Oral Cancer Screening

It all started in December 2002, when Boland noticed a white spot on her tongue. "I was working with about 30 general dental practices at that time, and because I couldn't get a good answer in the beginning when I first noticed the spot, I was showing my tongue to my clients. Every dentist said, ‘Oh come on, that's nothing. You don't smoke, you don't drink, you're too young, and you're a woman. It's nothing. You don't have anything to worry about.'"

But Boland knew better. "It wasn't normal," she says. "I knew the spot had not been there. I knew it was changing. Then an erythroplakia (red spot) showed up, and I knew this was not going to be OK."

Several months later, in May 2003, Boland was diagnosed with undifferentiated squamous cell carcinoma, and in July of that year she underwent surgery and had 25% of her tongue removed. Boland says that had it not been for her extensive training as a hygienist, she might not have persisted in getting an answer and might not be alive today. "Thankfully my cancer hadn't spread into my lymph nodes," she says. "If it had, my treatment certainly would have been significantly more involved, and I don't think my outcome would have been as good."

Boland's second bout with oral cancer came in 2019, when another spot appeared in the same place, a red one. "This spot was deeper, but thankfully it was caught earlier," she says. "I had another part of my tongue removed, but that was the only treatment that was necessary for that second lesion."

Thankfully, Boland says, the second lesion was caught during a routine oral cancer screening at a dental practice.

Under ideal circumstances, dental hygienists see their patients twice a year, and of all healthcare professionals they are undoubtedly the best equipped to screen for oral cancer, which is a significant health risk for large numbers of patients. While dentists are primarily interested in teeth, hygienists focus on the soft tissues. There are several types of oral cavity and oropharyngeal cancers and pre-cancers that can appear in all parts of the mouth and throat, including the lips, tongue, hard and soft palate, the floor of the mouth, the tonsils, and on the back wall of the oropharynx. Squamous cell carcinomas can originate in the flat and thin squamous cells that form the linings of the mouth and throat.¹ There are also HPV-related cancers, salivary gland cancers, and lymphomas.^1,2 Pre-cancerous conditions, such as leukoplakia and erythroplakia, also known as dysplasia, can manifest as white, gray, or red spots that do not come off when scraped or that bleed when scraped.¹ In addition, patients who use tobacco products and those who consume alcohol are at a higher risk for oral cancer,³ and a history of HPV infection in the mouth and throat increases cancer risk as well.^2-4

Cancers of the mouth and throat are prevalent, and early detection can be a matter of life or death. Statistics available from the National Cancer Institute on oral cavity and pharynx cancer for 2023 revealed an estimated 54,540 new cases and an estimated 11,580 fatalities.⁵ For those diagnosed with oral cancer, the federal government reported a 5-year survival rate of 68.5% between 2013 and 2019.⁵ As with all forms of cancer, early detection improves chances of survival. According to the National Institute of Dental and Craniofacial Research, there is a significant increase in 5-year survivability when oral cancer is detected at the localized stage (also known as stage 1).⁶ According to the American Cancer Society, the mortality rate for oral and pharyngeal cancer increased by 0.4% between 2009 and 2020.³ This uptick follows decades of a decline in deaths.³

Because government data indicates that oral cancer is so common in the United States, it is likely that most dental hygienists will knowingly or unknowingly encounter patients with some stage of the disease on a regular basis, which makes screening even more important. The National Cancer Institute reported that more than 424,000 Americans were living with cancer of the oral cavity or pharynx in 2020.⁵ The institute further reported, based on 2017-2019 data, that approximately 1.2% of men and women will be diagnosed with oral cavity or pharynx cancer at some point during their lifetime, and that men are twice as likely as women to be diagnosed.⁵

Becky Smith, CRDH, EdD, FADHA, president of the American Dental Hygienists' Association (ADHA) and a professor at Miami Dade College, says it is important for dental professionals to conduct an extraoral and intraoral cancer screening at the commencement of every appointment. According to the ADHA's Standards for Clinical Dental Hygiene Practice, screening for oral cancer is required for hygienists as part of their patient assessment and must also be documented in patient records.⁷

"Dental hygienists are dedicated to providing quality care, and that starts with a health assessment that includes screening for oral cancer," Smith says. "Hygienists should be checking the lips and the areas surrounding the lips, and they should be palpating the neck, thyroid area, and submandibular area for the lymph nodes, even down in the shoulders-almost like a little massage. At the same time, we also check the temporomandibular joint to see if there are any deviations, which has nothing to do with oral cancer but is part of the extraoral exam."

