DETECTING ORAL CANCER

A Guide for Healthcare Professionals

Objectives
Our objectives for this presentation we are to be able to
● Understand the significance of Oral Cancer
● Learn the screening process
● Identify oral lesions
● Detecting Oral Cancer
INCIDENCE AND SURVIVAL
>Oral cancer accounts for roughly 3% of all cancers diagnosed annually in the
United States.
>Approximately 53,000 people will be diagnosed with oral cancer each year
>about 10,800 will die from the disease. On average, 66 percent of those with the
disease will survive more than 5 years
 THE IMPORTANCE OF EARLY DETECTION
It’s important to find oral cancer early when it can be treated more
successfully.

The 5-year relative survival rate for those with localized disease at diagnosis is 85
percent compared with only 40 percent for those whose cancer has metastasized.
Early detection of oral cancer is often possible. Tissue changes in the mouth that
might signal the beginnings of cancer often can be seen and felt easily.
 WARNING SIGNS
Lesions that might signal oral cancer

Two lesions that could be precursors to cancer are leukoplakia (white lesions)
and erythroplakia (red lesions). Although less common than leukoplakia,
erythroplakia and lesions with erythroplakic components have a much greater
potential for becoming cancerous. Any white or red lesion that does not resolve
itself in 2 weeks should be reevaluated and considered for biopsy to obtain a
definitive diagnosis.
 WARNING SIGNS
Other possible signs/symptoms of oral cancer

Possible signs/symptoms of oral cancer that your patients may report: a lump or
thickening in the oral soft tissues; a sore throat or a feeling that something is caught in the
throat; diffculty chewing, swallowing, or speaking; ear pain; diffculty moving the jaw or
tongue; hoarseness; numbness of the tongue or other areas of the mouth; or swelling of the
jaw—in patients with dentures, swelling may produce a complaint that dentures have
become ill-ftting or uncomfortable.
If the above problems persist for more than 2 weeks, a thorough clinical examination
and laboratory tests, as necessary, should be performed to obtain a definitive diagnosis. If a
diagnosis cannot be obtained, referral to the appropriate specialist is indicated.
 RISK FACTORS
Tobacco & Alcohol Use

Tobacco use (cigarettes, cigars, pipes, and smokeless tobacco) is a risk factor
for oral cancer. Heavy alcohol use also increases the chances of developing the
disease. The risk is even greater for people who use both tobacco and alcohol
than for those who use only tobacco or only alcohol.
 RISK FACTORS
HPV

Infection with the sexually transmitted human papillomavirus (specifcally the

HPV 16 type) has been linked to a subset of oral cancers.
 RISK FACTORS
Age

Risk increases with age. Oral cancer most often occurs in people over the
age of 40.
 RISK FACTORS
Sun exposure

Cancer of the lip can be caused by sun exposure.

 WHAT YOU CAN DO
A regular dental check-up is an excellent opportunity for a head and neck
examination. Clinicians should be particularly vigilant in checking those
who use tobacco or excessive amounts of alcohol.

1. EXAMINE: your patients using the head and neck examination described
here
2. OBTAIN A HISTORY: of their alcohol and tobacco use
3. INFORM: your patients of the association between tobacco use, alcohol
use, and oral cancer
4. TALK: to your patients about the HPV vaccine for themselves and their
children (depending on their age)
5. FOLLOW-UP: to make sure a definitive diagnosis is obtained on any
possible signs/symptoms
 WHAT YOU CAN DO
This exam is abstracted from the standardized oral examination method
recommended by the World Health Organization. The method is consistent with
those followed by the Centers for Disease Control and Prevention and the
National Institutes of Health. It requires adequate lighting, a dental mouth
mirror, two 2 x 2 gauze squares, and gloves; it should take no longer than 5
minutes.
THE EXAMINATION
 THE EXAMINATION
The examination is conducted with the patient seated. Any intraoral prostheses
are removed before starting. The extraoral and perioral tissues are examined
first, followed by the intraoral tissues.
Figure 1 – Face
Figure 2 – Lips
Figure 3 – Labial Mucosa
Figure 4 – Labial Mucosa
Figure 5 – Right Buccal Mucosa
Figure 6 – Left Buccal Mucosa
Figure 7 –Gingiva
Figure 8 – Tongue Dorsum
Figure 9 – Tongue Left Margin
Figure 10 – Tongue Right Margin
Figure 11 – Tongue Ventral
Figure 12 – Floor of the Mouth
Figure 13 – Hard Palate
Figure 14 – Oropharynx
Figure 15 – Palpation
EXAM REVIEW
The examination is conducted with the patient seated. Any intraoral prostheses
(dentures or partial dentures) are removed before starting the examination. The
extraoral and perioral tissues are examined first, followed by the intraoral tissues.
I. THE EXTRAORAL EXAMINATION
◆ FACE: (Figure 1) The extraoral assessment includes an inspection of the face,
head, and neck. The face, ears, and neck are observed, noting any asymmetry or
changes on the skin such as crusts, fissuring, growths, and/or color change. The
regional lymph node areas are bilaterally palpated to detect any enlarged nodes,
and if detected, their mobility and consistency. A recommended order of
examination includes the preauricular, submandibular, anterior cervical, posterior
auricular, and posterior cervical regions.
Figure 1 – Face
II. PERIORAL AND INTRAORAL SOFT TISSUE EXAMINATION

