* A special thanks to the patients and families who granted permission to share their stories in the hopes of preventing someone else’s suffering. These patients were so very grateful to have had their cancer discovered.
Dentists are on the front line of diagnosing oral cancer. According to the Oral Cancer Foundation, 58,500 Americans will be diagnosed with oral cancer this year. Worldwide, the number of diagnoses is 450,000. There will be over 12,000 deaths attributed to oral cancer in the U.S. this year. The average general dentist in practice for 30 years will diagnose 2 oral malignancies. I diagnosed 8 oral cancers, 2 dysplasias, and a carcinoma in situ in a 32-year career. My total yielded 7 squamous cell carcinomas and one bone cancer found on a panorex. This bone cancer was metastasis from kidney cancer. When I share my record with lecture audiences, they are amazed. I was attending a symposium and an oral surgeon from the University of Iowa was speaking. He asked if I was in attendance. I raised my hand, and he presented a case study of one of my patients. I was asked if I remembered the patient. I replied that I remembered them all. A special shout-out to my Oral Pathology instructors at Iowa. I thank my mentors Dr. Gilbert Lilly and Dr. Steven Vincent. My patients and I appreciate that education more than you know!
Routine Screening: A Must
I routinely screened at the initial exam, at all routine exams, as well as on any emergency patient prior to treatment. In fact, my son, who practices in another state, recently saw an initial patient for emergency care. While performing his oral cancer screening before rendering emergency care, he found a suspect lesion and performed a biopsy. It was a squamous cell carcinoma. The patient was very grateful. The patient came in to have a tooth restored, and something much bigger was addressed. Imagine if the tooth was treated and this cancer was found a few years later. When my son Dylan shared this with me, I was most proud. The apple doesn’t fall far from the tree. Dylan, you now have one diagnosis under your belt just 2 years into your career.
How to Screen
- Evaluate the health history and ask about alcohol and tobacco use.
- Let your patient know that you are screening for oral cancer.
- Begin by palpating the lymph nodes in the upper neck and submandibular area.
- Evaluate the lips. Then proceed inside the mouth.
- Visually inspect all the mucosa and attached gingiva.
- Grab the tongue and pull it from side to side, examining the lateral border of the tongue.
- Inspect and palpate the floor of the mouth.
- Look at the palate and pharynx.
- Evaluate the radiographs for radiolucencies and unusual opacities.
All my diagnoses were by visual inspection. I did not have a light; however, the best product on the market today to aid in diagnosis is the VELscope. It provides fluorescence visualization. Get this valuable tool!
The Biopsy
All dentists should be able to perform excisional and incisional biopsies, as well as brush biopsies. They are not difficult. You can obtain specimen bottles of 10% formalin along with biopsy reports and mailing packets from a lab. Do them the same day and send them to a laboratory for evaluation. Your patients will thank you for it. Always include a photo and a radiograph.
Squamous cell carcinoma represents 90% of oral cancer cases.
Most Common Sites
The most common location is the tongue. Pay special attention to the lateral border of the tongue, as most lesions (45%) are found there. The floor of the mouth, buccal mucosa, and pharynx are the next most common areas.
What Are You Looking For?
The non-painful red-white lesion. The sore that doesn’t heal. An area of swelling with bleeding. Radiographic radiolucency/radiopacity or a combination thereof. The wrinkling and color change in the area of the buccal mucosa where the chewing tobacco resides.
Intraoral Camera
Use it! Document these areas. Educate your patients.
Causative Agents
- Tobacco use of any kind (smoking/chewing)
- Moderate to heavy alcohol consumption
- Human papillomavirus (HPV)
Sobering Statistics
Men are twice as likely to develop oral cancer (1 in 59 men vs 1 in 139 women). Most oral malignancies are diagnosed at age 64 and older, with 20% under age 55. More cases are being found among the younger population due to HPV. Smokers are 10 times more likely to develop oral cancer than non-smokers. Heavy alcohol users have a fivefold increase in developing oral and pharyngeal cancer. Add chewing tobacco into the mix, and there is a significant increase. It can take 6-7 years to develop cancer from chewing tobacco. Tell your patients to quit chewing tobacco. They should move it around at the very least. Education is the key!
Survival Rates
The 5-year survival rate averages 57%. This is because most cases are diagnosed in later stages. As many as 50% of oral cancers have metastasized by the time of diagnosis. The 5-year survival rate can be in the 80% range if caught early. Recurrence rates are 40-50%.
My Real-World Experience
As you know, I practiced in rural Iowa. My first diagnosis came my first year in practice. It was a male in his upper 60s who had been treated at the Mayo Clinic for squamous cell carcinoma of the tongue several years earlier and was in remission for a couple of years. He had a portion of his tongue removed. This gentleman was understandably concerned about the cancer coming back and wanted to be seen every 2 months or so. I saw this patient at no charge for these frequent exams. He was so appreciative. The cancer returned to the floor of the mouth, and I sent him back to Mayo. Several years later, he succumbed to his disease.
My next diagnosis was a male in his 60s who had been going to the University of Iowa as he had not been feeling well. He said that they were having difficulty in determining what was wrong. They were running tests to no avail. He presented to my office in my second year of practice complaining of discomfort in his jaw. I was the only dentist in my area to have a panorex. The panoramic radiograph revealed a large radiolucency in the body of his mandible. I remember sitting with this man and his wife. I discussed my concern but tried to reassure them as best I could and that we would have to have further evaluation. This was metastasized cancer from his kidney. This patient soon lost his battle with cancer. His entire family were patients of mine until retirement.