"Once you are done with the external, then you move inside the lips, the inside of both sides of the cheeks, the floor of the mouth, and the hard and soft palate. Then have the patient extend their tongue and say ‘aah' to see the pharynx area and the tonsillar area," Smith says. "I always ask my patients to extend their tongue, and I grab it with a gauze and take my mirror and pull it to one side and then to the other side and check underneath and the floor of the mouth. I also do a bimanual exam, which is taking each hand and feeling from the bottom and inside for any lumps or bumps that may not be obvious, but that can be felt through palpation. With the lips, it's a bi-digital exam, taking two fingers of one hand and feeling along for abnormalities."

Smith says that intraoral and extraoral cancer screenings, when done regularly, do not take up much time because with repetition hygienists develop speed. "Where you get slowed down," she says, "is when you detect something." Smith points out that while hygienists do not diagnose, all findings should be described, measured, and documented in the patient's records. The patient should be asked if they have ever noticed the anomaly before, and the dentist should be informed so the patient can be referred to an oral surgeon or other healthcare specialist.

Oral cancer coach, speaker, and author Susan Cotten, BSDH, RDH, OMT, says that dental hygienists can increase their skills and confidence in oral cancer screenings by taking advantage of continuing education opportunities. "As dental hygienists, we are committed to helping our patients get and stay healthy, which is why screening for signs of disease is so important," says Cotten, who, as founder and CEO of Oral Cancer Consulting, offers lectures and hands-on workshops throughout the country designed to help dentists and dental hygienists know what a comprehensive screening entails, to help increase confidence, and to reduce liability. "When we're confident, we're thorough and efficient and more likely to conduct effective screenings," she says.

The ultimate goal, according to Cotten, is to increase early detection of a life-threatening disease. She calls her oral cancer screening technique the "Cotten Method," and it contains four pillars: Etiologies, or known contributing factors, such as tobacco, alcohol use, betel quid, and HPV exposure; risk factors, such as periodontal disease, obesity, or being immunocompromised; signs and symptoms, which can include a persistent cough, difficulty swallowing, the sensation of something being caught in the throat, or a lump anywhere in the head or neck; and, lastly, the actual hands-on screening, which includes both visual and tactile examination.

"I also do some other things while I'm performing this screening," Cotten says. "While I palpate, I talk to the patient about HPV, and, if they are a longtime patient, I ask how Johnny is or what happened at the wedding. While I am screening, I'm building rapport with the patient. I am also a myofunctional therapist, so while I do the oral cancer screening, I also screen for myofunctional disorders and airway issues because I'm already looking at the same structures. When I look inside the mouth at the tongue, the back of the throat, the cheeks, and the floor of the mouth, I also look at the teeth. Are there any fractured teeth? What about restorative needs? If there is anything that needs documenting, further investigation, or a referral, I get the camera and take a photo for the dentist's exam."

Any sign or symptom that persists for two weeks or looks abnormal can be a concern. "I have some Susan-isms," Cotten says, "and one of them is, ‘If it's not right, it's wrong.'" She says, for example, that a patient might have a persistent sore throat or the feeling of something caught in the throat. "If something is not right, then it's time to react and refer," she says.

In addition to the "Cotten Method," various other screening protocols exist as well.⁸ To assist dental professionals with oral cancer screenings, several companies offer devices designed to detect warning signs, and Boland, Smith, and Cotten all say that these tools can be helpful. Some of the devices work by illuminating the tissues with special lights. Others can be used to perform biopsies, and yet others analyze a patient's saliva. Even more technologies are in development.⁹

Boland credits the discovery of her own oral cancer in 2003 to one of these devices, a brush biopsy test that was just being introduced at the time. According to Smith, although ancillary devices are not 100% accurate, they are indeed helpful. "Any tools that can help in detection at an early stage, I'm all for," Smith says.

"I think the adjunct screening devices are good, when thoughtfully implemented," Cotten says. "Fluorescence can show what we can't see with our naked eye. Such devices can show below the surface and can reveal things that might need further investigation."

More information about the various oral cancer screening devices can be found below.

