visible, or autofluorescence of tissues to see if they’re healthy or not (See Taming Technology, page 60). Then, of course, the gold standard is the surgical biopsy.

WHAT TO LOOK FOR

The most common sign of oral cancer is a sore in the mouth that lasts longer than 14 days. Other symptoms that patients may not be aware of but that should be recognizable to clinicians include lumps or thickening of the mucosa; white or red patches on the gums, tongue, or tonsils; or a lining in the mouth. Patients may describe such symptoms as a sore throat, having something caught in the throat, or having difficulty swallowing or chewing.6

The gene mutations and uncontrolled reproduction of cells that characterize cancer cause various types of tissue abnormalities that affect the oral cavity, head, and neck. Oral cancer typically affects the tongue, oral soft tissues, throat, and pharynx. In fact, as much as 3% of all cancer in the United States is related to the head or neck.7 Cancer of the oral cavity and pharynx are responsible for more than 2% of all newly diagnosed cancers. Other neoplasms may include keratoacanthoma (which is benign), verrucous carcinoma (a slow-growing, typically well-differentiated exophytic lesion that spreads late, if at all), sarcoma, mucoepidermoid carcinoma, and malignant melanoma (most commonly found on the palate).8

The most common malignant lesion of the oral cavity is squamous cell carcinoma. A little less than 40% of intraoral squamous cell carcinomas occur on the lower lip. Almost half of all carcinomas begin on the floor of the mouth or on the tongue (smoking and alcohol use increase these significantly). Other neoplasms can be found in the salivary glands, usually the parotid glands (85% of salivary gland cancer is located here), as well as the submandibular and the minor glands. These oral cancers often begin as leukoplakia, erythroplasia, and erythroleukoplakia (See this month’s CE article, Oral Cancer: Early Detection and Prevention by Nelson L. Rhodus, page 32).

TREATMENT

Typically surgery is required to remove the tumor and possibly a section of the oral cavity or soft tissue where it is located. Radiation used in conjunction with surgery is one of the most effective treatment options. Chemotherapy is often added to the treatment process to sensitize the malignant cells to the radiation, decrease the possibility of metastasis, or when patients already have confirmed distant metastasis of the disease.2 Therapy may also be needed to assist patients with speech, mastication, and other problems associated with a lack of salivary function that could result from surgery or treatment.

Oral medicine, a niche in dentistry focused on the interaction between medical, systemic, and oral health issues, is ideal for addressing the unique requirements of patients recovering from oral cancer. In this regarding, Rhodus emphasizes that members of the AAOM can be tremendous resources for clinicians whose patients are undergoing treatment not only for oral cancer, but any cancer for which the medications can impact the oral environment.

“There is terrible morbidity associated with oral cancer, and not many dentists feel comfortable treating these patients,” Kerr has observed. “That’s why members of the AAOM can be such tremendous resources because we are dedicated to the diagnosis and management of patients with mucosal diseases, orofacial pain, and medically complex patients.”

There have been advances in therapeutics, such as Cetuximab (an agent that targets the epidermal growth factor receptor), which has been shown to increase overall survival of head and neck cancer by 10% when combined with radiation therapy, Tabak says. “Given the very high death rate of advanced head and neck cancer, this is a very significant finding,” he says. “The hope is that this will be able to reverse disease progression earlier in the staging, although it has only been observedat the most advanced disease stage.”

CONCLUSION

Kahn reminds readers that if they follow the proper screening techniques in the proper order, using all of the available adjunctive tools and diagnostic aids, but fail to properly enter the resulting information into the patient’s medical record, then from a risk-management point of view, it hasn’t happened. What’s also necessary in the equation is effective communication to the patient that is properly and clearly documented. Following through isessential to the patient’s well-being.

“It’s great to put into practice everything that’s been discussed, but if it’s not properly documented then you’ve dropped the ball and can still cause problems for the patient and yourself,” Kahn explains. “We feel good when we’ve identified a suspicious lesion at its early stages. Now we need to make sure the patient is properly referred, actually gets to the referral appointment, and that this is followed up with proper diagnosis and treatment, if necessary.”

