A vast amount of my career has been spent on defining our powerful role as dental hygienists in the earlier discovery of an abnormal lesion through effective visual and tactile examination of the structures of the head, neck and oral cavity. Frankly, the omission of a thorough and effective extraoral/intraoral examination can cost a life. The incidence of oral and oropharyngeal cancer continues to rise each year with a vengeance in comparison to other cancers where we are making far greater inroads in reducing incidence.
Oral and oropharyngeal (posterior third and base of the tongue, soft palate, tonsillar tissue, uvula) is far more common than other cancers that we hear of more often such as liver, ovarian, stomach, thyroid and Hodgkin lymphoma, for instance. The perception and vast misunderstanding are that “oral cancer is relatively rare” with some practitioners claiming to never have seen it in their many years of clinical practice. This begs further questions: what and how are they looking for it? It is listed as the sixth leading site of projected new cancer cases for 2021 by the Canadian Cancer Society. Refer to Table 1. The projected new cases of head and neck cancer in Canada for 2021 were 7,400.2 These figures do not take into account those who “survive” the disease who are deemed the “lucky” ones living with permanent disfigurement, side effects of radiation – which include continual oral mucositis throughout the oral cavity and severe xerostomia often referred to as “cotton mouth” – the continual fear of recurrence, and so many more issues that are a day-to-day reminder of a diminished quality of life.
Despite all efforts, oral cavity cancer continues to be discovered in the later stages. When found at the early stages of development, oral cancers can have an 80 to 90 percent survival rate.1 Conversely, when discovered in the later stages, the mortality rate is high at approximately 43 percent, five years from diagnosis. The extremely challenging and arduous treatment regimens contribute to survivor morbidity as well. The lack of public awareness and perception of the risk of oral and oropharyngeal cancer coupled with a low incidence of self-reported oral cancer screening through population-based surveys, omission of extraoral palpation, and lack of confidence indicated by dental professionals, particularly regarding the HPV-related clinical presentation, all contribute to this dismal picture.3-7 This has to end.
There are two distinct etiologic pathways that we are aware of that contribute to the progression of oral and oropharyngeal cancer. Historically, tobacco and alcohol use and a more recently identified virally-transmitted etiology, HPV (Human papillomavirus) are responsible. A much lower percentage have no known etiology; however, it is suspected that a genetic predisposition may be associated with this smaller cohort.8 Simply stated, lifestyle behaviours are a strong contributor to oral and oropharyngeal cancer. The vaccination has the capability of preventing 92 percent of HPV-related cancers in the future according to the CDC.9 It is a matter of choice.
In Canada, we are fortunate to have one of the lowest incidence rates of cervical cancer in the world. This is due to screening practices and HPV vaccination. Presently, oropharyngeal cancer represents the highest number of HPV-related cancer cases in Canada. This has prompted a very recent expansion of the indication of the HPV vaccine for prevention of head and neck cancers. “Unfortunately, good epidemiological data are lacking because HPV is not a nationally notifiable disease, is usually asymptomatic and diagnostics for HPV are not publicly available or funded,” stated a document generated from the Office of the Chief Dental Officer of Canada published in the peer-reviewed journal, Canada Communicable Disease Report.10 The CDC estimates that 70 percent of oropharyngeal cancers are associated with HPV, whereas other sources estimate as high as 90 percent.11
The fastest-growing segment of the oral and oropharyngeal cancer population are otherwise healthy, non-smoking individuals in the 35–55 age range with an occurrence 4x greater in males vs. females.8 Screening has never been more important.
Some of the barriers to performing this potentially life-saving screening include the reality of time constraints, the fear of saying the “C-word” and talking about cancer risk openly, and, lastly, hesitancy of dental professionals to speak openly about HPV being a sexually transmitted risk factor. There is no stigma here. As the CDC points out, HPV is so common, that almost every sexually active adult will have one or more infections in a lifetime.12 The majority of those infected will clear the virus, however, for those afflicted with a persistent, high-risk HPV strain, the transformation to cancer is a very real threat.
The signs and symptoms that may be associated with oral and oropharyngeal cancer range from the obvious to the very subtle. Secondly, HPV-related oropharyngeal cancer has an affinity for lymphoid tissues presenting a further layer of complexity with clinical assessment. Even though we may not visually have access to see an HPV-related lesion, many symptoms are associated which, if identified, can be potentially life-saving. The Oral Cancer Foundation has a comprehensive listing of symptoms on their website that may be related to both oral and oropharyngeal cancer.
Signs and symptoms of oral cancer which is predominantly caused by tobacco usage and/or excessive alcohol usage may include one or more of the following:13
- Any sore or ulceration that does not heal within 14 days.
- A red, white, or black discoloration of the soft tissues of the mouth.
- Any abnormality that bleeds easily when touched (friable).
- A lump or hard spot in the tissue, usually border of the tongue (induration).
- Tissue raised above that which surrounds it; a growth (exophytic).
- A sore under a denture, which even after adjustment of the denture, does not heal.
- A lump or thickening that develops in the mouth.
- A painless, firm, fixated lump felt on the outside of the neck, which has been there for at least two weeks.
