As Ireland prepares for Mouth Cancer Awareness Day on 16th September, Imogen Fox discusses how to educate and inform your patients about the widely-misunderstood realities of oral cancers.
Oral cancer is the eighth most prevalent cancer in the UK and yet awareness of the disease is still extremely low (ONS, 2019). The rate has increased by 49% over the past 10 years and yet, according to the State of Mouth Cancer UK Report 2018/19 (Oral Health Foundation, 2019), only around 8% of British adults feel confident in their knowledge of the disease.
The increase in rate appears contradictorily with the decreasing rates of smoking tobacco. This is a known risk factor of the disease. However, there has been an increase in human papillomavirus (HPV) rates over this time. This is thought to play a heavy role in the rising statistics. It is well understood that early detection of oral cancer plays a vital part in survival rates.
With this in mind, we as dental professionals must continue to push awareness and understanding in our patients. Educating patients in risk factors can actively prevent oral cancer cases. Oral cancer screenings at every visit could save lives. With HPV being a key risk factor, we must consider that younger patients, who may be non-smokers and appear to have a healthy lifestyle, may also be at risk of the disease.
For this reason, it is important that every patient we see is screened routinely, irrespective of their apparent risk level.
Oral cancer screening
Completing an oral cancer screening only takes two minutes and it can begin before we even have the patient in the chair. We can visually check the patient’s face for any asymmetries, obvious external lumps or bumps, skin abnormalities – including moles and marks – as we greet them from the waiting area.
It is also important to note any changes in the colour or texture around the vermillion border of the lips and mouth. Once the patient is in the chair it is time to complete a physical check. Palpate the lymph nodes in the neck to feel for any enlargement of abnormalities.
The majority of intraoral lesions present in conjunction with an enlarged submandibular, submental or upper jugular node enlargement. Continue your screening to the intraoral zone. Check the labial mucosa and sulcus in both the upper and lower arch as well as the buccal mucosa.
Next, examine the tongue from front to back. Be aware that the lateral border of the tongue is an area where many lesions are found. Ensure you palpate all areas during your intraoral examination to feel for any changes in tissue consistency. This should extend to the floor of the mouth.
Finally, depress the tongue and examine the soft and hard palate. As well as the oropharynx, tonsils, uvula and pillars of fauces.
More information on screening protocols is available from the Mouth Cancer Foundation’s website, www.mouthcancerfoundation.org. lesions and referring to oral medicine If in doubt – refer! The sooner a cancerous lesion is spotted, the better the chance the patient has of successful treatment and recovery.
Suspected lesions must be sent as an urgent referral to the nearest oral medicine department. The team at the hospital will be far more experienced at recognising lesions and will be able to send the patient for further tests such as biopsies and CT or MRI scans.
A lesion, lump or swelling should be considering suspicious if any of the following applies:
- The patient has a history of previous oral cancer
- An intraoral lesion of any sort, in combination with enlarged nodes
- An ulcer that has not healed after 14 days
- A lump that feels rooted to its underlying structures
- A lesion with rolled margins, varying colour (red/white or both) or that has an irregular shape or border
- When a lesion is also bleeding
- A lesion that has a texture which dramatically differs from the surrounding tissue
- A lesion located in high risk areas (such as the lateral border of the tongue)
- No history of trauma to the area (particularly in combination with the absence of pain)
- Sudden tooth mobility with no apparent cause.
If you spot any abnormalities during a screening, it is important to make a clear record of the area. This may include a simple diagram either by hand or on the patient’s electronic records or a clinical photograph. Ensure your description includes the history, location, size, appearance and feel of the lesion.
If you think the area is unlikely to be cancerous, you should still arrange a review appointment for two weeks’ time to check the area again.
It is important to be considerate of the patient’s anxiety when you find any unusual lesions in their mouth. Explain to the patient when you begin your screening that you are going to check their mouth and neck for any lumps and bumps.
If you see anything, even non-suspicious, point it out to the patient and show them the area in the mirror. This will mean they can check the area at home. They can get in contact if it continues, changes or worsens.
Explaining to the patient that you are conducting an oral cancer check also opens conversations to allow the clinician an easy, comfortable bridge towards highlighting oral cancer risk factors and any ways they could reduce their risk with lifestyle changes, such as smoking cessation.
If a suspicious area is found then this must be brought to the patient’s attention but it is advisable to avoid using emotive words (such as cancer) if possible. Explain that you can see or feel an area that doesn’t seem quite right, that it may be nothing, but that you would like to seek a specialist opinion to be sure.
Reassure the patient that it is routine for us, as dental professionals, to send any unusual findings for assessment. Remember, if you have spotted a cancerous site then you could save their life.
Office for National Statistics (2019), cancer registration statistics, England: 2017
Oral Health Foundation, 2019, State of Mouth Cancer UK Report 2018/19
This article was first run in the September issue of Irish Dentistry magazine. You can read the latest issue of Irish Dentistry magazine here