Notes Mark Bride, DDS, director of medical affairs for Zila Pharmaceuticals, not only does performing an oral cancer screening and using adjunctive technologies improve the quality of patient care, but it also benefits the clinician in terms of risk mediation. “Some of the awards that are offered from lawsuits stemming from undiagnosed oral cancer sometimes exceed policy limits,” Bride says. “That puts the dentist at a great deal of risk.”

According to Jacobson, the issue with oral cancer isn’t necessarily that a dentist doesn’t see something when a screening examination has been performed. Rather, problems occur when he or she sees a red or white lesion but doesn’t follow up on that or do what is necessary.

“The classic watch and wait that was taught in dental schools for many years isn’t what’s advocated now,” Jacobson says. “Even if you can see a lesion with the naked eye it’s still early enough to do something about it.”

Curtailing the devastation associated with oral cancer is the responsibility and obligation of every dental professional, each of whom is in the unique position to interact with young and mature adults alike. Dental clinicians have the ability and knowledge to provide prevention and intervention as an integral part of their routine, and screening for oral cancer must be incorporated into their examination and disease prevention protocol. The earlier a suspicious lesion is identifiedand treated, the better a patient’s chances for survival.

“We are on the crest of a wave of public awareness, professional involvement, and technological development,” Hill observes. “These factors are coming together, so it’s an amazing place for the Oral Cancer Foundation and the oral health care profession to be at right now.”


1 Kahn MA. Screening for oral cancer: a matter of life and death. Inside Dentistry. October 2006; 2(8):26-28.

2 Oral Cancer Foundation. 2006. Available at: http://www.oralcancerfoundation.org/facts/index.htm. Accessed Nov 13, 2006.

3 Global Facts on Tobacco or Oral Health. 2005. http://www.who.int/oral_health. Accessed Nov. 13, 2006.

4 Canto MT, Drury TF, Horowitz AM. Use of skin and oral cancer examinations in the United States, 1998. Prev Med. 2003;37(3):278-282.

5 Horowitz AM, Canto MT, Child WL. Maryland adults' perspectives on oral cancer prevention and early detection. J Am Dent Assoc. 2002; 133(8):1058-1063.

6 American Cancer Society. 2006. www.cancer.org. Accessed Nov. 13, 2006.

7 Yul Brynner Foundation. 2005. www.yulbrynnerfoundation.org. Accessed Nov. 13, 2006.

8 Beers MH, Berkow R. The Mereck Manual of Diagnosis and Therapy. 17th ed. 1999.

The Inside Look from...

In each issue of Inside Dentistry, the publishers and staff strive to deliver clear, objective, and relevant reporting of the thought-provoking issues facing the dental profession. We gratefully acknowledge the following individuals, without whom this Inside look at oral cancer would not have been possible. The underlying concerns associated with this important topic could not have been brought to the surface without the insights shared by our knowledgeable and well-respected interviewees. For their collective generosity of time and perspectives, we extend our sincere gratitude.

ACADEMIA
D. Walter Cohen, DDS
Chancellor Emeritus
Drexel University College of Medicine
Dean Emeritus
University of Pennsylvania School of Dental Medicine
jmitchel@DrexelMed.edu

Lawrence I. Goldblatt, DDS, MSD
Professor of Oral and Maxillofacial Pathology and Dean
Indiana University School of Dentistry
lgoldbla@iupui.edu

Michael Kahn, DDS
Professor & Chairman
Department of Oral and Maxillofacial Pathology
Tufts University School of Dental Medicine
michael.kahn@tufts.edu

A. Ross Kerr, DDS, MSD
Clinical Associate Professor
Department of Oral & Maxillofacial Pathology, Radiology and Medicine
New York University College of Dentistry
ark3@nyu.edu

Michael A. Siegel, DDS, MS
Professor and Chairman
Department of Diagnostic Sciences
Nova Southeastern University College of Dental Medicine
masiegel@nsu.nova.edu

ASSOCIATIONS
Brian Hill
Founder & Executive Director
Oral Cancer Foundation
bhill@oralcancerfoundation.org