The perioral and intraoral examination procedure follows a seven-step systematic

assessment of the lips; labial mucosa and sulcus; commissures, buccal mucosa,
and sulcus; gingiva and alveolar ridge; tongue; floor of the mouth; and hard and
soft palate.

◆ LIPS: (Figure 2) Begin examination by observing the lips with the patient’s
mouth both closed and open. Note the color, texture and any surface
abnormalities of the upper and lower vermilion borders.
Figure 2 – Lips
II. PERIORAL AND INTRAORAL SOFT TISSUE EXAMINATION

◆ LABIAL MUCOSA: (Figures 3 and 4) With the patient’s mouth partially open,
visually examine the labial mucosa and sulcus of the maxillary vestibule and
frenum and the mandibular vestibule. Observe the color, texture, and any swelling
or other abnormalities of the vestibular mucosa and gingiva.
II. PERIORAL AND INTRAORAL SOFT TISSUE EXAMINATION

◆ BUCCAL MUCOSA: (Figures 5 and 6) Retract the buccal mucosa. Examine

first the right then the left buccal mucosa extending from the labial commissure
and back to the anterior tonsillar pillar. Note any change in pigmentation, color,
texture, mobility and other abnormalities of the mucosa, making sure that the
commissures are examined carefully and are not covered by the retractors during
the retraction of the cheek.
II. PERIORAL AND INTRAORAL SOFT TISSUE EXAMINATION

GlNGlVA: (Figure 7) First, examine the buccal and labial aspects of the gingiva
and alveolar ridges (processes) by starting with the right maxillary posterior
gingiva and alveolar ridge and then move around the arch to the left posterior
area. Drop to the left mandibular posterior gingiva and alveolar ridge and move
around the arch to the right posterior area. Second, examine the palatal and
lingual aspects as had been done on the facial side, from right to left on the palatal
(maxilla) and left to right on the lingual (mandible).
Figure 7 –Gingiva
II. PERIORAL AND INTRAORAL SOFT TISSUE EXAMINATION

◆ TONGUE: (Figure 8) With the patient’s tongue at rest, and mouth partially open,
inspect the dorsum of the tongue for any swelling, ulceration, coating or variation
in size, color, or texture. Also note any change in the pattern of the papillae
covering the surface of the tongue and examine the tip of the tongue. The patient
should then protrude the tongue, and the examiner should note any abnormality of
mobility or positioning. (Figure 9) With the aid of mouth mirrors, inspect the right
and left lateral margins of the tongue.
Figure 8 – Tongue Dorsum
Figure 9 – Tongue Left Margin
II. PERIORAL AND INTRAORAL SOFT TISSUE EXAMINATION

◆ TONGUE: (Figure 10) Grasping the tip of the tongue with a piece of gauze will
assist full protrusion and will aid examination of the more posterior aspects of the
tongue’s lateral borders.

(Figure 11) Then examine the ventral surface. Palpate the tongue to detect
growths.
Figure 10 – Tongue Right Margin
Figure 11 – Tongue Ventral
II. PERIORAL AND INTRAORAL SOFT TISSUE EXAMINATION

◆ FLOOR OF MOUTH: (Figure 12) With the tongue still elevated, inspect the floor
of the mouth for changes in color, texture, swellings, or other surface abnormalities.
II. PERIORAL AND INTRAORAL SOFT TISSUE EXAMINATION

PALATE: (Figures 13 and 14) With the mouth wide open and the patient’s head
tilted back, gently depress the base of the tongue with a mouth mirror. First
inspect the hard and then the soft palate.
II. PERIORAL AND INTRAORAL SOFT TISSUE EXAMINATION

PALATE: (Figure 14) Examine all soft palate and oropharyngeal tissues. (Figure
15) Bimanually palpate the floor of the mouth for any abnormalities. All mucosal or
facial tissues that seem to be abnormal should be palpated.
ORAL LESIONS
Suspicious for Oral Cancer
Homogenous leukoplakia
in the floor of the mouth
in a smoker. Biopsy
showed hyperkeratosis.
Clinically, a leukoplakia
on left buccal mucosa,
However, the biopsy
showed early squamous
cell carcinoma. The
lesion is suspicious
because of the presence
of nodules.
Nodular leukoplakia in
right commissure. Biopsy
showed severe epithelial
dysplasia.
Erythroleukoplakia in left
commissure and buccal
mucosa. Biopsy showed
mild epithelial dysplasia
and presence of candida
infection. A 2-3 week
course of antifungal
treatment may turn this
type of lesion into
homogenous leukoplakia.
Oral Cancer
 What is Cancer?