Oral cavity cancer triggered by abnormal cellular differentiation starts most often at the basement membrane. This means that by the time an abnormal lesion is clinically visible, it is often in later-stage development. Adjunctive screening devices such as VELscope Vx utilize a technology platform, direct fluorescence visualization, that has been previously used in the lungs, colon, and cervix for assessment purposes. Through the use of a proprietary and specific blue wavelength, it has the ability to penetrate beneath the surface to the basement membrane where abnormal cellular differentiation most often begins. This provides the dentist or dental hygienist to see beyond what may have been visible with white light examination. The VELscope Vx Enhanced Oral Assessment system was granted a medical device license and approved by the FDA and Health Canada to help clinicians discover cancerous and pre-cancerous tissue with a consecutive indication for the determination of surgical boundaries due to the device’s high-level sensitivity and specificity. Using direct fluorescence visualization to determine surgical borders has been studied at length and proven to decrease the recurrence of oral cancers. This technology is available to all dental practices. A couple of things to stress: training on interpretation is of paramount importance and secondly, an effective and comprehensive extraoral (head and neck), intraoral (soft tissue examination inside the oral cavity) employing both a visual and tactile approach is first and foremost the most important step. Lastly, devices such as VELscope Vx are not diagnostic tools. The only true diagnostic capability is through the performance of a biopsy. They are to aid us in our assessment by providing another “tool” to evaluate early changes in the oral cavity.
Signs and symptoms of HPV-caused oropharyngeal cancer may include one or more of the following:13
- Hoarseness or sore throat that does not resolve within a few weeks.
- Asymmetrical tonsil size usually painless.
- A painless, firm, fixated lump felt on the outside of the neck, which has been there for at least two weeks.
- A persistent cough that does not resolve after many days.
- Difficulty swallowing; a sensation that food is getting caught in your throat.
- An earache on one side (unilateral) that persists for more than a few days.
- [Tongue that tracks to one side when stuck out]
In addition, a high percentage of HPV-related oropharyngeal cases had a neck mass as the first visible sign.14 Palpation of the lymph nodes is critically important. Any symptom persisting beyond 14 days, should always be further investigated. Persistence is key!
The Office of the Chief Dental Officer of Canada presents a strong call to action to our profession to play a key role in elevating awareness, educating, and empowering our dental clients to understand risk factors and prevention strategies. We can improve survival rates through opportunistic cancer screening and fight HPV transmission by increasing HPV vaccination uptake. Presently in Canada, HPV vaccination uptake is far greater among females vs. males. This will only change through a concerted effort of the medical and dental professionals to educate. We accept vaccination due to perceived risk. Are your clients aware of the ubiquitous nature of this virus and the fact that merely being alive and sexually active may place them at inherent risk?15
As a dental professional, the gratification of saving a life or improving the quality of life for a fellow human being due to earlier discovery can be compared to nothing else we do in dentistry. Oral cancer screening is not a choice. It is our ethical responsibility. The 4-minute extraoral/intraoral screening examination can save a life. It’s an easy choice when it comes to serving our fellow human beings. Thank you in advance for making this decision.
- Canadian Cancer Statistics 2021. https://cancer.ca/en/research/cancerstatistics/canadian-cancer-statistics
- Akinkugbe, A.A., Garcia, D.T., Brickhouse, T.H. et al. Lifestyle risk factor related disparities in oral cancer examination in the U.S: a population-based cross-sectional study. BMC Public Health 20, 153 (2020).
- Stephenson MC, Gurenlian JR, Bowen DM. Perceptions of Oral Cancer Screenings as Compared to Other Cancer Screenings: A pilot study. J Dent Hyg. 2017 Jun;91(3):37-46.
- Clarke AK, Kobagi N, Yoon MN. Oral cancer screening practices of Canadian dental hygienists. Int J Dent Hyg. 2018 May;16(2):e38-e45.
- Aldossri M, Okoronkwo C, Dodd V, et al. Dentists’ Capacity to Mitigate the Burden of Oral Cancers in Ontario, Canada. J Can Dent Assoc 2020;86:k1
- Nelson JL, Kennedy EN, Aldosari M, Agaku I, Vardavas C. Patient-reported receipt of oral cancer screenings and smoking cessation counseling from US oral health care providers: National Health and Nutrition Examination Survey, 2015-2016. J Am Dent Assoc. 2019 Dec;150(12):995-1003.
- Office of the Chief Dental Officer of Canada. Human papillomavirus and oral health. Can Commun Dis Rep 2020;46(11/12):380-3.
- McIlwain WR, Sood AJ, Nguyen SA, Day TA. Initial Symptoms in Patients With HPV-Positive and HPV-Negative Oropharyngeal Cancer. JAMA Otolaryngol Head Neck Surg. 2014;140(5):441–447.
Clinical Practice Resources
Watch the Oral Cancer Screening Examination – A systematic guide to extraoral/intraoral cancer screening. https://www.youtube.com/watch?v=q9kPdQMyU40&t=213s
About the Author
As an international, award-winning speaker and recognized thought leader, Jo-Anne Jones has delivered over 1,000 presentations across North America and Europe. In the midst of preparing her research on HPV-related oropharyngeal cancer for the national association, Jo-Anne’s family was dealt a crushing blow by having a family member diagnosed with late-stage HPV-related tonsillar cancer; a young woman with none of the traditional risk factors and the loss of a life far too early. Jo-Anne proudly partners with the Oral Cancer Foundation in conveying the urgent need for change in the way we screen for both oral and oropharyngeal cancer. Jo-Anne played an active role in the development of the ‘Check Your Mouth’ campaign; a global initiative in collaboration with the Oral Cancer Foundation and Holland Healthcare Inc., promoting self-examination of the oral cavity between professional visits. Jo-Anne may be reached at firstname.lastname@example.org