Nelson L. Rhodus, DMD, MPH
Professor & Director
Division of Oral Medicine
University of Minnesota School of Dentistry
Adjunct Professor
Department of Otolaryngology
University of Minnesota School of Medicine
President & Diplomate
American Academy of Oral Medicine (2006-2007)
rhodu001@umn.edu

RESEARCH INSTITUTIONS
Lawrence Tabak, DDS, PhD
Director
National Institute of Dental and Craniofacial Research
tabakl@mail.nih.gov

INDUSTRY
Mark Bride, DDS
Director, Medical Affairs
Zila Pharmaceuticals
mbride@zila.com

Jed J. Jacobson, DMD, MS, MPH
Senior Vice President & Chief Science Officer
Delta Dental Plans of Michigan,Ohio, and Indiana
jjacobson@deltadentalmi.com

Wayne Rees
President
LED Dental, Inc
wayne.rees@led-md.com


Making the Public & Profession Perceive the Importance

Members of the public generally are more informed today regarding their health care, our experts say. The more informed the public, the more demanding patients will be in terms of wanting their health care providers to perform careful examinations and respond to abnormalities that are detected.

However, public awareness of oral cancer is not as high as awareness of other cancers, such as melanoma, breast cancer, cervical cancer, or colon cancer, for example. There is a disparity in the education of Americans about oral cancer and the need for regular screenings, says A. Ross Kerr, chair of the Oral Cancer Consortium. The Consortium, a group of interested parties that first came together in 1999 to elevate awareness principallyamong the public, consists of 28 members representing academic dental centers, hospitals, and dental societies. It hosts free regional oral cancer screenings throughout New York, New Jersey, and Pennsylvania.

“We realize these annual events are not necessarily going to bring out all of the people who have early lesions,” Kerr admits. “We have found that people who come to screenings are people who are already conscientious about their health and they may have a bit of free time. One of our goals for the future is to try and focus our efforts on reachinghigh-risk populations.”

The American Academy of Oral Medicine (AAOM) has developed an Oral Cancer Task Force—of which Kerr is one of the chairs—that has been charged with planning and implementing a broad and comprehensive initiative for the early detection and prevention of oral cancer. Related activities will include tobacco cessation integrated with, but not limited to, work with the Oral Medicine Research Foundation, the Oral Cancer Foundation, the American Cancer Society, the American Dental Association, Delta Dental, and other organizations, explains Nelson L. Rhodus, DMD, MPH, presidentof the AAOM. The goal is to increase the profile and actions toward this mission in the professional and public sectors, he says.

There are challenges in this regard, however. Unlike other cancers—such as colon, breast, prostate, or cervical—for which widely publicized detection programs are conducted almost endlessly, oral cancer thankfully doesn’t have a dramatically high prevalence. At the present time, the probability of getting lung cancer is far greater than getting oral cancer, explains Jed Jacobson.

“We don’t seem to have the kind of government support, public health coordination, or funding to promote awareness of oral cancer that is directed toward those other diseases,” Rhodus admits. “Yet, oral cancer is more common than ovarian cancer or melanoma.”

Brian Hill, founder and executive director of the Oral Cancer Foundation, points out that one of the organization’s missions is to increase public awareness of oral cancer. This is being accomplished through a variety of mechanisms including free public screening events, television and radio partnerships, and celebrity spokespeople. The organization also produces waiting room brochures (“What You Need to Know about Oral Cancer”), as well as other tools for professionals to encourage conversations with patients about oral cancer.

Because oral cancer is a cancer that responds very well to early detection and treatment, the number and frequency of oral cancer screenings that are performed need to increase. Since the introduction and widespread use of Pap smears for cervical cancer, mammograms for breast cancer, and PSA tests for prostate cancer, the death rates for those three cancers have been reduced significantly, Jacobson says, because they enable early detection and early treatment of those diseases.

“By the time someone with oral cancer is diagnosed, there is a two-thirds chance that it is already in an advanced stage (ie, stage 3 or 4) because we haven’t detected it early enough,” says Kerr. “The reason this happens is because those people who don’t receive regular oral or medical care don’t seek help until the problem becomes painful, even though it’s been a little time bomb waiting to go off in their mouths.”