● Cancer is a disease in which some of the body's cells grow uncontrollably

and spread to other parts of the body. Cancer can start almost anywhere in
the human body.
● WHO defines cancer as the rapid creation of abnormal cells that grows
beyond their usual boundaries, and which can then invade adjoining parts of
the body and spread to other organs; the latter process is referred to as
metastasis. Widespread metastases are the primary cause of death from
cancer.
 What causes Cancer?

● Tobacco and alcohol use. Tobacco use of any kind, including cigarette, pipe and
cigar, and electronic cigarette smoking, as well as chewing tobacco and snuff puts
you at risk for developing oral cancers. Heavy alcohol use also increases the risk.
Using both tobacco and alcohol increases the risk even further.
● HPV. Infection with the sexually transmitted human papillomavirus (specifically the
HPV 16 type) has been linked to oral cancers.
● Age. Risk increases with age. Oral cancers most often occur in people over the
age of 40.
● Sun Exposure. Cancer of the lip can be caused by sun exposure.
● Poor Nutrition. A diet low in fruits and vegetables has been linked with increased
risk of oral cancer.
● Genetics. People with inherited defects in certain genes have a high risk of
mouth and middle throat cancer.
 Symptoms
If you have any of these symptoms for more than two weeks, see a dentist or a
doctor.
• A sore, irritation, lump or thick patch in your mouth, lip, or throat.
• A white or red patch in your mouth.
• Persistent sore throat, a feeling that something is caught in your throat, or hoarseness or loss of your voice.
• A lump in the neck.
• Difficulty chewing, swallowing, or speaking.
• Difficulty moving your jaw or tongue.
• Swelling of your jaw that causes dentures to fit poorly or become uncomfortable.
• Pain or bleeding in the mouth.
• Numbness in your tongue or other areas of your mouth.
• Ear pain.
 Diagnosis
● Because oral cancer can spread quickly, early detection is important. An
oral cancer examination can detect early signs of cancer. The exam is
painless and takes only a few minutes. Your regular dental checkup is an
excellent opportunity to have the examination.
● During the examination, your dentist or dental hygienist will check your face,
neck, lips, entire mouth, and the back of the throat for possible signs of
cancer.
● If the dentist finds anything unusual, he or she will recommend additional
tests and/or refer you to a specialist.
 Treatment
● Oral cancer is treated with surgery and possibly radiation therapy or
chemotherapy. Oral cancer that is further along when it is diagnosed may
need a combination of treatments.
● Another treatment option is targeted therapy, which is a newer type of
cancer treatment that uses drugs to precisely identify and attack cancer
cells. Immunotherapy may also be a potential treatment; it can work with the
body’s natural defenses to improve immune function. The choice of
treatment depends on your general health, where in your mouth or throat
the cancer began, the size and type of the tumor, and whether the cancer
has spread.
Diagnosis: Squamous cell carcinoma, arising actinic cheilitis
Diagnosis: Squamous cell carcinoma,nodular/exothytic
Diagnosis: Erosive lichen planus
Diagnosis: Verrucous carcinoma
Diagnosis: Aspirin Burn
Diagnosis: Amalgam tattoo
Diagnosis: Squamous cell carcinoma
Diagnosis: Squamous cell carcinoma
Diagnosis: Squamous cell carcinoma
Clinical Diagnosis: Erythroplakia Microscopic | Diagnosis: Squamous cell
carcinoma
Diagnosis: Squamous cell carcinoma
Diagnosis: Squamous cell carcinoma
Diagnosis: Osteoma
Diagnosis: Tramatic ulcer (facticious)
Diagnosis: Carcinoma in situ
Diagnosis: Irritational fibroma
Diagnosis Edge biopsy revealed squamous cell carcinoma
Diagnosis: Median rhomboid glossitis
Diagnosis: Well-differentiated squamous cell carcinoma
Diagnosis: Biopsy at several locations revealed dysplasia and carcinoma in situ.
Diagnosis: Marginally invasive squamous cell carcinoma
Diagnosis: Lichen Planus
Diagnosis: Traumatic ulcer
Diagnosis: Early-stage squamous cell carcinoma
Diagnosis: Malignant melanoma
Diagnosis: Papillary squamous cell carcinoma
Diagnosis: Squamous cell carcinoma
Diagnosis: Peripheral giant cell granuloma
Diagnosis: Squamous cell carcinoma