The ADHA, which has abundant resources on its website of use to hygienists, is launching several new initiatives to raise awareness of the importance of oral cancer screenings, including an all-day, hands-on training program for dental professionals. Furthermore, the Oral Cancer Foundation is conducting its 23rd Annual Oral Cancer Awareness Month in April 2024 in collaboration with the ADHA, the Canadian Dental Hygienists Association, the California Dental Hygienists' Association, and many other dental associations to provide resources for early detection. The Oral Cancer Foundation also runs the Check Your Mouth^™ campaign as a public service to help raise awareness about the importance of self-discovering abnormalities that may be dangerous.

According to the Oral Cancer Foundation, early discovery of oral cancer leads to less invasive treatments and ultimately better long-term outcomes and survival.¹⁰ "We are not looking for huge tumors," Boland says, "but rather minor tissue changes, even as small as 2 mm. The only way to increase early detection rates is to investigate those minor tissue changes. If you investigate and it turns out benign, the patient is going to be happy, but if you find a dysplasia or an early lesion, you are going to save a life. Telling a patient ‘It's nothing' is not a diagnosis-please don't leave it there with a patient."

Preventing legal liability is another reason to always screen patients for signs of oral cancer. In a recent malpractice case, a jury awarded millions of dollars to a dental patient whose dentist failed to investigate the patient's tongue sore, resulting in a delayed oral cancer diagnosis.¹¹ Published reports describe other similar cases against dental professionals who failed to detect and refer patients with signs of oral cancer whose cases were later diagnosed and required extensive treatments.^12,13

"If you don't have the time in your appointments for oral cancer screenings, have a conversation with your dentist and advocate for that time; advocate for your patient," Cotten says. "The most common question I get in my courses is, ‘Susan, what do I do when I find something that I feel needs to be referred but the dentist says we'll just watch it?' My response is that it is time to have that conversation with your dentist. Share your knowledge and evidence-based reasons for further investigation and your concern for not only the patient, but also your liability concerns for you and the dentist. Advocate for your patient and advocate for yourself and for what you know is the right thing. Don't be afraid to speak up."

For hygienists who might be tempted to skip the oral cancer screening altogether because of time constraints and productivity pressures, Smith has this piece of advice: "Imagine it is your mom in the chair or somebody you love. How would you want them to be assessed and to be treated? You would want the best possible course of treatment for them, whether that is an oral cancer screening, scaling, polishing, or radiographs. You would want the best for that person. You can save your patient's life by taking a couple of minutes just to do a quick assessment."

The following devices can be used by dental professionals to assist with oral cancer screenings. Note that this is not a comprehensive list, and that new devices and technologies are in development.

Bio/Screen - AdDent, Inc.
Bio/Screen uses violet LEDs to show biofluorescence in the oral cavity. An eyepiece and an optical viewing filter increase the contrast between healthy and abnormal tissue.

https://addent.com/bioscreen/

Oral Health Pro - Viome
Oral Health Pro is an at-home saliva collection kit that can be used to detect biomarkers associated with oral and throat cancers, including early stages. It is powered by proprietary RNA sequencing and AI technology.

https://www.viomepro.com

OralCDx - CDx Diagnostics
OralCDx is a non-invasive oral brush biopsy with AI-enabled tissue analysis that is designed to empower doctors to help prevent oral cancer. If dysplasia is found, the cells can typically be removed to stop the progression of oral cancer.

https://www.cdxdiagnostics.com/oralcdx

OralID^® - Forward Science
OralID uses fluorescence technology to provide clinicians with an aid in visualization of oral mucosal abnormalities, such as oral cancer and pre-cancer. It is an FDA-cleared device that can be used without any rinses, dyes, sheaths, or barriers.

https://forwardscience.com/oralid

Throat Scope - Holland Healthcare Inc.
Throat Scope is an illuminating tongue depressor and retraction device that is designed to assist in oral examination.

https://hollandhealthcareinc.com/products/throat-scope/

VELscope - LED Dental
The VELscope is a fluorescence-based device that enhances the visualization of oral mucosal abnormalities such as oral cancer and premalignant dysplasia. Examinations can be performed in the dentist's office during routine hygiene exams.

https://velscope.com

ViziLite PRO^® Oral Lesion Screening System - DenMat
The VizLite Pro can be using during the visual portion of the head and neck exam to better see tissue changes and abnormalities in the oral cavity. It uses five LEDs to allow clinicians to screen for lesions without turning the overhead lights off.

https://www.denmat.com/vizilite-pro-oral-lesion-screening-system.html