As the Consortium thinks of new ways to reach higher-risk populations, Kerr encourages fellow academians and their dental students to get involved. In fact, in 2006, members of the New York University College of Dentistry’s chapter of the Student National Dental Association led New York City’s first Oral Cancer Walk through Harlem. The event drew some 300 participants, raised more than $20,000 for awareness efforts, and provided free oral cancer screenings along the walk route.

“One of the hopes is that the student dentist can push this agenda among the rest of the profession,” shares Kerr. “Oral cancer is something everyone can think about and talk about, no matter what level of the profession they’re at.”

According to D. Walter Cohen, once the public becomes aware of the high occurrence of oral cancer, as well as how devastating it is in terms of mortality and morbidity, an emphasis can be placed not only on screening but also prevention.

“We have a major responsibility of getting our patients to participate in tobacco cessation programs,” Cohen says. “I would say prevention and the elimination of tobacco and alcohol is as important as anything we do.”

So, clinicians can advise their patients to use lip balm containing an SPF of 15 or higher to protect against sunlight and ultraviolet rays, eat more fruits and vegetables, and avoid tobacco as well as excessive amounts of alcohol. Self exams in between routine check-ups can also be beneficial to a patient’s health and can be encouraged by dentists and hygienists alike.1


1 Oral Cancer. Cancer Research and Prevention Foundation. 2006. www.preventcancer.org


Not the Usual Suspects

Once upon a time, certain lifestyle risk factors characterized the people in whom oral cancer would most likely develop. It was previously overwhelmingly, if not exclusively, seen in people who smoked and/or abused alcohol, or men over the age of 60.

Excessive alcohol consumption makes oral cancers six times more common in drinkers than nondrinkers.1 Cigarette, cigar, and pipe smoking, and other types of tobacco usage all contribute to an increased likelihood of developing some form of oral cancer.2 Patients who smoke are six times more likely to develop these cancers than those who don’t smoke.1

However, there are other biological and chemical risk factors associated with oral cancer, including the foods that patients consume. Poor nutrition choices (eg, a lack of vegetables and fruit in the diet), family history, and exposure to sunlight for large amounts of time all increase a person’s risk for developing oral cancer.

Oral cancer is most prevalent in:3

  • Men (it is twice as common in men than in women)
  • People over the age 40 (half of all oral cancers are found in people older than 68 years of age2)
  • African American men
  • People with human papilloma virus (HPV)
  • Patients with Vitamin-A deficiencies

Clearly, the demographics are changing. An estimated 25% of oral cancer victims have not used tobacco and have no other known risk factors.2 What’s more, according to Michael Kahn, published literature in peer-reviewed journals clearly shows that oral cancer is now affecting people in their 30s and 40s—if not younger—who have never smoked or drank, and more and more women are succumbing to the disease, too (See Two Faces of Oral Cancer, page 56).

“Not expecting oral cancer in younger, so-called less risky individuals is a huge error in judgment,” Kahn explains. “Therefore, we should be doing very careful visual examinations and screenings followed up with appropriate diagnostic processes and tools on all of our adult patients.”

And, as previously noted, research points to HPV (specifically 16, 18, and 32) as causative for some forms of oral cancer, Michael A. Siegel says. In fact, according to NIDCR director Lawrence Tabak, institute scientists examined the cells of oral cancer patients and compared them to people the same age without the disease. They found that the high-risk HPV types were detected in oral cancer of 23% of the cancer patients compared to 11% of the control group. According to the American Cancer Society, HPV may contribute to the development of approximately 20% to 30% of oral cancer cases.1

Further, Tabak points out that we now know that like some other cancers, oral cancer is preceded by a premalignant lesion; the progression of this premalignant or dysplastic lesion to cancer occurs over time. Therefore, he says it is very important that clinicians identify these early signs of disease and be willing to follow up and/or biopsy them.

To this end, some of the newer screening methods do have their place, says Lawrence Goldblatt. In fact, they can assist clinicians in providing more evidence to a patient that they have a suspicious lesion or abnormality that needs to be biopsied.

“I think that is valuable in itself, particularly if the patient isn’t really anxious to have the procedure performed in the first place,” Goldblatt says.

