Oral cancer screenings are an important part of maintaining our dental patients' health. The incidence of oral cavity and oropharyngeal cancers have increased at a rate of one percent per year since the mid-2000s. Regular screening is critical given that early detection can find localized disease, which is potentially more treatable and therefore more survivable than cancers found later.
We're in an Ideal Position
Oral health professionals are a natural fit to screen for premalignancies and cancers in the mouth. Their training combined with knowledge of the normal and pathological appearance of the oral cavity makes them eminently qualified for this crucial task. They are uniquely positioned, literally, to examine a patient’s mouth, and they are equipped with tools, such as mirrors and adjustable lights, that aid close examination.
Oral cancer diminishes quality of life to an astonishing degree. For one thing, it restricts the foods you are able to eat. If you are fortunate, those restrictions are only temporary until you’ve recovered from successful treatment, though sometimes they are permanent. Radiation therapy often damages salivary glands, which leads to chronic dry mouth. This causes a host of other oral health issues such as dental caries and soft tissue infections. The activities that we take for granted can become much more difficult. Consider what it would be like to engage in vigorous exercise without the ability to produce saliva. The harm to oral cavity structure that results from tumor extraction can be even more debilitating. Patients often have impaired articulation as a result. Oral cancer is often a life-changing diagnosis, and it can alter how we see ourselves.
A Life-Changing Diagnosis
Imagine if the activity that you saw as your central purpose, the thing that you perceived as your identity, was taken from you. This is what happened to Kathleen Watt, an opera singer whose dentist found an anomaly on her upper jaw during a routine screening. Upon further examination, it was determined to be osteosarcoma. While her dentist detected Ms. Watt’s cancer early, which likely saved her life, she nonetheless lost her previous identity in two significant ways. The surgeries to save her life permanently changed her face and the duration and extent of the treatment took her profession from her.
Ms. Watt said the diagnosis was cataclysmic. As an opera singer, it “put her very instrument at risk.” After the initial tumor resection, she had multiple surgeries to combat the aggressive cancer. Sections of her lateral nasal wall and orbital socket were removed to achieve satisfactory margins. By the time her care team completed her facial reconstruction years later, her appearance had changed significantly, and it was clear that she would not return to her previous life as an opera singer.
Ms. Watt’s dentist initially identified her cancer, but her subsequent treatment required the combined efforts of a multidisciplinary team. Treating something as complex as aggressive oral cancer calls for more than an oral surgeon, an oncologist, radiotherapist, ophthalmologist, speech pathologist, psychologist, or nutritionist. It requires all of them working together with clear communication, a shared electronic health record, and a carefully coordinated treatment plan. This is one advantage in dental schools being part of academic health centers, and not just co-located on campus, but actually integrated with medicine. It is an opportunity for those of us in different disciplines to work together and learn from each other. This collaboration benefits the patient most of all and it is an important reminder that the patient is the center of our academic and clinical endeavors.
Gathering the Evidence
Kathleen Watt’s experience is an extreme example, but I and most dentists I know have had the experience of finding something suspicious in a patient's mouth. To us, it is a routine and important part of our stewardship of our patients' health. It’s even more crucial for us to continue screening for oral cancer, since it is not something that primary care providers routinely do. In 2014, the U.S. Preventive Services Task Force issued the recommendation statement to primary care providers that “current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults.” Given that recommendation, it’s clear that oral health providers are the first line of defense in keeping our patients free from oral cancer and at the same time it is a call action to improve the research.
While we safeguard our patients’ health, we also have the opportunity to accumulate the data we need to prove the efficacy of oral cancer screening. A 2019 National Dental PBRN Collaborative Group report showed that there is evidence to support the practice. During their 2017 study, 1061 participants screened their patients for suspicious lesions. Of those, 87% referred or biopsied and 15.4% reported discovering a lesion that was later confirmed as cancerous. This is just one study and many more are needed. However, as more practices shift to electronic health records, potentially integrated with their patients’ medical records, we will accumulate more high-quality data.
It's Up to Us
It’s up to us as oral health providers to safeguard our patients’ health the best we can. That includes taking the time to document oral cavity screening, including staging and grading, and diligently enter that information into health records. This will give researchers the data required to conclusively demonstrate that oral health providers are providing an invaluable service in the fight against oral cancers and with that, perhaps other healthcare providers will follow our lead.
Michael S. Reddy, DMD, DMSc
Dean, UCSF School of Dentistry
Associate Vice Chancellor, Oral Health Affairs