My next couple of cases were on two males in their 30s and 40s. They presented for initial exams with lesions found on the tongue and floor of the mouth, as I recall. Both were heavy drinkers and chewed tobacco. I performed an incisional biopsy on one of the patients. The other was sent directly to Iowa. Both patients were confirmed to have squamous cell carcinomas. Both men underwent radical surgical intervention and radiation.
One of these men was a case study at Iowa. This patient was referred to me by his mother, as the patient was in town for his father’s funeral and had not had a dental exam for many years. I found a large lesion consuming half of the floor of his mouth. I took photos with my intraoral camera. The patient said he knew about that sore as he went to a local physician recently. I asked him what the physician was doing for him. He said he placed him on amoxicillin. I called his physician, who felt it was some kind of infection. This looked like a large squamous cell carcinoma, but I would need a biopsy to confirm. I advised this patient to go to Iowa City for a biopsy as the lesion was so large.
I asked if he wanted his mother to join us in the treatment room. The patient gave me permission to have his mother come back to the operatory after the exam. I knew it was bad. How could I tell her? She just lost her husband. I told them that we would have to wait for the results from the biopsy. I told them I was very concerned. They sensed the seriousness. His mother said, “It’s cancer, isn’t it?” I said we must wait on the biopsy. They don’t teach you in school how to break this news to a patient and their family. It was a hard day for me. I could see the pain in this mother’s eyes. This young man underwent radical surgery and radiation and passed away within a year of diagnosis. This mother wanted me to share this story with other young men who chewed tobacco.
I went on to diagnose a couple of cases found in females in their 50s. These were squamous cell carcinomas on the lateral border of the tongue. One was a particularly small red-white lesion, as I recall. I performed an excisional biopsy. That lesion was found early. The patient was ecstatic.
The Farmer
I remember an older patient who presented for an initial exam. This was an older farmer in his 70s. He had blue eyes with a fair complexion and a large sore on his lip. He reported never wearing a hat. I asked him how long the sore was present, and he said, “A few months.” I told him I wanted to see him back in a few weeks. If it was still there, I would remove it and send it for biopsy. It was a squamous cell carcinoma. Iowa surgeons confirmed that I had removed all the borders of the lesion. He continued to see me for the next 10 years right up to my retirement.
Stick to Your Guns
I was once referred a male in his mid-60s. The patient arrived saying that the sore on his soft palate was a denture sore, according to his ENT, who he had been seeing for a while. His specialist told him to find a dentist to address his denture issue. This was the first time I had seen the patient. He reported being a heavy drinker. I examined the patient. He wore a complete upper denture for several years. He had an aggressive-looking large lesion on his soft palate. It looked like a squamous cell carcinoma. I do not biopsy the soft palate extending into the pharynx. I called his ENT to express my concern. I requested that he biopsy the area. His physician did not see the need, as he felt it was a denture sore. I told the physician that I evaluated the denture and that was not the issue. I said it appears to be a squamous cell carcinoma and I think it should be biopsied. The ENT disagreed. I made this phone call while the patient was in the chair. I returned to the treatment room and let the patient know I called his physician and how the call went. I recommended that he be seen at the University of Iowa for a biopsy of this region, as I suspected it could be a malignancy. The patient saw no need to take the word of a dentist if his specialist saw no cause for alarm. The patient left.
I called the patient later that night and for the next several weeks. I urged him to get that lesion biopsied. I documented in the record that I did everything outside of physically driving the patient to Iowa. I sent a letter to his ENT urging him to biopsy this lesion.
Several months went by, and into my office walks his daughter. I greeted his daughter, and she said, “I just wanted to stop and thank you for staying on Dad regarding the biopsy.” She said he went to Iowa and had the biopsy. It was cancer. She was having trouble remembering the diagnosis, so I said squamous cell carcinoma. She replied, “That’s it.”
This patient had surgery and radiation and came to my office right before Christmas of that year. My office manager said someone wanted to see me in the waiting area. I walked out to greet this grateful gentleman who gave me a big hug and said how much he appreciated my persistence. He said that my keeping after him persuaded him to get the biopsy. He said it was the reason he was around to celebrate Christmas with his daughter and granddaughter. He couldn’t thank me enough; and you all thought dentistry was just about the teeth and gums.
You Do Make a Difference
You make a difference in your patients’ lives. I ate, slept, and drank the profession of dentistry. I never stopped striving for excellence! Your patients recognize this! Believe me, they do! The respect follows your efforts. My patients always addressed me as “Doc” or “Dr. James.” This was not some ego thing that I demanded. In fact, I did not mind if they called me by my first name. Integrity is recognized and rewarded. Respect is earned. Word-of-mouth referrals follow and are the greatest compliment. This was all before the solicited 5-star reviews. In my market, I was held in high esteem and well-respected.
Go the extra mile. Perform thorough oral cancer screenings. You might be surprised at what you find. I know your patients will appreciate it! Let me know your experiences in the comment section!
Wishing you a successful career!
* A special thanks to the patients and families who granted permission to share their stories in the hopes of preventing someone else’s suffering. These patients were so very grateful to have had their cancer discovered.