According to Mark Bride from Zila Pharmaceuticals, the profession normally uses death rate as a barometer to measure its success in finding and treating invasive oral cancer in early-stage development. The real key is to find the premalignant lesions and treat those appropriately, he says.

“While there is no guarantee that the patient will never get oral cancer if a premalignant lesion is found and treated, it will give those who do survive a much better opportunity to avoid the disfiguring reminders that they cheated death,” Bride observes.


1 American Cancer Society. 2006. Available at: www.cancer.org

2 Oral Cancer Foundation. 2006. Available at: www.oralcancerfoundation.org/facts/index.htm

3 Oral Cancer. Cancer Research and Prevention Foundation. 2006. Available at: www.preventcancer.org


Taming Technology to Tackle the Disease
The National Institute of Dental and Craniofacial Research(NIDCR) has invested heavily in researching the next generation of screening tools to help oral health care providers detect premalignant and cancerous lesions, notes director Lawrence Tabak. For example, NIDCR-funded scientists in Canada have established a comprehensive referral network that’s designed to help facilitate decision making at critical points during the management of oral cancer. There are studies investigating the use of such technologies as autofluorescence visualization and TBlue, Tabak says.

In addition, there is research underway at UCLA by Dr. David Wong and colleagues into the use of saliva as a noninvasive diagnostic tool to detect numerous diseases, although their primary focus is on oral cancer, Tabak says. What they have shown is a unique combination of proteins and messenger RNAs in human saliva that could detect oral cancer with a high degree of specificity and sensitivity, he explains.

“Over the next few years they will be developing prototypes with industrial partners, ultimately allowing for broad clinical testing,” Tabak shares. “It’s estimated that the platform could be ready for commercialization within the next 10 years.”

What’s available currently for dental professionals are several screening technologies designed to enhance the visual examination process. Although a thorough and meticulous examination is taught in dental schools, it can often lose its priority status when dentists enter private practice, explains Mark Bride, DDS, medical affairs director for Zila Pharmaceuticals. Therefore, it will take a concerted effort by everyone—academics, screening tool and diagnostics manufacturers, and researchers—to increase professional awareness of the importance of performing oral cancer screenings.

“In reality, we have a tendency to forget about oral cancer screening,” Bride admits. “So, we all have a mission to reawaken what we were taught in dental school.”

To do that, dentists can choose to incorporate into their practices intraoral visual enhancement devices. These include chemiluminescent light and toluidine blue vital tissue stain (such as Zila Pharmaceuticals’ ViziLite Plus® with TBlue630™) for the identification and marking of an oral lesion after ViziLite identification, as well as autofluorescence (such as LED Dental’s VELscope™) for the identification of healthy or unhealthy soft tissue on the surface and below the surface. Both of these are adjunctive aids that help guide the clinician in the early discovery of situations and conditions requiring a biopsy.

“If premalignant or cancerous lesions are found early, the survivability rate can be as high as 80%,” explains Wayne Rees, president of LED Dental. “Therefore, it is so important for clinicians to be able to find these lesions early, before they’ve progressed to later stages.”

Or, there are cytological in-vitro diagnostics that involve laboratory diagnosis after intraoral sampling. These include transepithelial brush biopsy (Oral CDx®, CDx Laboratories, Inc, Suffern, NY), which collects potentially cancerous tissue samples using a spiral brush; cells are fixed to a slide and sent for computerized laboratory analysis. There is also liquid-based cytology (SurePath®, TriPath Imaging®, Inc, Burlington, NC; ThinPrep®, Cytyc Corp, Marlborough, MA). These liquid-based cytology procedures have only been FDA-approved for use on the female cervix, although non-gynecological applications (as listed in the American Medical Association pathology and laboratory procedure codes) are possible with this diagnostic method.

“There have been several technologies that have been used in dentistry to assist in highlighting abnormalities,” explains Lawrence I. Goldblatt, DDS, MSD, dean of Indiana University School of Dentistry. “But the truth is, there isn’t a magic bullet or a fool-proof way to detect oral cancer. The only real way to diagnose it is to find a lesion, biopsy it, and examine it under a microscope.”

