# Presentation: 132803

## Detecting Oral CancerA guide for health care professionals

**U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES**
- NATIONAL INSTITUTES OF HEALTH
- National Institute of Dental and Craniofacial Research

## Incidence and Survivalof Oral or Pharyngeal Cancer

- 30,000 new cases diagnosed yearly
- 8,000 deaths each year
- 5 year survival rate: 50%

**Notes:**
Oral or pharyngeal cancer will be diagnosed in an estimated 30,000 Americans this year, and will cause approximately 8,000 deaths. On average, only half of those with the disease will survive more than five years.

## Early Detection Saves Lives 

- 5-year survival for localized disease is 76%
- 5-year survival for metastatic disease is 19%

**Notes:**
With early detection and timely treatment, deaths from oral cancer could be dramatically reduced. 
The five-year survival rate for those with localized disease at diagnosis is 76 percent compared with only 19 percent for those whose cancer has spread to other parts of the body.

## Early Detection is Often Possible

- Tissue changes in the mouth that may signal cancer can often be seen and felt easily

**Notes:**
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

- Leukoplakia
- Erythroplakia

**Notes:**
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 two weeks should be reevaluated and considered for biopsy to obtain a definitive diagnosis.

## Other Possible Warning Signs

- Lump or thickening of oral soft tissue
- Soreness or “lump” in throat
- Difficulty chewing or swallowing
- Ear pain
- Difficulty moving jaw or tongue
- Hoarseness
- Numbness of tongue or mouth
- Swelling of the jaw

**Notes:**
Possible signs and symptoms of oral cancer that your patients may report include: a lump or thickening in the oral soft tissues, soreness or a feeling that something is caught in the throat, difficulty chewing or swallowing, ear pain, difficulty moving the jaw or tongue, hoarseness, numbness of the tongue or other areas of the mouth, or swelling of the jaw that causes dentures to fit poorly or become uncomfortable. 
If these problems persist for more than two 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 use
- Alcohol use
- Exposure to sunlight
- Age
- Gender
- Race

**Notes:**
Tobacco/Alcohol Use: Tobacco and excessive alcohol use increases the risk of oral cancer. Using both tobacco and alcohol poses a much greater risk than using either substance alone. 
Sunlight: Exposure to sunlight is a risk factor for lip cancer. 
Age: Oral cancer is typically a disease of older people, usually because of their longer exposure to risk factors. Incidence of oral cancer rises steadily with age, reaching a peak in persons aged 65–74. For African Americans, incidence peaks about 10 years earlier. 
Gender: Oral cancer strikes men twice as often as it does women. 
Race: Oral cancer occurs more frequently in African Americans than in whites.

## Examination Overview

- Head and neck exam should be a routine part of dental and medical check-ups.
- Take a history of alcohol and tobacco use.
- Follow up on suspicious signs.

**Notes:**
A thorough head and neck examination should be a routine part of each patient's dental visit and general medical examination. Clinicians should be particularly vigilant in checking those who use tobacco or excessive amounts of alcohol. 
Examine your patients using the head and neck exam illustrated in this program. 
Take a history of their alcohol and tobacco use. 
Follow up to make sure a definitive diagnosis is obtained on any possible signs or symptoms of oral cancer.

## Tools and Time

- Proper lighting
- Dental mouth mirror
- Gauze squares
- Gloves
- 5 minutes

**Notes:**
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 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.

## Extraoral Examination

**Notes:**
The extraoral assessment includes 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. If enlargement is detected, the examiner should determine the mobility and consistency of the nodes. 
A recommended order of examination includes the preauricular, submandibular, anterior cervical, posterior auricular, and posterior cervical regions.

## Perioral and Intraoral Soft Tissue Examination: Lips

**Notes:**
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. 
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.

## Perioral and Intraoral Soft Tissue Examination: Labial Mucosa

**Notes:**
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.

## Perioral and Intraoral Soft Tissue Examination: Labial Mucosa

## Perioral and Intraoral Soft Tissue Examination: Buccal Mucosa

**Notes:**
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.

## Perioral and Intraoral Soft Tissue Examination: Buccal Mucosa

## Perioral and Intraoral Soft Tissue Examination: Gingiva

**Notes:**
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).

## Perioral and Intraoral Soft Tissue Examination: Dorsum of the Tongue

**Notes:**
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.

## Perioral and Intraoral Soft Tissue Examination: Left Margin of the Tongue

**Notes:**
With the aid of mouth mirrors, inspect the left and right lateral margins of the tongue.

## Perioral and Intraoral Soft Tissue Examination: Right Margin of the Tongue

**Notes:**
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.

## Perioral and Intraoral Soft Tissue Examination: Ventral Surface of the Tongue

**Notes:**
Then examine the ventral surface. Palpate the tongue to detect growths.

## Perioral and Intraoral Soft Tissue Examination: Floor of the Mouth

**Notes:**
With the tongue still elevated, inspect the floor of the mouth for changes in color, texture, swellings, or other surface abnormalities.

## Perioral and Intraoral Soft Tissue Examination: Hard Palate

**Notes:**
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.

## Perioral and Intraoral Soft Tissue Examination: Oropharynx

**Notes:**
Examine all soft palate and oropharyngeal tissues.

## Perioral and Intraoral Soft Tissue Examination

**Notes:**
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
- Leukoplakia with early squamous cell carcinoma
- Nodular leukoplakia with severe epithelial dysplasia
- Erythroleukoplakia with candida infection

## Homogenous Leukoplakia

**Notes:**
Homogenous leukoplakia in the floor of the mouth in a smoker. Biopsy showed hyperkeratosis.

## Leukoplakia with early squamouscell carcinoma 

**Notes:**
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 with severeepithelial dysplasia

**Notes:**
Nodular leukoplakia in right commissure. Biopsy showed severe epithelial dysplasia.

## Erythroleukoplakia withcandida infection

**Notes:**
Erythroleukoplakia in left commissure and buccal mucosa. Biopsy showed mild epithelial dysplasia and candida infection. Anti-fungal treatment may turn this type of lesion into a homogenous leukoplakia.

## In Appreciation	

- Slides for this program were graciously provided by Joseph Konzelman, D.D.S. and Jens Jorgen Pindborg, Dr. Odont.

## Detecting Oral Cancer: A Guide for Health Care Professionals was developed by the National Institute of Dental and Craniofacial Research, one of the federal National Institutes of Health. The program is not copyrighted and may be reproduced. For additional information about oral cancer, contact:

- National Institute of Dental and Craniofacial Research
- National Oral Health Information Clearinghouse
- 1 NOHIC Way
- Bethesda, MD 20892-3500
- nohic@nidcr.nih.gov
- www.nidcr.nih.gov

**Notes:**
This slide program was developed by the National Institute of Dental and Craniofacial Research. For additional information about oral cancer, please contract the National Institute of Dental and Craniofacial Research.