Many agree that the gold standard for oral cancer detection is the surgical biopsy. The other adjunctive, technology-based tools mentioned can help pave the way for better understanding by patients of their condition and help get them to that point.

“Even without any of these new technologies, the old fashioned oral examination is still a very important method for detecting oral cancer,” Tabak emphasizes. “I think the most important need is for practitioners to perform the routine visual oral examinations that we were all taught in dental school that can still be extremely valuable. We need not wait for more specific or sensitive tests.”


Impressionable Minds Today, Statistical Changes Tomorrow

Training students in the manner in which to perform an oral cancer examination is the responsibility of dental schools, says D. Walter Cohen, DDS, Chancellor Emeritus of Drexel University College of Medicine and Dean Emeritus of the University of Pennsylvania School of Dental Medicine. In some schools, oral cancer falls under the domain of oral medicine. In others, the topic is covered in the department of oral surgery. Regardless, dental schools are charged with making students aware that they are the physicians of the oral cavityand therefore obligated to perform oral cancer screenings.

In the past, dental education—like medical education—followed a discipline-based course approach where students attended separate classes in the basic medical and technical sciences. The coordination among the subjects wasn’t always optimal, explains Lawrence I. Goldblatt, DDS, MSD, dean of Indiana University School of Dentistry. In addition to the traditional lecture format, schools today are incorporating more problem-based approaches as part of the learning process.

“The problem is always a clinical problem centered on a patient,” Goldblatt says. “From the start, students know that they are responsible for assessing and understanding everything there is to know about their patients. Oral health is by no means only about the mouth anymore; it is impossible to separate the oral cavity from the rest of the body.”

Such a transition in how students approach the clinical oral cancer examination is symbolic of large and small curriculum changes made by dental schools in general over a period of years. Overall, the intent has been to equip students with the tools they need to follow the literature over the next 40 years of their careers regarding oral, molecular, and cellular biology.

“I think we have done a good job of trying to make progress in those areas,” Goldblatt believes. “Dentistry also has done a great job of demonstrating its value to the overall assessment and management of patients with some serious conditions, certainly such as cancer.”

The dental students of today are the clinicians of tomorrow who will impact the oral cancer statistics. For this reason, the importance of conducting regular, thorough head and neck examinations for patients—as well as maintaining a high index of suspicion—are emphasized in curricula throughout the country.

“The overall survival rate for oral cancer remains rather shocking, considering it is one of the types of cancer that is most amenable to early diagnosis and treatment,” Goldblatt says. “That’s what really maximizes survival; the less advanced the cancer is when it is found, the better the survival rate.”

Therefore, students are taught to search for and recognize specific abnormalities that could represent precancerous or premalignant lesions. In this regard, Goldblatt says educatorscan share in some sense of satisfaction based on the nature of specimens that are received from oral pathology biopsies.

“We are seeing significantly more precancerous lesions come through our pathology services than we have in recent years,” Goldblatt explains. “This suggests to me that dentists in the community—many of whom we have trained—are doing a good job of screening their patients and detecting precancerous lesions before they ever get to the stage of invasive cancer.”


Do It...

  1. During Hygiene Appointments. Without question, intraoral screening devices can be used in the hygiene department of a private practice, believes Mark Bride, DDS. “Typically, hygienists will treat recall patients, which creates the opportunity to screen annually, and annual screenings have proven successful in other cancer models,” Bride says. “The doctor would oversee the process and perform soft tissue examinations on all new patients.”
  2. During the Annual Examination. The oral cancer screening (ie, soft tissue, head and neck examination) is considered part of the American Dental Association standard annual examination, explains Wayne Rees.
  3. To Make Your Patients Aware of Oral Cancer. No matter what adjunctive screening product is used, making patients aware of oral cancer and the importance of regular screenings is what will “knock down the death rate,” says Rees. “A product alone isn’t going to do that, but a product, awareness, and education will.”
    According to A. Ross Kerr, DDS, MSD, the presence and use of screening devices that intrigue patients affords clinicians the opportunity to talk about oral cancer, how to modify risk factors for the disease, and prevention strategies. Anything—including these screening technologies—that will help elevate the public’s and profession’s awareness of oral cancer is a positive thing, Kerr believes.
  4. Because it’s Covered. In the typical oral health care benefit plan, most Americans are covered for an oral examination. Within that oral examination are procedures for performing a visual and palpation cancer screening, explains Jed J. Jacobson from Delta Dental Plans of Michigan, Ohio, and Indiana. “This is a classic benefit for patients that are covered,” Jacobson says.
    If you see something (eg, an unexplained red or white lesion for which there isn’t a definitive diagnosis), you can then performadditional adjunctive screening or diagnostic tests. According to Jacobson, the two most notable second-level adjunctive steps are using a brush biopsy—which Delta Dental plans often cover—or chemiluminescence. If those produce abnormal results, then a scalpel/surgical biopsy—the gold standard for definitive diagnostics—is performed to allow thorough pathological examination of the tissues.
  5. To Save Lives. Speaking based on data submitted since the brush biopsy technique was covered in 2004, Jacobson says that the Delta Dental system has processed nearly 24,000 brush biopsies as a result of the screenings dentists have performed. Of those, 1,400 were premalignant. Further still, 39 of those were later found to be definitively oral cancer. “Those patients are still alive today,” Jacobson says.
    Once oral cancer has progressed from the local site and metastasized into the regional lymph nodes, survival statistics immediately plummet from 80% to 50%, explains Kerr. If it moves into distant organ systems, the 5-year survival rate is less than 30%.
  6. So You Won’t Know What It Feels Like When You Miss Something. Kerr points out that it’s easy to make performing the oral cancer examination a routine part of practice after you’ve found a suspicious lesion early enough to save a patient’s life. That only has to happen once, he says, to stay motivated to continue doing it.
    Conversely, it only has to happen once in your career where you don’t detect something—where you neglected to thoroughly screen the patient—and he or she later presents to you again with a mass. “You would feel terrible and you would ask yourself if you should have seen it or not,” Kerr says.
  7. Most Importantly—Because It’s Your Ethical Responsibility. “I feel it is every dentist’s ethical and legal responsibility to perform a comprehensive oral examination, including an oral cancer examination,” emphasizes Nelson L. Rhodus, DMD, MPH, president and diplomate of the American Academy of Oral Medicine (AAOM). In addition, the AAOM recognizes performing the oral exam with oral cancer screening as the minimum standard of care dentists should provide.

Resources

FOR MORE EDUCATION & INFORMATION
According to Lawrence I. Goldblatt, DDS, MSD, dean of Indiana University School of Dentistry, continuing education in the area of oral cancer is something that always merits review and reminders so that dentists can continue to identify anything during a head and neck examination that appears suspicious. Michael Kahn, DDS, professor and chairman of the department of oral and maxillofacial pathology at Tufts University School of Dental Medicine, says that keeping up with journals—both peer-reviewed and dental trade magazines—as well as taking advantage of online courses, can help clinicians pursue recommended lifelong learning in the areaof oral cancer.

“You can go to dental meetings, take courses, and learn what is new compared to when you were in dental school, even if it was only 5 years ago,” Kahn says. “There are new technologies available that you can consider incorporating into your practice for screening your patients in order to catch something early or discover the pathology at its earliest possible stages.”

Also, consider reaching out the following organizations for information about how you can help make a difference in raising public awareness about oral cancer; enhance your screeningand diagnostic skills; and help save your patients’ lives.

American Academy of Oral and Maxillofacial Pathology
www.aaomp.org

American Academy of Oral Medicine

www.aaom.com

American Cancer Society

www.cancer.org

Cancer Research and Prevention Foundation

www.preventcancer.org

Global Facts on Tobacco or Oral Health

World Health Organization
www.who.int/oral_health

National Institute of Dental and Craniofacial Research

www.nidcr.nih.gov/HealthInformation/DiseasesAndConditions/OralCancer/default.htm
National Cancer Institute
www.nci.hih.gov/cancertopics/types/head-and-neck/

Oral Cancer Consortium

www.oral-cancer.org

Oral Cancer Foundation

www.oralcancerfoundation.org

Yul Brynner Head and Neck Cancer Foundation

www.yulbrynnerfoundation.org


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